The Limitation of Endoscopic Surgery Using the Full Endoscopic Discectomy System for the Treatment of Destructive Stage Pyogenic Spondylodiscitis: A Case Series.

INTRODUCTION: Conservative therapy, including appropriate antibiotics and bracing, is usually adequate for most patients with pyogenic spondylodiscitis. If conservative treatment fails, surgical intervention is needed. However, major spinal surgery comprising anterior debridement and accompanying bone grafting with or without additional instrumentation is often related to undesired postoperative complications. In recent years, with minimally invasive surgery, the diagnostic and therapeutic value of endoscopic lavage and drainage has been proven. This study reports a case series of patients who required open revision surgery after treatment with endoscopic surgery using the full endoscopic discectomy system (FED), indicating the surgical limitations of endoscopic surgery for pyogenic spondylodiscitis. METHODS: We retrospectively investigated the medical records of 4 patients who underwent open debridement and anterior reconstruction with posterior instrumentation following endoscopic surgery for their advanced lumbar infectious spondylitis. They had been receiving conservative treatment with antibiotics for 12-15 days. They also had various comorbidities, including kidney disease, heart failure, and diabetes. Numerical rating scale pain response, perioperative imaging studies, and C-reactive protein (CRP) levels were determined, and causative bacteria were identified. Primarily, the bone destruction stage was classified using computed tomography with reference to Griffiths' scheme. RESULTS: All patients had severe back pain before surgery with no relief of the pain after FED. Increased pain, including radicular pain after FED, was noted in one case. Causative pathogens from biopsy specimens were identified in 3 (75%) of the 4 cases. In preoperative radiological evaluation, all cases were classified as destructive stage in Griffiths' scheme. The CRP levels of all the patients decreased slightly after endoscopic surgery. Relapse of spinal infection after revision surgery was not noted in any patient during the follow-up period. CONCLUSION: The surgical treatment of destructive-stage spondylitis with FED alone can increase low back pain due to aggressive debridement.

A Rare Case of Thoracic Pyogenic Facet Joint Infection.

Pyogenic facet joint infection is a rare but severe infection. The most common complaint on presentation is pain followed by fever, then neurologic impairment. While the lumbar spine is involved in the vast majority of cases presented in the literature, the case presented here occurred in the thoracic spine. The patient was a 48-year-old immune-competent female who presented with left back pain. Magnetic resonance imaging (MRI) indicated a facet effusion, paraspinal abscess, and epidural abscess in the level of 9th-11th thoracic vertebra. On the 6th day of treatment, she presented a neurological disorder and underwent decompressive laminectomy and surgical debridement. We observed immediate improvement as a result of the surgery.

Initial Clinical Outcomes of Percutaneous Full-Endoscopic Lumbar Discectomy Using an Interlaminar Approach at the L4-L5.

BACKGROUND: Percutaneous full-endoscopic discectomy (PED) is being increasingly used because of its potential to minimalize soft-tissue damage and decrease hospital stay. PED using the interlaminar approach (PED-IL) at L4-L5 is performed by only a few surgeons. To the best of our knowledge, the safety and efficacy of PED-IL at L4-L5, without experience in PED via a transforaminal approach (PED-TF) has not been previously reported. OBJECTIVE: This study aimed to evaluate initial clinical outcomes and complications of PED-IL at L4-L5 without experience in PED-TF. STUDY DESIGN: Retrospective evaluation. SETTING: An urban minimally invasive spine hospital. METHODS: Of a total of 50 patients (36 men and 14 women, ages ranging from 21-59 years, with the average age being 40.3 years old), 16 cases were performed at L4-L5 and 34 cases were performed at L5-S1. PED-IL was successfully completed in all cases, and no case required conversion to open surgery. The operative time, hospital stay, modified MacNab criteria, and visual analog scale (VAS) scores were examined at L5-S1 (range: 41-112). There was no significant difference in operative time between the L4-L5 and L5-S1 groups; the operative time was gradually decreased. The mean hospital stay was 2.9 days (range: 2-8 days). According to modified MacNab criteria, 20 cases (6 at L4-L5 and 14 at L5-S1) were excellent, 27 (10 at L4-L5 and 17 at L5-S1) were good, one at L5-S1 was fair, and 2 at L5-S1 were poor. Two perineurium tears occurred at L5-S1. There was no infection or recurrence of herniated nucleus pulposus (HNP). The clinical outcomes of PED-IL at L4-L5 were equal to those at L5- S1. RESULTS: The mean operative time was 71.3 ± 19.3 minutes for all cases (range: 41-112 mins.),76.1 ± 16.8 minutes at L4-L5 (range: 52-102 mins.), and 70.5 ± 20.1 minutes at L5-S1 (range: 41-112 mins.). LIMITATIONS: A small sample size and a short follow-up period. CONCLUSIONS: The clinical outcomes of PED-IL at L4-L5 were equal to those at L5-S1. Therefore, PED-IL is suitable to be a standard method for any type of intracanalicular disc herniation.

Plasma cells and the chronic nonsuppurative destructive cholangitis of primary biliary cirrhosis.

UNLABELLED: There has been increased interest in the role of B cells in the pathogenesis of primary biliary cirrhosis (PBC). Although the vast majority of patients with this disease have anti-mitochondrial antibodies, there is no correlation of anti-mitochondrial antibody titer and/or presence with disease severity. Furthermore, in murine models of PBC, it has been suggested that depletion of B cells may exacerbate biliary pathology. To address this issue, we focused on a detailed phenotypic characterization of mononuclear cell infiltrates surrounding the intrahepatic bile ducts of patients with PBC, primary sclerosing cholangitis, autoimmune hepatitis, chronic hepatitis C, and graft-versus-host disease, including CD3, CD4, CD8, CD20, CD38, and immunoglobulin classes, as well as double immunohistochemical staining for CD38 and IgM. Interestingly, CD20 B lymphocytes, which are a precursor of plasma cells, were found in scattered locations or occasionally forming follicle-like aggregations but were not noted at the proximal location of chronic nonsuppurative destructive cholangitis. In contrast, there was a unique and distinct coronal arrangement of CD38 cells around the intrahepatic ducts in PBC but not controls; the majority of such cells were considered plasma cells based on their expression of intracellular immunoglobulins, including IgM and IgG, but not IgA. Patients with PBC who manifest this unique coronal arrangement were those with significantly higher titers of anti-mitochondrial antibodies. CONCLUSION: These data collectively suggest a role for plasma cells in the specific destruction of intrahepatic bile ducts in PBC and confirm the increasing interest in plasma cells and autoimmunity.

Rice cake ileus--a rare and ethnic but important disease status in east-southern Asia.

INTRODUCTION: Rice cake is a traditional but very popular food in Asia including Japan and has never been known as a cause of ileus. Rice cake is now becoming widespread in the United States and European countries along with other Japanese foods. We may encounter rice cake ileus all over the world. This study was aimed at characterizing the rice cake ileus. METHODS: We consecutively encountered 14 patients with rice cake ileus from April 2003 to October 2010 in our hospital. All of the characteristics of the cases were reviewed and analyzed. RESULTS: All patients had ingested rice cake by swallowing without chewing. It has most frequently occurred in January (57.1%). The main symptoms were abdominal colicky pain (100%) and nausea (85.7%) and physical findings included abdominal tenderness (100%) and muscular defense (28.6%). All patients improved by conservative therapy including fluid supply (100%), naso-gastric tube (28.6%) and long tube (28.6%) insertion. No patient needed emergency open surgery. CONCLUSION: Rice cake ileus which is caused by swallowing the rice cake without chewing, frequently occurs in January, has previous history of abdominal surgery and shows high density intestinal contents on CT and only needs conservative therapy. Globalism in food culture may provide a new disease entity. Therefore, we should be aware of this type of ileus and be prepared to manage it appropriately.

[Palliative anti-cancer chemotherapy is safely executable in a hemodialytic patient with unresectable advanced gastric cancer].

A 75-year-old man with chronic renal failure was on maintenance hemodialysis.He was admitted to our hospital for advanced gastric cancer with multiple liver metastases (cStage IV).Three courses of tegafur-uracil (300 mg/day daily) plus docetaxel (20 mg/m², every 3 weeks) as first-line treatment and nine courses of tegafur-uracil (same dose) plus CPT-11 (64 mg/m², day 1, 15, every 4 weeks) were given without any complications.Docetaxel and CPT-11 were given on days between hemodialyses. No severe adverse effects of more than grade 3 were encountered. The standard regimens in our country for unresectable advanced gastric cancer are the S-1 single or S-1/CDDP combined chemotherapies that have already been evidenced in the JCOG 9912 and SPIRITS trial. However, no standard chemotherapy for patients on hemodialysis has been reported as yet.Therefore, doctors in charge must arrange an individualized regimen for each patient, considering metabolic characteristics of each anti-cancer agent.In this context, our case was considered to be very suggestive, and that is why we report it here in detail.

Hepatocellular carcinoma, with portal thrombus after viral eradication, disappeared by 5-fluorouracil and interferon.

Hepatocarcinogenesis after a sustained virological response (SVR) in type C chronic hepatitis and cirrhosis is an important issue in endemic areas; hepatocellular carcinoma (HCC) with portal vein tumor thrombus (PVTT) therapy is especially very hard. We herein report a first case in which combination therapy with interferon-α and continuous intra-arterial infusion of 5-fluorouracil (designated as FAIT) provided a complete response in HCC with PVTT after SVR. Therefore, we think that FAIT is a good option to treat HCC with or without PVTT, even after SVR.

TTF-1 is useful for primary site determination in duodenal metastasis.

We report here on a case of duodenal metastasis from primary lung adenocarcinoma. A 69-year old man was diagnosed with primary lung adenocarcinoma. Four courses of combined chemotherapy with carboplatin and paclitaxel associated with irradiation of 60 Gy shrunk the lung tumor. However, soon after,the para-aortic lymph node became swollen. Esophagogastroduodenoscopy revealed three duodenal tumors. Differential diagnosis between malignant lymphoma and metastatic duodenal cancer was endoscopically difficult. The histology of biopsied specimens was poorly differentiated adenocarcinoma. Immunohistochemical analysis revealed a positive reaction for thyroid transcription factor-1 (TTF-1). Thus, we concluded that these were metastatic duodenal tumors from lung adenocarcinoma. Two courses of gemcitabine led to a complete remission in this duodenal metastasis and para-aortic lymph node swelling with only scarring remaining in computed tomography. He is now on the continuous generalized chemotherapy. In conclusion, duodenal metastasis from primary lung adenocarcinoma is rare and hard to diagnose. In such an instance, TTF-1 immunostaining is crucial to obtain the correct diagnosis.

A Fatal Aortoesophageal Fistula Caused by Critical Combination of Double Aortic Arch and Nasogastric Tube Insertion for Superior Mesenteric Artery Syndrome.

Double aortic arch (DAA) is a rare vascular congenital abnormality. Since a vascular ring surrounds bronchus and esophagus, any oral or nasal intubation can physically cause fatal aortoesophageal fistula (AEF). We report herein the first case of association of DAA and superior mesenteric artery (SMA) syndrome and the second case of AEF caused by nasogastric intubation in an adult with DAA. A 19-year-old woman visited our hospital for nausea and vomiting. She was diagnosed with SMA syndrome by computed tomography (CT). Nasogastric intubation relieved her symptoms in 4 days. Extramural compression with top ulceration was found in esophagogastroduodenoscopy on the 5th hospital day. She suddenly showed massive hematemesis on the 12th hospital day. AEF was found by CT. Soon, she died despite of intensive care. Retrospective interview disclosed the fact that DAA was pointed out in her childhood. We conclude that intubation must be avoided in DAA and a detailed clinical interview about DAA is mandatory to avoid AEF.

[An elderly hemodialytic case of recurrent esophageal cancer given combination chemotherapy with docetaxel and nedaplatin who showed temporal relief of swallowing disturbance].

An 82-year-old man was admitted for recurrent and unresectable esophageal cancer. His performance status was grade 2, although he was on hemodialysis due to chronic renal failure since 2003. Esophagogastroduodenoscopy revealed stenosis of esophagus by the recurrent tumor. After percutaneous endoscopic gastrostomy, he received biweekly combination chemotherapy with docetaxel (18 mg/m(2)) and nedaplatin (16 mg/m(2)). Hemodialysis was carried out one hour after termination of nedaplatin infusion. As severe adverse reactions due to anticancer-chemotherapy were not encountered, he could receive four courses of chemotherapy in our outpatient clinic. Difficulty in swallowing improved after the second course was finished. Finally, he died of acute myocardial infarction. In conclusion, combination chemotherapy with docetaxel and nedaplatin can be safely carried out for a patient with recurrent and unresectable esophageal cancer even on hemodialysis by appropriate down-dosing of anticancer agents.

Intestinal anisakiasis can cause intussusception in adults: an extremely rare condition.

We report an extremely rare case of adult intussusception caused by anisakiasis. A 41-year-old man was admitted into our hospital for right lower abdominal colicky pain. Ultrasonography and computed tomography revealed the presence of intussusception. As pneumo-dynamic resolution by colonoscopy failed, surgery was performed. The anisakis body was found in the submucosal layer of the resection specimen. The patient was discharged 9 d after the operation. Anisakiasis may cause intussusception in any country where sushi or sashimi now exists as a popular food. If suspicious, detailed clinical interview as to food intake prior to symptom development is crucial.

[A case of intestinal tuberculosis associated with ileo-ileal fistula].

A 25-year-old woman was admitted with fever and right lower abdominal pain that had started 3 days after the administration of antituberculosis agents for pulmonary tuberculosis. She was given a diagnosis of intestinal tuberculosis with ileo-ileal fistula formation on computed tomography, colonoscopy and laboratory test findings. She was kept on anti-tuberculosis agents. Soon after, ileus and a micro abscess appeared near the fistula. Ileocecal resection with partial ileal resection resulted in a good postoperative clinical course. Tuberculosis is still a major infectious disease. Intestinal tuberculosis is very rarely associated with fistula formation, and when it occurs, is difficult to differentiate from Crohn disease. Our case strongly suggests that typical intestinal tuberculosis findings can help in differential diagnosis between intestinal tuberculosis and Crohn disease.

[Retrospective analysis of generalized chemotherapy for unresectable advanced gastric cancer].

In Japan where the incidence of gastric cancer is high, the standard regimens for unresectable advanced gastric cancer are the S-1 single or S-1/CDDP combined therapies that are evidenced by the JCOG9912 and SPIRITS trial. We performed retrospective analysis on chemotherapy for unresectable advanced gastric cancer in our division from 2003 to 2008. Seventy-six patients were subjected to this study. Among them, 66 patients (86.8%) received S-1-containing regimens. Mean survival time (MST) of all patients was 309 days. MST of S-1/Paclitaxel (PTX), S-1/CPT-11 and S-1/CDDP regimens were 289, 339 and 411 days, respectively. MST of S-1/CPT-11 was significantly longer than that of S-1/PTX (p<0. 01). Next, we compared the MST among different performance statuses (PS). The respective MST of PS 0, 1, 2 cases (361, 289 and 161 days) evidenced no statistically significant difference, although the MST was shorter depending on the progression of PS. Considering the histology, the MST of patients with well- and moderately-differentiated adenocarcinoma was significantly longer than that of poorly-differentiated adenocarcinoma and signet-ring cell carcinoma (p=0. 04). The call is for more effective chemotherapy in the future based on results we will obtain from controlled studies that may also deal with the second-line chemotherapy regimens, chemotherapy for aged people and molecular-targeting cancer agents.

Thyroid Metastasis of Gastric Cancer: A Rare Occasion With Poor Prognosis.

A 68-year-old man was diagnosed as having advanced gastric cancer. Computed tomography showed a thyroid tumor with trachea deviation. This tumor exhibited mosaic echogenecity in ultrasonography. Signet-ring cell carcinoma was found by means of fine needle aspiration biopsy. This tumor gradually became swollen and the thyroid hormone levels in blood were increased without any clinical symptom. Shortly, he died from his illness in the 29th hospital day. Autopsy disclosed that the left lobe of the thyroid gland was highly invaded by malignant cells and that lymphogenic rather than angiogenic metastasis was highly probable. Thyroid metastasis of gastric cancer is extremely rare. The prognosis is very poor. Ultrasonography is a very useful modality especially when coupled with recently developed fine needle aspiration biopsy in differential diagnosis of thyroid tumors once malignancy is suspected. Therapeutic strategy largely depends on the nature of primary malignant tumor. If the tumor is slowly progressive such as renal cell carcinoma and breast cancer, extirpation of thyroid tumors may extend life expectancy. In conclusion, the metastatic thyroid tumor of gastric cancer is rare and shows poor prognosis. Fine needle aspiration biopsy under ultrasonography is strongly recommended as a useful diagnostic tool.

A case of SAPHO syndrome with destructive spondylodiscitis suspicious of tuberculous spondylitis.

We report a rare case of synovitis, acne, pustulosis, hyperostosis, osteitis (SAPHO) syndrome in which the differential diagnosis included tuberculous spondylitis and the patient ultimately required reconstructive spinal surgery. The patient was a 60-year-old woman who presented with severe low-back and leg pain after treatment for tuberculosis. Roentgenography and magnetic resonance imaging of the lumbar spine revealed destructive changes suggestive of tuberculous spondylitis. [(18)F]-fluoro-2-deoxyglucose positron emission tomography/computed tomography showed uptake in the cervical spines, lumbar spines, and sacroiliac joints from which she was suspected of having SAPHO syndrome without skin manifestations. However, as her symptoms did not respond to conservative treatment, we performed reconstructive surgery of the lumbar spine. Spinal specimens obtained surgically showed nonspecific inflammation and fibrous hypertrophy of the bone marrow, confirming a diagnosis of the SAPHO syndrome. Her symptoms improved markedly after surgery, although she required occasional prednisolone for moderate polyarthralgia and leg pain.

[A pregnant woman with inoperable advanced gastric cancer who received systemic anti-cancer chemotherapy after the non-full term fetus delivery by cesarean section].

A 28-year-old pregnant woman at 26 weeks and 2 days gestation visited a local outpatient clinic complaining of a tender abdominal mass. Examinations revealed an advanced gastric cancer with multiple liver, bone, lymph node metastasis and mesenteric dissemination, thus she was transferred to our division at 27 weeks and 1 day-gestation. With her consent we decided to maintain her pregnancy until 28 weeks when the delivered fetus could be kept alive an incubator, avoiding the adverse effect on the fetus by anti-cancer chemotherapy to mother. Rapid fetus delivery by cesarean section was carried out at 28 weeks and 1 day gestation, yielding a 958-gram baby. The mother complained of respiratory distress and suffered from lymphangitis carcinomatosa on the 3 postoperative day. We began combination chemotherapy with S-1 and paclitaxel (S-1 100 mg/day, 3 weeks on, 2 weeks off and paclitaxel 70 mg/day on 1, 8 and 15) was started on the 4th postoperative day. Although temporary regression of lymphangitis carcinomatosa was seen with a relief of symptoms, her condition deteriorated on the 24th days. The second course chemotherapy was started on the 28th days without any relief of symptoms. Her general status deteriorated and she died on the 33rd postoperative day. The association of pregnancy and gastric cancer is rare but such cases are often in an advanced clinical stage, with bad prognosis. It is necessary to determine the treatment strategy on the basis of comprehensive consideration of the status of both the mother and fetus. Upper gastrointestinal endoscopy when gastric cancer is suspected is recommended in any pregnant woman with long-term morning sickness.

[A case of interstitial pneumonia induced by gemcitabine hydrochloride for unresectable bile duct cancer].

A 78-year-old man was admitted for obstructive jaundice and unresectable bile duct cancer on March 4, 2008. Since biliary drainage was extremely difficult, he began 2 treatment courses of gemcitabine hydrochloride (GEM 800 mg/m(2) on days 1, 8, 15 every 4 weeks). He suffered from dry cough and dyspnea on May 13, 2008. He was diagnosed as GEM-induced interstitial pneumonia with severe hypoxemia by CT scan and arterial blood gas examination. He recovered with two courses of steroid pulse therapy, diuretics and antibiotics. Alternatively, he was given oral S-1 ( 80 mg/m(2) 4 weeks on and 2 weeks off) from June 12, 2008. His QOL was well kept without jaundice for as long as a half year. This is the first report of GEM-induced interstitial pneumonia in bile duct cancer. In conclusion, interstitial pneumonia must be taken into consideration as a rare adverse reaction when GEM is used for biliary neoplasms.

[A case of hepatocellular carcinoma with liver cirrhosis type C surviving over 2 years by repeated transarterial infusion therapy using cisplatinum].

A 58-year-old man with hepatocellular carcinoma (HCC) with liver cirrhosis type C was admitted to our division in April, 2004 to receive transarterial chemo-embolization (TACE) as a first-line chemotherapy for HCC. Thereafter, he had TACE twice for multicentric HCC. In December, 2005, TACE was thought to have become ineffective since his multicentric HCC progressed. So, we employed transarterial injection therapy (TAI) with fine powder cisplatinum (IAC) as a second-line chemotherapy. Stable disease was accomplished by the 22 sessions of TAI with IAC. After February 2008, IAC was given in combination with degradable starch microspheres (DSM) to reinforce the anti-cancer effect. The total therapeutic sessions using IAC became 26 in number. Total IAC amount used reached to more than 2,200 mg without any serious adverse reaction. In conclusion, TAI using IAC is thought to be effective in the chemotherapy of HCC, safely controlling the tumor progression.

A case of lamivudine-sensitive de novo acute hepatitis B induced by rituximab with the CHOP regimen for diffuse large B cell lymphoma.

A case of de novo acute hepatitis B that showed symptoms of general malaise and anorexia during rituximab therapy with the CHOP regimen for diffuse large B cell lymphoma is reported. Lamivudine was strikingly effective, showing a rapid recovery from liver damage with jaundice. Hepatitis B virus (HBV) DNA in serum became and stayed undetectable even after the withdrawal of lamivudine, although HBsAg remained positive over 42 months from the onset. Liver biopsy showed a picture suggestive of acute viral hepatitis with multinucleated giant hepatocytes and CD38-positive plasma cell infiltration into liver parenchyma. Immunohistochemically, CD3-positive T-cells were predominant cells that infiltrated in liver parenchyma, whereas CD20-positive B cells were essentially null. Hence, it is suggested from these findings that B lymphocytes might be crucial for the continuous latency in HBV infection and may give rise to de novo acute hepatitis B if totally deleted. Moreover, the CHOP regimen might have some additive effects with the repeated on-off use of corticosteroids to the onset of the disease. In addition, significance of plasma cell infiltration in this setting is discussed.

Programs for calculating the statistical powers of detecting susceptibility genes in case-control studies based on multistage designs.

MOTIVATION: A two-stage association study is the most commonly used method among multistage designs to efficiently identify disease susceptibility genes. Recently, some SNP studies have utilized more than two stages to detect disease genes. However, there are few available programs for calculating statistical powers and positive predictive values (PPVs) of arbitrary n-stage designs. RESULTS: We developed programs for a multistage case-control association study using R language. In our programs, input parameters include numbers of samples and candidate loci, genome-wide false positive rate and proportions of samples and loci to be selected at the k-th stage (k=1,..., n). The programs output statistical powers, PPVs and numbers of typings in arbitrary n-stage designs. The programs can contribute to prior simulations under various conditions in planning a genome-wide association study.