Anatomy of the lacrimal point and the vertical portion of the lacrimal canaliculus

In order to define more accurately normal dimensions and form of the lacrimal point as well as peculiarities in the structure of the vertical part of the lacrimal canaliculus, 315 practically healthy persons (630 eyes) at the age of 18-60 years have been examined. The procedure has been performed by means of the slit lamp (shchl-1) . The lacrimal point has been found to have a round (36.1%) and an oval (63.9%) form. Transition of the lacrimal point into the vertical part of the lacrimal canaliculus in 83.5% of the observations is "fannel"-shaped with a maximal narrowing at the depth of 0.4-0.5 mm, and in 16.5%-- well"-shaped (without any narrowing). The normal diameter of the lacrimal point is 0.2-0.6 mm (the arithmetic mean-- 0.35 mm). When the diameter of the lacrimal point is less than 0.2 mm (at least in one of its sections), the lacrimation function correspondingly deteriorates, indices of the coloured nasolacrimal test become decreased or negative.     

Naso-ethmoid-orbital fractures: classification and role of primary bone grafting

A detailed review of 80 patients with severe naso-ethmoid-orbital injuries has facilitated the classification of these injuries into five types. The recognition and diagnosis of each specific injury pattern will define the correct treatment choice in each instance. Special attention should be focused on injuries with comminution and bone loss in the medial wall and floor of the orbit, with loss of cartilaginous nasal support, and with orbital displacement and dystopia. An open, direct approach to these fractures with meticulous reduction, internal fixation, and repair of the medial canthal ligaments provides optimal repair. The use of craniofacial surgical techniques and immediate bone graft replacement of missing or severely damaged bone will allow reconstruction of even the most difficult injuries in one stage. Two hundred and eighteen primary bone grafts have been utilized in 49 patients. No significant complications with their use have occurred. The incidence of nasolacrimal system injury in naso-ethmoid-orbital injuries is less than suspected. Eight of 46 patients (17.4 percent) required a dacryocystorhinostomy for persistent nasolacrimal system obstruction. Immediate assessment or exploration of the nasolacrimal system is not performed. Delayed assessment and dacryocystorhinostomy resulted in the relief of nasolacrimal system obstruction in all cases.     

Reconstruction of the lacrimal excretory system.

Primary surgical repair of the lacrimal drainage apparatus may not be feasible in patients with maxillofacial injuries involving extensive structural damage. If secondary restoration of the tear duct is not possible, reconstruction of an aberrant passage then will be necessary for tear drainage. Although the Pyrex conjunctivorhinostomy has been considered to be the most effective modality of treatment in managing patients with tear-duct dysfunction, this procedure can be plagued with problems of tube dislodgment, infection, and cicatricial tract obliteration. The patients are, furthermore, required to wear the device for the remainder of their lives. Autologous material is therefore best suited for reconstructing a conduit. A medially based mucosal flap fashioned in the lower palpebral conjunctiva, 5 mm in anteroposterior dimension and 15 mm in horizontal length, can be used to form a conduit. This is then sutured to a flap mobilized from the nasal cavity, the lacrimal sac, or the maxillary antrum. In the past 15 years, a total of 24 fistulous tracts utilizing this technique were reconstructed in 20 patients with tear-duct obstruction. The experience accumulated from managing this group of patients forms the basis of this report.     

Nasolacrimal duct lavage in rabbits

Eye problems are common in both laboratory and pet rabbits. This column reviews the anatomy of the nasolacrimal duct system in rabbits and describes the appropriate techniques for working up a rabbit with an ocular problem related to nasolacrimal drainage.     

Alligator tears: a reevaluation of the lacrimal apparatus of the crocodilians

The Harderian gland is a poorly understood anterior ocular gland that occurs in most terrestrial vertebrates. Numerous extraorbital functions have been ascribed to the Harderian gland, principally based on its association with the nasolacrimal duct. Few studies have centered on archosaurs and the majority of those available focused solely on the Harderian gland of birds. Little is known about the lacrimal apparatus of the crocodilians. We examined the lacrimal apparatus of several specimens of Alligator mississippiensis anatomically, histologically, and histochemically and studied the embryogenesis of this system. The nasolacrimal duct possesses a distal secretory area, which is more convoluted than that of typical mammals or lepidosaurs. The alligator Harderian gland possesses a unique combination of characteristics found in lepidosaurs, birds, and mammals. Like that of both mammals and lepidosaurs, it is a large, tuboloacinar gland that appears to secrete both mucoprotein and lipids. However, the presence of blood vessels and immune cells is reminiscent of that of the avian Harderian gland. The immunogenesis of the alligator Harderian gland appears to be tied to the development of the vascular system. The presence of a distinct palpebral gland in the anterior aspect of the ventral eyelid is a feature unique to alligators. Based on position, this gland does not appear to be homologous to the anterior lacrimal gland of lepidosaurs. Lymphatic aggregations were also found in the palpebral gland. The presence of interstitial immune cells in the orbital glands of alligators suggests that the alligator lacrimal apparatus, like that of birds, may play a role in the head-associated lymphatic tissue system.     

MUC16 in the lacrimal apparatus

The aim of the present study was to determine the possible expression of the mucin MUC16 in the lacrimal apparatus. Expression and distribution of MUC16 in lacrimal gland, accessory lacrimal glands, and nasolacrimal ducts was monitored by RT-PCR and immunohistochemistry. MUC16 was expressed and detected in all tissues investigated. Comparable to conjunctiva and cornea it was membrane-anchored in accessory lacrimal glands whereas in lacrimal gland acinar cells and columnar cells of the nasolacrimal ducts it was stored in intracytoplasmic vesicles without membrane-association. Subepithelial serous glands of the nasolacrimal ducts revealed staining of the secretion product. Intracelluar production of MUC16 is present in lacrimal gland and epithelial cells of the nasolacrimal ducts but it is not clear whether this MUC16 is secreted. MUC16 seems to be shedded or secreted from the epithelial surface of subepithelial serous glands of the nasolacrimal ducts. Our results show that MUC16 is present in the whole lacrimal apparatus. Its distribution pattern suggests different physiological functions with regard to tear film physiology and tear outflow. Moreover, the results demonstrate the existence of so far not recognized qualitative differences in the secretion product of main lacrimal gland and accessory lacrimal glands (glands of Krause).     

Endonasal Endoscopic Treatment of Recurrent Dacryocystitis

This report assessed clinical conditions leading to recurrent dacryocystitis and success rates of its treatment by endonasal endoscopic dacryocystorhinostomy. Forty-eight patients with recurrent dacryocystitis underwent endonasal endoscopic surgery and were followed up for at least 6 months. High bone windows, small bone window openings, small lacrimal sac stomas, scar tissues, and organic diseases of the nasal cavity led to fistula closure. Out of 48 patients, 45 (93.8 %) patients were cured by endonasal endoscopic surgery. Endonasal endoscopic dacryocystorhinostomy is beneficial for recurrent dacryocystitis.     

Malignant Ureteral Obstruction: Functional Duration of Metallic versus Polymeric Ureteral Stents

Background

Ureteral obstruction caused by extrinsic compression is often associated with intra-abdominal cancers. Internal drainage with ureteral stents is typically the first-line therapy to relieve such obstructions. Novel designs of ureteral stents made of different materials have been invented to achieve better drainage. In this study, we described the functional outcomes of a Resonance metallic ureteral stent (Cook Medical, Bloomington, Indiana, USA) in patients with malignant ureteral obstruction and compare the functional duration of Resonance stents with regular polymeric stents in the same cohort.

Methods

Cancer patients who received polymeric stents and subsequent Resonance stents for ureteral obstruction between July 2009 and November 2012 were included in a chart review. Stent failure was detected by clinical symptoms, imaging studies, and renal function tests. The functional durations of each stent were calculated, and possible factors affecting stent patency were investigated.

Results

A total of 50 stents were successfully inserted into 50 ureteral units in 42 patients with malignant ureteral obstruction. There were 7 antegrade stents and 43 retrograde stents. There were no major complications. Stent-related symptoms were similar in both kinds of stents. After polymeric stents were replaced with Resonance metallic stents, hydronephrosis subsided or remained stable in 90% (45/50) of the ureteral units. Serum creatinine decreased or remained stable in 90% (38/42) of these patients. The Resonance stent exhibited a mean increase in functional duration of 4 months compared with the polymeric stents (p<0.0001), and 50% (25/50) of the Resonance stents exhibited a significant increase in functional duration (more than 3 months). Pre-operative serum creatinine < 2 was associated with a substantial increase in stent duration.

Conclusions

Resonance stents are effective and safe in relieving malignant ureteral obstructions after polymeric stents failure. Resonance stents can provide a longer functional duration than polymeric stents and should be offered as an option for internal drainage.     

恶性胆道梗阻患者所行经皮穿刺肝内胆管引流术中成功置入金属支架的术前影响因素分析

目的:探讨恶性胆道梗阻患者行PTBD(Percutaneous Transhepatic Biliary Drainage)术中金属支架置入成功率的影响因素。方法:回顾性搜集2010年10月-2017年1月上海市第一人民医院收治的因患有近端恶性胆道梗阻行PTBD术患者的相关临床资料。比较不同原发病因患者支架置入情况。根据患者支架置入是否成功将其分为支架组和非支架组,比较患者的一般临床特征。结果:胰腺癌、胃癌和胆囊癌为本研究中数量上前3位的肿瘤,将以上3组分别按照支架置入数行x~2检验,其中胰腺癌(n=18,支架=6)和胃癌(n=14,支架=11)有统计学意义。将50例患者分为支架组(n=28)和非支架组(n=22),组间比较差异有统计学意义的因素包括:白细胞计数(支架组=6.40±3.40×10~9/L,非支架组=10.74±6.41×10~9/L),中性粒细胞计数(支架组=4.90±3.06×10~9/L,非支架组=8.92±6.25×10~9/L),胆道感染(支架组=9,非支架组=15)。进一步将该50例患者分为6组:胰腺癌-胆道感染组、胃癌-胆道感染组、其他肿瘤-胆道感染组、胰腺癌+胆道感染组、胃癌+胆道感染组、其他肿瘤+胆道感染组。将以上6组分别按照支架置入数行x~2检验,胰腺癌+胆道感染组(n=11,支架=1,P=0.001)有统计学意义。结论:PTBD术对于恶性胆道梗阻是一种有效的姑息治疗手段。胆道感染是PTBD术中支架置入成功的不利因素,胰腺癌合并胆道感染会显著降低PTBD术中支架置入成功率。     

Clinical Management of Patients Presenting with Non-Adjustable Gastric Band (NAGB) Complications

Background: A number of bariatric surgical procedures have been developed to manage morbid obesity and related co-morbidities. The non-adjustable gastric band (NAGB) was one such procedure that created restriction to food intake by gastric segmentation. Benefits of the procedure included a low risk of perioperative complications and substantial early weight loss. Unfortunately, the long term results of NAGB include a high incidence of complications and failure to maintain weight loss. The purpose of this study was to examine the presentation, workup, and treatment of patients presenting with complications following NAGB placement.Methods: A retrospective review of the diagnosis and management of 11 patients who presented with complications related to NAGB placement.Results: All patients presented with some degree of proximal gastric outlet obstruction. The majority of patients (8/11) presented with vomiting as the main complaint. Other complaints included intolerance to solids, liquids, and reflux. Only 2/11 patients presented with weight loss since undergoing NAGB placement, while the remainder had weight regain to their pre-NAGB level and above. Depending on clinical presentation, desire for additional weight loss and co-morbid conditions, patients underwent a variety of treatments. This included NAGB removal (endoscopic, laparo-endoscopic, and laparoscopic) as well as conversion to another bariatric procedure (sleeve gastrectomy, Roux-en-Y gastric bypass).Conclusion: Patients with NAGB complications present with symptoms related to a proximal gastric outlet obstruction, related to constriction imposed by the band. This may result in severe food and liquid intolerance and subsequent weight loss, but more likely results in maladaptive eating and subsequent weight gain. Optimal therapy involves removal of the NAGB. Laparoscopic conversion to another bariatric procedure, optimally a Roux-en-Y gastric bypass, is warranted to treat morbid obesity and associated co-morbidities.     

Efficacy and safety of inferior turbinate coblation-channeling in the treatment of nasal obstructions

The aim of this study was to evaluate the safety and effectiveness of coblation-channeling in the treatment of inferior turbinate hypertrophy. The study was conducted in the Department of ENT Head and Neck Surgery, Split University Hospital Center, Split, Croatia. Fifty-two patients with inferior turbinate hypertrophy who were refractory to medical therapy were evaluated for coblation. The procedures were performed under local anesthesia using an ArthroCare ReFlexUltra 45 wand; three submucosal channels were made per turbinate. Clinical examinations, a questionnaire on individual nasal symptoms (hyposmia, nasal drainage and post-nasal drip), a 10-cm visual analog scale (VAS) grading general nasal obstructions, and rhinomanometry before and 8 weeks after the treatment were administered to assess treatment outcomes. No adverse effects were encountered. Nasal breathing was significantly improved in all patients, decreasing the VAS from a median of 7 (range 2-9) to 1 (range 0-3) (p < 0.001). Total nasal resistance decreased from 0.44 Pa +/- 0.50 to 0.24 Pa +/- 0.11 (p = 0.005). Improvement was statistically significant for all three symptoms (hyposmia [p = 0.005], nasal drainage [p = 0.003] and post-nasal drip [p < 0.001]). In this paper, we demonstrate that coblation-channeling of the hypertrophic inferior turbinate is an effective and safe way to reduce nasal obstruction symptoms.     

Grey-scale ultrasonography and percutaneous transhepatic cholangiography in biliary tract disease.

Fifty-one patients with suspected obstructive jaundice and 14 without jaundice in whom disease of the biliary tract was suspected but infusion cholangiography had been unhelpful were examined by grey-scale ultrasonography and percutaneous transhepatic cholangiography and the findings analysed retrospectively. Grey-scale ultrasonography distinguished between obstructive and hepatocellular jaundice in 35 out of 46 patients (76%) and indicated the site of the obstruction in 27 (58%) and the cause of the obstruction in 13 (28%). Percutaneous transhepatic cholangiography distinguished between obstructive and hepatocellular jaundice in 42 of the patients (91%) and indicated the site of the obstruction in 42 (91%) and the cause in 29 (63%). In the 14 patients without jaundice percutaneous transhepatic cholangiography showed bile-duct stones in one an ampullary stenosis in three. It is concluded that grey-scale ultrasonography and percutaneous transhepatic cholangiography are complementary examinations and that ultrasonography should always be undertaken first as it is a non-invasive procedure that may provide the surgeon with all the diagnostic information he requires. Percutaneous transhepatic cholangiography should be performed when grey-scale ultrasonography has shown dilated bile ducts but failed to provide adequate diagnostic information. Cholangiography is also required when preoperative percutaneous drainage of the bile duct is contemplated. In those patients in whom grey-scale ultrasonography shows non-dilated ducts endoscopic retrograde cholangiopancreatography is probably the contract examination of choice.     

Frontoethmoidal encephalomeningocele: surgical correction by the Chula technique

This study reevaluates a surgical technique known as the Chula technique, previously reported in 1991 for correction of frontoethmoidal encephalomeningocele. From 1986 to 1999, 108 patients were operated on with this technique, which could remove the herniation mass, repair dural and bone defects, reconstruct the naso-orbital area, and restore aesthetic facial appearance in a single stage. Formal frontal craniotomy was not necessary. The result has been very satisfying in terms of safety, cure rate, and aesthetic outcome. Spontaneous improvement of lacrimal passage obstruction occurred in 85.2 percent of cases, and dacryocystorhinostomy was required in the rest. There was no mortality. Complications (e.g., wound infection, 6.5 percent; wire extrusion, 3.7 percent; meningitis, 2.8 percent; cerebrospinal fluid leakage, 2.8 percent; and postoperative increased intracranial pressure, 2.8 percent) were much less frequent than in other reports. With a mean follow-up period of 439 days (maximum, 12 years), there has been no recurrence.     

Late proximal coronary artery stenosis complicating percutaneous endovascular catheterisation procedures

Background

Late-onset proximal coronary artery stenosis caused by preceding percutaneous catheterisation procedures remains under-surveyed.

Methods

From 1993, all patients undergoing percutaneous coronary procedures and a second session within 3 years were included except those ever treated by coronary bypass surgery or chest radiotherapy during this 3-year period. Emergence of a new lesion or worsening of an initially insignificant lesion to >50% of diameter stenosis at the never-treated ostial/proximal coronary segment on the follow-up angiogram was defined as late coronary stenosis caused by the previous catheterisation procedure and was analysed.

Results

From January 1993 to December 2005, 3240 patients who underwent 5025 procedures met the inclusion criteria. Of them, 23 patients experienced an event of late coronary artery stenosis (overall incidence 0.46%), and interventional procedures, specifically shaped catheters (Voda, XB, Amplatz Left) and atherosclerosis vulnerability correlated with risks of adverse events. Most of these events could be managed by contemporary medical, interventional, or surgical strategies, yet hazards of mortality and long-term restenosis still existed from this catheter-induced complication.

Conclusions

Percutaneous catheterisation procedures could be complicated by late proximal coronary artery stenosis. Thus, when conducting these procedures, operators should select and manipulate catheters with caution, especially in patients with susceptible clinical characteristics.     

Selective Proximal Vagotomy with and without Pyloroplasty

The early results of a prospective randomized clinical trial of selective proximal vagotomy with and without gastric drainage in a total of 36 patients are reported. In spite of adequate average acid reduction and little evidence of gastric retention two definite recurrent ulcers have occurred in the 16 patients who did not have a pyloroplasty. Further trials of the effect of selective proximal vagotomy without gastric drainage are necessary before the procedure is widely adopted.     

大鼠泪腺睾酮受体直空负压ABC法光镜观察与免疫金探针超微结构定位

动物实验发现睾酮能改善干眼病动物模型干眼症状,促进泪腺分泌,但作用机理不明,本研究探讨泪腺细胞中是否存在睾酮受体。雌雄各8只大鼠的泪腺分别制成石蜡切片和超薄切片,睾酮分别采用ABC法及免疫金标记,通过真空负压ABC法光镜观察及免疫金探针超微结构定位进行细胞睾酮受体检查。结果：光镜下泪腺导管上皮细胞的胞浆及胞核中出现免疫染色阳性,泪腺上皮细胞则很少见到;电镜下泪腺细胞胞浆及核中可见金颗粒,对照组则染色阴性。结论 泪腺细胞存在着睾酮受体,睾酮通过受体对泪腺发生作用。     

Site of airway obstruction: effects on the acoustic impedance of excised pig lungs

We investigated the relationship between the site of airway obstruction and the frequency dependence (FD) of lung acoustic impedance (ZL). The real (RL) and imaginary (XL) parts of ZL were measured by forced random noise in excised left pig lungs, before (base line) and after 1) no airway obstruction (controls, n = 10), 2) insufflation of 1-mm (B1, n = 5) or 2-mm (B2, n = 7) beads, and 3) partial reversible obstruction of lower lobar (LL) and then main-stem (MS) bronchus (n = 4). The beads caused both partial and total obstruction of airways with internal diameters of 2 mm (B1) and 2-6 mm (B2). Compared with base line, a negative FD of RL appeared from 4 to 10 Hz in LL, B1, and B2 obstructions. The FD of XL greater than 20 Hz increased in MS and LL obstruction exclusively and was the ZL feature that most clearly differentiated central from peripheral obstruction. In this experimental model, the anatomic limit distal from which obstruction no longer causes the "central" type of ZL change lies in airways with internal diameters notably greater than 2 mm.     

Coronary artery surgery.

Coronary artery disease has been described as the largest public health problem in Western society. In spite of the many advances in recent years in its medical management, many patients remain disabled even after optimal medical therapy. The aortocoronary bypass operation, introduced in the mid-1960s, has been shown to have consistent subjective and objective effects on the course of the disease in a large proportion of patients. The procedure consists of inserting a portion of the saphenous vein into both the aorta and a coronary artery to bypass the obstruction. It is usual now to bypass obstructions in several coronary arteries at the same operation if necessary. The prognosis for patients with ischemic heart disease with medical management depends on the extent of the disease. Patients with obstruction of only one coronary artery have a prognosis very little different from normal. On the other hand, obstruction of several arteries is consistently associated with a mortality approaching or exceeding 10% per year.     

Airflow pattern complexity and airway obstruction in asthma

The scientific and clinical value of a measure of complexity is potentially enormous because complexity appears to be lost in the presence of illness. The authors examined the effect of elevated airway obstruction on the complexity of the airflow (Q) pattern of asthmatic patients analyzing the airflow approximate entropy (ApEnQ). This study involved 11 healthy controls, 11 asthmatics with normal spirometric exams, and 40 asthmatics with mild (14), moderate (14), and severe (12) airway obstructions. A significant (P < 0.02) reduction in the ApEnQ was observed in the asthmatic patients. This reduction was significantly correlated with spirometric indexes of airway obstruction [FEV(1) (%): R = 0.31, P = 0.013] and the total respiratory impedance (R = -0.39; P < 0.002). These results are in close agreement with pathophysiological fundamentals and suggest that the airflow pattern becomes less complex in asthmatic patients, which may reduce the adaptability of the respiratory system to perform the exercise that is associated with daily life activities. This analysis was able to identify respiratory changes in patients with mild obstruction with an adequate accuracy (83%). Higher accuracies were obtained in patients with moderate and severe obstructions. The analysis of airflow pattern complexity by the ApEnQ was able to provide new information concerning the changes associated with asthma. In addition, this analysis was also able to contribute to the detection of the adverse effects of asthma. Because these measurements are easy to perform, such a technique may represent an alternative and/or a complement to other conventional exams to help the clinical evaluations of asthmatic patients.     

Small free vascularized iliac crest bone grafts in reconstruction of the scaphoid bone: a retrospective study in 60 cases.

Carpal instability may result in progressive degenerative arthritis of the wrist. The surgical goal of the reconstruction of scaphoid nonunion is to achieve bone union and to restore the scaphoid. Many procedures are described to treat scaphoid nonunion for different indications. This retrospective study reports on the anatomical fundamentals, the operative procedure, and the results of 60 patients (21 with recalcitrant scaphoid nonunion that lasted longer than 4 years, 26 with an avascular pole fragment, and 13 with scaphoid nonunion after previous surgery) who were treated by a small free vascularized iliac crest bone graft. All 60 patients have routinely been followed up clinically and with magnetic resonance imaging. Union was achieved in 91.7 percent by improvement of stability and the compromised vascularity of the scaphoid. The bone flap loss rate and persisting nonunion was 8.3 percent, leading to progressive arthritis and carpal collapse. Complaints concerning discomforts caused by the scar were heard from 40.1 percent of the patients, and 31.7 percent complained of discomforts caused by the bony deformity. Bone deformations on the donor site were detected radiologically in 63.3 percent of the patients. In 31.7 percent, an impairment of the lateral femoral cutaneous nerve was noted. Reconstruction of the scaphoid by means of implantation of a vascularized iliac bone graft proved efficient to treat avascular recalcitrant scaphoid nonunion and pseudarthrosis with avascular proximal pole fragments.