Can laparoscopic antireflux surgery improve the quality of life in children with neurologic and neuromuscular handicaps?

Purpose

Children with neurologic and neuromuscular handicaps frequently have various symptoms related to gastroesophageal reflux (GER) disease. The long-term efficacy of antireflux surgery remains controversial in such children with GER. The clinical results of such patients who underwent laparoscopic fundoplication were examined in the current study.

Methods

Between 1997 and 2003, laparoscopic fundoplication was performed in 56 handicapped children (mean age, 6 years), and gastrostomy was performed concurrently in 52. The main symptoms were emesis/hematemesis in 40 and respiratory symptoms, including repeated respiratory infection and distress, in 31.

Results

There were no severe postoperative complications or operative mortality. Emesis/hematemesis was controlled adequately in those without recurrence. Respiratory symptoms were controlled unsuccessfully in 16 patients (52%), 8 of whom required further respiratory care including nasal airway tube, tracheostomy, and laryngotracheal separation. Recurrence of GER disease occurred in 10 patients, 7 of whom underwent a second Nissen fundoplication successfully. Thirteen died within the median follow-up period of 14 months.

Conclusions

Laparoscopic fundoplication is effective in controlling emesis/hematemesis, but its efficacy is limited in terms of respiratory problems in handicapped children. Further refinements in diagnostic and treatment strategies are mandatory to improve the quality of life in such patients.     

The immunohistochemical analysis of pendrin in the mouse inner ear

Pendred's syndrome (PS) is an autosomal recessive disorder characterized by deafness and goiter, which are caused by mutations in the Pendred's syndrome gene (PDS). PDS encodes a membrane protein named pendrin that is considered to act as an anion transporter. An expression pattern of the PDS ortholog (Pds) mRNA in the auditory and vestibular systems has been reported in mice, and the localization of pendrin has been reported recently. We generated antipeptide antibodies against human pendrin, and performed immunohistochemical analysis of mouse inner ears. We detected pendrin in the endolymphatic duct and sac, and the utricle, saccule, and external sulcus. In the endolymphatic duct and sac, the expression of pendrin was apparent at the apical membrane. In addition, we detected pendrin in the spiral ligament, Claudius cells, Deiter's cells, and the spiral ganglion of the cochlea. Our results are key to defining the role of pendrin in inner ear development and elucidating the pathogenic mechanisms underlying deafness in PS.     

Clinical impact of using chemoradiotherapy as a primary treatment for hypopharyngeal cancer

Eighty-eight patients with hypopharyngeal cancer who received chemoradiotherapy as the primary treatment between 1979 and 1997 were investigated. Forty-six patients who received surgery as the primary treatment were analyzed as a control group. There were no statistically significant differences regarding TN classification, tumor stage, tumor site, age or sex between the radiation and surgery groups. The 5-year cumulative survival rate of primary chemoradiotherapy was 47% and this did not differ significantly from that for the primary surgery group. The larynx was preserved in 74% of cases in the primary chemoradiotherapy group, a far better preservation rate than that in the surgery group. After primary chemoradiotherapy, complete remission (CR) was observed in 59% of cases and the average period of CR was 38 months. Among patients with residual tumor, a salvage operation was employed in 31 cases, 13 patients refused to receive surgery and 8 were inoperable. A salvage operation was performed in 35% of all cases and the 5-year cumulative survival rate was 50%. Based on the 5-year survival, primary CR, salvage and laryngeal preservation rates, we conclude that chemoradiotherapy is a good primary treatment for hypopharyngeal cancer.     

Treatment of maxillary sinus carcinoma: clinical results using the Kitasato modality

The conventional therapeutic regimen for maxillary sinus carcinoma consists of dissection of the maxilla, full-dose irradiation and extensive chemotherapy. However, the results obtained with this treatment are often poor. Even when patients recover, their quality of life is significantly reduced as a result of deformity of facial structures and swallowing and articulation dysfunctions. A retrospective analysis of 68 patients with maxillary sinus carcinoma treated with the Kitasato modality between 1975 and 1999 was conducted. All patients underwent pergingival maxillary sinus surgery combined with pre- and postoperative irradiation therapy with standardized total doses of 16 Gy; the postoperative irradiation was given in combination with regional intra-arterial infusion chemotherapy administered via the superficial temporal artery. All visible tumor lesions were removed where possible in order to preserve or facilitate cellular immunity after surgery. The cumulative 5-year survival rates were 85.7% for Stage II patients, 88.1% for Stage III, 76.6% for Stage IVA and 75.% for Stage IVB.     

Carcinoma of the nasopharynx: analysis of treatment results in 91 patients

The outcome of 91 patients (69 males, 22 females; age range 16-82 years) with nasopharyngeal carcinoma treated in our hospital between 1971 and 1999 was evaluated. Factors that appeared to influence prognosis were assessed using the Kaplan-Meier method. The cause-specific cumulative 5-year survival rate for the entire study population was 61.2%. The 1997 International Union Against Cancer classification was used for disease staging. The 5-year survival rates were as follows: 66.7% (n = 3) for Stage I; 100% (n = 2) for Stage IIA; 90.9% (n = 11) for Stage IIB; 78.8% (n = 25) for Stage III; 53.0% (n = 29) for Stage IVA; 37.5% (n = 16) for Stage IVB; and 20.0% (n = 5) for Stage IVC. The disease-free cumulative 3-year survival rates of the patients classified based on initial therapy were as follows: radiation alone, 50.0% (n = 28); combined radiotherapy and chemotherapy that included an undefined anti-cancer drug, 67.2% (n = 39); combined radiotherapy and chemotherapy that included carboplatin (CBDCA), 92.3% (n = 19). These results showed a statistically significant difference (p = 0.043; log-rank test). Stage IVC patients were excluded from the analysis. We conclude that combined therapy, including chemotherapy with CBDCA, is necessary for the treatment of nasopharyngeal carcinoma. In terms of radiation therapy, a field covering the bilateral cervical regions seemed to produce favorable results, even if cervical node metastasis was not confirmed by palpation at the first hospital visit. Key words: carboplatin, chemotherapy,     

Head and neck malignancy statistics at Kitasato University

We analyzed and reported on those patients with head and neck (H&N) malignancies who had visited our university within the last 30 years. The number of H&N patients registered per year has gradually increased with time and approximately 120 new patients have been registered annually in recent years. Age-adjusted morbidity has also increased gradually, from 7.06 to 10.55 per 100,000 citizens, in recent years. The population of Sagamihara city has gradually increased in parallel over the same period. Cancers of the pharynx, larynx and oral cavity are the three major H&N tumors. Squamous cell carcinoma was the most commonly seen pathological diagnosis, followed by malignant lymphoma. The 5-year crude survival rate for all patients was 50%. It is suggested that improving the survival rates of cancers of the oral cavity, nasal cavity and paranasal sinuses should be a prerequisite, in order to diminish H&N tumor deaths in Japan. A satisfactory survival rate for cancer of the paranasal sinuses has been achieved at Kitasato University and it is hoped that our modality will further prevail in the near future. Cancer of the oral cavity is visible and can be detected by a simple clinical examination. As H&N surgeons it is necessary to educate all physicians as to the importance of early detection of H&N tumors. We also need to encourage the public to reduce smoking and drinking in order to prevent a further increase in the number of H&N patients. Our assertions are based on the fact that the number of H&N patients in 2050 is estimated to be three times greater than that at present due to the increase in the population of elderly people (assuming the morbidity rate remains constant). Key words: alcohol, cancer trends, morbidity, predictions, tobacco.     

Surgical influence on TH1/TH2 balance and monocyte surface antigen expression and its relation to infectious complications

Abstract Malignancy and operation for it cause several alterations in immune function that are considered to be concerned with the development of infectious complications. Forty-three patients who underwent curative surgery for gastrointestinal malignancies were entered into this study and were divided into two groups, those with and those without postoperative infection. Changes in the proportion of Th1/Th2 subsets in CD4⁺ T cells and the expression of human leukocyte antigen (HLA)-DR and CD16a molecules on monocytes were measured by flow cytometry before and after surgery. We performed intracellular cytokine stainings to exactly detect Th1/Th2 subsets. The proportions of interferon-γ-producing CD4⁺ T (Th1) cells in the preoperative state were almost equal in the two groups, and the proportion decreased on postoperative day (POD) 1 in both groups. On POD 7, the proportion of Th1 cells recovered to the preoperative level in the noninfection group, while the suppression was further reinforced in the infection group (26.8% versus 18.3%, p < 0.005). In contrast, the proportion of interleukin-4-producing CD4⁺ T (Th2) cells in the infection group (11.3%) was already suppressed in the preoperative state when compared with the noninfection group (17.3%, p < 0.005). Changes in HLA-DR and CD16a expression on monocytes were similar to the changes in the proportion of Th1 cells. These results indicate that the suppression of Th1 cell and monocyte functions during the early phase of the postoperative course was directly related to the occurrence of infectious complications and that several immunological impairments have already occurred in the preoperative state in cancer patients. Electronic Publication     

A case of sarcoidosis overlapping with rheumatoid arthritis

We report the case of a 54-year-old woman who presented on May 28, 2001 with sarcoidosis overlapping with rheumatoid arthritis. She had experienced morning stiffness 2 years previously and was diagnosed as having rheumatoid arthritis. She had been treated with bucillamine and loxoprofen for 3 months. In October 2000, she developed proteinurea. The patient discontinued treatment with bucillamine and loxoprofen. Proteinurea persisted, and the patient's renal function declined. On admission, subcutaneous nodules were palpable in the patient's legs. The patient's serum creatinine and calcium levels were 2.49 mg/dl and 11.6 mg/dl, respectively. Intact-PTH was suppressed, and PTHrP was not elevated. Despite the presence of hypercalcemia, the patient's serum 1 alpha 25(OH)2D3 was not suppressed. Serum ACE and lysozyme levels were elevated beyond the normal ranges. A renal biopsy was performed, and non-caseous epithelioid granuloma was found in the renal interstitium. Based on the histological findings, the patient was diagnosed as having sarcoidosis. Following treatment with prednisolone, the patient's serum calcium levels returned to normal and her renal function improved.     

Human CD200 suppresses macrophage-mediated xenogeneic cytotoxicity and phagocytosis

Purpose

Various strategies, such as the generation of alpha-1,3-galactosyltransferase knocked-out pigs and CD55 transgenic pigs, have been investigated to inhibit pig to human xenogeneic rejection. Our aim is to develop strategies to overcome the hurdle of not only hyper acute rejection, but also that of cellular xenogeneic rejection (CXR). Although macrophages have been well known to play a critical role in CXR, monocyte/macrophage-mediated xenogeneic rejection has not been well studied. In this study, we evaluated the effect of CD200 in xenogeneic rejection by macrophages.

Methods

Naïve swine endothelial cells (SEC) and SEC/CD200 were co-cultured with M0 macrophages and the cytotoxicity was measured by a WST-8 assay. The phagocytosis of SEC and SEC/CD200 by macrophages was analyzed by flow cytometry.

Results

While CD200 failed to suppress a significant amount of cytotoxicity against SEC by monocytes, M0 macrophage-mediated cytotoxicity was significantly suppressed by human CD200. The phagocytosis by M0 macrophages was also tested. The phagocytosis assay revealed that human CD200 suppresses M0 macrophage-mediated phagocytosis.

Conclusions

Our findings indicate that human CD200 suppresses the xenogeneic rejection by CD200R⁺ macrophages and that the generation of hCD200 transgenic pigs for use in xenografts is very attractive for preventing the macrophage-mediated rejection.

     

The Japanese experience with prenatally diagnosed congenital diaphragmatic hernia based on a multi-institutional review

Purpose

To review the recent Japanese experience with prenatally diagnosed congenital diaphragmatic hernia (CDH) based on a multi-institutional survey.

Methods

A multicenter, retrospective cohort study was conducted on 117 patients born between 2002 and 2007 with isolated prenatally diagnosed CDH. All patients were managed by maternal transport, planned delivery, immediate resuscitation and gentle ventilation. The primary outcome measurements were the 90-day survival and intact discharge. The examined prenatal factors included gestational age (GA) at diagnosis, lung-to-head ratio (LHR), lung-to-thorax transverse area ratio (L/T) and liver position. Physical growth and motor/speech development were evaluated at 1.5 and 3?years of age. Data were expressed as the median (range).

Results

The mean GA at diagnosis was 29 (17?C40) weeks. The LHR and L/T were 1.56 (0.37?C4.23) and 0.11 (0.04?C0.25), respectively. There were 48 patients with liver up. The mean GA at birth was 38 (28?C42)?weeks. The 90-day survival rate and intact discharge rate were 79 and 63%, respectively. Twelve patients had major morbidity at discharge, and 71% of these patients had physical growth or developmental retardation at 3?years of age.

Conclusion

This multicenter study demonstrated that the 90-day survival rate of isolated prenatally diagnosed CDH was 79%, and that subsequent morbidity remained high. A new treatment strategy is needed to reduce the mortality and morbidity of severe CDH.