Anterior choroidal artery aneurysm and stroke

We report the unique combination of a mid anterior choroidal artery (AChA) aneurysm and ischemic stroke presenting as a movement disorder in a young man. The mechanism for stroke in the AChA territory may either reflect a cause or an effect of aneurysm formation. We provide evidence for both arguments and speculate on the anatomic basis for the initial presentation of hemibody spasm.     

Interferon gamma up-regulates a novel protein in vascular smooth muscle cells

PURPOSE: By means of the technique of messenger RNA (mRNA) differential display, we previously isolated a partial DNA clone found to be down-regulated at the polytetrafluoroethylene (PTFE) hyperplastic arterial anastomosis compared with the normal artery. The partial DNA gene sequence was found to be homologous with interferon gamma up-regulated protein (IGUP) first found in human psoriatic keratinocytes. We cloned the entire IGUP gene from human vascular smooth muscle cells (VSMCs) to determine its regulation by gamma interferon (gamma-IFN) and other cytokines in cultured human VSMCs. METHODS: By means of polymerase chain reaction, the IGUP gene was amplified from a QUICK-Clone complementary DNA human aorta kit using 5' and 3' oligonucleotide primers to the known IGUP sequence. Immunohistocytochemistry studies compared normal artery and distal anastomotic IH. Human VSMCs were stimulated with 1000 U/mL of gamma-IFN, 5 ng/mL of platelet-derived growth factor BB (PDGF-BB), 3. 2 ng/mL basic fibroblast growth factor, 3.3 ng/mL transforming growth factor beta(TGF-beta), 10 ng/mL of vascular endothelial growth factor, and 10% fetal bovine serum (FBS) for zero, 24, 48 and 72 hours. Western blot analysis of lysates of the stimulated VSMCs was performed to determine up-regulation of IGUP. RESULTS: DNA sequencing confirmed the cloning of the entire coding region of the IGUP gene with 100% homology to the known IGUP DNA sequence. There was strong expression of IGUP in quiescent VSMCs and marked reduction of expression of IGUP in proliferating smooth muscle cells. gamma-IFN was the only cytokine, of the cytokines evaluated, to up-regulate production of IGUP in VSMCs. CONCLUSION: IGUP is a novel protein in VSMCs found to be down-regulated in areas of anastomotic IH, as compared with a normal artery. We have now shown IGUP to be up-regulated only by gamma-IFN in human VSMCs. IGUP may, therefore, be the intermediary for the known gamma-IFN inhibition of human VSMC proliferation.     

Hyperplastic persistent pupillary membrane

PURPOSE: To report a child with extensive bilateral hyperplastic pupillary membranes and good visual acuity. METHOD: We examined a 9-year-old child with bilateral hyperplastic persistent pupillary membranes present since birth. RESULTS: The patient had a visual acuity of BE, 20/30, stereopsis of 50 seconds of arc, orthophoria, and normal extraocular movements. The remainder of the ophthalmic examination was normal. CONCLUSION: Patients with bilateral hyperplastic pupillary membranes may not require surgical intervention.     

The value of early postoperative oesophagography following repair of oesophageal atresia

The aim of the study was to examine the relationship between anastomotic leaks and the development of symptomatic anastomotic strictures after primary repair of oesophageal atresia (OA) with or without tracheo-oesophageal fistula (TOF) and the prognostic value of the anastomotic appearance on postoperative oesophagography. The records and X-ray films of 49 patients with OA with or without TOF admitted between January 1990 and June 1995 were reviewed retrospectively. Of these, 37 had a primary repair (34 immediate and 3 delayed) and a postoperative contrast swallow was done between day 5 and day 30 (median day 7). Radiological leaks were documented. In addition, the maximum transverse diameters of the upper pouch and anastomotic region and the length of the anastomotic narrow segment were measured; the ratio of upper-pouch diameter to that of the anastomosis was calculated (anastomotic index, AI). The need for dilatation of symptomatic anastomotic strictures and for repeat dilatation as a separate episode were documented. Of the 37 patients, 4 developed an anastomotic leak (11%), 3 radiological and 1 clinical. A symptomatic stricture occurred in 55% of patients. There was no correlation between a leak and later development of a symptomatic stricture, although the small number of patients with leaks precluded definite conclusions. No radiological leak progressed to a clinical leak. There was no correlation between the AI or the length of the anastomotic narrow segment and the need for dilatation, the need for repeat dilatation, or the number of dilatations. In this study, the presence of a leak, the AI, and the length of the narrow segment on early postoperative contrast swallow did not correlate with the later development of a symptomatic stricture. A radiological leak was of no clinical significance. Since major leaks are apparent clinically, an early routine contrast study did not influence management and is not necessary.     

Early detection of anastomotic leaks after colorectal surgery by measuring endotoxin in the drainage fluid

BACKGROUND/AIMS: Early detection of anastomotic leaks after colorectal anastomosis is essential for adequate intervention to prevent peritonitis. We investigated whether the measurement of endotoxin (LPS) concentrations in the drainage has any value for the early detection of anastomotic leaks. MATERIALS AND METHODS: Twenty two patients with colorectal anastomosis were enrolled in this study, 3 developed clinically established signs of anastomotic leaks and 19 recovered without complications. LPS concentrations in the drainage, the total daily excreted LPS amounts, leukocyte and thrombocyte counts, plasma urea and creatinine, and body temperature were measured for up to 8 days after surgery and tested for their value to detect anastomotic leaks. RESULTS: LPS concentrations in the drainage fluid and daily excreted LPS amounts of patients with anastomotic leaks were significantly higher compared to the group without anastomotic leaks. On the third postoperative day, LPS concentrations ranged from 5270 to 6750 pg/ml in patients with anastomotic leaks and from 1 to 1848 pg/ml in patients without complications. Total daily excreted LPS amounts were 270-675 ng/day in patients with anastomotic leak and 0-92 ng/day in patients without anastomotic leaks. Both LPS-related parameters allowed reliable detection of anastomotic leaks on day 3 after surgery (Student's t-Test, p < 0.0005), while leukocyte and thrombocyte counts, plasma urea and creatinine, and body temperatures of both patient groups were not significantly different at any time (p > 0.05). CONCLUSION: We found that the measurement of LPS concentrations in the drainage and the daily excreted LPS amount could be valuable parameters for the early detection of anastomotic leaks as early as on the third post-operative day.     

Role of chronic inflammation in the promotion of prostatic hyperplasia in rats

PURPOSE: Chronic prostatitis is a common histopathological finding in prostatectomized patients. A possible interrelationship between the presence of leukocyte exudate and the extent of the hyperplastic lesions has been suggested. The aim of the present study was to analyze the effect of the immunomodulator compounds, Complete Freund Adjuvant (CFA) and cyclosporin A (CsA), administered alone or together with citral on the induction and extent of rat prostatic hyperplasia. MATERIALS AND METHODS: Adolescent Wistar rats (42 days old) were given citral alone or combined with CFA or CsA for one month. Semiquantitative analysis of the extent of the hyperplastic lesions was made with the histoscore protocol. RESULTS: CsA did not induce hyperplastic changes or abolish the ability of citral to promote hyperplastic changes or to affect the extent of the lymphocytic exudate in the stroma. CFA itself, however, had a proliferative action on the prostatic epithelium, and it augmented the hyperplastic changes induced by citral and even induced atypical transformations of the acinar epithelium. CONCLUSIONS: Immunoinflammatory stimulators might play a role in the prostatic epithelial cell growth and proliferation processes, most probably by modulation of the cytokine system.     

A new technique of esophagogastrostomy above the aortic arch--covering and suspending of the anastomotic area with mediastinal pleura flap

The postoperative anastomotic leakage is the most severe complication and the principal cause of death after resection of esophageal carcinoma. Especially, anastomosis above the aortic arch is accompanied by high incidence of anastomotic leakage usually with fatal prognosis. The authors improved the conventional method of anastomosis by using a mediastinal pleura flap to cover and suspend the anastomotic area with excellent result. From January of 1990 to April of 1995, 210 patients with esophageal carcinoma were so treated. No anastomotic leakage or stricture developed. Only one patient died of extensive myocardial infarction with an overall mortality of 0.47%. The major merit of this procedure was that the mediastinal pleura flap could cover the area of anastomosis and sustain the dragging force acting on this area, providing a better condition for the anastomosis to heal and thus reducing the possibility of anastomotic leakage.     

Effect of dose size on the pharmacokinetics of orally administered quinine

Parathyroid scintigraphy is useful in detecting residual hyperplastic parathyroid tissue in patients who continue to have hyperthyroidism after "total parathyroidectomy." Typically, only the neck and mediastinum are imaged. The authors report a case in which images of the forearm were helpful in detecting hyperplastic autologous transplanted parathyroid tissue.     

In situ hybridization to detect the mRNA for insulin-like growth factor-I and II in the prostate

In order to well understand the expression of mRNA for insulin-like growth factor I and II in normal and hyperplastic prostate, in situ hybridization were used to detect them in a total of 35 cases of prostate. Both the normal and the hyperplastic prostate expressed the mRNA for IGF-I/II. The mRNA for IGF-I was mainly expressed by the epithelial cells and the IGF-II was mainly expressed by the stromal cells. The hyperplastic tissues expressed higher levels of the mRNA for IGF-I and IGF-II. The results suggested that the IGF might play an important role in the regulation of prostate growth and the pathogenesis of benign prostatic hyperplasia.     

Clinical evaluation of fundic gland polyps and hyperplastic polyps

We performed a retrospective review of 477 cases of fundic gland polyps compared with 562 cases of hyperplastic polyps, which were detected endoscopically during the past 8 years between January, 1989 and December, 1996. All lesions were histologically confirmed by endoscopic biopsy or the examination of polypectomy specimens. Fundic gland polyps were more prevalent in middle aged-female, and were not associated with gastric adenomas and gastric cancers. These results suggested that the background mucosa of patients with fundic gland polyp was different from that of patients with hyperplastic polyp. Fundic gland polyps in 55 patients were followed up. No change was observed in the polyps of the about half subjects, the polyps of 12 cases (21.8%) decreased in size and number or resolved completely. Cases decreased in size and number or resolved completely were much more in fundic gland polyps than hyperplastic polyps. There were no malignant transformation of fundic gland polyps. We claimed that fundic gland polyps were benign and distinct from hyperplastic polyps which had a possibility of malignant transformation.     

Effects of the synthetic anti-oxidant, probucol, on the U937 monoblastoid cell line

We examined physiological events in the hyperplastic artery, using a method based on the mechanical responsiveness and myosin light-chain phosphorylation in response to various stimulants. Six weeks after endothelial denudation by ballooning of the right carotid artery, strips of this artery with moderate intimal hyperplasia (intimal area was 30-50% of medial area in 20 of 28 rabbits) were used for experiments. Strips from the left carotid served as the normal control. When the hyperplastic artery was stimulated with 30 microM PGF2 alpha, the maximal tension (232.4 +/- 49.1 mg/mg dry wt, mean +/- SD) was significantly higher (P < 0.05) than that of the control (129.5 +/- 16.4 mg/mg). The maximal extent of myosin light-chain monophosphorylation (45.4 +/- 8.9%) and diphosphorylation (10.9 +/- 5.2%) in the hyperplastic artery was significantly higher (P < 0.05) than that in the control artery (33.0 +/- 4.8 and 4.0 +/- 4.8%, respectively). The monophosphorylation of the myosin light chain in the hyperplastic artery was sustained for up to 20 min, while that in the control artery decreased to the basal level within 20 min. Similar observations were obtained by stimulation with 60 mM K+ or 30 microM norepinephrine. Dose-response curves of the development of tension in the hyperplastic artery to various agonists (K+, PGF2 alpha, norepinephrine) shifted upward the curves for the control artery. These results suggest that qualitative changes in the characteristics of smooth muscle cells may occur in the intimal hyperplastic portion, including a hyperreactive contraction associated with enhanced and sustained phosphorylation of the myosin light chain.     

Pneumocephalus and respiratory depression after accidental dural puncture during epidural analgesia--a case report

BACKGROUND: Adenomatous colonic polyps are accepted as premalignant lesions. There is controversy regarding the significance of the hyperplastic polyp. The aim of this study was to determine the incidence of further polyps in patients with only hyperplastic polyps on a first colonoscopy in comparison with patients without polyps and with adenomatous polyps. METHODS: Ninety patients had only hyperplastic polyps (group I). These patients were paired according to age and sex with subjects having no polyps (group II) and with patients having adenomas (group III). RESULTS: Fifty-six patients in group I had at least one follow-up examination. New polyps were found in 46.4% in group I versus 15.5% in group II (p < 0.001) and 50% in group III (NS). In group I, 30.7% of new polyps were hyperplastic and 69.3% were adenomas. In fact, 32.2% of group I patients developed further adenomas (mean 1.5 +/- 0.8 adenomas). These adenomas occurred 1 to 4 years after the first polypectomy (mean 2.4 +/- 0.8 years). Most of these adenomas were small and tubular, but 16.6% were villous or had severe dysplasia. CONCLUSION: Patients with hyperplastic polyps were 2.4 times more likely to have further adenomas than were those without polyps.     

Anastomotic stenoses correlated with the use of mechanical staplers in the surgery of esophageal cancer

From 1990 to 1995, 187 patients underwent esophagectomy and esophagogastrostomy with the anastomosis performed inside the chest using a circular stapler. Twenty-three patients (12.3%) developed an anastomotic stricture. The incidence of anastomotic stricture was inversely related to the diameter of the stapler. Also concomitant cardiovascular diseases, morpho-functional disorders of the tubulized stomach (possible related to duodeno-gastric reflux) and neoadjuvant chemotherapy were recognized as significant risks factors. Endoscopic dilations were safe and effective in the treatment of anastomotic strictures.     

A case-control study of dietary intake and other lifestyle risk factors for hyperplastic polyps

BACKGROUND & AIMS: Despite the high prevalence of the hyperplastic polyp, little is known about its etiology. The aim of this study was to assess the relationship between diet and other lifestyle factors and the presence of colorectal hyperplastic polyps. METHODS: Information on diet and other known or suspected risk factors for colorectal cancer or adenoma was collected among 81 subjects with hyperplastic polyps and 480 controls. RESULTS: The multivariate-adjusted odds ratio (OR) for hyperplastic polyps for individuals in the upper vs. the lower quartile was 0.30 (95% confidence interval [CI], 0.10-0.88) for dietary fiber, 0.32 (95% CI, 0.11-0.96) for dietary calcium, 0.90 (95% CI, 0.27-2.95) for total fat, and 2.02 (95% CI, 1.05-3.91) for alcohol consumption. Compared with individuals in the lower category, those in the upper category of body mass index had a higher risk for hyperplastic polyps (OR, 4.50; 95% CI, 1.84-10.97). Cigarette smoking was associated with a higher risk (OR, 1.97; 95% CI, 1.02-3.81 for > 20 pack-years vs. never), whereas an inverse association was seen for use of aspirin and other nonsteroidal anti-inflammatory drugs (OR, 0.29; 95% CI, 0.12-0.67 for once per day or more vs. never). CONCLUSIONS: Hyperplastic polyps share common lifestyle risk factors with colorectal adenomas and carcinomas.     

Protective effect of RibCys following high-dose irradiation of the rectosigmoid

Ribose-cysteine (RibCys) is a prodrug of L-cysteine that stimulates glutathione biosynthesis. Increased glutathione levels have been shown to have a protective effect against radiation-induced injury and oxidative stress. Surface oximetry has previously been used successfully to predict anastomotic leakage. PURPOSE: The following study was done to evaluate the protective effect of RibCys and the predictive value of PtO2 determinations in a swine model. METHODS: Domestic swine were divided into three groups: Group A served as a nonradiated control; Group B received 6,000 to 6,500 rad to the rectosigmoid; and Group C received RibCys (1 g/kg) prior to receiving 6,000 to 6,500 rad. Radiated animals and controls underwent rectosigmoid resection after a three-week rest period. Intraoperative anastomotic PtO2 was checked with a modified Clark electrode. Anastomoses were evaluated radiographically at three and seven days; animals were sacrificed, and bursting strength was recorded at 10 days. RESULTS: Mean bursting pressures were 243.8 +/- 59.4, 199.5 +/- 37.8, and 209.5 +/- 54.9 mmHg (NS) for Groups A, B, and C, respectively. Anastomotic PtO2 ranged from 19 to 98 mmHg and could not be correlated with anastomotic leaks or bursting pressure. There were 11/15 radiation-related deaths and leaks (eight deaths and three leaks) in the radiated group and 4/12 radiation-related deaths and leaks (three deaths and one leak) in the group receiving radiation and RibCys (P < 0.04). CONCLUSIONS: 1) RibCys protected animals against radiation-related deaths and anastomotic leaks following high doses of pelvic irradiation; 2) anastomotic PtO2 levels did not correlate with anastomotic healing in this model.     

Wound healing of intestinal anastomosis after digestive surgery under septic conditions: participation of local interleukin-6 expression

This study aimed to evaluate the integrity of anastomotic wound healing after digestive surgery under septic conditions and to observe local interleukin-6 (IL-6) expression around the anastomotic segment. Experimental animals were separated into lipopolysaccharide (LPS) and control groups. Each was injected with LPS or normal saline solution into the peritoneal cavity 24 hours before transection and anastomosis of the colon. The anastomotic bursting pressure (ABP) and tissue hydroxyproline concentration (HP) were measured as indicators of wound healing. Immunohistochemical staining for IL-6 was performed on tissue samples obtained from the anastomotic segment, lung, liver, and kidney. The reactive cells were counted by light microscopy. The ABP and HP were significantly lower in the LPS group than the control group 7 days after the surgery. In the LPS group, IL-6 expression around the anastomotic segment was enhanced 1 and 6 hours after surgery but suppressed 24 hours afterward. In contrast, IL-6 expression in lung, liver, and kidney was enhanced in the LPS group 24 hours after surgery but not in the control group. It is suggested that anastomotic wound healing is impaired after digestive tract surgery under septic conditions, and local IL-6 expression participates in wound healing.     

Regional chemotherapy of liver tumors

In the absence of adequate autogenous vein for tibial artery bypass in limb salvage surgery, the use of prosthetic grafts with a distal anastomotic vein cuff or patch has shown promising results. Here, we describe how the Florester Internal Vessel Occluder (Meadox UK, Bedfordshire, UK) can facilitate the construction of a distal anastomotic vein cuff.     

Intestinal anastomosis with the biofragmentable anastomosis ring

BACKGROUND: The fear of anastomotic complications prevents the spread of the use of the biofragmentable anastomosis ring (BAR) in intestinal surgery. PATIENTS AND METHODS: A total of 453 patients underwent intestinal resection and anastomosis with the BAR. RESULTS: In all, 514 anastomoses have been carried out, 424 (83%) in elective settings, and 90 (18%) in emergency. Fifty-one patients had multiple anastomoses. Reoperation was performed in 4 patients (1%) who had a complete anastomotic leakage. In 13 patients (3%), anastomotic leakage was partial, and only 1 patient required reoperation. No postoperative intestinal obstruction occurred. Four patients (1%) developed late anastomotic strictures, which have been treated by endoscopic dilation. CONCLUSIONS: The results of our experience and those of other large clinical series definitely confirm the effectiveness of the BAR method, which seems to be a standard, easy, rapid, and safe technique either in elective or emergency surgery.     

Growth and function of human parathyroid tissue transplanted to athymic mice

The morphology, cell proliferation and function of transplanted normal, hyperplastic and adenomatous human parathyroid tissue was studied after transplantation to athymic mice. The iPTH was evaluated in relation to morphology. Human parathyroid tissue collected during surgery for hyperparathyroidism was implanted subcutaneously into athymic mice (nu/nu-BALB/cA) and was analysed 1, 4, 7 and 12 weeks after transplantation. The transplants were examined by light and electron microscopy and by autoradiography after continuous infusion of 3H-thymidine. The relative amount of viable tissue was evaluated using a computer image analysing programme. Graft function was evaluated by measuring human iPTH in mouse serum. A transplant take ratio of 93% was observed. The proliferation rate in adenoma grafts at 12 weeks after transplantation was five and fifteen times that observed in normal and hyperplastic transplants, respectively. In normal and adenoma groups, a continuous increase in iPTH concentrations was observed, but in the hyperplastic group the iPTH remained on the same level. The secretion of iPTH in relation to the amount of transplanted tissue and the fraction of viable tissue was at the same level at 12 weeks in normal and adenomatous grafted animals. In conclusion, human parathyroid tissue was successfully transplanted and maintained its original structure. The growth potential, but not the iPTH secretion, was significantly higher in adenoma grafts compared to grafts from hyperplastic and normal glands.