Efficacy of the straight endorectal pull-through in the management of familial adenomatous polyposis--a 16-year experience

From 1979 to 1995, 27 patients who had familial adenomatous polyposis (FAP) were treated at the authors' institution. Most patients (n = 23) presented as a result of a previous family history of FAP. Eighteen patients presented with symptomatic colonic disease that included bloody stools (n = 14), diarrhea (n = 10), and abdominal pain (n = 6). Treatment consisted of a total colectomy, rectal mucosectomy, and straight endorectal pull-through (ERPT) in 26 of 27 patients. One patient preferred to undergo an ileoanal J pouch reconstruction. A temporary diverting loop ileostomy was performed in 25 patients and closed at an average of 100 days after the ERPT. Follow-up has been achieved in 100% of the patients and ranges from 6 to 182 months with an average of 48 months. Postoperative complications included partial bowel obstruction (two patients, one requiring enterolysis); and mild pouchitis (one patient). Two of the 27 patients required proctectomy and permanent ileostomy procedures, one for rectal cancer that was present microscopically in the initial rectal specimen from the ERPT and the other because of recurrent anastomotic complications. No patient required revision of the straight pull-through to a pouch or takedown of the pull-through as a result of persistent diarrhea or dissatisfaction. All of the patients are continent, and 80% deny any soiling during bouts of gastroenteritis. The mean number of bowel movements reported was 10 per day at the first postoperative clinic visit with a gradual decreased to six per day after 2 years. Initial use of bulking (62%) and antimotility agents (88%) decreased significantly over the course of follow-up to 29% and 67%, respectively at the most recent follow-up (average, 48 months) of each patient. Pelvic sepsis, which occurs in 8% of most series of patients who have pouches, did not occur in any of our patients. Pouchitis, a common complication with pouches (23%), occurred in only one of the patients and was mild and easily treated medically. This series demonstrates that total colectomy with rectal mucosectomy and straight ERPT eliminates the risk of colorectal cancer and achieves continence with a low complication rate and excellent functional results and patient satisfaction.     

Laparoscopic Swenson pull-through: a comparison with the open procedure

This study was performed to compare the standard open Swenson pull-through (OSP) with the laparoscopic Swenson pull-through (LSP) for Hirschsprung's disease. The Swenson pull-through was performed on eight patients with a rectosigmoid transition zone, during a 14-month period, using one camera port and three working ports. The results were compared with those of 10 patients with a similar lesion treated by the open procedure during an overlapping 19-month period. One laparoscopic procedure was converted to the open version because of technical difficulties. Both methods had a hand-sewn anastomosis approximately 1 cm above the pectinate line. The preoperative variables of age, weight, incidence of colostomy, and incidence of Down's syndrome were similar for the two groups. The operating time for LSP was similar to that for OSP (4 hours 42 minutes v 4 hours 37 minutes, respectively: P = NS). Postoperatively, the laparoscopic group had a shorter hospital stay (5.25 v 8.8 days; P < .05) and had a shorter period until the start of oral intake (2.75 v 5 days; P < .05). The requirement for narcotic pain medication was similar (12.6 v 12.8 doses; P = NS). Early postoperative complications were more common in the open group (3 wound infections, 1 prolonged ileus, and 1 anastomotic leak). No complications occurred in the laparoscopic group. Late postoperative follow-up was too short to compare functional results. The authors conclude that the Swenson pull-through can be performed safely with the laparoscope, with reduced morbidity.     

Experimental assessment of endoscopic mucosectomy with a cap-fitted panendoscope

BACKGROUND AND STUDY AIMS: The use of a cap-fitted panendoscope is one method of carrying out endoscopic mucosectomy in the esophagus, stomach, and large intestine. The purpose of this study was to determine the optimal volume of physiological saline for submucosal injection, the rate of mucosal extension after saline injection, the initial size of the resected mucosal specimen, and the most appropriate heights for the fitted caps used in the colon and in the rectum, respectively. METHODS: Endoscopic mucosectomies using cap-fitted panendoscopes were carried out on resected surgical specimens from ten patients with colorectal cancer. RESULTS: It was necessary to inject 12 ml of saline under the mucosa to prevent perforation. Submucosal saline injection extended the mucosa by 1.4 +/- 0.2 times. A cap with a height of 7 mm is suitable for performing mucosectomy in the colon safely, while both 7 mm and 10 mm caps can be used in the rectum. The initial size of the resected mucosal specimens obtained with both caps was 12-20 mm (mean 14 mm) in diameter, with no significant differences. As the sizes of resected mucosal specimens reported in the past have been obtained after submucosal saline injection, it appears that larger specimens can be resected with the cap-fitted panendoscope than with conventional methods. CONCLUSIONS: The conditions under which endoscopic mucosectomy using the cap-fitted panendoscope can be performed safely in the colon and the rectum were suggested by this experimental study using resected specimens. A saline injection of 12 ml under the mucosa is necessary to prevent perforation. A cap with a height of 7 mm is the most suitable size for the colon, while both 7 mm and 10 mm caps can be used in the rectum.     

Absorption-edge fluoroscopy using a three-spectrum technique

We have recently reported on a 1-kVp, two-filter image subtraction method for visualizing low concentrations of elements like iodine which have K-shell absorption edges in the diagnostic x-ray energy range. However, in the application of this technique to human thyroid imaging, superimposed images due to variations in tissue and bone thickness presented serious difficulties. In this paper, a technique is described for implementing a 3-kVp, three-filter approach. Using carefully chosen spectra and logarithmic image processing, images are produced which are compatible with our previously described two-stage storage-tube subtraction device. Proper manipulation of the resulting difference images results in a final absorption-edge image in which only the element of interest is visualized, with unwanted background images suppressed. Computer calculations are presented to illustrate the relative sizes of difference signals arising from the element of interest and from tissue and bone backgrounds. Phantom studies using iodine concentrations as small as 1 mg/cm2, with variations of 10 cm of tissue and 2 g/cm2 of bone, suggest that the theory is sound and that, with straightforward apparatus modifications, images of good quality should be possible.     

High-resolution magnetic resonance tomography of the lesser pelvis using an endorectal coil

Spatial resolution of MRI within the true pelvis can be increased by a factor of 12 using an endorectal coil. The value of this new method for demonstrating the prostate, the rectum, the cervix and vagina and of pathological processes of these organs was examined in 89 patients and the results compared with conventional body coil MRI. In 25 patients who underwent radical surgery the results of the preoperative studies were compared with the histological findings. Detailed recognition of anatomical structures was markedly improved by using the endorectal coil. Diagnosis of carcinoma of the prostate and extension of the tumour was accurately assessed in 33 patients. Preoperative staging was correct in 87%, compared with 73% when using a body coil. The difference was less marked in examinations for carcinomas of the rectum, the cervix and vagina. Nevertheless, staging was more accurate in a few cases with a better recognition of recurrences. MRI with endorectal coils will have an important role in diagnosis of carcinomas of the prostate in the future. Its use in the diagnosis of carcinomas of the rectum and cervix must be subject to further studies.     

Myxoma of the mitral valve prolapsing into the left atrium and ventricle: report of a case

A rare case of myxoma originating from the mitral valve is reported. A 25-year-old woman was found to have a mobile mass around the mitral valve that prolapsed into the left atrium and the left ventricular outflow tract. The mitral valve was approached via the left atrium and aorta, and was excised completely along with the tumor; it was thus replaced with a mechanical prosthesis. The patient recovered and demonstrated no signs of recurrence 16 months postoperatively.     

Posterior proctomucosectomy and ileal pull-through reconstruction: a new restorative procedure after total proctocolectomy

We reported a new method of restorative proctocolectomy using posterior approach and pull-through reconstruction. This method obviated transanal manipulation, a major factor causing damage to the internal sphincter, thus preventing fecal incontinence due to sphincter dysfunction. Also, temporary ileostomy was not necessary because the spout of an S-pouch was pulled down below the anal verge and its distal free end acted as a diverting stoma while the more proximal, healing zone (future anastomotic line) was kept from fecal contamination. This method was applied to a 32-year-old woman with familial polyposis coli and a 50-year-old woman with ulcerative colitis. Their bowel movements steadily decreased to three times and five times a day, respectively. There was no fecal leakage or perianal excoriation. The advantages as well as disadvantages of this method compared with the conventional techniques were discussed.     

Magnetic resonance imaging of prostate cancer: comparison of image quality using endorectal and pelvic phased array coils

OBJECTIVE: To compare endorectal coil (ERC) and pelvic phased array (PPA) coil magnetic resonance imaging for delineation of the prostate gland and seminal vesicles. To compare ERC images at different inflation volumes of the ERC air balloon. MATERIALS AND METHODS: Twenty-one patients underwent T2-weighted examinations using PPA and ERC. The ERC evaluations were performed at three balloon inflation volumes (60, 100 and 140 ml). All patients had proven prostate cancer. Images were analysed for visibility of anatomic structures, gland distortion, tumour visualization, artefacts (coil flare, coil-related artefact and rectal movement) and overall image quality. A grading system was used for each parameter. RESULTS: ERC assessments at increasing balloon inflations showed equivalent anatomical detail and overall image quality. However, increasing gland distortion and decreasing coil related flare was found with higher air inflations (P = 0.13 and P = 0.006, respectively). When compared with ERC images, visibility of the anterior gland and neurovascular bundles was better with the PPA coil (P = 0.0001 and 0.002, respectively). The overall image quality was superior with the PPA coil (P = 0.0001). However, no significant difference in visualization of tumour or delineation of tumour extent was observed between the two techniques. CONCLUSIONS: PPA imaging of the prostate gland provides images of superior quality compared with the ERC. This is mainly due to fewer artefacts with the PPA coil and improved anterior gland visibility. When ERC is used, air inflation to at least 100 ml reduces coil flare artefact.     

A new assisted hatching technique using a piezo-micromanipulator

OBJECTIVE: To estimate the efficacy of a new assisted hatching technique using a piezo-micromanipulator to support embryonic implantation. DESIGN: Sibling spare embryos from human cycles of IVF were allocated to either a treated group for assisted hatching by a piezo-micromanipulator or a nontreated control group. SETTING: The Infertility and IVF unit of the Kyoto University Hospital. PATIENT(S): Sixty-eight women undergoing conventional IVF treatment. INTERVENTION(S): One hundred ten spare 4- or 8-cell embryos from 68 patients undergoing IVF were treated with the new assisted hatching technique, and the results were compared with those obtained for 112 sibling embryos without the treatment. In the assisted hatching procedure, zona thinning combined with drilling was performed by the vibration of a microneedle produced by the piezo-micromanipulator unit. MAIN OUTCOME MEASURE(S): The rates of partial hatching and completely hatched blastocysts. RESULT(S): The rates of hatching and of hatched blastocysts per total developing blastocysts were significantly higher in the treated group (86.7% and 33.3%, respectively) than in the control group (15.3% and 2.8%, respectively). CONCLUSION(S): These results demonstrate that the newly devised zona thinning and drilling technique using a piezo-micromanipulator is useful for assisted hatching.     

Prostate cancer: local staging with endorectal magnetic resonance imaging

BACKGROUND: Prostate cancer has received increasing attention during the past decades. Staging of tumors before treatment is imperative for planning appropriate therapy. The purpose of this study is to assess the role of endorectal magnetic resonance imaging (MRI) in local staging of prostate cancer. METHODS: Endorectal MRI was performed in 31 patients with histologically-proven prostate cancer. MRI was done three to 100 days (mean, 32.1 days) after either transrectal ultrasonography (TRUS) with biopsy or transurethral resection of the prostate (TURP). Radical prostatectomies were performed within two weeks after MRI. The diagnostic accuracy of endorectal MRI for local tumor staging, specifically for extracapsular extension (ECE) and seminal vesicle invasion (SVI), was evaluated by correlating MRI results with histopathologic findings of whole-mount specimens. RESULTS: The accuracy of endorectal MRI for the detection of tumor presence and estimation of tumor volume was 48%. Sensitivity, specificity and positive predictive value for evaluation of ECE were 88%, 69% and 80%, respectively, and for SVI, were 66%, 84% and 50%, respectively. The overall accuracy of MRI in local tumor staging (using the TMN system) was 61%. Accuracy in differentiating localized from invasive cancer was 84%. CONCLUSION: Endorectal MRI is not accurate enough to detect tumor presence or estimate tumor volume. Diagnostic accuracy for local tumor staging is unsatisfactory. However, endorectal MRI is highly accurate in differentiating localized (stage B) from invasive (stage C) cancer.     

Channel-opening mechanism of a kainate-activated glutamate receptor: kinetic investigations using a laser-pulse photolysis technique

Kainate is an excitatory neurotransmitter that binds to the kainate and AMPA receptor subtypes of the glutamate receptor and triggers the formation of cation permeable transmembrane channels in these receptors. In the present report the channel-opening mechanism of the AMPA receptors by kainate has been determined in rat hippocampal neurons using two different kinetic methods, namely, the rapid-flow method (cell-flow) with a 10 ms time resolution and a laser-pulse photolysis technique with a approximately 65 microseconds time resolution. The whole-cell currents induced by kainate, using the cell-flow method, are nondesensitizing and inhibited significantly by CNQX and hence pertain to activation of the AMPA receptors and not the kainate receptors. The cell-flow measurements were used to evaluate the constants pertaining to the minimum mechanism that could account for the concentration of the receptor in the open-channel form over a 500-fold range of kainate concentration. These constants, namely, the intrinsic dissociation constant of kainate from the AMPA receptor and the channel-opening equilibrium constant, were determined to be 140 +/- 30 microM and 8 +/- 2, respectively. On the other hand, the kinetics of the steps leading to channel opening was evaluated using the laser-pulse photolysis techniques. In this technique whole-cell currents were obtained by releasing kainate in the submillisecond time scale near the cell by photolysis of N-(alpha-carboxy-2-nitrobenzyl) kainate. The concentration of the released kainate was calculated by comparing the whole-cell currents obtained from the laser-pulse photolysis experiments with the whole currents obtained with 100 microM kainate on the same cell using cell-flow measurements. The rate constants for channel opening and closing were then determined from the observed rate constants for the current rise obtained as a function of kainate concentration. These rates were 5000 +/- 2000 and 640 +/- 30 s-1, respectively. The rate and equilibrium constants obtained in the present report allow an evaluation of the fraction of the receptors in the open-channel form as a function of time and kainate concentration, hence providing insight into the role of kainate in neuronal signal transmission.     

Virtual cisternoscopy of intracranial vessels: a novel visualization technique using virtual reality

This paper introduces a different visualization method which we call "virtual cisternoscopy" using 3D MRA data sets. Virtual cisternoscopy uses well known tools, such as perspective volume rendering (pVR), fly-through techniques, and interactive visualization and combines them to a new approach featuring motion to resolve spatial relationships of intracranial vessels and vascular malformations. With a dedicated flight protocol extraluminal topography of intracranial arteries was analyzed using pVR. For evaluation of difficult vascular malformations extraluminal views are necessary. Therefore, movies of pVR views were produced simulating virtual tracks of neurosurgical flexible endoscopes, by flying around the intracranial vessels and vascular malformations within the cisterns. Endoluminal views were acquired additionally for precise evaluation of cases with complex vessel topography. Two healthy volunteers and three patients were examined. Comparing MIP and pVR images relevant advantages of pVR were found, such as depth information, perspective, lighting, and color. In contrast to MIP and source images of the MRA data set, virtual cisternoscopy of an aneurysm of the left middle cerebral artery demonstrated clearly an early origin of an artery in the region of the aneurysm neck/sac. In this case only virtual cisternoscopy led to the correct therapeutical decision. In a newborn, the type of a vein of Galen aneurysmal malformation could only be evaluated reliably by means of virtual cisternoscopy. The third case of a patient with a clipped aneurysm was evaluated more easily with virtual cisternoscopy than with DSA. In conclusion, virtual cisternoscopy may improve the pretherapeutic visualization of intracranial vascular malformations.     

Periarticular heterotopic ossification: a complication of arthroscopic anterior cruciate ligament reconstruction using a two-incision technique

Extra-articular heterotopic bone formation was recognized as a postoperative complication of arthroscopic anterior cruciate ligament reconstructions in four knees around the femoral drill hole. Although laxity of the reconstructed anterior cruciate ligament was not observed in these patients, local pain, swelling, and deformity at the site of heterotopic ossification required surgical intervention. The ectopic bone can be successfully excised with restoration of function. The incidence rate of this complication is less than 1%.     

Alexithymia in patients with eating disorders: an investigation using a new projective technique

The concept of alexithymia was scrutinized in a group of female patients with eating disorders: 15 anorectics and 13 bulimics (mean age of 27 yr.), plus a control group of 21 (mean age 38 yr.). Subjects were interviewed and tested. In the main test an ambiguous face was flashed briefly on a screen opposite the viewer who had to describe her impressions. To enhance the ego-involvement, subliminal words (I, I ILL, I WELL) were presented before each exposure. Contrary to expectations the present patients used more emotional words than controls. Instead, they employed alternative strategies to avoid empathizing. The results were interpreted as indicating a pronounced incapacity for emotional understanding.     

Hysterical blindness: A case report and study using a modern psychophysical technique.

Investigated a 16-yr-old girl with constricted tubular visual fields and a presumptive diagnosis of hysterical blindness, to determine if she could see in the claimed blind field. Using a modified Goldmann perimeter and 2-alternative forced-choice procedure, evidence was obtained strongly suggesting sight where the S claimed she was blind. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Measurements of colour constancy by using a forced-choice matching technique

In order to compare the reactivity of glutamic acid decarboxylase (GAD) antibodies recognizing linear and conformational epitopes as islet cell cytoplasmic antibodies (ICA), monoclonal antibodies were generated. An ELISA displacement test using two biotinylated monoclonals recognizing a linear (M61/7E11) or a conformational GAD65 epitope (M65/6B12) was performed to identify epitope regions recognized by monoclonal GAD antibodies. The GAD binding by monoclonal GAD antibodies was tested by immunofluorescence on fixed and unfixed pancreatic sections of human, rat, and mouse, and by Dot-blot experiments. 16/23 (69.6%) of the monoclonals were specifically reactive with GAD65 and 7/23 (30.4%) were reactive with both GAD isoforms. 8/16 (50%) of monoclonal GAD65 antibodies recognized a linear GAD epitope located at the N-terminus (pattern 1). 5/16 (31.3%) displaced M65/6B12, indicating the recognition of a conformational GAD epitope (pattern 2). Monoclonals belonging to patterns 1 and 2 showed strong ICA binding. 3/16 (18.8%) of monoclonals specific for GAD65 with weak or no immunostaining of pancreatic islets (pattern 3) did not inhibit the binding of both biotinylated antibodies in the displacement test, indicating other epitope specificities. In conclusion, GAD antibodies recognizing both conformational and linear epitopes of the GAD65 molecule are involved in ICA binding with strong reactivity. Furthermore, results obtained with monoclonals of pattern 3 suggest the occurrence of GAD65 epitopes partly inaccessible on cryosections, which may result in an ICA-negative test of GAD65 autoantibody positive sera.