Postoperative computed tomography findings predict re-drainage cases after early drain removal in pancreaticoduodenectomy

PURPOSE

This study aimed to investigate the risk factors for re-drainage in patients with early drain removal after pancreaticoduodenectomy (PD).

METHODS

This study retrospectively analyzed 114 patients who underwent PD and prophylactic drain removal on postoperative day (POD) 4 between January 2012 and March 2021. We analyzed the risk factors for re-drainage according to various factors. Peri-pancreaticojejunostomic fluid collection (PFC) index and pancreatic cross-sectional area (CSA) were evaluated using computed tomography on POD 4. The PFC index was calculated by multiplying the length, width, and height at the maximum aspect.

RESULTS

Among the 114 patients, 15 (13%) underwent re-drainage due to postoperative pancreatic fistula. Multivariate analysis identified a PFC index ≥ 8.16 cm3 on POD 4 (odds ratio [OR], 20.40, 95%CI 2.38-174.00; p = 0.006) and pancreatic CSA on POD 4 ≥ 3.65 cm2 (OR, 16.40, 95%CI 1.57-171.00; p = 0.020) as independent risk factors for re-drainage.

CONCLUSION

A careful decision might be necessary for early drain removal in patients with a PFC index ≥ 8.16 cm3 and pancreatic CSA ≥ 3.65 cm2.

Effect of early administration of tolvaptan on pleural effusion post-hepatectomy

PURPOSE

This study evaluated the efficacy of tolvaptan administration at the early stage after hepatectomy to control pleural effusion and improve the postoperative course.

METHODS

Patients were administered tolvaptan (7.5 mg) and spironolactone (25 mg) from postoperative day 1 to postoperative day 5 (tolvaptan group, n = 68) for 13 months. Early administration of tolvaptan was not provided in the control group (n = 68); however, diuretics were appropriately administered according to the patient's condition. The amount of pleural effusion on computed tomography on postoperative day 5 was compared between the two groups.

RESULTS

The amount of pleural effusion and increase in body weight on postoperative day 5 showed significant differences in both groups (p < 0.001 and p = 0.019, respectively). However, the rate of pleural aspiration and the duration of postoperative hospitalization were comparable between the groups. The amount of intraoperative blood loss and lack of early administration of tolvaptan were identified as independent risk factors contributing to pleural effusion on multivariate analysis.

CONCLUSION

Early administration of tolvaptan to patients after hepatectomy was found to be capable of controlling postoperative pleural effusion and increase in body weight, but it did not reduce the rate of pleural aspiration or the hospitalization period.

Clinical impact of postoperative malnutrition after pancreaticoduodenectomy: prediction based on estimated functional remnant pancreatic volume, prognostic nutritional index, and body mass index

BACKGROUND

The present study aimed to evaluate the association between estimated functional remnant pancreatic volume (eFRPV) and postoperative malnutrition after pancreaticoduodenectomy (PD).

METHODS

The medical records of 131 patients who underwent PD and preoperative computed tomography were retrospectively reviewed. Onodera's prognostic nutritional index (PNI) was assessed 6-months after PD. Patients with PNI values of at least 45 were included in the non-malnutrition group, while those with values <45 and <40 were included in the mild and severe malnutrition groups, respectively. Associations between eFRPV and postoperative nutritional status were evaluated to identify factors predictive of severe malnutrition after PD.

RESULTS

Fifty-three patients (40%) were included in the non-malnutrition group, while 38 (29%) and 40 (31%) were included in the mild and severe malnutrition groups, respectively. Overall survival was significantly shorter in the severe malnutrition group (p < 0.001). The eFRPV was significantly lower in the severe malnutrition group (p = 0.003; Jonckheere-Terpstra trend test, p < 0.001). In the multivariate analysis, eFRPV ≤55.2 mL·HU (odds ratio [OR] = 5.20; p = 0.004), preoperative PNI ≤41.9 (OR = 6.37; p = 0.010), and body mass index ≤19.1 kg/m2 (OR = 3.43; p = 0.031) were independent predictors of severe malnutrition after PD.

CONCLUSION

The current results indicate that eFRPV may predict low PNI values after PD.

Colonization of the gastric juice by Candida spp. promotes surgical site infection after hepatectomy

PURPOSE

Candida spp. cause opportunistic infections in conditions of immunodeficiency. Here, we investigated the relationship between colonization of the gastric juice by Candida spp. and surgical site infection (SSI) in hepatectomy.

METHODS

Consecutive hepatectomy cases between November 2019 and April 2021 were enrolled. Gastric juice samples (collected intraoperatively through a nasogastric tube) were cultured. We compared factors related to patient background, blood test findings, surgical findings, and postoperative complications between the Candida + group (positive for colonization of the gastric juice by Candida spp.) and the Candida - group (negative). In addition, we identified the factors that contribute to SSI.

RESULTS

There were 29 and 71 patients in the Candida + and Candida - groups, respectively. The Candida + group was significantly older (average age: Candida + 74 years vs. Candida - 69 years; p = 0.02) and contained more patients negative for the hepatitis B and C virus (Candida + 93% vs. Candida - 69%; p = 0.02). SSI was significantly more common in the Candida + group (Candida + 31% vs. Candida - 9%; p = 0.01). Postoperative bile leakage and colonization of the gastric juice by Candida spp. were independent predictors of SSI.

CONCLUSION

Colonization of the gastric juice by Candida spp. is a risk factor for SSI after hepatectomy.

[Short- and Long-Term Effects of Palliative Stoma Creation on Quality of Life]

Palliative stoma creation for malignant gastrointestinal obstruction improves quality of life, and advances in chemotherapy have resulted in long-term survival after stoma creation. We reviewed early and late complications in 24 patients treated with palliative stoma creation. Results: 14 men(58%)and 10 women(42%)had a median age of 60 years. Twenty-three patients(96%)were able to eat more than a porridge diet postoperatively, and the median The ColoRectal Obstruction Scoring System(CROSS)improved from 1(0-3)to 4(2-4)(p<0.001). Postoperative complications(all Clavien-Dindo grades)were observed in 10 patients(42%), with a longer postoperative hospital stay in the complication group than in the group without complication(median 34 days: 17 days, p=0.026). When divided into long-term survivors and short- term survivors based on a median overall survival of 101 days, more stoma prolapse occurred in the long-term survivors(4 cases 33% vs 0 cases 0%, p=0.028), one of which required repair surgery. Conclusion: Long-term survivors after exploratory stoma creation are more likely to develop a stoma prolapse. Careful surgical manipulation and postoperative support system including stoma care are important.

Preoperative predictive nomogram based on alanine aminotransferase, prothrombin time activity, and remnant liver proportion (APART score) to predict post-hepatectomy liver failure after major hepatectomy

Introduction: Post-hepatectomy liver failure (PHLF) is a serious complication associated with major hepatectomies. An accurate prediction of PHLF is necessary to determine the feasibility of major hepatectomy. This study aimed to assess the association between PHLF and preoperative laboratory and computed tomography (CT) findings. Methods: Medical records of 65 patients who underwent major hepatectomy and preoperative CT were retrospectively reviewed. We evaluated future remnant liver volume evaluation models and remnant liver hemodynamics, which were assessed by arterial enhancement fraction (AEF) by using preoperative CT. Variables, including CT findings, were compared between patients with and without PHLF after major hepatectomy, and the preoperative PHLF predicting nomogram was constructed using multivariate logistic regression. Results: The PHLF group included 21 patients (32.3%). The AEF was not significantly different between the two groups. In the future remnant liver volume evaluation models, future remnant liver proportion (fRLP) had the highest concordance index (C-index) in the receiver operating characteristic curve analysis (C-index, 0.755). Multivariate analysis of preoperative evaluable factors revealed that alanine aminotransferase levels (p = 0.034), prothrombin time activity (p = 0.021), and fRLP (p = 0.012) were independent predictive factors of PHLF. A nomogram (APART score) was constructed using these three factors, with a receiver operating curve showing a C-index of 0.894. According to the APART score, scores of 51 to 60 indicated moderate risk (40.0%), and scores over 60 indicated a high risk of PHLF (83.3%) (p < 0.001). Discussion/Conclusion: The APART score may help predict PHLF in patients indicated for major hepatectomies.

Impact of Preoperative Muscle Mass Maintenance and Perioperative Muscle Mass Loss Prevention After Pancreatectomy: Association Between Perioperative Muscle Mass and Postoperative Nutritional Status

OBJECTIVES

We investigated how preoperative sarcopenia and perioperative muscle mass changes affect postoperative nutritional parameters in patients undergoing pancreatectomy.

METHODS

This study included 164 patients undergoing pancreatectomy between January 2011 and October 2018. Skeletal muscle area was measured by computed tomography before and 6 months after surgery. Sarcopenia was defined as the lowest sex-specific quartile, and patients with muscle mass ratios less than -10% were classified into the high-reduction group. We examined the relationship between perioperative muscle mass and postoperative nutritional parameters 6 months after pancreatectomy.

RESULTS

There were no significant differences in nutritional parameters between the sarcopenia and nonsarcopenia groups at 6 months after surgery. In contrast, albumin (P < 0.001), cholinesterase (P < 0.001), and prognostic nutritional index (P < 0.001) were lower in the high-reduction group. According to each surgical procedure, albumin (P < 0.001), cholinesterase (P = 0.007), and prognostic nutritional index (P < 0.001) were lower in the high-reduction group of pancreaticoduodenectomy. In distal pancreatectomy cases, only cholinesterase (P = 0.005) was lower.

CONCLUSIONS

Postoperative nutritional parameters were correlated with muscle mass ratios but not with preoperative sarcopenia in patients undergoing pancreatectomy. Improvement and maintenance of perioperative muscle mass are important to maintain good nutritional parameters.

The Change in the Fibrosis-4 Index for the Assessment of Liver Fibrosis After Pancreaticoduodenectomy

OBJECTIVES

Nonalcoholic fatty liver is a complication of pancreaticoduodenectomy (PD); however, liver fibrosis after PD is not well documented. Therefore, we estimated the hepatic fibrotic index of nonalcoholic fatty liver after PD.

METHODS

We retrospectively examined the electronic medical records of patients who had underwent PD and had computed tomography (CT) records preoperatively and 6 months postoperatively between 2011 and 2019 at the Shiga University of Medical Science Hospital.

RESULTS

Overall, 115 patients were enrolled. After 6 months from PD, body mass index significantly decreased from 21.90 to 19.57 kg/m2 (-10.6%). The Fibrosis-4 (FIB-4) index significantly increased from 1.756 to 2.384 (P < 0.001). The FIB-4 grade significantly worsened. Contrarily, neither the albumin-bilirubin (ALBI) score nor the ALBI grade demonstrated significant differences. The CT attenuation value significantly decreased (P < 0.001) from 57.6 to 49.5. Multivariate analysis predicted a high preoperative FIB-4 index, high ALBI index, and hypo-CT attenuation value (<30 HU) as risk factors for a high postoperative FIB-4 index.

CONCLUSIONS

The FIB-4 index worsened when the follow-up period was only 6 months, regardless of the eternalness in the ALBI score. Liver fibrosis should be assessed using the FIB-4 index for a long-term survivorship after PD.

Effect of gastrojejunostomy position on the postoperative amount of oral intake in pancreaticoduodenectomy

Introduction We investigated the effect of the gastrojejunostomy position on the postoperative oral intake in patients who have undergone PD. Methods We investigated 119 patients who underwent PD between June 2013 to December 2019 and examined the effect of the horizontal and vertical distance rates of the gastrojejunostomy position on the postoperative oral intake. The patients were categorized as having poor or good oral intake based on whether their intake was up to half the required calorie intake. Results There were significant differences in the number of cases with grade B or C postoperative pancreatic fistula (good, 20.3% vs. poor, 60.0%; p<0.001), horizontal distance rate (good, 0.57 vs. poor, 0.48; p=0.02), and postoperative hospitalization period (good, 15 vs. poor, 35 days; p<0.001). However, there was no significant difference in the vertical distance rate (good, 0.67 vs. poor, 0.71; p=0.22). The horizontal distance rate was the independent risk factor for postoperative poor oral intake at 2-3 weeks (risk ratio, 3.69; 95% CI, 1.48-9.20). Discussion/Conclusion The oral intake was greater in patients whose gastrojejunostomy position in PD was farther from the median, suggesting the necessity of intraoperative placement of the gastrojejunostomy position as far from the median as possible.

Pleural empyema caused by dropped gallstones after laparoscopic cholecystectomy for acute cholecystitis: a case report

BACKGROUND

Dropped gallstones during laparoscopic cholecystectomy (LC) sometimes induce postoperative infectious complications. However, pleural empyema rarely occurs as a complication of LC.

CASE PRESENTATION

We present the case of a 66-year-old woman with right pleural empyema. She previously underwent LC for acute gangrenous cholecystitis 11 months ago. The operative report revealed iatrogenic gallbladder perforation and stone spillage. The bacterial culture of the gallbladder bile was positive for Escherichia coli. Chest and abdominal computed tomography revealed right pleural effusion, perihepatic fluid collection, and multiple small radiopaque density masses. Although ultrasound-guided transthoracic drainage was performed, the drainage was incomplete, and systemic inflammatory reaction persisted. Consequently, thoracotomy and laparotomy with gallstone retrieval were performed, and the patient recovered completely. The patient has remained well without complications after 14 months of follow-up.

CONCLUSIONS

We report a rare case of pleural empyema caused by dropped gallstones after LC. This case emphasized the importance of completely retrieving the dropped gallstones to prevent late infectious complications after LC.

Aggressive Intervention of Pancrelipase After Pancreatectomy Prevents Deterioration of Postoperative Nutritional Status

OBJECTIVES

This study aimed to investigate the effect of early administration of delayed-release high-titer pancrelipase.

METHODS

The medical records of 120 patients who had undergone pancreatectomy with computed tomography (CT) before and 6 months after surgery were retrospectively reviewed. Delayed-release high-titer pancrelipase were administered daily starting on postoperative day 3, which was defined as the EP group. The postoperative nutritional status and CT attenuation values of the liver were compared between the EP and control groups.

RESULTS

Thirty-three patients (28%) were categorized into the EP group. With regard to the postoperative nutritional status 6 months after surgery, the body mass index, total lymphocyte count, and Onodera's prognostic nutritional index were higher, and controlling nutritional status score was lower in the EP group than that in the control group. The CT attenuation values of the liver were not significantly different. After propensity score matching analysis, body mass index (20.7 vs 19.2, P = 0.049) and Onodera's prognostic nutritional index (47.9 vs 44.2, P = 0.045) were significantly higher, and controlling nutritional status score was significantly lower in the EP group than that in the control group (1 vs 3, P = 0.046).

CONCLUSIONS

The early administration of pancrelipase after pancreatectomy improved nutritional status after pancreatectomy.

Estimated tumor blood flow as a predictive imaging indicator of therapeutic response in pancreatic ductal adenocarcinoma: use of three-phase contrast-enhanced computed tomography

BACKGROUND

Preoperative chemotherapy or chemoradiotherapy is a common strategy for treating pancreatic ductal adenocarcinoma (PDAC). This study aimed to assess the association between the therapeutic response in PDAC and tumor blood circulation.

METHODS

The medical records of patients who underwent chemotherapy or chemoradiotherapy prior to pancreatectomy for PDAC were reviewed. Of these, patient data that included three-phase contrast-enhanced computed tomography (CECT) findings before treatments were used in this study. We evaluated the estimated tumor blood flow (eTBF) using CECT. According to the therapeutic histopathological response defined by the Evans classification, patients were divided into poor (grade I/IIa) and good (grade IIb/III/IV) responder groups. The variables, including eTBF, were compared between the two groups.

RESULTS

Thirty patients were enrolled in this study. Of these, 13 (43.3%) (grade IIB/III/IV: 8/4/1 patients) were categorized into the good responder group and 17 patients (56.7%) (grade I/IIA: 4/13 patients) were categorized into the poor responder group. eTBF was significantly higher in the good responder group (0.39 s^-1 vs. 0.32 s^-1, p = 0.007). An eTBF ≥ 0.36 s^-1 was found to be an independent predictive factor for the destruction of over 50% of tumor cells (p = 0.036; odds ratio, 9.71; 95% confidence interval, 1.16-81.30).

CONCLUSIONS

eTBF can be used to predict the therapeutic histopathological response in PDAC prior to treatment.

Pathological complete response in a patient with metastatic pancreatic acinar cell carcinoma who received a chemotherapy regimen containing cisplatin and irinotecan

Pancreatic acinar cell carcinoma is a rare tumor of the pancreas, and patients with such tumors rarely have a pathological complete response to treatment. Herein, we present a case involving a 48-year-old woman with a pancreatic tail mass. The pancreatic mass was connected to splenic and portal vein thrombosis. Distal pancreatectomy and removal of portal vein tumor thrombosis were performed. Ten months after surgery, multiple liver metastases and local recurrence in the pancreatic bed were detected, and chemotherapy was administered through the administration of a regimen containing both cisplatin and irinotecan. After seven courses of the cisplatin-plus-irinotecan regimen had been administered, computed tomography revealed that the patient had a partial response to treatment. Radical resection of multiple liver metastases and the locally recurrent tumor was performed. Pathological examination did not reveal the presence of carcinoma in any of the resected specimens. Thus, this case involves a pathological complete response in a patient with metastatic pancreatic acinar cell carcinoma who received a regimen containing both cisplatin and irinotecan. Our findings reveal that the administration of the cisplatin-plus-irinotecan regimen may be an option for the management of such tumors.

Differences in the safety line of the future liver remnant plasma clearance rate of indocyanine green necessary to prevent post-hepatectomy liver failure associated with underlying diseases

PURPOSE

To evaluate differences in the safety line of the future liver remnant plasma clearance rate of indocyanine green (RemK) necessary to prevent posthepatectomy liver failure (PHLF) associated with liver tumors and comorbidities.

METHODS

The subjects of this retrospective study were patients who underwent trisectionectomy, hemihepatectomy, or sectionectomy, other than left lateral sectionectomy, between 2011 and 2018, at the Shizuoka Cancer Center. We analyzed the risk factors for PHLF grades B and C and then evaluated the RemK in these groups, according to various risk factors.

RESULTS

A total of 463 patients were selected for the analyses. Among the patients with PHLF grades B and C, those with diabetes mellitus (DM), liver cirrhosis (LC), or hepatocellular carcinoma (HCC) had significantly higher RemK than those without these diseases. Multivariate analysis identified RemK ≤ 0.078, DM, and creatinine clearance rate < 60 mL/min as independent risk factors for PHLF grades B and C.

CONCLUSIONS

Hepatectomy for patients with DM, HCC, or LC requires more functional hepatic reserve than that evaluated by RemK.

Prognostic Impact of Paraaortic Lymph Node Metastasis in Extrahepatic Cholangiocarcinoma

BACKGROUND

Surgical resection in patients with extrahepatic cholangiocarcinoma (EHCC) with paraaortic lymph node metastasis (PALNM) remains controversial. The objective of this study was to investigate the prognostic impact of PALNM in resected EHCC.

METHODS

The present retrospective study included 410 patients, including 16 patients with PALNM, who underwent surgical resection of EHCC between September 2002 and December 2018. These were compared to 9 patients in whom EHCC was not resected due to PALNM. The clinicopathological features and survival outcomes were investigated to identify the prognostic factors in resected EHCC.

RESULTS

The overall survival in the resected patients with PALNM was significantly better than that in unresected patients (median survival time [MST] 33.7 vs. 16.7 months, p=0.009) and was not significantly worse than that of patients with regional lymph node metastasis (LNM) (MST 33.7 vs 36.0 months, p=0.278). The multivariate analysis identified age > 70 years, male sex, tumor location (perihilar), residual tumor status, histological grade, microscopic venous invasion, and regional LNM as independent prognostic factors.

CONCLUSIONS

There was no significant difference in survival between the resected patients with PALNM and patients with regional LNM, and PALNM was not a significant prognostic factor in the multivariate analysis. Surgical resection may be considered an acceptable approach for EHCC with PALNM in selected patients.

Middle segment-preserving pancreatectomy for multifocal pancreatic ductal adenocarcinoma located in the head and tail of the pancreas: a case report

A 77-year-old woman with a solitary existence was referred to our hospital for the treatment of pancreatic tumors. Computed tomography revealed an 18-mm mass in the pancreatic head that had invaded the right side of the superior mesenteric vein (SMV) and a 32-mm mass in the pancreatic tail. We performed middle segment-preserving pancreatectomy (MSPP) with SMV resection and reconstruction. The TNM classifications were T2, N1, M0, stage IIB in the pancreatic head, and T2, N0, M0, stage IB in the pancreatic tail, respectively. Postoperatively, the blood glucose was well controlled using only hypoglycemic drug, and insulin preparation was not necessary. No fatty diarrhea was found using a pancreatic enzyme supplement. After 9 months of follow-up, no recurrence was found. MSPP for pancreatic head and tail carcinomas seemed acceptable for both preserving the postoperative quality of life and ensuring curative resection especially in elderly patient with a solitary existence.

Prognostic Impact of Pancreatic Invasion in Duodenal Carcinoma: A Single-Center Experience

BACKGROUND

The prognostic factors for duodenal carcinoma (DC) remain unclear because of its rarity. This study aimed to investigate the prognostic impact of pancreatic invasion (PI) on postoperative survival for patients with DC.

METHODS

This study retrospectively analyzed 86 patients with DC, including 18 patients with PI, who underwent surgical resection between October 2002 and March 2018. The clinicopathologic features and survival outcomes of these patients were investigated to identify the prognostic factors in DC. The long-term survival for the DC patients with PI was compared with that for the patients who underwent resection for resectable pancreatic head carcinoma (RPHC) during the same period.

RESULTS

The median survival time (MST) for the DC patients with PI was 25.7 months, which was significantly worse than for the patients with T2 or deeper DC without PI (p = 0.010). The multivariate analysis showed that the independent prognostic factors were PI (hazard ratio [HR] 7.59; p = 0.019) and lymph node metastasis (LNM) (HR 5.01; p = 0.026). The MST for the DC patients with PI did not differ significantly from that for the RPHC patients treated without adjuvant chemotherapy (p = 0.135). Comparable rates of microscopic venous invasion and hematogenous metastasis were observed for the DC patients with PI and the RPHC patients.

CONCLUSIONS

Pancreatic invasion was an independent prognostic factor in DC. The survival outcomes for the DC patients with PI did not differ from those for the patients with RPHC, which was associated with a high rate of hematogenous recurrence.

A case of pancreatic cancer invading the superior mesenteric artery causing extensive intestinal necrosis that was successfully treated by surgery

Introduction

Pancreatic cancer often invades major arteries. However, there are few reports about extensive bowl necrosis caused by superior mesenteric artery (SMA) occlusion associated with pancreatic cancer invasion.

Case report

A 73-year-old woman who was receiving chemotherapy for locally advanced pancreatic cancer (LAPC) was referred to our hospital for abdominal swelling and vomiting that had persisted for 2 days. Contrast-enhanced computed tomography revealed occlusion of the SMA by pancreatic cancer, which had invaded the whole circumference of the SMA. On emergency laparotomy, a large amount of necrotic and ischemic intestine was resected, preserving approximately 100 cm of the ileum. Gastroileostomy was also performed. She had an uneventful postoperative course.

Conclusions

Surgical treatment is a good option for acute SMA occlusion due to invasion by LAPC.

Pathophysiology and therapeutic strategies for peritoneal recurrence after gastric cancer surgery

4050

Background: We recently showed that cancer cells, with proliferative and tumorigenic potential, can spill into the peritoneal cavity during curative (R0) gastric cancer (GC) surgery, which is associated with peritoneal recurrence (PM). To elucidate the pathophysiology of PM, the relationship between spilled cancer cells and cancer stem cells was evaluated. Furthermore, to identify a therapeutic strategy for PM, the prognostic impact of hyperthermic intraperitoneal chemotherapy (HIPEC) following GC surgery with spillage of cancer cells was evaluated. Methods: Patients with advanced GC (≥pT2 [MP]) who underwent R0 gastrectomy between 2010 and 2015 were enrolled. Ninety-four consecutive patients with negative results in peritoneal cytology and cancer cell culture (CCC [-]) following peritoneal washing (PW) before GC surgery were included. Spilled cancer cells in PW after GC surgery (PW-Post) were examined to identify any CD44-positive cancer stem-like cells associated with cancer metastasis. Based on the PW-Post CCC results, associations between HIPEC and recurrence-free survival (RFS), or overall survival (OS) were evaluated. HIPEC was performed following GC surgery using CDDP, MMC, and 5-FU in 5 L saline maintained at 42˚C for 30 min. Results: Spilled cancer cells included CD44+ cancer stem-like cells. In 48 patients with PW-Post positive CCC (CCC [+]), the number of patients with pStage I, II, and III were 4, 7, and 15, respectively, in those who received HIPEC (n = 26), and 3, 9, and 10, respectively, in those who did not (n = 22). Among patients with CCC (+), the 5-year peritoneal RFS, hepatic RFS, and lymph node RFS rates were 93.3%, 100%, and 68.5%, respectively, in patients who received HIPEC, and 56.7%, 35.6%, and 66.7%, respectively, in those who did not ( P = 0.008, P = 0.008, and P= 0.24, respectively). Among patients with PW-Post CCC (-), none developed recurrence, regardless of whether they received HIPEC (n = 28) or not (n = 18). Conclusions: The results show that PW-Post CCC is a promising predictive biomarker for recurrence after R0 GC surgery. Adjuvant HIPEC performed with R0 GC surgery showed preventive effects on peritoneal and hepatic recurrence and survival benefits for patients with PW-Post CCC (+).

MRI study of atherosclerotic plaque progression using ultrasmall superparamagnetic iron oxide in Watanabe heritable hyperlipidemic rabbits

OBJECTIVE

The purpose of this study was to evaluate plaque progression by using MRI with ultrasmall superparamagnetic iron oxide (USPIO) and by histopathological studies.

METHODS

We divided 12 Watanabe heritable hyperlipidemic (WHHL) rabbits into 4 groups based on their age (3, 9, 14 and 26 months) and injected them intravenously with 0.8 mmol (Fe) kg(-1) of USPIO (size, 32 nm; concentration, 15 mg dl(-1)). On the fifth post-injection day, they were again given an intravenous injection with 40 μmol kg(-1) of the same USPIO, and MR angiography (MRA) was performed. The signal-to-noise ratio (SNR) in regions of interest in the wall of the upper abdominal aorta was calculated on coronal images. Specimens from the same level of the aorta were subjected to iron staining and RAM-11 immunostaining and used for histopathological study. For statistical analysis of the MRA and histopathological findings, we used analysis of variance [Tukey's honest significant difference (HSD) test].

RESULTS

In 9-month-old rabbits, the SNR was significantly lower than in rabbits of the other ages (p < 0.01), and the area of RAM-11 (DAKO Corporation, Glostrup, Denmark) and iron uptake in the aortic wall was significantly larger (RAM-11, p < 0.01; iron, p < 0.05). These areas were the smallest in 3-month-old rabbits.

CONCLUSION

Histopathologically, the number of macrophages was the greatest in 9-month-old rabbits. Our findings indicate that the SNR on MRI scans reflects the number of macrophages in the aortic wall of WHHL rabbits.

ADVANCES IN KNOWLEDGE

USPIO-enhanced MRI visualized the accumulation of macrophages in early atherosclerotic plaques of WHHL rabbits in the course of natural progression.

Direct measurement of speed of sound in cartilage in situ using ultrasound and magnetic resonance images

This study verified the accuracy of the speed of sound (SOS) measured by the combination method, which calculates the ratio between the thickness values of cartilage measured by using the magnetic resonance imaging (MRI) and the ultrasonic pulse-echo imaging, and investigated in vivo application of this method. SOS specific to an ultrasound imaging device was used as a reference value to calculate the actual SOS from the ratio of cartilage thicknesses obtained from MR and ultrasound images. The accuracy of the thickness measurement was verified by comparing results obtained using MRI and a non-contact laser, and the accuracy of the calculated SOS was confirmed by comparing results of the pulse-echo and transmission methods in vitro. The difference between laser and MRI measurements was 0.05 ± 0.22 mm. SOS values in a human knee measured by the combination method in the medial and lateral femoral condyles were 1650 ± 79 and 1642 ± 78 m/s, respectively (p < 0.05). The results revealed the feasibility of in situ SOS measurement using the combination method.

Correlation between apparent diffusion coefficient and viscoelasticity of articular cartilage in a porcine model

OBJECTIVE

Quantitative MR imaging techniques of degenerative cartilage have been reported as useful indicators of degenerative changes in cartilage extracellular matrix, which consists of proteoglycans, collagen, non-collagenous proteins, and water. Apparent diffusion coefficient (ADC) mapping of cartilage has been shown to correlate mainly with the water content of the cartilage. As the water content of the cartilage in turn correlates with its viscoelasticity, which directly affects the mechanical strength of articular cartilage, ADC can serve as a potentially useful indicator of the mechanical strength of cartilage. The aim of this study was to investigate the correlation between ADC and viscoelasticity as measured by indentation testing.

MATERIALS AND METHODS

Fresh porcine knee joints (n = 20, age 6 months) were obtained from a local abattoir. ADC of porcine knee cartilage was measured using a 3-Tesla MRI. Indentation testing was performed on an electromechanical precision-controlled system, and viscosity coefficient and relaxation time were measured as additional indicators of the viscoelasticity of cartilage. The relationship between ADC and viscosity coefficient as well as that between ADC and relaxation time were assessed.

RESULTS

ADC was correlated with relaxation time and viscosity coefficient (R(2) = 0.75 and 0.69, respectively, p < 0.01). The mean relaxation time values in the weight-bearing and non-weight-bearing regions were 0.61 ± 0.17 ms and 0.14 ± 0.08 ms, respectively.

CONCLUSIONS

This study found a moderate correlation between ADC and viscoelasticity in the superficial articular cartilage. Both molecular diffusion and viscoelasticity were higher in weight bearing than non-weight-bearing articular cartilage areas.

Treatment of Spontaneous Intradural Vertebral Artery Dissections

Spontaneous intradural vertebral artery dissections may cause subarachnoid hemorrhage and often result in devastating damage. Increased use of noninvasive imaging studies has allowed larger numbers of patients to be diagnosed. In addition, intracranial vertebral artery dissection tends to induce multiple lesions affecting both intracranial vertebral arteries recurrently. Although unruptured dissections in this area usually have a benign nature, some authors have reported on the incidence of rupture from this lesion. Once hemorrhage from a dissecting vessel wall has occurred, it needs to be treated in the acute phase because of the high risk of rebleeding resulting in high morbidity and mortality. From December 2004 to July 2010, we managed 47 patients with spontaneous vertebral artery dissection, 31 patients were ruptured and 16 were unruptured. All patients who suffered from subarachnoid hemorrhage were treated with endovascular procedures. Most of the patients with unruptured dissection received medical therapy, but if the aneurysmal dilatation persisted or grew, surgical interventions were performed. Stenting with or without coils was deployed for 13 patients with posterior inferior cerebellar artery involvement at the site of dissection and/or were affected on the dominant side. In some patients, stenting was performed even if they were in the acute phase. For other ruptured patients, internal coil trappings were performed. Six patients died due to severe initial subarachnoid hemorrhage and one patient, who underwent stent deployment with coils for the dominant vertebral artery, with bilateral dissection continuing to the basilar artery died due to rerupture while the next additional coiling was planning. There were two cases of complications related to the intervention. During the follow-up period no bleeding occurred in any of the patients except for the previously mentioned patient. In conclusion, internal coil trapping or stent placement with or without coils was effective in preventing rebleeding of ruptured vertebral artery dissection. If the dissection is unruptured, it is necessary to detect the risk of bleeding with careful watching and when progress appears to be made, patients should be treated promptly. Stent-assisted therapy for preserving the patency of the parent artery and major branches is a promising treatment for vertebral artery dissection, even in the acute stage of subarachnoid hemorrhage. However, the risk of acute rerupture and recurrence remains even with the porous stent placement with or without coils.

Anti-tumour effects of transcatheter arterial embolisation administered in combination with thalidomide in a rabbit VX2 liver tumour model

OBJECTIVE

Using a liver tumour model we investigated whether thalidomide enhances the anti-tumour effect of transcatheter arterial embolisation (TAE).

METHOD

First, the viability of VX2 tumour cells co-cultured with thalidomide in a 21% and 1% O(2) atmosphere was assessed by 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide assay. Second, we randomly assigned 20 rabbits bearing VX2 liver tumours to 4 groups: Group 1 (thalidomide plus TAE), Group 2 (TAE only), Group 3 (thalidomide only) and Group 4 (control). Thalidomide was orally administered for 5 days. The anti-tumour effects were assessed by the tumour proliferation rate using MRI and by immunohistochemical analysis of the area of intratumoural vessels. Analysis of variance and Tukey's honestly significant difference test were used for statistical analysis.

RESULTS

The viability of cells grown under hypoxic and normal conditions was not significantly different, nor was there a difference among the four groups. The tumour size increased by 55.9±29.3% in Group 1, 250.6±73.3% in Group 2, 355.2±51.7% in Group 3 and 424.7±110.7% in Group 4; the difference between Group 1 and the other three groups was significant. The area of intratumour vessels in specimens was 0.22±0.28% in Group 1, 0.42±0.29% in Group 2, 1.44±1.00% in Group 3 and 6.00±2.17% in Group 4; the difference between Group 1 and the other groups was statistically significant, as was the difference between Groups 3 and 4.

CONCLUSION

Thalidomide used in combination with TAE enhanced anti-tumour effects in rabbits bearing VX2 liver tumours.

A combination of cisplatin-eluting gelatin microspheres and flavopiridol enhances anti-tumour effects in a rabbit VX2 liver tumour model

The aim of this study was to investigate whether the combination of cisplatin-eluting gelatin microspheres (GMSs) and flavopiridol enhances anti-tumour effects in a rabbit VX2 liver tumour model. Tumour-bearing rabbits (n = 21) were divided into five groups and infused from the proper hepatic artery. Group 1 (n = 5) received cisplatin-eluting GMSs (1 mg kg(-1)) and flavopiridol (3 mg kg(-1)), group 2 (n = 5) cisplatin-eluting GMSs alone (1 mg kg(-1)), Group 3 (n = 5) flavopiridol (3 mg kg(-1)), Group 4 (n = 3) GMSs alone (1 mg kg(-1)), and Group 5 (n = 3) was the control group receiving physiological saline (1 ml kg(-1)). On days 0 and 7 after procedures the liver tumour volume was measured using a horizontal open MRI system and the relative tumour volume growth rates for 7 days after treatment were calculated. On T(1) weighted images, the tumours were visualised as circular, low-intensity areas just below the liver surface. After treatment, the signals remained similar. The relative tumour volume growth rate for 7 days after treatment was 54.2+/-22.4% in Group 1, 134.1+/-40.1% in Group 2,166.7+/-48.1% in Group 3, 341.8+/-8.6% in Group 4 and 583.1+/-46.9% in Group 5; the growth rate was significantly lower in Group 1 than the other groups (p<0.05). We concluded that in our rabbit model of liver tumours the combination of cisplatin-eluting GMSs and flavopiridol was effective.

Does the concomitant intra-arterial injection of asialoerythropoietin and edaravone mitigate ischaemic mucosal damage after acute superior mesenteric artery thromboembolism in a rabbit autologous fibrin clot model?

To increase the survival rate of patients with acute superior mesenteric artery thromboembolism (ASMAT) treated by catheter thrombolysis, we examined the effects of delivering edaravone and asialoerythropoietin, agents with tissue-protective activities, using a rabbit autologous fibrin clot ASMAT model. Japanese white rabbits (n=32) were randomly separated into four equal groups. 45 min after introducing autologous fibrin clot, Group U received urokinase and heparin; Group E received urokinase and heparin plus edaravone; Group A received urokinase and heparin plus asialoerythropoietin; and Group EA received urokinase, heparin and edaravone plus asialoerythropoietin via a catheter. The intestines were removed 6 h later and intestinal mucosal damage was scored using the Park's injury score. Survival time was assessed. Average mucosal injury was 5.78+/-1.52 (Group U), 2.88+/-0.72 (Group E), 1.90+/-1.23 (Group A) and 1.18+/-1.25 (Group EA). The degree of mucosal injury was significantly lower in Group EA than in Groups U and E (p<0.05). Conversely, there was no significant difference between Group A and Group EA, or between Group A and Group E. The survival times were 31.50+/-13.30 h (Group U), 51.00+/-24.74 h (Group E), 48.00+/-16.97 h (Group A) and 82+/-51.07 h (Group EA); the difference among the four groups was not significant. In conclusion, the concomitant administration of asialoerythropoietin and edaravone reduced mucosal membrane injury significantly compared with edaravone alone. However, to improve the survival of ASMAT rabbit models, the delivery of an appropriate dose of asialoerythropoietin is required, together with the development of methods to assess peripheral recanalisation.

Ultrasonic measurement of vascular scaffold elasticity using catheter system

Characterization of grafted vascular scaffold is essential for evaluating its biocompatibility, maturity and structural intensity. Quantitative elastic modulus measurement of vascular scaffold powerfully assists its characterization because the mechanical property is closely related with the biocompatibility, maturity and structural intensity of the vascular scaffold. We have presented an in vitro or in vivo measurement system for the tissue-engineered vessel before and after grafting in the previous study, we present a novel and modified method for in vivo assessment and follow-up of the vascular scaffold in this study. The measured quantitative elastic modulus is converted into the regeneration score for in vivo assessment. The effectiveness of the proposed evaluation method was validated by in vivo experimental data using canines.

Cisplatin-conjugated degradable gelatin microspheres: fundamental study in vitro

The object of this study was to generate cisplatin-conjugated gelatin microspheres (GMSs) and to confirm the subsequent release of cisplatin in vitro. The GMSs (1 mg) were immersed in 50 microl of a cisplatin solution (0.06, 0.15, 0.27, 0.30 or 0.54 mg ml(-1)) at 38 degrees C to allow conjugation. The cisplatin-conjugated GMSs were then extensively washed in double-distilled water and freeze-dried. The platinum concentration in the GMSs samples was investigated as a function of the concentration of cisplatin solution used in their preparation, the number of immersions in cisplatin (1, 2, 3, 4 or 5) and the period of immersion (1, 6 or 11 h). In vitro release tests were performed at different time intervals (1, 3, 6, 12 or 24 h) to allow the rate of cisplatin release to be calculated. The platinum concentration of the GMSs increased in proportion to the concentration of cisplatin solution and the length or number of immersions in cisplatin. In vitro release tests demonstrate that the release rate (%) from GMSs after 1, 3, 6, 12 or 24 h was 4.8, 5.5, 7.6, 10.0 and 12.4, respectively. We demonstrated the ability of GMSs to bind cisplatin forming cisplatin-conjugated GMSs. Moreover, we showed that cisplatin continued to bind GMSs strongly during the in vitro release test.

Formation of porous GaSb compound nanoparticles by electronic-excitation-induced vacancy clustering

Porous semiconductor compound nanoparticles have been prepared by a new technique utilizing electronic excitation. The porous structures are formed in GaSb particles, when vacancies are efficiently introduced by electronic excitation and the particle size is large enough to confine the vacancy clusters. The capture cross section of the surface layer in particles for the vacancies is smaller than that for the interstitials. Under the condition of supersaturation of vacancies in the particle core, porous structures are produced through the vacancy clusters to a void formation.

Fat-saturated diffusion-weighted imaging of the rat pelvis using three-dimensional MP-RAGE MR sequence

In this work we report on the development of a novel technique for fat-saturated three-dimensional (3D) diffusion-weighted (DW) MRI sequence based upon 3D magnetization-prepared rapid gradient-echo (3D-MP-RAGE). In order to saturate fat, two kinds of procedures were competed CHESS-DW-3D-MP-RAGE sequence (CHESS-3D-DWI) and DW-3D-MP-WE-RAGE sequence (WE-3D-DWI) "chemical shift selective: CHESS method vs. water-excitation: WE method". The CHESS-3D-DWI sequence and WE-3D-DWI sequence were compared in terms of their degree of fat suppression. In CHESS-3D-DWI sequence a preparation phase with a "CHESS-90 degrees RF-motion probing gradient: MPG-180 degrees RF-MPG-90 degrees RF" pulse-train was used to sensitize the magnetization to fat-saturated diffusion. In contrast, WE-3D-DWI sequence a RAGE-excitation pulse with a "binominal-pulse 1-1 or 1-2-1" was selected to water-excited (fat-saturated) diffusion imaging. These imaging were done during in vivo studies using an animal experiment. From experimental results obtained with a phantom, the effect of diffusion weighting and the effect of fat-saturation were confirmed. Fat-saturation was much better in the WE-3D-DWI sequence than CHESS-3D-DWI sequence. From rat experimental results, fat-saturated diffusion-weighted image data were obtained. This sequence was useful for in vivo imaging.

An outbreak of psittacosis in a bird park in Japan

An outbreak of psittacosis related to a bird park occurred in Matsue City, Shimane Prefecture, Japan, during winter 2001. Seventeen cases of psittacosis (12 visitors, three staff, and two student interns) were confirmed. A cohort study was conducted among the park staff and students to determine the risk factors for the development of acute serologically confirmed psittacosis (SCP) infection. Being 'bird staff' had an increased risk of SCP infection (RR 3.96, 95% CI 1.48-10.58). Entering the staff building, where ill birds were maintained without proper isolation, was also associated with an increased risk of SCP infection (RR 3.61, 95% CI 1.03-12.6). Isolation of ill birds and quarantine measures were found to be insufficient. Dehumidifiers and a high-pressure water spray under a closed ventilation environment may have raised the concentration of Chlamydophila psittaci in the hothouses. Bird park staff and visitors should be educated about psittacosis.

Gastrointestinal tract perforation: CT diagnosis of presence, site, and cause

Gastrointestinal tract perforation is an emergent condition that requires prompt surgery. Diagnosis largely depends on imaging examinations, and correct diagnosis of the presence, level, and cause of perforation is essential for appropriate management and surgical planning. Plain radiography remains the first imaging study and may be followed by intraluminal contrast examination; however, the high clinical efficacy of computed tomographic examination in this field has been well recognized. The advent of spiral and multidetector-row computed tomographic scanners has enabled examination of the entire abdomen in a single breath-hold by using thin-slice sections that allow precise assessment of pathology in the alimentary tract. Extraluminal air that is too small to be detected by conventional radiography can be demonstrated by computed tomography. Indirect findings of bowel perforation such as phlegmon, abscess, peritoneal fluid, or an extraluminal foreign body can also be demonstrated. Gastrointestinal mural pathology and associated adjacent inflammation are precisely assessed with thin-section images and multiplanar reformations that aid in the assessment of the site and cause of perforation.

Pattern recognition as a caring partnership in families with cancer

Pattern recognition as a caring partnership in families with cancer The purpose of this study was to address the process of a caring partnership by elaborating pattern recognition as nursing intervention with families with cancer. It is based on Newman's theory of health as expanding consciousness within the unitary-transformative paradigm and is an extension of a previous study of Japanese women with ovarian cancer. A hermeneutic, dialectic method was used to engage 10 Japanese families in which the wife-mothers were hospitalized because of cancer diagnosis. The family included at least the woman with cancer and her primary caregiver. Each of four nurse-researchers entered into partnership with a different family and conducted three interviews with each family. The participants were asked to describe the meaningful persons and events in their family history. The family's story was transmuted into a diagram of sequential patterns of interactional configurations and shared with the family at the second meeting. Evidence of pattern recognition and insight into the meaning of the family pattern were identified further in the remaining meetings. The data revealed five dimensions of a transformative process. Most families found meaning in their patterns and made a shift from separated individuals within the family to trustful caring relationships. One-third of them went through this process within two interviews. The families showed increasing openness, connectedness and trustfulness in caring relationships. In partnership with the family, each nurse-researcher grasped the pattern of the family as a whole and experienced the meaning of caring. Pattern recognition as nursing intervention was a meaning-making transforming process in the family-nurse partnership.

A retrospective study of speech development in patients with submucous cleft palate treated by four operations

Fifty patients with submucous cleft palate (SMCP) who had had four different operations were reviewed. The operations were pushback palatoplasty (n = 18), pharyngeal flap (n = 21), pushback palatoplasty combined with a pharyngeal flap (n = 8), and Furlow palatoplasty (n = 3). Postoperatively the speech of 8, 19, 7, and 2 patients, respectively, improved so that it was within normal limits. A secondary pharyngeal flap was done for six patients, each of whom had previously had a pushback palatoplasty. They all improved, five achieving relatively normal speech, and one good speech. No patient developed hyponasality or airway compromise associated with the pharyngeal flap. The results show that pharyngeal flap and pushback palatoplasty combined with a pharyngeal flap seem to be more reliable procedures than pushback palatoplasty for patients with SMCP.

The Effect of Hydrostatic Weighting on the Vertical Temperature Structure of the Solar Corona

We investigate the effect of hydrostatic scale heights lambda(T) in coronal loops on the determination of the vertical temperature structure T&parl0;h&parr0; of the solar corona. Every method that determines an average temperature at a particular line of sight from optically thin emission (e.g., in EUV or soft X-ray wavelengths) of a mutlitemperature plasma is subject to the emission measure-weighted contributions dEM&parl0;T&parr0;&solm0;dT from different temperatures. Because most of the coronal structures (along open or closed field lines) are close to hydrostatic equilibrium, the hydrostatic temperature scale height introduces a height-dependent weighting function that causes a systematic bias in the determination of the temperature structure T&parl0;h&parr0; as function of altitude h. The net effect is that the averaged temperature seems to increase with altitude, dT&parl0;h&parr0;&solm0;dh>0, even if every coronal loop (of a multitemperature ensemble) is isothermal in itself. We simulate this effect with differential emission measure distributions observed by SERTS for an instrument with a broadband temperature filter such as Yohkoh/Soft X-Ray Telescope and find that the apparent temperature increase due to hydrostatic weighting is of order DeltaT approximately T0h&solm0;r middle dot in circle. We suggest that this effect largely explains the systematic temperature increase in the upper corona reported in recent studies (e.g., by Sturrock et al., Wheatland et al., or Priest et al.), rather than being an intrinsic signature of a coronal heating mechanism.

Relation between Flare-associated X-Ray Ejections and Coronal Mass Ejections

In an attempt to identify the direct signatures of coronal mass ejections (CMEs) in soft X-ray wavelengths, we have searched for plasma ejections in Yohkoh soft X-ray telescope (SXT) images in a total of 17 limb flares, and compared the results with the Solar and Heliospheric Observatory LASCO data. A general correlation exists between the presence/absence of the X-ray ejection and the CME. Although the height versus time relation often indicates (under the assumption of constant speed) that the CME onset coincides with the X-ray ejection, the latter probably does not represent the CME front, because the CME speed must result from acceleration, which would put the estimated onset at an earlier time. In some cases, the estimated CME onset time comes well before the impulsive phase of the associated flare. Although the role of the flare-associated plasma ejection in a CME is still unclear, we propose that its occurrence depends on the presence of open field lines, which can be due to a preceding CME. Lastly, we present a rare example of SXT observations of what appeared to be the three-part structure of a CME, which was seen a few minutes before a major flare started.

Ultra low-dose helical CT of the chest: evaluation in clinical cases

OBJECTIVE

To compare the visibility of normal lung structures and pulmonary abnormalities between ultra low-dose helical CT (ULHCT: 6 mA) and low-dose helical CT (LHCT: 50 mA), and to assess the feasibility of ULHCT for lung cancer screening.

MATERIALS AND METHODS

The reduction of tube current to 6 mA was achieved by using an alminum filter installed in an X-ray tube. After obtaining informed consent, both ULHCT and LHCT of the whole lung were performed in five volunteers and 51 patients, with scanning parameters of 120 kV, 1 rotation/second, 10 mm collimation, and 20 mm/second table speed, during a single breath hold. Images were reconstructed every 5 mm with a 180-degree interpolation algorithm. Three chest radiologists were independently asked to compare the visibilities of normal lung structures using a four-point grading scale, and the scores were compared between ULHCT and LHCT. Pulmonary abnormalities including nodules (less than 20 mm) and other abnormalities (mass, consolidation) were evaluated using four decision levels (A: ULHCT equal to LHCT, B: inferior to LHCT but acceptable, C: much inferior to LHCT and not acceptable, D: not visible) and compared between ULHCT and LHCT. Visibility was also compared between the apical and non-apical regions.

RESULTS

99% of the normal lung structures were judged to be visible in ULHCT, and 236 of 345 (68%) of the nodules were judged as "A" and 92 (27%) as "B". Even with nodules of less than 5 mm, judgements of "A" and "B" were made in 74% and 23%, respectively. The visibility of nodules on the ULHCT was worse in the apical region than in the non-apical region (p<0.01). Other lung abnormalities were also graded as "A" (61%) or "B" (34%). No nodules or abnormalities were graded as "D".

CONCLUSION

ULHCT has the potential to be utilized in lung cancer screening.

Craniofacial morphology of conotruncal anomaly face syndrome

OBJECTIVE AND DESIGN

The conotruncal anomaly face syndrome (CTAF) comprises congenital heart disease and dysmorphic face, and is frequently associated with cleft palate or hypernasality. There have been many discussions about the overlap with velocardiofacial syndrome (VCF). The aim of this study was to clarify the craniofacial characteristics of CTAF patients by clinical examination, and photogrammetric and cephalometric analyses, and to clarify the differences compared to published data on VCF.

RESULTS

The facial features of CTAF included hypertelorism, small palpebral fissures, upward slanting of palpebral fissures, bloated eye lids, low nasal bridge, small mouth, open mouth at rest, and malformed auricles. Cephalometric features included bialveolar protrusion, small gonial angle, backward rotation of the mandibular ramus, and labial inclination of the maxillary incisors. An acute cranial base angle was also noted. These results differed from those of VCF. There were, however, no obvious pathognomonic findings for the differential diagnosis between CTAF and VCF.

CONCLUSIONS

Considering these findings, use of CATCH 22, the inclusive classification of cardiac anomalies, cleft palate, and dysmorphic face may be of value for the clinical understanding in these patients.

[A new mechanically manipulated unit for CT-guided biopsy]

To avoid radiation exposure to the radiologist during biopsy with CT fluoroscopy, we have developed a new system for CT-guided biopsy. The system is composed of three parts, a needle holder, arm and support. The automatic biopsy needle is mechanically remote controlled by flexible shafts with four functions. In the phantom study and the clinical trial, we were able to biopsy nodules under remote control with this equipment, eliminating radiation exposure to the radiologist. Although a few refinements of the system are necessary, it may enable us to perform CT-guided biopsy more safely and easily.

Hilar and mediastinal invasion of bronchogenic carcinoma: evaluation by thin-section electron-beam computed tomography

The diagnostic accuracy of thin-section incremental dynamic computed tomography (IDCT) using an electron-beam scanner in evaluating hilar or mediastinal invasion of bronchogenic carcinoma was assessed. Thirty-seven patients with proven bronchogenic carcinoma, contiguous with hilar or mediastinal structures, underwent IDCT. The area of contact was scanned using 19 contiguous 3-mm thick sections during injection of contrast material. The degree of contact between mass and pulmonary artery or vein and their distortion were recorded. Irregular thickening of the bronchial wall, soft tissue within the lumen, or distortion were used to determine airway involvement. Sixty-nine sites were assessed retrospectively and compared with pathology reports. The accuracy, sensitivity, and specificity in evaluating invasion of the pulmonary artery were 75.0%, 77.8%, and 71.4%, respectively. Limited reliability also was found for invasion of the main bronchus and "secondary" carina, with accuracies of 66.7% and 70.5%, sensitivities of 75.0% and 70.0%, and specificities of 57.1% and 71.4%, respectively. Thin-section IDCT with electron beam scanner is not accurate in the detection of hilar or mediastinal invasion by bronchogenic carcinoma.

Double cystic duct found by intraoperative cholangiography in laparoscopic cholecystectomy

We report a rare case of double cystic duct in a 74-year-old woman. The patient complained of mild epigastric discomfort, and several stones were discovered by ultrasonography and computed tomography. Any anomalies of the biliary tract were undetectable in the preoperative examinations without direct cholangiography. Laparoscopic cholecystectomy was performed. After clipping the cystic duct close to the gallbladder, as usual, serial intraoperative cholangiography was performed and unexpectedly showed the inflow of contrast medium into the gallbladder via another cystic duct arising from the right hepatic duct, thus revealing one gallbladder and two cystic ducts, one of which joined the common hepatic duct and the other the right hepatic duct. There was only one cystic artery that arose from the right hepatic artery and accompanied the primary cystic duct to be distributed to the gallbladder. The existence of contrast medium in the resected specimen was confirmed by radiography. No complications occurred during or after laparoscopic cholecystectomy. This is the first report of double cystic duct found in laparoscopic cholecystectomy. We recommend routine preoperative or intraoperative cholangiography.

MAGGY, a retrotransposon in the genome of the rice blast fungus Magnaporthe grisea

Full-length copies of a previously described repetitive DNA sequence (CH2-8) were isolated from the genome of the Magnaporthe grisea strain 2539. One copy of the complete element was sequenced and found to resemble a gypsy-like LTR retrotransposon. We named this element MAGGY (MAGnaporthe GYpsy-like element). MAGGY contains two internal ORFs putatively encoding Gag, Pol and Env-like proteins which are similar to peptides encoded by retroelements identified in other filamentous fungi. MAGGY was found to be widely distributed among M. grisea isolates from geographically dispersed locations and different hosts. It was present in high copy number in the genomes of all nine rice-pathogenic isolates examined. By contrast, M. grisea strains isolated from other Gramineae were found to possess varying copy numbers of MAGGY and in some cases the element was completely absent. The wide distribution of MAGGY suggests that this element invaded the genome of M. grisea prior to the evolution of rice-specific form(s). It may since have been horizontally transmitted to other sub-specific groups. One copy of MAGGY, corresponding to the element we sequenced, was located at identical locations in the genomes of geographically dispersed strains, suggesting that this copy of the element is a relatively ancient insertion.

Peribronchovascular interstitium of the pulmonary hilum: normal and abnormal findings on thin-section electron-beam CT

The peribronchovascular interstitium, including bronchial vessels and lymphatic channels, is an important anatomic component of the lung, especially the pulmonary hilum [1-3] (Fig.1). Various pathologic processes involve and spread along this interstitium [4, 5]. Although it has been difficult to accurately evaluate the morphologic changes occurring in the peribronchovascular interstitium with conventional CT or MR imaging [6], spiral CT and electron-beam CT can show these changes clearly and consistently [7, 8]. A judgement as to whether the peribronchovascular interstitium is normal or abnormal is necessary for the CT diagnosis of pulmonary hilar lesions. In this assay, the normal peribronchovascular interstitium and various pathologic processes involving this interstitium are shown as they appear on thin-section electron-beam CT scans.

[Ultra-low-dose spiral (helical) CT of the thorax: a filtering technique]

To reduce the radiation dose from spiral (helical) CT, a custom-made aluminium filter was installed in the X-ray tube and a reduction of effective tube current was attempted. A pronounced reduction of effective tube current, namely, 6 and 3 mA, was achieved with 26 and 37 mm thick aluminium filters, respectively. Visualization of normal lung structure was accomplished with both 6 and 3 mA settings. However, images of 3 mA failed to delineate mediastinal structures because of marked beam hardening resulting from the bone structure of the thoracic inlet. Six mA was considered the lowest dose setting of spiral (helical) CT of the thorax that could be used for lung cancer screening.

The pattern of palatal rugae in submucous cleft palates and isolated cleft palates

The early diagnosis of submucous cleft palate is important. In children too young to tolerate nasendoscopy and videofluoroscopy the diagnosis depends on the clinical history and intraoral examination. We have studied the pattern of the hard palate rugae to investigate their possible diagnostic significance. Maxillary dental casts were obtained from 16 patients with submucous cleft palate, 17 patients with isolated clefts of the secondary palate, and 10 non-cleft controls. The hard palate mucosa had a unique feature in 14 (87.5%) of the submucous cleft palates: one or more of the palate rugae curved towards the region of the bony notch in the posterior border of the hard palate. The 2 cases without this rugae pattern did not have a detectable bony notch. In 100% of the isolated cleft palate cases, one or more of the rugae curved towards the anterior end of the cleft. This feature was not seen in any of the non-cleft controls. We consider this rugae pattern to be an additional diagnostic feature of submucous cleft palate.

[Anaphylactoid purpura: intestinal ultrasonographic findings]

We evaluated six children with anaphylactoid purpura for ultrasonographic changes in the small intestine. Of 16 ultrasonographic scans, eight showed abnormal findings, consisting of circumscribed hypo-echoic enlargement, reduced peristalsis, equivocal structure of the small intestinal wall and ascites in patients with abdominal pain. Follow-up ultrasonography after steroid therapy demonstrated the small intestine to be normal in four of six patients. We believe that ultrasonography is an useful diagnostic modality to detect changes in the small intestinal wall in anaphylactoid purpura and plays an important role in its differentiation from other causes of abdominal pain.