A 75-year-old man with hyperlipidemia suddenly presented with difficulty in lifting his left arm, despite the lack of shoulder pain. Moderate weakness restricted to the left shoulder with normal joint flexibility was observed, despite normal muscle strength in the elbow, wrist and fingers. There were no other neurologic abnormalities. Shoulder magnetic resonance imaging (MRI) findings were normal. Cranial MRI (Picture 1A, B: diffusion-weighted image, Picture 1C, D: T2-weighted image) demonstrated a small infarction in the right precentral gyrus (arrow). Electrocardiogram, echocardiogram, and carotid ultrasonography demonstrated normal findings. Because atherothrombosis was considered, intravenous ozagrel sodium was initiated. Thereafter, he became asymptomatic within 10 days.In the primary motor cortex, there is a broad somatotopic representation of the different body parts in an arranged order, and the area corresponding to the shoulder is very small. Therefore, to date there are only 2 reported cases of isolated shoulder palsy due to a cortical infarction detected by diffusion-weighted MRI (1, 2). The authors state that they have no Conflict of Interest (COI). References1. Nah HU, Park HK, Kang DW. Isolated shoulder weakness due to a small cortical infarction.
Background: The aim of this study was to evaluate the safety and feasibility of venous access via the internal jugular vein (IJV) for totally implantable venous access device (TIVAD) placements. In Japan, TIVADs are generally placed in position by the percutaneous subclavian vein puncture approach (SVPA). However, this approach causes infrequent intraoperative or postoperative complications. Using the internal jugular vein puncture approach (IJVPA), TIVADs could be placed more easily and safely. Materials and Methods: Fifty-six patients who received TIVADs for chemotherapy of colorectal carcinomas were enrolled in this study. The choice of approach (IJVPA or SVPA) was adopted at the discretion of each doctor in charge of the patient. The operation time, success rate and complications of the two approaches were compared and evaluated. Results: TIVAD placement was successful in all patients. Thirty patients received the device via IJV puncture, but 1 patient required conversion to SVPA. Twenty-six patients underwent SVPA for device placement, but 3 of these patients required conversion to IJVPA. Mean operation time was 34.3 min in IJVPA and 35.2 min in SVPA. The success rate was 96.6% in IJVPA and 88.5% in SVPA. No severe perioperative complications were observed. However, long-term complications were observed in five cases, 3 by IJVPA and 2 by SVPA, but no significant difference in the rate of complications was observed between these two approaches. A catheter-related thrombosis was found by CT scan in 3 patients, two of whom underwent IJVPA (6.7%) and one case underwent SVPA (3.8%). Two patients received simultaneous administration of bevacizumab. Catheter infections occurred in 1 patient who underwent IJVPA (3.3%) and 1 patient who underwent SVPA (3.8%). Conclusions: The IJVPA is a safe and feasible method for TIVAD placement.
BackgroundUlcerative colitis (UC) patients have an increased risk of colorectal dysplasia and carcinoma. The purpose of this study was to analyze the clinical features and surgical treatment of ulcerative colitis associated with dysplasia or carcinoma.MethodsWe operated on 41 UC patients since April 2000. Twelve of the cases were associated with dysplasia or carcinoma. Ten patients were male and two were female; the median age was 58.0 years, and the average duration of disease was 19.2 years. Nine cases were pancolitis type and three were left-sided type. Six cases were remission-relapsing type and six were chronic inflammation type. In 10 of 12 cases, dysplasia or carcinoma was diagnosed before the operations. Nine cases were primary operations and two were second-time operations.ResultsAmong ten patients who underwent primary operations, four patients had open surgery and six patients had hand-assisted laparoscopic surgery (HALS). Seven patients received anus/anal sphincter-preserving operations with reconstruction by the ileal pouch technique. Ileal pouch anal-canal anastomosis (IPACA) was performed in five cases and ileal pouch anal anastomosis (IPAA) in two cases. Abdomino-peritoneal resection was performed in two cases, proctcolectomy with permanent ileostomy in one case, and right hemicolectomy in one case. A 39-year-old patient was unresectable due to dissemination of the carcinoma. A 55-year-old patient who underwent IPACA showed night soiling postoperatively. Other patients who received IPAA and IPACA showed favorable anal function postoperatively. Histological examination showed low-grade dysplasia in two cases, high-grade dysplasia in three cases, and adenocarcinoma in seven cases. In the seven cases of adenocarcinoma, four, two, and one cases were stage 1, 3, and 4 according to TNM classification. Three of five cases with dysplasia were detected by surveillance colonoscopy. All patients with carcinoma were symptomatic and did not undergo surveillance colonoscopy.ConclusionsIPACA by HALS was safely performed as an anal-preserving operation in UC patients with dysplasia or carcinoma. Non-anal-preserving operations for aged patients showed a preferable postoperative course. Surveillance colonoscopy is essential for detecting dysplasia before the development of carcinoma.
BackgroundDuodenal obstruction occurs mainly due to physical lesions such as duodenal ulcers or tumors. Obstruction due to bezoars is rare. We describe an extremely rare case of obstruction in the third portion of the duodenum caused by a diospyrobezoar 15 months after laparoscopic distal gastrectomy for early gastric cancer.Case presentationA 73-year-old man who underwent laparoscopic distal gastrectomy for early gastric cancer 15 months before admission experienced abdominal distension and occasional vomiting. The symptoms worsened and ingestion became difficult; therefore, he was admitted to our department. Computed tomography (CT) performed on admission revealed a solid mass in the third portion of the duodenum and dilatation of the oral side of the duodenum and remnant stomach. Esophagogastroduodenoscopy (EGD) revealed a bezoar deep in the third portion of the duodenum. We could neither remove nor crush the bezoar. At midnight on the day of EGD, he experienced sudden abdominal pain. Repeat CT revealed that the bezoar had vanished from the duodenum and was observed in the ileum. Moreover, small bowel dilatation was observed on the oral side of the bezoar. Although CT showed neither free air nor ascites, laboratory data showed the increase of leukocyte (8400/μL) and C-reactive protein (18.1 mg/dL), and abdominal pain was severe. Emergency surgery was performed because conservative treatment was considered ineffective. We tried advancing the bezoar into the colon, but the ileum was too narrow; therefore, we incised the ileum and removed the bezoar. The bezoar was ocher, elastic, and hard, and its cross-section was uniform and orange. The postsurgical interview revealed that the patient loved eating Japanese persimmons (Diospyros kaki); therefore, he was diagnosed with a diospyrobezoar. His postoperative progress was good and without complications. He left the hospital 10 days after surgery. EGD performed 4 weeks after surgery revealed no abnormal duodenal findings.ConclusionsWe describe a rare case of obstruction in the third portion of the duodenum caused by a diospyrobezoar 15 months after laparoscopic distal gastrectomy with Billroth I reconstruction for early gastric cancer.
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