Delayed ossification of the proximal capital femoral epiphysis in Legg-Calvé-Perthes' disease.

We studied radiographs of 125 children (105 boys, 20 girls) with unilateral Legg-Calvé-Perthes' disease to examine the epiphyseal development of the femoral head in the contralateral (unaffected) hip. The epiphyseal height (EH) and width (EW) of the unaffected hip were measured on the initial anteroposterior pelvic radiograph. In 109 of the patients (87.2%) the EH was below the mean for normal Japanese children and a significantly small EH (below -2 SDs) was observed in 23 patients (18.4%). By contrast, the EW of most patients (95.2%) lay within +/- 2 SDs of normal values except for six with a significantly small EW. A strong positive linear correlation (R = 0.87) was observed in the EH:EW ratio in the patients. A smaller EH than expected for EW in our series indicated epiphyseal flattening of the femoral head in Legg-Calvé-Perthes' disease. Our findings support the hypothesis that a delay in endochondral ossification in the proximal capital femoral epiphysis may be associated with the onset of Perthes' disease.

End-to-end duodenojejunal bypass for unresectable periampullary carcinoma.

Palliative operation plays an important part in the treatment of periampullary carcinoma. However, gastric bypass such as the widely practiced side-to-side gastrojejunostomy frequently fails to provide adequate drainage. Here we attempted to fashion an end-to-end duodenojejunostomy in the hope of establishing physiological continuity of the stomach and duodenum. Biliary bypass with side-to-side choledochojejunostomy is performed simultaneously. Eight patients underwent this surgery. In seven of these, radical resection proved to be impossible, and in one the duodeno-biliary decompression was attempted before the radical operation. Early results were satisfactory in all patients. They began to eat liquid meals within a week, and were discharged uneventfully within the third postoperative week, when they were able to eat a regular diet. No ulcer developed in any of the patients. Plasma gastrin levels following a test meal was significantly lower after the operation, but plasma CCK-N and GIP levels showed no statistical difference prior to and after surgery. This duodenojejunal bypass is recommended as a means of improving the quality of the remaining life of the patients.

The state of recurrence and the role of hepatectomy in hepatocellular carcinoma.

The subjects involved in the present study were 113 patients with hepatocellular carcinomas who had undergone hepatectomy in our hospital during the past 10 years. During the surveillance, 79 of the 113 patients (69.9%) had recurrence in the residual liver. The cumulative non-recurrence rate at 2 and 5 years was 48.4% and 18.1%, respectively and the cumulative survival rate at 2 and 5 years was 83.8% and 47.5%, respectively. The recurrence in the residual liver tended to occur in the group with the larger tumor size, in the single nodular surrounding proliferative types and in the aneuploid types. There were no differences in the recurrence rate and state relating to the operative procedure. To improve the prognosis of hepatocellular carcinoma, it is necessary to consider the hepatic functional reserve after hepatectomy, and to make plans for multidisciplinary therapy, including such further treatment as transcatheter arterial embolization, infusion chemotherapy and preoperative percutaneous ethanol injection.

A case of glaucoma with choroidal hemangioma managed by nonpenetrating trabeculectomy.

BACKGROUND: Nonpenetrating trabeculectomy was used in a patient with glaucoma complicated by diffuse choroidal hemangioma. CASE: A 12-year-old boy suffered from glaucoma with choroidal hemangioma in the left eye. Intraocular pressure was 28 mm Hg and visual acuity was 0.04. Nonpenetrating trabeculectomy was then performed. OBSERVATIONS: Postoperative intraocular pressure was controlled at around 15 mm Hg with pilocarpine hydrochloride eye drops. Visual acuity and visual field were preserved over 19 months after the operation. CONCLUSIONS: An increase in aqueous outflow resistance was considered to be the major mechanism in the rise in intraocular pressure, based on distinct dilatation and tortuosity of the episcleral blood vessels and congestion of Schlemm's canal. Therefore, construction of aqueous drainage by nonpenetrating trabeculectomy was effective. Retaining the trabecular meshwork was also considered effective in controlling complications such as choroidal hemorrhage and postoperative flat anterior chamber.

[Disorders of choroidal circulation in diabetic maculopathy].

Diabetic maculopathy is classified into 3 types, namely, macular edema, ischemic maculopathy, and pigment epitheliopathy. Blood-retinal barrier disturbance and the influence of the posterior vitreous membrane have been reported as the cause of diabetic maculopathy. However, its association with the choroidal circulation feeding the outer layer of the retina which involves the outer blood-retinal barrier has not been clarified yet. In this work, we studied the presence of the choroidal circulatory disturbance by performing indocyanine green angiography (IA) on patients with diabetic maculopathy. Choroidal circulatory disturbance was also differentiated from fluorescent block with a scanning laser ophthalmoscope (SLO). The proportion of hypofluorescence observed in IA was 4 eyes in 2 patients among 37 eyes in 24 patients (11%) in the macular edema group, 3 eyes in 2 patients among 14 eyes in 10 patients (21%) in the ischemic maculopathy group, and 26 eyes in 17 patients among 33 eyes in 22 patients (79%) in the pigment epitheliopathy group. Of the cases showing hypofluorescence in IA in the pigment epitheliopathy group, 4 eyes in 4 patients had hypofluorescence due to both choroidal circulatory disturbance and fluorescent block. This suggests that the choroidal circulation disturbance is partly involved in diabetic maculopathy mainly in the pigment epitheliopathy group.

[Preoperative diagnosis of internal mammary node metastases in patients with breast cancer by using ultrasonography].

US findings of 81 patients with breast cancer were analyzed respectively to evaluate the usefulness of US in the preoperative diagnosis of internal mammary mode metastases. The internal mammary area (I.M.A.) in which internal mammary nodes lie was shown as a hypoechoic stripe in a sagittal scan along the sternum and as a triangular or spindle-shaped hypoechoic area in a transverse scan in the intercostal space. The US features of each I.M.A. in the first three intercostal spaces were divided into three patterns: Pattern-A wad defined as widening of the ipsilateral side of the I.M.A. compared with the contralateral side; Pattern-C was defined as normal at both sides of the I.M.A. Pathological examination confirmed the node metastases in 85.7% of intercostal scans showing Pattern-A and in 35% of intercostal scans showing Pattern-B. Only one of 189 intercostal scans showing Pattern-C had nodal metastases. The overall accuracy was 88.1% in 243 intercostal scans and 90.1% in 81 patients. We conclude that US is useful in the detection of internal mammary node metastases in patients with breast cancer.

Retinal sensitivity measurement over drusen using scanning laser ophthalmoscope microperimetry.

BACKGROUND: Retinal sensitivity over drusen was examined using a scanning laser ophthalmoscope to confirm a previous report of no change in sensitivity over drusen. METHODS: Microperimetry was performed using a scanning laser ophthalmoscope in 23 eyes of 19 subjects. Subject age ranged from 42 to 86 years (mean 68.5 years). Fifty-four drusen bigger than the diameter of a major retinal vein at the optic disc rim were examined, and drusen were classified as soft drusen and other large drusen. RESULTS: Nine eyes of eight subjects showed a decrease in retinal sensitivity over drusen. The decrease in retinal sensitivity was more than 5 dB less than the sensitivity at a peripheral non-drusen area peripheral to the measurement point. The sensitivity decrease was noted over 15 of 29 large drusen and the decrease was statistically significant (P < 0.02). However, no relationship between the size of the drusen and the amount by which sensitivity decreased was found. Nevertheless, a decrease in retinal sensitivity was not seen over any of 25 soft drusen. CONCLUSION: Large drusen may influence retinal sensitivity and function.

Lymphangioma of the duodenum: report of a case.

A case of lymphangioma of the duodenum with a successful preoperative diagnosis is reported herein. A 76-year-old man who complained of tarry stool was found to have a hemorrhagic polypoid tumor in the third portion of the duodenum. The tumor was diagnosed histologically as cavernous lymphangioma by endoscopic biopsy. Since such a tumor is essentially benign, a partial resection of the duodenum including the tumor was performed. Therefore, an endoscopic biopsy seems to be valuable in the diagnosis of duodenal lymphangioma.

Carcinosarcoma of the esophagus: a report of two cases.

Among 137 cases of esophageal neoplasms surgically treated at Kobe City General Hospital from 1983 to 1990, there were two patients with a huge polypoid lesion identified as carcinosarcoma by light microscopic examination, both of whom underwent radical resection and esophagogastrostomy. Microscopic examination of the resected specimens revealed the tumors to be composed of carcinomatous and sarcomatous elements. Additional immunohistochemical examination disclosed keratin-positive cells in the carcinomatous element and vimentin-positive cells in the sarcomatous element. In case 1, keratin-positive cells were also found in the sarcomatous element, which suggested that the sarcomatous cells were derived from epithelial cells. Despite the huge size of the tumors, the depth of invasion to the esophageal wall was limited to the mucosal layer in case 1 and the submucosal layer in case 2, and there has been no evidence of recurrence in either case since surgery.

Des-gamma-carboxy prothrombin (PIVKA-II) and alpha-fetoprotein-producing IIc-type early gastric cancer.

We describe the case of a 56-yr-old man with primary gastric adenocarcinoma, who had an extremely high plasma level of des-gamma-carboxy prothrombin (2.45 AU/ml) and of serum alpha-fetoprotein (2810 ng/ml). Histopathologically, the gastric cancer was a IIc type of early cancer which consisted of a combination of a poorly differentiated adenocarcinoma and a well-differentiated tubular adenocarcinoma. The association of a hepatic tumor including hepatocellular carcinoma or liver metastasis was ruled out by ultrasonography, computed tomography, radiocolloid liver scan, magnetic resonance imaging, and angiography. Foci strongly resembling hepatocellular carcinoma (hepatoid differentiation) were noted in the gastric tumor. Localization of des-gamma-carboxy prothrombin and alpha-fetoprotein within the tumor cells, especially within the hepatoid differentiated foci, was demonstrated by the immunohistochemical staining of tissue obtained at biopsy and the resected specimen. This case seems to be the first case reported in which des-gamma-carboxy prothrombin was produced by the gastric cancer. This finding supports the theory of hepatoid differentiation of a gastric cancer.