Increased number of eosinophils in ascites is associated with intestinal anisakidosis.

The aim of this study was to evaluate the association between eosinophils in ascites and the diagnosis of intestinal anisakidosis in patients with peritoneal signs on physical examination. We reviewed retrospectively 16 patients diagnosed with intestinal anisakidosis, evaluated between 2012 and 2015. All patients had ingested raw anchovies. The analysis of ascites fluid in ten of these patients was compared with that of 15 patients with ascites and other abdominal pathology (except liver cirrhosis). All patients had an increased number of white blood cells in the ascites fluid. The eosinophil count was significantly higher in patients with intestinal anisakidosis (P < 0.01). All patients had a good outcome. Increased eosinophils in ascites fluid is strongly associated with the diagnosis of intestinal anisakidosis.

Internal hernia caused by epiploic appendices successfully treated by single-incision laparoscopic surgery (SILS).

Internal hernia is a rare and often overlooked cause of small bowel obstruction. We report a case of internal hernia with an orifice composed of epiploic fat, successfully diagnosed and treated by single-incision laparoscopic surgery. This is the second report of this type of internal hernia and the first reported case addressed laparoscopically. Although the use of laparoscopy for the treatment of small bowel obstruction is not firmly established today, it may be beneficial for both its diagnostic value and as a less invasive treatment.

Proximal bowel necrosis after high ligation of the inferior mesenteric artery in colorectal surgery.

BACKGROUND AND AIMS: High ligation of the inferior mesenteric artery may jeopardize blood supply to the proximal bowel. We undertook this study to review the clinical features and outcomes of patients who developed proximal bowel necrosis after high ligation of the inferior mesenteric artery, and to assess the incidence and the risk factors for this complication. MATERIALS AND METHODS: A retrospective analysis of patients undergoing high or low ligation for sigmoid colon and rectal cancer with a primary anastomosis between April 2004 and March 2009 was performed. Patient and tumor characteristics and the incidence of bowel necrosis were reviewed. RESULTS: Four hundred and nine patients were included to the analysis. Six out of 302 patients (2.0%) with high ligation developed proximal bowel necrosis, while the remaining 107 patients with low ligation did not suffer from this complication. All patients who developed proximal bowel necrosis underwent secondary surgery with resection of necrotic bowel. The pathological examination of the resected specimen revealed mucosal to transmural ischemic necrosis without the evidence of vascular thrombosis or embolic occlusion. Univariate analysis revealed that advanced age, cerebrovascular disease, and hypertension were significantly associated with proximal bowel necrosis. Multivariate analysis demonstrated that cerebrovascular disease was an independent predictor of this complication. Of these six patients, two died from associated complications. CONCLUSIONS: Proximal bowel necrosis after high ligation is potentially fatal, and this report provides a warning in clinical settings where high ligation is indicated. Further studies are warranted to evaluate its distinct relationship with high ligation and to clarify whether low ligation would be a safeguard.

Accelerated learning curve for colorectal resection, open versus laparoscopic approach, can be attained with expert supervision.

BACKGROUND: Laparoscopic colorectal resection (LCR) is gaining popularity. Nonetheless, open surgery remains an important technique. Thus, surgeons should be technically proficient in both open and laparoscopic surgery. One question however remains unanswered: Can training for open and LCR occur simultaneously? The objective of this paper is to review the learning curve for open and laparoscopic colon resection of one surgeon who underwent a rigorous training program. METHODS: A review of consecutive patients who underwent surgery for colon and rectosigmoid junction cancers by one trainee surgeon was performed. This surgeon had completed his basic surgical residency but had limited experience in colorectal cancer surgery. In total, 75 patients were included in this study. All operations were supervised by at least one staff surgeon with experience of more than 300 LCR cases. The trainee surgeon was allowed to train in both laparoscopic and open colorectal resection simultaneously. RESULTS: Forty-three patients underwent laparoscopic resection, while 32 patients underwent open surgery. Age, gender, mean body mass index (BMI), preoperative risk, and history of past abdominal surgery showed no significant difference between laparoscopic and open groups. There were no differences in tumor stage [International Union against Cancer (UICC)] or tumor size (p = 0.068 and 0.228, respectively). The morbidity rate for open and laparoscopic surgery was 3.1% (1/32) and 4.7% (2/43), respectively (p = 0.484). Operation time decreased with increasing experience, and plateaued after 25 cases in the laparoscopic group and 22 cases in the open group. The learning curve for open cases was 11 cases, and 7 for laparoscopic surgery. CONCLUSIONS: Surgeons who have completed a basic surgical residency but have limited colorectal surgery experience can learn both open and laparoscopic colorectal surgery simultaneously in an effective manner under supervision by well-experienced surgeons.

Distribution of the first metastatic lymph node in colon cancer and its clinical significance.

INTRODUCTION: The pattern of distribution of lymph node metastasis in resected specimens of colon cancer has been rarely reported in the English literature. The aim of this study was to determine the location of the first metastatic lymph node, giving insight into the drainage pattern of colon cancer lymphatics. METHOD: All lymph nodes in the mesentery of the resected specimen were carefully harvested and their precise locations documented. Patients with a single metastatic node in the resected specimen were included in the study. RESULTS: Ninety-three patients with only one metastatic lymph node found on histology were studied. The mean number of lymph nodes per specimen was 22.3 (range: 8-72). The patients' first metastatic node was not directly below the tumour in 48% of cases. The first metastatic node was found in the region either along the feeding vessels (skipping the pericolic nodes) or in the pericolic area outside 5 cm on either side of the tumour edge in 18% of cases. No factors were found to be predictive for lymph node metastasis occurring elsewhere other than in the pericolic region just below the tumour. CONCLUSION: Although there has been recent resurgence of interest in using sentinel node biopsy to limit surgical dissection to facilitate minimally access and natural orifice surgery, the present study is a warning that this may compromise oncological clearance. Radical surgery should remain standard practice for colorectal cancer.

Sushi-roll wrap of Seprafilm for ileostomy limbs facilitates ileostomy closure.

BACKGROUND: Sodium hyaluronate and carboxymethylcellulose membrane (Seprafilm) reduced postoperative intraabdominal adhesion. In this study, we examined whether Seprafilm reduces operative difficulties in ileostomy closure. PATIENTS AND METHODS: During the creation of the ileostomy, Seprafilm was cut in half and used to wrap both the ileum and mesentery. Patients who underwent ileostomy closure before February 2008 (without Seprafilm, Group T, n = 18) and after March (with Seprafilm, Group S, n = 18) were enrolled in this study. All operations were performed by surgical residents. Operative time and perioperative complications were analyzed. RESULTS: The mean operative time of Group S (106.88 min) was significantly less than that of Group T (120.6 min). The amount of intraoperative bleeding in Groups S and T was not significantly different and there were no major complications. CONCLUSION: Seprafilm applied to the two limbs of the ileostomy and mesentery facilitate ileostomy closure done by non-expert surgeons.

Colorectal surgery in octogenarian patients--outcomes and predictors of morbidity.

INTRODUCTION: Surgery for elderly patients pose a constant challenge. This study aims to review the outcome and find predictors of adverse outcome in octogenarians undergoing major colorectal resection for cancer. METHODS: A review of 121 octogenarians who underwent colorectal cancer surgery between September 1992 and May 2008 was performed. Comorbidities were quantified using the weighted Charlson Comorbidity Index and ASA classification. CR-POSSUM scores and ACPGBI scores and the predicted mortality rates were calculated. Outcome measures were morbidity rates and 30-day mortality rates. RESULTS: The patients had a mean age of 83.5 years (range, 80-99). The mean index of comorbidity was 3.1 (2-7) and 12.5% of patients were classified ASA III and above. The mean predicted mortality rate based on CR-POSSUM and ACPGBI scoring models were 11.2% and 5.4% respectively. The overall observed morbidity rate was 30.7% and 30-day mortality was 1.6. Factors found on bivariate analysis to be significantly associated with an increased risk of morbidity were tumor presenting with complication, comorbid coronary heart disease, serum urea levels, ASA classification > or =3 and comorbidity index 3 of 5 > or = 5. Multivariate analysis revealed the latter two factors to be independent predictors of morbidity. CONCLUSION: Octogenarians undergoing major colorectal resection have an acceptable perioperative morbidity and mortality rate and survival rate and should not be denied surgery based on age alone. Comorbidity index scores and ASA scores are useful tools to identify poor risk patients.

[An operated case of bitemporal lobe epilepsy associated with old infarction in the left occipital lobe].

A 15-year-old female, who presented with bitemporal lobe epilepsy associated with old infarction in the left occipital lobe, was reported. MRI with fluid attenuated inversion recovery sequence demonstrates cortical atrophy with hyperintensity of the white matter in the left occipital lobe as well as volume loss and hyperintensity of the left hippocampus. Interictal positron emission tomography with [18F]fluorodeoxy glucose (FDG-PET) and single photon emission computed tomography with technetium-99m-ethyl-cysteinate dimer indicate hypometabolism and hypoperfusion in the left occipital lobe and the left temporal lobe, respectively. Scalp recorded EEG did not lateralize the side of the epileptogenic zone. Chronic subdural electrode recording demonstrated that the ictal onset zones were located in the bilateral side of the temporal lobe. Eighty-nine percent of 19 spontaneous seizures were left sided onset. The anterior temporal lobectomy with hippocampectomy was performed for the left side. Although temporal lobe epilepsy is sometimes a bilateral disease, unilateral lobectomy for a strong predominant side, based on the MRI and FDG-PET findings, is effective for some patients.

[Brain stem hemorrhage associated with venous angioma: report of two cases].

The incidence of hemorrhage associated with venous angioma has been considered to be rare. We here report two cases of brain stem venous angioma which also showed brain stem hemorrhage. Case 1; a 15-year-old female had experienced weakness in the left upper extremity 8 months prior to admission. She developed dysfunction of the left cranial nerves, and magnetic resonance imaging (MRI) showed a huge enlarging hematoma in the pons. Cerebral angiography showed venous angioma penetrating through the pons. Evacuation of the hematoma was performed through the fourth ventricle and many small vessels were found in the hematoma. Although all symptoms were partially resolved after the operation, a re-hemorrhage occurred 1 month after the operation. Case 2; a 50-year-old man had suddenly developed headache and vertigo several days prior to admission. Computed tomography (CT) and MRI showed a small hematoma in the lesion with venous angioma adjacent to the hematoma. All symptoms gradually resolved with conservative therapy.

[Small epidermoid induced trigeminal neuralgia unrecognized by conventional CT and MRI for over 25 years].

A 65-year-old woman had been conservatively treated as idiopathic trigeminal neuralgia for over 25 years, because conventional computed tomography (CT) and magnetic resonance imaging(MRI) showed no abnormality in the cerebello-pontine(CP) angle cistern. She received a detailed MRI by constructive interference in steady state and diffusion weighted image(DWI) sequences. Those sequences on MRI well demonstrated a epidermoid tumor in the CP angle cistern, and the removal of the tumor completely resolved the neuralgia. Since a small epidermoid in the CP angle cistern seems to be unrecognized by conventional CT and MRI, detailed evaluation by DWI sequence, which has been widespread recently, is required for patients with trigeminal neuralgia.

[Effect of topical carteolol on visual function in normal-tension glaucoma].

The effects of carteolol hydrochloride on visual function in normal-tension glaucoma (NTG) were investigated. 22eyes of NTG patients were divided into two groups, i.e., (1) a group receiving topical application of 2% carteolol hydrochloride b.i.d. and 2 an unmedicated group. During a 18 month period, intraocular pressure and visual field (measured by Humphrey automated perimetry) were measured every 3 months, and the measurements obtained in the two groups were compared. Analysis of the results revealed a considerable reduction in intraocular pressure in the carteolol group as compared with the control group. The progression of mean deviation tended to be less in the carteolol group, but the intergroup difference in this respect was not statistically significant. However, increase in corrected pattern standard deviation was clearly less pronounced in the carteolol group than in the control group. These results supported the conclusion that carteolol is effective in inhibiting deterioration of the local visual field. This is attributed to increased ocular perfusion due to diminished intraocular pressure, as well as an inhibitory effect upon vasoconstriction in the optic nerve head due to intrinsic sympathomimetic activity, preventing decrease in papillary blood flow and adverse effects upon ocular circulation.

[Comparison of a trabeculotomy and trabeculectomy combined with phacoemulsification and foldable lens implantation].

Combined phacoemulsification, foldable lens implantation, and trabeculotomy (12 eyes, LOTOMY group) or trabeculectomy (22 eyes, LECTOMY group) were performed. At 6 months after the operation the visual acuity improvement (over 0.5 improvement, 83.3% in the LOTOMY group, and 95.5% in the LECTOMY group) was not significantly different between the two groups. 9 months postoperatively ocular pressure values (15.6 +/- 3.0 mmHg in the LOTOMY group, and 14.2 +/- 8.0 mmHg in the LECTOMY group) were not significantly different between the two groups. But within 7 days postoperatively average values of the maximal ocular pressure (25.5 +/- 5.9 mmHg in the LOTOMY group, and 11.8 +/- 3.0 mmHg in the LECTOMY group) were significantly higher in the LOTOMY group. The value was higher than the preoperative level. In the follow-up, progressive visual field loss was seen in 17% of the cases in the LOTOMY group. There was no progressive visual field loss in the LECTOMY group. Especially in cases with advanced glaucomatous visual field loss, the occurrence of ocular pressure spikes in the initial postoperative period may be closely related to postoperative progressive visual function loss. Phacotrabeculectomy was effective in avoiding these spikes.

[Changes in optic disc rim color with glaucomatous visual field damage--a quantitative study on pattern of color changes].

We developed a new computerized method for measuring the color of the optic disc directly with objective reproductivity. We compared the optic disc color with sensitivity loss in visual fields corresponding to the disc area measured by Humphrey Field Analyzer. 11 normal eyes, 40 glaucomatous eyes, and 27 eyes with ocular hypertension were studied. In the temporal segment of the disc rim, with the exception of the area, a significant correlation between rim color and sensitivity loss was detected. In the nasal rim and macular area, however, the correlation was less significant in early stage glaucoma. Compared with normal discs, glaucomatous discs showed significant decrease in the red color element of the rim area, and some discs with ocular hypertension showed a decrease without any visual field defect.

[The development of human trabecular meshwork].

The fetal development of the trabecular meshwork of the human eye was quantitatively studied by light and electron microscopy. From the 20th fetal week onward, the progressive thickening of the trabecular meshwork was achieved mainly by the widening of intertrabecular spaces, whereas the thickness and the number of trabeculae were almost constant. Significant alterations in the number of trabecular meshwork cells did not occur with development. However, a decrease in trabecular meshwork cellularity occurred by the widening of intertrabecular spaces. As development proceeded, there was an increase in the proportion of the width of the posterior trabecular meshwork, which is the main site of aqueous drainage, in accordance with the increase of aqueous production.

[A comparative study on visual field defect in low tension glaucoma].

The mode of visual field defect and the change of intraocular pressure (IOP) were analyzed between progressive low tension glaucoma (LTG) and non-progressive LTG. Maximum IOP and phasic fluctuation in IOP during the follow-up period in progressive cases were significantly higher than those in non-progressive cases (p less than 0.01). This greater range in phasic fluctuation may lead to the development of glaucomatous damage. Analysis of the pattern of visual field defect revealed significantly greater frequency of dense defects within 10 degrees of the fixation area in progressive cases. Another analysis on the mode of visual field damage between progressive LTG and POAG demonstrated higher frequency of focal progression of the damage. These results suggest that there are some different etiological factors among progressive LTG, non-progressive LTG and POAG, while focal anatomical weakness at the optic nerve head also influences the development of damage in some case of progressive LTG.

[The development of the Schlemm's canal in human eyes].

The fetal development of Schlemm's canal of the human eye was investigated by light and electron microscopy. Schlemm's canal was not yet a circumferential structure at the 20th fetal week, and at the 26th fetal week the canal appeared to form by a process of confluence of the channels. As development proceeded, the canal positioned relatively anterior to the apex of the angle, as a result of posterior shift of the angle recess. The remarkable increase in the width of the canal during the fetal period was mainly achieved by the elongation of the endothelial cells, whereas the number of endothelial cells in meridional sections did not alter. From the 26th fetal week onward, the frequency of giant endothelial vacuoles and pores increased together with the discontinuity of the basal lamina, which corresponds with the increase of aqueous flow.

[A comparative study of optic disc appearances in progressive and non-progressive low-tension glaucoma].

The relation between the optic disc appearances and the progression of visual field defects was studied by retrospective case review of 148 eyes of 74 patients with a diagnosis of low-tension glaucoma (LTG). Visual fields were tested by a Goldmann perimeter and the subjects were divided into two groups, i.e. 43 eyes (29.1%) with progression and 105 eyes (70.9%) without progression, according to Esterman's scale. In the group which showed progression, mean IOP (p less than 0.05), level of change in IOP and maximum of IOP (p less than 0.01) were significantly higher. No differences were observed in any of the following parameters: prevalence of peripapillary hemorrhage or crescent, rim pallor, disc/arteriole ratio, number of rim-crossing vessels. Mildly hypoplastic disc, however, was statistically more frequent in the progressive group (p less than 0.05). The authors suspect that not only IOP but some inherent factors concerning the optic nerve head may play an important role in the progression of LTG.

Epidemiology of glaucoma in Japan--a nationwide glaucoma survey.

A population-based, collaborative glaucoma survey was conducted in seven regions throughout Japan, during the years of 1988 and 1989. The total number of subjects examined was 8,126 out of 16,078 residents aged 40 years or older, representing a participation rate of 50.54%. There were no significant differences in background factors between participants and randomly sampled nonparticipants. A mainstay of the screening consisted of tonometry and fundus photography with nonmydriatic camera, followed by automatic perimetry as a recall examination. Overall prevalences obtained were primary open-angle glaucoma (POAG) 0.58%, low-tension glaucoma (LTG) 2.04%, primary angle closure glaucoma (PACG) 0.34%, other types of glaucomas 0.60%, and ocular hypertension (OH) 1.37% at the time of screening. The very high prevalence of LTG and extremely low prevalence of OH in the Japanese might reflect a racial peculiarity in the age-specific trend of the intraocular pressure. The prevalence of PACG was found much higher in Japanese than in Caucasians, with a predilection for women. Racial peculiarities as revealed in this study were discussed, with particular reference to the refractive status in the Japanese that showed progressive decrease in myopia with age.

[Retinal ganglion cell topography during prenatal development].

A fundamental feature of the human visual system is nonuniform distribution of ganglion cells across the retinal surface. In adults, the density of ganglion cells peaks around the fovea and declines sharply towards the periphery, whereas in fetal retina it does not. In the fetal retina, the retinotopic map is dominated by nonuniform expansion and/or ganglion cell death. We examined how the numbers and distributions change according to the horizontal eccentricity from the foveola, using toluidine blue stained vertical sections of the human fetal retina (gestational age 32W and 40W). The vertical section of the fovea showed almost similar density at 32 weeks, 40 weeks and in adults. This fact suggested that the fundamental structure of the fovea is already established at 32W. In the nasal retina, the cellular density was higher than that in the temporal half at 32W, then markedly decreased at 40W and in adults. We assume that in the nasal retina, it is impossible to account for the cell decrease only with nonuniform expansion and that even after 32W ganglion cell death occurs. On the other hand, in the mid-temporal retina, the cellular density was almost similar at 32W, 40W and in adults. It suggested that in the mid-temporal retina, the topography is already established at 32W. In the peripheral temporal retina, the cellular density was relatively high at 32W and decreased at 40W and in adults. In this area, the topography is still changing. We assume that in the fetal retina, retinotopic map is dominated by several factors and the dominant factor differs according to stage and retinal area.