Adenosquamous carcinoma of the lung in a patient with complete situs inversus.

We present a rare case of adenosquamous carcinoma of the lung in a patient with complete situs inversus. The patient was a 76-year-old woman with the chief complaint of hemosputum. Chest X-ray and computed tomography (CT) scans of the thorax showed a mirror image of the organs and vessels and revealed a tumor 3.5 cm in diameter, in the left lower lung field. She was referred and admitted to KKR Hokuriku Hospital, Kanazawa, Japan to undergo surgery. Bronchoscopy showed a mirror image of the usual arrangement of the bronchi, and 5 segmental branches in the left lower bronchi. During surgery, care was exercised when intubation with the Univent bronchial tube for one-lung ventilation. On thoracotomy, the gross appearance of the left lung and the arrangement of the pulmonary vessels and the bronchi corresponded to those normally found on the right side. We were successful in performing a left lower lobectomy. Postoperative diagnosis confirmed an adenosquamous carcinoma with localized pleural dissemination as p-t4n1m0, stage IIIa. Preoperative imaging, including CT, bronchoscopy, and angiographic examination of the patient, will be useful for prevention of vascular or bronchial injury during surgery in patients with complete situs inversus undergoing lung resection. Possible vascular or bronchial anomalies should always be taken into consideration while operating on these patients.

Advanced lung cancer invading the left atrium, treated with pneumonectomy combined with left atrium resection under cardiopulmonary bypass.

A 68-year-old man presented with a chief complaint being a cough. Based on a bronchoscopic biopsy, it was diagnosed at a nearby clinic as an advanced left lung cancer, and he was referred to our hospital. Chest computed tomography (CT) scans demonstrated a giant mass of the left lower lobe, 14 × 12 cm in size, which appeared to have invaded the left atrium (LA). The operation was started with double vena cava cannulation via the right internal jugular vein and the right femoral vein as well as arterial cannulation via the right femoral artery. The patient underwent left pneumonectomy combined with LA resection using cardiopulmonary bypass (CPB), without aortic clamping, through left posterolateral thoracotomy under hypothermia (32 °C). The tumor-invaded LA was resected in a 3.5 × 3.0 cm area, with vascular clamping, and the stump was closed with 3-0 Prolene sutures. The surgical margin was free of tumor cells, and the duration of CPB was 28 minutes. The patient was smoothly weaned from CPB. His postoperative course was uneventful, and he received 2 courses of adjuvant chemotherapy. For a combined resection of the LA, it is safer to use CPB than simple vascular clamping, since the latter involves the risk of dislocation. If CPB is used, the tension of the LA is removed by blood extraction into the bypass, and bradycardia is induced by a reduction of body temperature, probably reducing the risk of clamp dislocation. Even when clamp dislocation or bleeding resulting from injury of the LA wall unfortunately takes place during surgery, these events can be dealt with appropriately during the use of CPB.

Long-term results of ankle arthrodesis using an intramedullary nail with fins in patients with rheumatoid arthritis hindfoot deformity.

We report herein the results of a retrospective study of 30 ankle arthrodesis procedures performed in 27 patients with rheumatoid arthritis from 1994 through 2001 using a novel design of intramedullary nail with fins. The surgical treatment, post-operative management and clinical evaluation are described. The clinical evaluation, at an average follow-up period of more than 10 years, was based on foot disease scores from the Japanese Orthopaedic Association and scores obtained preoperatively, postoperatively, and during follow-ups 1 (November 2001) and 2 (November 2007) were compared. These variables showed significant improvement between before surgery and at follow-up evaluations. Non-union was not observed and no marked changes of the Chopart joint were seen between before surgery and at follow-up evaluations. Delayed wound healing was seen in 9 of 30 joints. However, infection neuropathy or other complications were not found. We conclude that arthrodesis using an intramedullary nail with fins is an effective treatment for severe hindfoot deformities in patients with rheumatoid arthritis because no cases of non-union were observed and because clinical results over the mean 10-year follow-up period were good or satisfactory.

Single incision laparoscopic surgery (SILS) using cross hand technique.

Single incision laparoscopic surgery (SILS) was developed as a less invasive surgical procedure, but it remains difficult because of its specific skills and left-right reversal of the instruments. Such a difference makes manipulating endoscopic instruments more challenging and increases the risk. In this study, we introduce the cross hand technique allowing the surgeon to manipulate instruments with intuitive movement.

Postoperative results and complications of total elbow arthroplasty in patients with rheumatoid arthritis: three types of nonconstrained arthroplasty.

Postoperative results and complications of total elbow arthroplasty (TEA) conducted for rheumatoid arthritis (RA) patients at our institute were studied. Primary TEAs were performed in 72 patients. The mean follow-up period was 3.5 years. Three types of prostheses were implanted: JACE prosthesis in 34 elbows, STABLE prosthesis in 13 elbows, and KUDO prosthesis (type 5) in 32 elbows. The outcome was evaluated by the change in the range of motion and the Japanese Orthopaedic Association functional evaluation score for the elbow joint (JOA score). The arc of motion and the JOA score at discharge and at final examination significantly improved in patients with the three types of prosthesis. The loosening rates for the JACE, STABLE and KUDO prostheses were 15, 23, and 0%, respectively, although the follow-up periods were different. The loosening rate decreased to 2.5% when the humeral component was fixed with cement. Intraoperative fractures occurred in eight (10.1%) elbows and ulnar nerve palsy in six. Deep infection developed in three (4.8%) elbows and was treated by removing the prosthesis. Although there were considerable complications, the marked improvements in pain and function favor TEA in patients with rheumatoid elbow.

Osteoclast inhibitory effects of vitamin K2 alone or in combination with etidronate or risedronate in patients with rheumatoid arthritis: 2-year results.

OBJECTIVE: To investigate the effects of vitamin K2 (Vit K2) alone or in combination with etidronate and risedronate on bone loss, osteoclast induction, and inflammation in patients with rheumatoid arthritis (RA). METHODS: Subjects comprised 79 patients with RA who were receiving prednisolone, divided into 3 groups: Group K, Vit K2 alone; Group KE, Vit K2 plus etidronate; and Group KR, Vit K2 plus risedronate. During a 24-month treatment and followup period, levels of N-terminal telopeptide of type I collagen (NTx) and bone alkaline phosphatase were measured. Bone mineral density (BMD) of the 3 groups was measured using dual-energy x-ray absorptiometry. Damage score to fingers on radiographic findings were measured according to the Larsen method. Serum levels of receptor activator of nuclear factor-kappaB ligand (RANKL) and osteoprotegerin (OPG) were measured. RESULTS: Falls in rate of change of BMD decreased after 18 months in groups KR and KE. Larsen damage scores indicated a significant difference between Group KE and other groups. Significant decreases in serum NTx were observed in groups KE and KR at all timepoints, but not in Group K. Levels of RANKL decreased significantly in all 3 groups. CONCLUSION: Vit K2 alone or in combination with bisphosphonates for treatment of osteoporosis in patients with RA may inhibit osteoclast induction via decreases in levels of RANKL.

Ten years results of bucillamine in the treatment of rheumatoid arthritis.

A 10-year cohort study was performed, involving all of the 118 patients treated with bucillamine in our hospital between 1988 and 1990. Evaluation was made on the basis of erythrocyte sedimentation rate, grip strength, joint score, duration of morning stiffness, and Lansbury index consisting of the above four parameters. Eleven patients were male and 107 were female, with a mean age of 53 years (range: 20-79 years) and a mean duration of illness of 8.2 years (range: 2-31 years). Lansbury index remained significantly suppressed throughout the 10-year period of treatment. Continuous treatment was possible for 10 years in 18 patients (15%: 2 men and 16 women). Stage of disease did not advance in 14 patients. Six patients met the criteria for remission. Of all patients, 50% dropped out of treatment at 2.4 years after the start of treatment and 75% at 5 years. The 100 patients who dropped out could be roughly divided into three groups. One third of them dropped out because of lack of or attenuation of response. Another third dropped out because of referral to other medical facilities or discontinuation of visits to our hospital, and the remaining third dropped out because of adverse reactions to treatment. There was no particular trend in terms of sex, age, duration of sickness, drugs used before bucillamine, or level of activity of rheumatoid arthritis. There were no significant difference in the stage and class of the disease, and other backgrounds between 10-year treatment group and dropout group.

[Clinical examination of safety and effectiveness of primary chemotherapy with CEF followed by docetaxel in preoperative breast cancer].

SUBJECTS: The subjects were patients with resectable breast cancer who visited our department between August 2003 and November 2004, did not have any other risk factors defined in the St. Gallen Consensus Conference,and were receptor-negative or had axillary lymph node metastasis. METHODS: The histological type, ER, PgR, HER2, and histological grade were evaluated by needle biopsy. Four courses of CEF (5-FU: 500 mg/m(2)+EPI: 75 mg/m(2)+CPA: 500 mg/m(2)) were performed at 3-week intervals, followed by 4 courses of Docetaxel (70 mg/m(2)). RESULTS: Treatment was performed in 14 patients including a male. Their age ranged from 37 to 69 years (mean, 55.3 years). Stage IIA was observed in 5 patients, IIB in 4, IIIA in 1, and IIIB in 4. In patients with Grade 3 or more, leukocytopenia was observed in 7 patients and diarrhea in 1 as adverse events. CR was obtained in 6 patients, PR in 5, and NC in 3 (response rate, 78.5%). Pathological examination showed pCR in 1 patient and pPR in 10 (response rate, 78.5%). Of the 10 patients with pPR, 2 showed a state near pCR. DISCUSSION: Our results showed the safety and effectiveness of preoperative chemotherapy with CEF followed by Docetaxel.

Long-term follow up of patients with multiple gastric carcinoids associated with type A gastritis.

Little is known about the natural course of multiple gastric carcinoids associated with type A gastritis. Between 1993 and 2003, we enrolled eight patients, diagnosed as having multiple gastric carcinoids associated with type A gastritis, in a follow-up program without surgical resection. In these patients, endoscopy showed multiple small polyps on the gastric body, with nonantral atrophic gastritis. Histologically, biopsy specimens obtained from the polyps revealed carcinoid tumors. The serum gastrin level was found to be very high in all patients, and testing for anti-parietal cell antibody was positive in seven. The mean follow-up was 5.8 years (range, 1.5-10.8 years). The levels of serum gastrin increased in all patients, but, endoscopically, the carcinoid tumors did not change in size. Neither hepatic nor lymphatic metastasis was detected on abdominal computed tomography (CT). These patients were free of the development or metastasis of carcinoids, in spite of their continuous hypergastrinemia. It was concluded that multiple gastric carcinoids associated with type A gastritis may be indolent.