Sphincter-preserving surgery for recurrent pelvic malignancy using a hybrid procedure of open laparotomy and transanal endoscopic approach.

BACKGROUND: Surgery for the treatment of recurrent pelvic malignancy is challenging. Sphincter-preserving surgery (SPS) has been applied in limited cases. Transanal endoscopic approach (TEA) has been used for primary rectal cancer, predominantly for hybrid transabdominal-transanal total mesorectal excision. Here, we describe the use of TEA as a hybrid approach in a case of recurrent ovarian cancer. CASE PRESENTATION: A 59-year-old woman had recurrence of serous ovarian adenocarcinoma in the vaginal stump, near the site of anastomosis from a rectal resection 18 months previously. We used a hybrid approach comprising conventional open laparotomy and TEA to accomplish sphincter preservation. In addition to sphincter preservation, TEA allowed for the creation of a "terminal" space, which was made by anterior dissection between the rectum and the vagina. We employed TEA to create an opening in the scar tissue along the sacrum, which was used as a "guide" for pelvic dissection to prevent nerve injury. After exteriorization of the tumor, bowel continuity was achieved by hand-sewn coloanal anastomosis with a protective diverting ileostomy. Pathological examination revealed no involvement of the surgical margins. The diverting ileostomy was taken down 8 months postoperatively. CONCLUSION: A hybrid approach comprising conventional open laparotomy and TEA allowed for safe and secure SPS and complete excision of a recurrent pelvic malignancy. This hybrid surgical approach expands the use of SPS in highly selected cases.

Surgical complications, especially gastroesophageal reflux disease, intestinal adhesion obstruction, and diaphragmatic hernia recurrence, are major sequelae in survivors of congenital diaphragmatic hernia.

PURPOSE: This study aimed to characterize the surgical complications, especially gastroesophageal reflux disease (GERD), intestinal adhesion obstruction (IAO), and diaphragmatic hernia recurrence, in patients with congenital diaphragmatic hernia (CDH). METHODS: Between January 1995 and December 2013, we determined the incidence of surgical complications and their predictors in CDH patients. We also examined whether the CDH repair and patch closure were associated with the incidence of IAO and the severity of adhesion. RESULTS: Seventy-four CDH survivors were evaluated. GERD occurred in 28 patients (37.8%) and recurred in 8 patients (10.8%). Stomach herniation was a risk factor for GERD, and occurred in 25 patients. IAO occurred in 13 patients (17.6%). In 240 neonatal laparotomies in the same period, the incidence of IAO was significantly higher in patients who underwent CDH repair than in patients who underwent other neonatal laparotomy (p = 0.023). Surgical time and intraoperative bleeding were significantly greater following CDH repair with an artificial patch compared with CDH repair with direct closure. CONCLUSION: Surgical complications are major sequelae in survivors of CDH repair. CDH repair and artificial patch closure were significantly associated with the incidence of IAO and the severity of adhesion.

Identification of Epstein-Barr virus-infected CD27+ memory B-cells in liver or stem cell transplant patients.

To analyse the phenotype of Epstein-Barr virus (EBV)-infected lymphocytes in EBV-associated infections, cells from eight haematopoietic stem cell/liver transplantation recipients with elevated EBV viral loads were examined by a novel quantitative assay designed to identify EBV-infected cells by using a flow cytometric detection of fluorescent in situ hybridization (FISH) assay. By this assay, 0.05-0.78% of peripheral blood lymphocytes tested positive for EBV, and the EBV-infected cells were CD20+ B-cells in all eight patients. Of the CD20+ EBV-infected lymphocytes, 48-83% of cells tested IgD positive and 49-100% of cells tested CD27 positive. Additionally, the number of EBV-infected cells assayed by using FISH was significantly correlated with the EBV-DNA load, as determined by real-time PCR (r2  = 0.88, P < 0.0001). The FISH assay enabled us to characterize EBV-infected cells and perform a quantitative analysis in patients with EBV infection after stem cell/liver transplantation.

Hypogenesis of intramural vascularity and perivascular plexuses of gallbladder in patients with congenital biliary dilatation.

BACKGROUND: We hypothesized neuronal disorders of the biliary tract as the cause of congenital biliary dilation (CBD). METHODS: Gallbladders were removed from a total of 15 patients who were categorized into two study groups: a CBD group (eight patients) and in a control group (neuroblastoma, acute myelogenous leukemia, wandering gallbladder, Wilms' tumor, glycogen storage disease, familial amyloid polyneuropathy; seven patients). Whole-mount preparations of the gallbladders were made to immunostain the intramural nerves. RESULTS: The intramural vascularity in the gallbladders of the CBD group (5.5 +/- 1.9/cm(2)) was significantly lower than that in the control group (27.6 +/- 14.4/cm(2)). The rate of perivascular plexuses on the surface of intramural vessels was also significantly lower in the CBD group than in the controls (37.7 +/- 18.1 vs. 80.2 +/- 17.4%, respectively). The numbers of ganglion cells per visual field were 38.5 +/- 24.0 and 42.3 +/- 20.6, respectively, in the CBD and control groups; this difference was not statistically significant. CONCLUSIONS: There may be a mechanism in CBD causing contractile failure and dilatation of the biliary tract as a result of decreased intramural blood flow that accompanies the diminished vascularity.

Effectiveness of lidocaine infusion for status epilepticus in childhood: a retrospective multi-institutional study in Japan.

We evaluated the usefulness of intravenous lidocaine therapy for managing of status epilepticus (SE) during childhood in a retrospective multi-institutional study. Questionnaires were sent to 28 hospitals concerning patients admitted for SE who were managed with lidocaine, assessing patient characteristics, treatment protocols and efficacy. In 279 treated patients, 261 SE occurrences at ages between 1 month and 15 years were analyzed. SE was classified as showing continuous, clustered, or frequently repeated seizures. Considering efficacy and side effects in combination, the usefulness of lidocaine was classified into six categories: extremely useful, useful, slightly useful, not useful, associated with deterioration, or unevaluated. In 148 SE cases (56.7%), lidocaine was rated as useful or extremely useful. Multivariate analysis indicated lidocaine was to be useful in SE with clustered and frequently repeated seizures, and SE attributable to certain acute illnesses, such as convulsions with mild gastroenteritis. Efficacy was poor when SE caused by central nervous system (CNS) infectious disease. Standard doses (approximately 2mg/kg as a bolus, 2mg/kg/h as maintenance) produced better outcomes than lower or higher doses. Poor responders to the initial bolus injection of lidocaine were less likely to respond to subsequent continuous infusion than good initial responders. We recommend lidocaine for use in SE with clustered or frequently repeated seizures, and in SE associated with benign infantile convulsion and convulsions with mild gastroenteritis. Lidocaine should be initiated with a bolus of 2mg/kg. If SE is arrested by the bolus, continuous maintenance infusion should follow; treatment should proceed to different measures when SE shows a poor response to the initial bolus of lidocaine.

Efficacy of intravenous midazolam for status epilepticus in childhood.

A retrospective multicenter study was conducted, designed to evaluate the efficacy and safety of midazolam for the treatment of status epilepticus. The subjects were 358 inpatients who received intravenous midazolam therapy for status epilepticus. The mean age was 48.6 +/- 46.5 months. The underlying disorder was epilepsy in 195 cases, and acute symptomatic diseases in 163 (encephalitis or encephalopathy in 88 cases). Midazolam was administered as a bolus dose (0.25 +/- 0.21 mg/kg), followed if necessary by continuous infusion (0.26 +/- 0.25 mg/kg/hr). The bolus injection was effective in 162 (56.6%) of the 286 cases. In the end, seizure suppression was obtained in 231 cases (64.5% of the total). The effectiveness of midazolam was lower in patients in whom midazolam was initiated more than 3 hours after seizure onset, and this tendency was particularly marked in the epilepsy group. During the treatment period, 10 patients died, but none of these deaths were associated with midazolam therapy. The incidence and types of adverse events were consistent with previously reported data. The present results indicate that midazolam is highly effective for the management of status epilepticus, if used sufficiently early after seizure onset.

Simplified quantification of urinary protein excretion using a novel dipstick in children.

Although the quantification of protein excretion is valuable for diagnosing and monitoring renal disease, accurate, timed, urine collection entails practical difficulties in children. Several authors have shown that the random urine protein/creatinine ratio (UP/UC) correlates well with timed protein excretion. A novel dipstick, Multistix PRO, has recently enabled us to analyze concentrations of both urinary protein and creatinine, semi-quantitatively, in 60 s. The aim of this study was to investigate whether the UP/UC values obtained by Multistix PRO correlate well with those obtained by quantitative methods and daily urinary protein excretion. In order to obtain the UP/UC values, we measured urinary protein and creatinine concentrations both semi-quantitatively by Multistix PRO and quantitatively by conventional methods. The relationship between the semi-quantitative UP/UC by Multistix PRO and the quantitative UP/UC by conventional methods was analyzed. Similarly, the relationship between the semi-quantitative UP/UC and daily urinary protein excretion was studied. Semi-quantitative UP/UC by Multistix PRO correlated closely with both quantitative UP/UC and daily urinary protein excretion (r=0.86 and r=0.91, respectively). A cut-off level of heavy proteinuria, i.e., nephrotic range of proteinuria (>3.5 g/day) corresponded to 3.0, assessed by UP/UC by Multistix PRO. The semi-quantitative UP/UC by Multistix PRO correlated well with both quantitative UP/UC and daily urinary protein excretion, and use of the Multistix PRO would avoid errors and difficulties associated with timed urine collection. It is, therefore, a useful tool to monitor the urinary protein excretion in children with renal diseases at outpatient clinic.