Hepatic metastasis after laparoscopic cholecystectomy for polypoid gallbladder cancer followed by radical surgery

While laparoscopic cholecystectomy is being increasingly performed on patients with gallbladder disease, this approach in cases of polypoid lesions in the gallbladder may not always be justified. We report here a case of early development of intrahepatic metastasis after laparoscopic cholecystectomy for polypoid gallbladder cancer; wedge resection of the gallbladder bed and dissection of regional lymph nodes had to be done. When a malignancy of the gallbladder is suspected during preoperative examinations, open cholecystectomy should be done.

Portal and gastric mucosal hemodynamics in cirrhotic patients with portal-hypertensive gastropathy

Controversy exists as to the nature of gastric perfusion in portal-hypertensive gastropathy. To investigate portal hemodynamics and gastric mucosal perfusion in cirrhotic patients with and without portal-hypertensive gastropathy, we subjected 56 cirrhotic patients with portal hypertension to portal vein catheterization, pneumatic pressure sensor technique, duplex sonography and laser Doppler flowmetry. Thirteen patients had portal-hypertensive gastropathy: In 10 it was mild, and in 3 it was severe. The presence of portal-hypertensive gastropathy seemed to be independent of age, sex, cause of cirrhosis or grade of esophageal varices. Portal venous pressure, esophageal variceal pressure, portal venous flow and congestion index in patients with portal-hypertensive gastropathy were not significantly different from the values in those without portal-hypertensive gastropathy. However, portal-variceal pressure gradient (subtracting esophageal variceal pressure from portal venous pressure) (p < 0.01) and the incidence of palisading-type esophageal varices on portography (p < 0.05) was increased in patients with portal-hypertensive gastropathy significantly more than in those without portal-hypertensive gastropathy. In the fundus, gastric mucosal blood flow was significantly higher in patients with portal-hypertensive gastropathy than in those without portal-hypertensive gastropathy, whereas in the corpus and the antrum the values were not significantly different. We suggest that the mucosa of the upper stomach in patients with portal-hypertensive gastropathy is congestive and highly perfused. The pathogenesis of portal-hypertensive gastropathy may be related to both congestion and hyperemia in the upper stomach.

Budd-Chiari syndrome and Epstein-Barr virus (EBV) associated plasmacytoma in a patient with chronic active EBV infection

A 42-year-old Japanese man with chronic active Epstein-Barr virus (EBV) infection initially responded to treatment with interleukin-2 (IL-2). Six months later he developed thrombosis in the hepatic veins, and Budd-Chiari syndrome associated with severe hepatic damage was diagnosed. He also developed a solitary EBV-positive plasmacytoma in the right femur. Since these rare complications occurred after long-term IL-2 therapy, the possibility that long-term IL-2 therapy might cause Budd-Chiari syndrome and liver damage as well as EBV-associated plasmacytoma is discussed.

Laparoscopy-assisted surgery: a new technique for transhiatal esophageal dissection

Esophageal dissection under laparoscopic monitoring is performed during total esophagectomy to treat patients with cervical esophageal carcinoma. Using this technique, a safe esophageal dissection can be made from the surrounding mediastinal tissues. Some of the disadvantageous consequences of a blunt dissection, including the blind maneuver, may thus be prevented and various intraoperative and postoperative complications may be avoided.

Endoscopic injection sclerotherapy for esophageal varices in the elderly

A group of 1127 patients who underwent sclerotherapy for esophageal varices were compared for outcome in terms of age: over and under age 70 years. Esophageal varices were completely eradicated in 81 of 110 patients > 70 years (73.6%) and in 791 of 1017 patients < 70 years (77.8%). Gastrointestinal bleeding after sclerotherapy occurred in 9 patients > 70 years (8.2%) and in 84 of those < 70 years (8.3%). Complications occurred in 16 patients > 70 years (14.5%) and in 141 < 70 years (13.9%). Liver failure and hepatoma accounted for more than 80% of the causes of death in both groups (80.3% versus 83.8%). The 5-year cumulative survival rates in patients with bleeding esophageal varices (bleeders) without hepatoma were 21.8% in those > 70 years and 58.7% in those < 70 years (p < 0.01), the relative survivals being 25.3% versus 66.6%. Patients without hepatoma and treated by prophylactic sclerotherapy accounted for 66.2% of patients > 70 years and 61.7% of those < 70 years, the relative survivals being 75.9% versus 71.9%. As analyzed by the Cox proportional-hazards model, age > 70 years was a prognostic factor in the bleeders (p < 0.01) but not in the nonbleeders. We recommend that elderly patients with esophageal varices be given prophylactic sclerotherapy, as the outcome for these patients is poor once bleeding has occurred.

[11 operated cases of spontaneous hemopneumothorax]

During the period 1984-1993, we experienced 11 operated cases of spontaneous hemopneumothorax, which correspond 7.3% of total 150 cases of operated spontaneous pneumothorax. All cases were male, 19-36 years of age. From admission to the end of operation, 6 cases with hemorrhagic shock had bleeding of 2,305-6,670 ml, the average 3,708 ml, whereas 5 cases without shock had bleeding of 1,209-2,405 ml, the average 1,979 ml. In 9 cases operated within 5 days after admission (6 cases with shock and 3 cases without shock), the source of bleeding was detected, but in 2 cases operated over 6 days after admission, the source was not detected. For the emergency operation of hemopneumothorax, we employed axillary thoracotomy by half lateral position in order to avoid the blood pressure depression due to position changing of the patient. The operation performed safely with enough exposure, and all the patients recovered without severe complication.

CONCLUSION

the treatment of spontaneous hemopneumothorax is better to choose early operation by axillary thoracotomy with half lateral position.

Metoclopramide inhibits development of esophageal varices in rat model

We examined the preventive effect of metoclopramide on the development of esophageal varices in a rat model. Thirty rats were divided into three groups: metoclopramide (7.5 mg/kg twice a day, intraperitoneally), control group I (saline 2 ml/kg twice a day, intraperitoneally), and control group II (incised lower esophageal sphincter and metoclopramide 7.5 mg/kg twice a day, intraperitoneally). On the 14th postoperative day, lower esophageal sphincter pressure in the metoclopramide group (8.6 +/- 1.4 cm H2O) increased more than in the control groups (5.4 +/- 0.5, 5.0 +/- 0.5 cm H2O, P < 0.01). Development of small collateral vessels from the spleen to the retroperitoneum was evident only in the metoclopramide group, as seen on the portography (P < 0.01). Histologically, the variceal area of the horizontal cross section of the esophagus in the metoclopramide group (0.62 +/- 0.26 mm2) was significantly smaller than in the controls (2.67 +/- 0.95, 2.78 +/- 0.82 mm2), determined using an image processor-analyzer for photographing histological specimens (P < 0.01). We also investigated the effect of metoclopramide on smooth muscle cells in the rat portal vein, using isometric-tension recording. Metoclopramide relaxed the smooth muscle precontracted with norepinephrine, in a concentration-dependent manner. Thus, metoclopramide inhibits the development of esophageal varices in this rat model due to both an increase in resistance of the lower esophagus and to development of small collaterals.

Effect of beta-alanyl-L-histidinato zinc on protein components in osteoblastic MC3T3-El cells: increase in osteocalcin, insulin-like growth factor-I and transforming growth factor-beta

The effect of beta-alanyl-L-histidinato zinc (AHZ) on protein components in osteoblastic MC3T3-E1 cells was investigated. Cells were cultured for 3 days at 37 degrees C in CO2 incubator in plastic dishes containing alpha-modified minimum essential medium supplemented with 10% fetal bovine serum. After the cultures, the medium was exchanged for that containing 0.1% bovine serum albumin plus various concentrations of AHZ or other reagents, and the cells were cultured further 3 or 6 days. The homgenate of cells was analyzed with SDS-polyacrylamide gel electrophoresis (SDS-PAGE). The presence of AHZ (10(-7) to 10(-5) M) caused an appreciable increase of many protein components in cells. Especially, the 67 killo-dalton (kDa) and 44 kDa proteins which are the major components from control cells were clearly increased by the presence of AHZ. Furthermore, the concentrations of osteocalcin, insulin-like growth factor-I and transforming growth factor-beta in the culture medium secreted from osteoblastic cells were markedly increased by the presence of AHZ (10(-6) and 10(-5) M). The effect of AHZ was a greater than that of zinc sulfate (10(-6) and 10(-5) M). The present findings suggest that AHZ can increase many proteins which are involved in the stimulation of bone formation and cell proliferation in osteoblastic cells.

Laparoscopy-assisted devascularization of the lower esophagus and upper stomach in the management of gastric varices

Devascularization of the lower esophagus and the upper stomach is one method of treating patients with clinically significant gastric varices. We describe a new method of laparoscopically-assisted devascularization which has been applied in seven patients with esophagogastric varices. Three of the seven patients had an episode of gastric variceal bleeding, and the remaining four had moderate to large gastric varices with red color signs. The operative procedure was carried out without pneumoperitoneum by using an ordinary forceps and laparoscopic instruments through a small skin incision (3-5 cm); the abdominal wall was elevated with a U-shaped retractor. The operative field was obtained by laparoscopic and direct vision illuminated by laparoscopic light. The procedure time ranged from 100 to 180 minutes with minimal blood loss (70-320 g). No complications were encountered. All patients could be discharged within one week; postoperative pain was minimal and all patients returned to work early. Follow-up (mean 11.4 months) showed no recurrence of gastric varices although, due to an incomplete procedure in two cases, two patients were treated additionally by endoscopic injection of histoacryl.

Laparoscopic splenectomy

A technique for laparoscopic splenectomy is described. The patient is placed in the right semidecubitus position and pneumoperitoneum is prepared. The splenic artery and vein are exposed near the hilum, using a laparoscopic ultrasonic dissector. The larger vessels are doubly ligated, and the spleen is resected and maneuvered into a nylon surgical sack; the sack is removed through a 2-cm incision along the midaxillary line. This procedure has been used for four patients requiring splenectomy for benign disease, and the outcome has been entirely satisfactory for all concerned.

Bleeding from gastric ulcer halted by laparoscopic suture ligation

In a 48-year-old Japanese man there was an uncontrollable and recurrent bleeding from a gastric ulcer and laparoscopic surgery was done. Two cannulae were placed in the gastric cavity through the abdominal wall and suture ligation of the bleeding vessel at the posterior wall of the stomach was done under video-visual control with endoscopic guidance. The bleeding ceased, complications were nil, and he remains well. This article reports on surgery done to repair uncontrollable, recurrent bleeding from a gastric ulcer. Two cannulae were placed in the gastric cavity through the abdominal wall and suture of the vessel at the posterior wall of the stomach was done with videovisual control and endoscopic guidance. This approach is concluded to have supplied minimal-access surgery, cost effectiveness, early discharge, less pain, and doctor-patient satisfaction.

Synthesis and pharmacological evaluation of phenolic 2-methyl-4-phenyl-1,2,3,4-tetrahydroisoquinolin-4-ols as a new norepinephrine potentiator

2-Methyl-4-phenyl-1,2,3,4-tetrahydroisoquinoline-4-ol(PI-OH) (2a) and its derivatives form a new class of compounds possessing norepinephrine (NE) potentiating activity. As a new series of compounds, the isomeric 4-(4-hydroxyphenyl)- and 4-(3-hydroxyphenyl)-2-methyl-1,2,3,4- tetrahydroisoquinolin-4-ols (3a and 3b), and 4-(3,4-dihydroxyphenyl)-1,2,3,4-tetrahydroisoquinolin-4-ol (3c) were prepared and their NE potentiating activities were evaluated. The 4-(4-hydroxyphenyl) analogue (3a) had only moderate activity and the 4-(3-hydroxyphenyl) analogue (3b) possessed a slightly higher activity than PI-OH. The 4-(3,4-dihydroxyphenyl) analogue (3c) was the most active compound and the pD2 value was 7.71 +/- 0.06 (activity ratio; 26.9 fold) at a concentration of 3 x 10(-6) M. These results indicate the importance of dihydroxyphenylethanolamine moiety of 3c for the inhibition of NE uptake.

Hemodynamic study of splenic artery aneurysm in portal hypertension

In our ongoing studies on the hemodynamics of splenic artery aneurysms (SAA) in portal hypertension, 32 patients with portal hypertension were examined by duplex sonography and angiography. Four out of 32 (12.5%) had SAA, and SAA(+) and SAA(-) groups were formed. On duplex sonography, splenic venous blood flow in the SAA(+) group (1058 +/- 211 ml/min) increased more than in the SAA(-) group (423 +/- 173 ml/min, p < 0.01), but there was no significant difference in portal venous flow. On angiography, there were significant differences in the diameters of the splenic arteries between the SAA(+) group (7.5 +/- 0.5 mm) and the SAA(-) group (5.6 +/- 1.0 mm, p < 0.01). All patients (100%) in the SAA(+) group had prominent portosystemic shunts, while 8 out of 28 (28.6%) in the SAA(-) group had these shunts (p < 0.05). Thus, there seems to be a splenic hyperkinetic state in patients with SAA and portal hypertension, a finding which may closely relate to the pathogenesis of SAA.

Role of endotoxin in L-arginine-induced relaxation of rat thoracic aorta mediated by muscle-derived nitric oxide

The contribution of endotoxin to the L-arginine-induced relaxation of the endothelium-denuded rat thoracic aorta, which appears to be mediated by nitric oxide synthase in the vascular smooth muscle, was investigated. Special attention was paid to the time course of the phenomenon and its dependence on the concentration of endotoxin. In the absence of endotoxin, L-arginine induced scarcely any relaxation of the arteries. Treatment of the arteries with endotoxin initiated relaxation in response to 10 microM L-arginine with lag periods of 2-4 hours. The degree of relaxation increased on repeated applications of L-arginine, to reach a consistent level after several hours. Increase in the concentration of endotoxin shortened the lag period, enhanced the degree of relaxation and lowered the threshold concentration of L-arginine required to relax the arteries. In endotoxin-primed arteries, L-arginine, at concentrations necessary to induce relaxation, stimulated the cyclic GMP production. Prophylactic application of actinomycin D or dexamethasone, which inhibits the induction of nitric oxide synthase, prevented the induction by endotoxin of the L-arginine-induced relaxation and cyclic GMP formation. Polymyxin B, which inhibits the action of endotoxin, also prevented the development of the endotoxin-sensitized relaxation and the cyclic GMP formation induced by L-arginine. When the Krebs solution was prepared using deionized water, the amount of endotoxin in the reservoir was above the level required to initiate the L-arginine-induced relaxation and cyclic GMP formation. These results suggest that endotoxin triggered the time-dependent development of the L-arginine-induced relaxation by expressing nitric oxide synthase in the vascular smooth muscle.

Effect of beta-alanyl-L-histidinato zinc on differentiation of osteoblastic MC3T3-E1 cells: increases in alkaline phosphatase activity and protein concentration

The effect of beta-alanyl-L-histidinato zinc (AHZ) on bone cell function was investigated in osteoblastic MC3T3-E1 cells. Cells were cultured for 3 days at 37 degrees C in a CO2 incubator in plastic dishes containing alpha-modified minimum essential medium supplemented with 10% fetal bovine serum. After the cultures, the medium was exchanged for that containing 0.1% bovine serum albumin plus AHZ (10(-7)-10(-5) M) or other reagents, and the cells were cultured further for appropriate periods of time. The presence of AHZ (10(-7)-10(-5) M) produced a remarkable increase of alkaline phosphatase activity and protein concentration in osteoblastic cells. Thus increase were seen with the prolonged cultivation (12-21 days). With the culture of 1, 3 and 12 days, the effect of AHZ (10(-6) M) to increase alkaline phosphatase activity and protein concentration was more intensive than the effect of zinc sulfate (10(-6) M). The AHZ effects were completely abolished by the presence of cycloheximide (10(-6) M), indicating that AHZ stimulates protein synthesis in the cells. The present study suggests that AHZ has a stimulatory effect on cell differentiation, and that this effect is partly involved on protein synthesis in osteoblastic cells.

Laparoscopy-assisted colostomy

The surgical modality of laparoscopic cholecystectomy is now widely accepted, and other intra-abdominal operations are also being done laparoscopically. This paper presents a case of laparoscopy-assisted colostomy in which a complete obstruction of the sigmoid colon associated with intraperitoneal dissemination and massive ascites in the end-stages of ovarian cancer was encountered. This procedure was found to be less invasive and thus should be considered the treatment of choice for an obstruction of the gastrointestinal tract in patients with a poor general status.

Analysis of hepatic vein waveform by Doppler ultrasonography in 100 patients with portal hypertension

OBJECTIVES

We classified the Doppler waveform seen in patients with portal hypertension and examined the associations of the waveform type with the diagnosis of Budd-Chiari syndrome and severity of the liver cirrhosis.

METHODS

The Doppler pattern of right and left hepatic veins in 100 consecutive Japanese patients with portal hypertension and esophagogastric varices was classified into six types: I, triphasic waveform; II, biphasic waveform without reversed flow; III, decreased amplitude of phasic oscillations; IV, flat waveform with fluttering; V, completely flat waveform with fluttering; VI, no waveform. All patients underwent computed tomography and magnetic resonance imaging. Patients in whom hepatic vein waveform showed type IV, type V, or type VI, positively underwent hepatic venography and inferior vena cavography.

RESULTS

Type I was seen in 31 of 100 patients, type II in 35, type III in 17, type IV in eight, type V in four, and type VI in five. Types I-IV waveform indicated no lesion in hepatic veins and inferior vena cava, type V indicated stenosis of hepatic veins or occlusion of inferior vena cava, and type VI, occlusion of hepatic veins. For one patient with type V hepatic veins, balloon angioplasty was done, and the waveform changed from type V to type II. Examining the relationship between hepatic vein waveform and the Child-Pugh score, liver function of type IV cases was worse than that of type I cases in 66 cirrhotic patients without hepatocellular carcinoma (p < 0.05). There was no clear relationship between hepatic vein waveform and portal venous perfusion, as based on Nordlinger's grade.

CONCLUSIONS

Our classification of hepatic vein waveform in Doppler ultrasonography is useful in diagnosing Budd-Chiari syndrome, in judging the efficiency of treatment for hepatic vein lesions, and in assessing severe liver function in cirrhotic patients.

Effect of zinc-chelating dipeptides on osteoblastic MC3T3-E1 cells: activation of aminoacyl-tRNA synthetase

The effect of zinc-chelating dipeptides on osteoblastic MC3T3-E1 cells was investigated. As zinc compounds, we used zinc sulfate, AHZ, di(N-acetyl-beta-alanyl-L-histidinato)zinc (AAHZ), and di(histidino)zinc (HZ). Cells were cultured for 72 h in the presence of zinc compounds (10(-8)-10(-5) M). The effect of AHZ (10(-7) and 10(-6) M) to increase protein and deoxyribonucleic acid (DNA) contents in the cells was the greatest in comparison with those of other zinc compounds. Zinc sulfate and HZ at 10(-7) M did not have an effect on the cellular protein content. AHZ (10(-6) M) had a potent effect on cell proliferation, although zinc sulfate (10(-6) M) had no effect. beta-Alanyl-L-histidine (10(-6) and 10(-5) M) did not have an appreciable effect on the cells. Those effects of AHZ (10(-6) M) on osteoblastic cells were completely abolished by the presence of cycloheximide (10(-6) M). AHZ (10(-8)-10(-5) M) directly activated [3H]leucyl-tRNA synthetase in the cell homogenate, whereas the effect of zinc sulfate was seen at 10(-6) and 10(-5) M. The present study suggests that the chemical form of zinc-chelating beta-alanyl-L-histidine (AHZ) can reveal a potent anabolic effect on osteoblastic cells, and that AHZ directly stimulates protein synthesis.

Effect of parathyroid hormone and interleukin-1 alpha in osteoblastic MC3T3-E1 cells: interaction with beta-alanyl-L-histidinato zinc

beta-Alanyl-L-histidinato zinc (AHZ), which is an activator of bone formation, has an inhibitory effect of bone resorption. Whether AHZ can inhibit the effect of parathyroid hormone (PTH) or interleukin-1 alpha (IL-1 alpha), which is a bone resorbing factor, on osteoblastic MC3T3-E1 cells was investigated. After subculture for 3 days, the cells were cultured for 48 h with peptides. Parathyroid hormone (10(-9)-10(-7) M) or IL-1 alpha (50 U/ml) caused a significant decrease in the cellular alkaline phosphatase activity and a remarkable increase of prostaglandin E2 (PGE2) production in the cells. Parathyroid hormone (10(-7) M) or IL-1 alpha (50 U/ml) did not have an appreciable effect on the protein content of the cells. beta-Alanyl-L-histidinato zinc (10(-5) M) significantly increased the cellular alkaline phosphatase activity and protein content, whereas it had no effect on PGE2 production. This increasing effect of AHZ was also seen in the presence of PTH (10(-7) M) or IL-1 alpha (50 U/ml), although the effect of PTH and IL-1 alpha to stimulate PGE2 production was not modulated by AHZ treatment. The present finding suggests that the inhibitory effect of AHZ on bone resorption is not through osteoblasts.

Vascular anatomy of duodenal varices: angiographic and histopathological assessments

Duodenal varices are a rare occurrence, and the diagnosis and control of related bleeding is problematic. The vascular anatomy of duodenal varices in four patients was examined angiographically. The incidence of these varices was 0.4% in the patients with portal hypertension seen in our clinics from 1982 to 1991. The transparent specimen obtained at autopsy and treated with methyl salicylate and portographies in the remaining three patients revealed that the duodenal varix consisted of a single vessel with afferent and efferent vessels, forming a portasystemic shunt in the retroperitoneum. The varix transversed the duodenum and was present in the submucosal layer of the posterior wall. The afferent vessel was the superior or inferior pancreaticoduodenal vein originating in the portal vein trunk or superior mesenteric vein. The efferent vein drained into the inferior vena cava. In view of these observations, devascularization or percutaneous transhepatic obliteration of the varix would be our first choice of treatment for patients with duodenal varices.

The significance of methicillin-resistant Staphylococcus aureus infection in general surgery: a multivariate analysis of risk factors and preventive approaches

To investigate the characteristics, risk factors, and prevention of methicillin-resistant Staphylococcus aureus (MRSA), a total of 3,627 patients were studied. Among these, 1,336 patients with various infections were used in a risk factor analysis of MRSA to determine the relationship between the use of antibiotics and the incidence of MRSA. Only 3.0% of infections were attributed to MRSA, the esophagus and colorectal region being highly involved, as anastomotic or pelvic abscesses, while the lung had a lower incidence. Almost half the patients with MRSA infections (47.6%) had concomitant infection. A univariate analysis revealed the following significant factors: The coexistence of gastrointestinal or metastatic malignancy, sepsis, tracheostomy, and the prior use of antibiotics such as the beta-lactam compounds or aminoglycosides. A multivariate analysis showed that gastrointestinal malignancy, sepsis, and the prior use of aminoglycosides, tetracycline, macrolides, and carbapenems were independently significant factors. To promote the education of doctors and nurses, regular in-service meetings on MRSA were held in the ward. Moreover, preventive approaches such as patient isolation, strategically placed hand washing equipment, and the use of disposable gloves and contaminated waste bags, have been initiated, and the incidence of MRSA has decreased significantly since then. Thus, to control MRSA, the following steps should be taken: (1) constant and careful surveillance, (2) regular risk factor analyses, (3) the optimal administration of antibiotics, and (4) the education of all hospital staff.

Laparoscopic oversewing of a bleeding Mallory-Weiss tear under endoscopic guidance

Continuous bleeding from a Mallory-Weiss tear required laparoscopic surgery to halt the bleeding. The oversewing of the laceration at the esophagogastric junction was readily performed under video control with endoscopic guidance and the bleeding ceased. To stop bleeding from such a tear, we prefer to use this modern approach.

Stimulatory effect of beta-alanyl-L-histidinato zinc on cell proliferation is dependent on protein synthesis in osteoblastic MC3T3-E1 cells

The effect of beta-alanyl-L-histidinato zinc (AHZ) on bone metabolism was investigated in osteoblastic MC3T3-E1 cells. Cells were cultured for 3 days at 37 degrees C in a CO2 incubator in plastic dishes containing alpha-modified minimum essential medium supplemented with 10% fetal bovine serum. After the cultures, the medium was exchanged for that containing 0.1% bovine serum albumin plus various concentrations of AHZ or other reagents, and the cells were cultured further for appropriate periods of time. The presence of AHZ (10(-7)-10(-5) M) stimulated the proliferation of cells. AHZ (10(-6) and 10(-5) M) increased deoxyribonucleic acid (DNA) content in the cells with 48 hr-culture. This increase was completely blocked by the presence of cycloheximide (10(-6) M) or hydroxyurea (10(-3) M). Also, the presence of cycloheximide (10(-6) M) completely inhibited the AHZ (10(-5) M)-induced increase in the proliferation of cells. Meanwhile, parathyroid hormone (10(-7) M), estrogen (10(-9) M) and insulin (10(-8) M) significantly increased cellular DNA content. However, these hormonal effects clearly lowered in comparison with that of AHZ (10(-5) M). Dibutyryl cyclic AMP (10(-4) M) and zinc sulfate (10(-5) M) did not cause a significant increase in cellular DNA content. The present results support the view that AHZ has a direct specific proliferative effect on osteoblastic cells in vitro and that this effect is dependent on protein synthesis.

[Measurement of platelet thromboxane A2/prostaglandin H2 receptor in asthmatic patients]

To evaluate the characteristics of platelet TXA2/PGH2 receptors in patients with bronchial asthma, we performed radiobinding assay of gel-filtrated washed platelets obtained from 15 asthmatic patients and 8 normal adults using [3H]-labeled S-145, a TXA2/PGH2 receptor antagonist, as a radiolinged. Data were evaluated by Schatchard's analysis, and the dissociation constant (Kd), an index of the binding characteristic of receptors, and the maximum number of binding sites (Bmax) were calculated. Venous blood was simultaneously collected and was centrifuged, and platelet-rich plasma was prepared. The platelet aggregation rates induced by various concentrations of U-46619, a TXA2 analogue, were measured by Born's method (nephelometry), and the concentration that induced 50% of the maximum platelet aggregation (EC50) was calculated using a concentration-response curve. The Kd value did not differ between the asthmatic patients and normal controls. Some of the asthmatic patients showed a low EC50 and a high Bmax. EC50 was inversely correlated with Bmax. The number of platelet TXA2/PGH2 receptors was shown to be increased in some asthmatic patients.

Hereditary spherocytosis with congestive heart failure: report of a case

We report herein a case of 62-year-old woman with hereditary spherocytosis (HS) and congestive heart failure (CHF). Although her history revealed jaundice in the early neonatal period, she had never undergone a physical examination and thus, the diagnosis of HS and CHF was not made until the age of 61 when she complained of dyspnea and palpitations on exertion. The CHF was subsequently found to be related to severe anemia in the presence of underlying heart disease. Splenectomy was performed in an attempt to relieve the severe hemolytic process. Following this, all the symptoms improved without the need for any cardiovascular drugs and she has been well throughout the 34 months follow up.

Successful treatment of early hepatocellular carcinoma and concomitant esophageal varices

Twenty-two cirrhotic patients with hepatocellular carcinoma (HCC) and concomitant esophageal varices underwent aggressive hepatic resection accompanied by simultaneous devascularization, perioperative endoscopic injection sclerotherapy, or both (group A). To evaluate this treatment, 37 cirrhotic patients without esophageal varices who underwent hepatic resection for small HCC (2 cm or less) during the same period (group B) were studied to compare clinical data, preoperative laboratory data, pathologic findings, disease-free rates, and survival rates. The operative time, blood loss, and resected liver weight did not differ between the two groups; however, the tumor size of group A (2.7 +/- 1.6 cm, mean +/- SD) was significantly larger than that of group B (1.5 +/- 0.3 cm). The preoperative liver function of group A was also more severe than that of group B except for prothrombin time. Despite these disadvantages, the 1-, 3-, and 5-year disease-free rates of the two groups were 72% versus 94%, 48% versus 54%, and 38% versus 45%, respectively, and the 1-, 3-, and 5-year survival rates were 91% versus 97%, 79% versus 79%, and 54% versus 67% (group A versus group B), respectively, which showed no significant differences. Furthermore, there was no variceal bleeding in group A after treatment. Based on the above findings, for treatment of HCC and concomitant esophageal varices, aggressive hepatic resection accompanied by simultaneous devascularization, perioperative endoscopic injection sclerotherapy, or both is the preferred form of treatment.

Endoscopic ligation of esophageal varices compared with injection sclerotherapy: a prospective randomized trial

Fifty cirrhotic patients with esophageal varices underwent endoscopic treatment in a prospective randomized trial carried out to compare variceal ligation with injection sclerotherapy, with respect to safety, efficacy, and complications in the initial session. Twenty-five patients each were treated using endoscopic variceal ligation or endoscopic injection sclerotherapy in the initial session and then only endoscopic injection sclerotherapy for all following sessions. Ligations numbered 4.1 at the initial session. The total number of sessions of endoscopic injection sclerotherapy was 4.0 +/- 1.3 in the endoscopic injection sclerotherapy group compared with 3.6 +/- 1.4 in the endoscopic variceal ligation group. The total volume of the sclerosant used by the end of all the sessions was 23.9 +/- 10.3 ml in the endoscopic variceal ligation group and 39.0 +/- 11.5 ml in the endoscopic injection sclerotherapy group (p < 0.0001). In all patients, complete eradication of the varices was achieved, and at 7 to 15 months follow-up no evidence of recurrence was seen. Adverse effects such as pyrexia, chest pain, and pleural effusion after the initial session were significantly lower in the endoscopic variceal ligation group (p < 0.05), and total bilirubin, serum creatinine, lactate dehydrogenase, and urinary beta 2-microglobulin were significantly increased and PaO2 decreased after endoscopic injection sclerotherapy (p < 0.05). This study shows that endoscopic variceal ligation significantly decreased the adverse effects associated with endoscopic injection sclerotherapy in the initial session, and it is recommended as an alternative to sclerotherapy.

Laparoscopic ligation of splenic artery aneurysm

Efforts should be made to avoid splenectomy because host resistance is maintained by the spleen. We describe here a 50-year-old woman in whom laparoscopic ligation of a splenic artery aneurysm 3.0 cm in diameter was successfully performed, without major complications. Computed tomography performed 5 months later revealed no infarction in the spleen. For this patient with liver cirrhosis and cholelithiasis, laparoscopic cholecystectomy was performed at the same operation. Laparoscopic surgery is most feasible when the splenic artery is markedly tortuous and protrudes from the pancreas.

[Oculopharyngeal myopathy with autoimmune disease]

A 34-year-old woman had suffered from systemic lupus erythematosus (SLE) and autoimmune hemolytic anemia (AIHA) in the teen age. She developed progressive ptosis of the eyelids, and difficulty in swallowing and speaking for several years. Endocrinological studies showed primary hypothyroidism. A serum IgG level was elevated (1,973 mg/dl), and antinuclear antibody, thyroid test and microsome test were positive. A muscle biopsy showed massive inflammatory cell infiltrates in the perivascular area in addition to some myopathic change; some variation in fiber size. Immunological staining demonstrated most of these inflammatory cell infiltrates were CD3+ cells and CD4+ cells were counted more than CD8+ cells (CD4/CD8 = 2.3). The diagnoses were confirmed as oculopharyngeal myopathy and Hashimoto's disease. In addition, she had suffered from SLE and AIHA. Therefore we conclude that manifestation of this myopathy may be associated with some autoimmune process.

Pharmacokinetics of sulfadimethoxine in skin of broiler-chicken after single and multiple intravenous injections

Pharmacokinetics of sulfadimethoxine (SDMX) in skin of broiler chicken after intravenous and in-drinking-water administrations were investigated to examine the reason for a longer residue of SDMX in the skin which was observed in the residue study after administration via drinking water at a concentration of 1,000 ppm. The decay curve of SDMX in the skin after single intravenous injection of 200 mg/kg, the highest dose, was fitted to the two compartment model with T1/2 of 4.4 hrs in the first elimination phase and 173 hrs in the second one. The extrapolated concentrations in the skin at 24 hrs after the injection were calculated to be 69.0 micrograms/g for the 1st phase and 0.11 micrograms/g for the 2nd phase. The decay curves in the skin after single injection of 30 and 100 mg/kg were fitted to the one compartment model with T1/2 of 3.2 and 5.7 hrs, respectively. Dividing a high dose into 3 to 5 doses and injecting sequentially with intervals of the previously measured T1/2, SDMX concentrations in the skin were about half of those in the plasma and ran parallel. The plasma concentration-time curves after single intravenous injection of SDMX more than 100 mg/kg showed nonlinear kinetics with concentrations over 100 micrograms/ml for 12-30 hrs after the injection. By administration of SDMX via drinking water, a sustained residue curve of SDMX in the skin at 1,000 ppm reported previously was not observed at 500 ppm.(ABSTRACT TRUNCATED AT 250 WORDS)

Albumin inhibits hemolysis of erythrocytes induced by ethanolamine oleate during endoscopic injection sclerotherapy

In attempts to avoid hemolytic nephropathy following injection of 5% ethanolamine oleate during endoscopic injection sclerotherapy for esophageal varices, the relationship between serum levels of albumin and hemolysis induced by ethanolamine oleate was investigated. The rate of hemolysis at various concentrations of ethanolamine oleate and albumin was examined using a spectrophotometer in ten cirrhotic patients and five healthy volunteers (controls). Hemolysis induced by ethanol-amine oleate increased in an ethanolamine oleate concentration-dependent fashion (p < 0.01) but was dose-dependently inhibited by albumin (p < 0.05). The state of liver function was unrelated to the rate of hemolysis. The relationship between hemoglobinuria and serum albumin levels in seventy-nine cirrhotic patients with esophageal varices treated by endoscopic injection sclerotherapy with ethanolamine oleate was also examined. Hemoglobinuria was evident in 20 out of 24 patients (83.8%) in whom the serum albumin level was less than 3.0 g/dl, and in 24 out of 55 (43.6%) in whom it exceeded 3.0 g/dl, the difference being statistically significant (p < 0.01). On the day after endoscopic injection sclerotherapy, creatinine clearance fell from 81.6 +/- 33.8 m/l min to 60.1 +/- 31.4 ml/min in the hemoglobinuria-positive patients (p > 0.01) and two went into acute renal failure. The creatinine clearance ranged from 79.5 +/- 27.9 ml/min to 83.0 +/- 39.9 ml/min in the hemoglobinuria-negative patients (p < 0.1). In the light of this evidence we correct the serum albumin level cut off point to 3.0 g/dl prior to endoscopic injection sclerotherapy in order to maintain renal function.

[Study on the inhibitory effect of AA-2414 on platelet aggregation and its clinical effect in asthmatic patients]

We previously reported that AA-2414, an eicosanoid receptor antagonist, inhibits platelet aggregation mediated by TXA2/PGH2 receptors in patients with bronchial asthma, but that the inhibitory effects differ among individuals. In this study, we measured the in vitro inhibition rate of platelet aggregation by AA-2414 using U-46619 as an aggregating agent in 22 asthmatic patients and classified them into Group A (showing an inhibition rate of 60% or more) and Group B (showing a rate of less than 60%). Subsequently, AA-2414 tablets (40 mg/day) were orally administered to both groups for 6 weeks, and the clinical effects were compared. A positive correlation was observed between the in vitro U-46619-induced platelet aggregation rate and the inhibition rate of aggregation by AA-2414. At the end of administration, marked inhibition of U-46619-induced platelet aggregation was observed in all patients. However, Group A showed a higher improvement rate of symptoms than Group B. Asthmatic patients can be classified into the groups showing good or poor platelet responses. The response may reflect reactivity to TXA2 in the local airway.

Comparative effects of 5% ethanolamine oleate versus 5% ethanolamine oleate plus 1% polidocanol for sclerosing esophageal varices

Sixty-six patients with portal hypertension and esophageal varices due to liver cirrhosis were randomized to receive either 5% ethanolamine oleate (EO) or 5% EO plus 1% polidocanol (EOP) as a sclerosant for endoscopic injection sclerotherapy (EIS). The two groups were well matched with regard to age, sex and the severity of liver disease. In no patient in the two groups was there any major complication, such as esophageal perforation or esophageal bleeding. Eradication of esophageal varices was attained with an average of 4.7 and 4.3 sessions of endoscopic injection sclerotherapy in the ethanolamine oleate and polidocanol groups, respectively. Data on one patient in the ethanolamine oleate group had to be excluded because he left the hospital after 2 sessions of endoscopic injection sclerotherapy. Esophageal ulcers occurred earlier in the polidocanol group (after an average of 2.8 weeks) than in the ethanolamine oleate group (3.8 weeks), the difference being statistically significant (P < 0.01). The rate of occurrence of esophageal stricture requiring more than 2 sessions of bougienage was significantly (P < 0.01) higher in the polidocanol group (16/33, 48%) than in the ethanolamine oleate group (4/32, 12%). This study suggests that the two sclerosants have equal efficacy for treating patients with esophageal varices. With polidocanol there was ulceration and stricture in the distal esophagus.

[Surgical versus non-surgical treatment in patients with esophageal varices--a prospective randomized study]

In Japan, non-shunting procedures and selective shunt such as esophageal transection (ET), and distal splenorenal shunt (DSRS) have been widely performed. A prospective randomized trial was done to assess the effects of EIS and DSRS for treating patients with esophageal varices. Ninety-six Japanese with good liver function (Child A or B) and large esophageal varices were randomly assigned to one of three groups given different treatments; (EIS, n = 32), (ET, n = 32) and (DSRS, n = 32). Five patients (15.6%) of the DSRS group has to be excluded from this study, because of severe chronic pancreatitis. No patient died within 30 days of the treatments. The 5-year cumulative bleeding rates were 0%, 4.3% and 12.1% in the EIS, ET and DSRS groups, respectively, with no statistical significances. In no case in the three groups did the death occur because of variceal bleeding. Nineteen patients died mainly due to the underlying liver disease; 5 in the EIS, 5 in the ET and 9 in the DSRS group. There was no statistically significant difference in the survival rates among the three groups. We conclude that EIS is a satisfactory alternative to ET or DSRS for the management of patients with large esophageal varices.

Effects of endoscopic injection sclerotherapy on portal hypertensive gastropathy: a prospective study

The effect of endoscopic injection sclerotherapy (EIS) for esophageal varices on portal hypertensive gastropathy (PHG) was investigated in 137 patients who underwent EIS from July 1987 to March 1990. Two groups, PHG(+) (N = 35) and PHG(-) (N = 102) were distinguished by endoscopic findings obtained before EIS. PHG was classified into four grades by endoscopy scored as 0, 1, 2, or 3. The PHG score significantly worsened after EIS (p < 0.01), and PHG became worse 6 to 9 months after the eradication of varices followed by gradual improvement. Recurrent small veins, which required additional EIS, appeared more frequently in the PHG(+) group (p < 0.05). New gastric varices appeared or gastric varices enlarged after EIS more frequently in the PHG(+) group (7 patients, 20.0%) than in the PHG(-) group (12 patients, 11.8%), but this was not statistically significant. Thus, frequent endoscopy after EIS is needed with special attention directed to development of PHG and gastric varices, especially for patients with PHG prior to treatment.

The nature of inner cellular lining of the expanded polytetrafluoroethylene vascular graft: immunohistochemical study

Histological and immunohistochemical studies of the healing processes of expanded polytetrafluoroethylene (PTFE) vascular graft were performed. In the animal experiment, endothelial cell lining, confirmed by immunohistochemical staining for anti-Factor VIII related antigen, existed nearly over all of the pannus. The endothelial cells also formed to some extent over the graft without pannus. Endothelialization showed a close dependency on the surface condition of the underlying tissue rather than on a time factor. In the human experiment, an endothelial island was observed in the middle portion of the graft in one case, supporting the hypothesis of the blood stream origin of endothelial cells.

Over-tube is preferable to free-hand technique to avoid recurrence of varices after endoscopic injection sclerotherapy. Prospective randomized trial

One hundred and two patients undergoing sclerotherapy of esophageal varices, using 5% ethanolamine oleate, were randomly allocated to either the over-tube (O-T) or the free-hand (F-H) group, and 100 patients could be followed at monthly intervals for a period of 30.8 +/- 14.7 months (mean +/- SD) after the varices had been eradicated. Endoscopy performed one month after the final session of sclerotherapy revealed circumferential ulcers and scarring in the lower esophagus in 42 of 50 patients (84%) in the O-T group and in 16 of 50 patients (32%) of the F-H group, the difference being statistically significant (P less than 0.01). In the remaining 8 and 34 patients in the O-T and the F-H groups, respectively, a partly fibrotic residual mucosa was seen. There was a recurrence of the varices in the residual mucosa in 14 (28%) in the F-H group during the mean follow-up period of 25.6 months, while there were five patients (10%) with a recurrence of varices in the O-T group, the difference being statistically significant (P less than 0.05). The survival rates showed no statistical significance. Two patients in the F-H group had recurrent bleeding. We conclude that the over-tube technique of sclerosing esophageal varices reduces the rate of recurrence of the varices, in the long term follow-up, and after formation of a circumferential scarring in the lower esophagus.

[Clinical studies of panipenem/betamipron in pediatrics]

We conducted clinical studies on panipenem/betamipron (PAPM/BP), a newly developed parenteral carbapenem antibiotic, for its clinical application in the field of pediatrics. 1. A clinical study was performed on 13 children with infections, including 6 with acute bronchopneumonia, 1 each with acute pharyngitis, acute bronchitis, sepsis, staphylococcal scalded skin syndrome, urinary tract infection, subcutaneous abscess and furuncle. PAPM/BP was administered by intravenous drip infusion. Doses varied from 12 to 27 mg/kg body weight were given t.i.d. or q.i.d. Lengths of treatment ranged from 4 to 25 days. Clinical efficacies were excellent in 3 and good in 9 cases, with an efficacy rate of 92%. 2. No adverse reactions were observed. In laboratory tests, elevations of GOT, GPT and urobilinogen were observed in 3 cases. It was concluded that PAPM/BP was a promising drug for the treatment of bacterial infections in children.

[alpha-Interferon in the treatment of essential thrombocythemia]

Two patients with essential thrombocythemia were successfully treated by administering native alpha-interferon (alpha-IFN). One patient was a 38-year-old man in whom thrombocytosis was found accidentally. His platelet count on admission was 880,000/microliters and megakaryocytes increased. Three million units of alpha-IFN was administered subcutaneously everyday, and the platelet count decreased gradually to about 500,000/microliters within 2 weeks. The other patient was a 66-year-old woman who visited our hospital complaining of tenderness and swelling of the fingertips. Her platelet count was 1,610,000/microliters, and megakaryocytes increased and showed abnormal morphology. Six million units of alpha-IFN was administered subcutaneously every other day. The tenderness and swelling of the fingertips disappeared soon after the beginning of alpha-IFN administration. The platelet count decreased to about 500,000/microliters within 10 days, but she developed itching of the skin over the entire body. Therefore, alpha-IFN treatment was discontinued. It was suggested that alpha-IFN suppresses not only the maturation and proliferation of the progenitors of megakaryocytes but also the production of platelets from megakaryocytes. Administration of alpha-IFN should be considered in treating patients with essential thrombocythemia, because effects appear soon and alpha-IFN does not induce a second malignancy.

Sclerotherapy vs. esophageal transection vs. distal splenorenal shunt for the clinical management of esophageal varices in patients with child class A and B liver function: a prospective randomized trial

Ninety-six patients with good liver function (Child class A or B) and esophageal varices were randomly assigned to one of three groups given different treatments: endoscopic injection sclerotherapy (n = 32), esophageal transection (n = 32) or distal splenorenal shunt (n = 32). Five patients (5.2%) had to be excluded from this study because severe chronic pancreatitis made separation of the distal splenic vein from the pancreatic bed difficult. Esophageal transection was performed for these patients. No deaths occurred during the 30 days of treatment. The 5-yr cumulative bleeding rates were 0%, 5.9% and 12.9% in the endoscopic injection sclerotherapy, esophageal transection and distal splenorenal shunt groups, respectively (no statistical significance). In no case in the three groups did death occur because of variceal bleeding. Sixteen patients died, mainly because of underlying liver disease; four were in the endoscopic injection sclerotherapy group, five were in the esophageal transection group and seven were in the distal splenorenal shunt group. No statistically significant difference in survival rate among the three groups was found. These results show that endoscopic injection sclerotherapy is a satisfactory alternative to esophageal transection or distal splenorenal shunt for the clinical management of patients with esophageal varices.

Endoscopic injection sclerotherapy for 1,000 patients with esophageal varices: a nine-year prospective study

We report here the results of endoscopic injection sclerotherapy performed in 1,000 consecutively treated Japanese patients with esophageal varices. This prospective study covered the period from 1982 to 1990. Variceal bleeding was controlled in 215 (97.7%) of 220 patients. Esophageal varices were completely eradicated in 778 patients (77.8%); the mean number of sessions was 4.2. In only 3 of the 778 patients did esophageal varices of the same size recur. Small, dilated, venous vessels that required additional sclerotherapy in follow-up endoscopy at 3-mo intervals appeared in 171 (22.2%) of 778 patients. The cumulative nonbleeding rate at 5 yr was 94.5% in patients in whom the varices had been eradicated. Deaths caused by upper gastrointestinal bleeding accounted for 2.6% of cases, whereas the rates of liver failure and hepatoma were 4.6% and 47.3%, respectively. The 5-yr cumulative survival rate was 54.1% in patients without concomitant hepatoma; it was 12.0% in patients with hepatomas. Multivariate analysis showed that hepatoma, Child classification, indication (acute, elective or prophylactic) and eradication were independent factors that significantly influenced survival time. This study clearly shows that close follow-up with endoscopy and complete eradication lead to significant reduction in bleeding from esophageal varices and reduction of mortality related to this bleeding.

ATP diphosphohydrolase is responsible for ecto-ATPase and ecto-ADPase activities in bovine aorta endothelial and smooth muscle cells

An ATP diphosphohydrolase (EC 3.6.1.5) is an enzyme hydrolyzing pyrophosphate bonds in nucleoside di- and triphosphates with broad substrate specificity in the presence of divalent cations. The ATPase and ADPase activities in the enzyme purified to homogeneity from bovine aortic vessel wall were insensitive to oligomycin, ouabain, and various protease treatments, and sensitive to azide and Ap5A. Bovine aorta endothelial and smooth muscle cells were cultured separately to characterize the ectonucleotidase activities. The activities were dependent on the addition of divalent cations and had broad substrate specificity. The ecto-ATPase and -ADPase activities were insensitive to oligomycin, ouabain, and protease treatments, and sensitive to azide and Ap5A. No enzyme degrading only ADP was found in the aortic vessel wall. Moreover, antiserum raised against purified ATP diphosphohydrolase inhibited the ecto-ATPase and -ADPase activities. These results indicated that ecto-ATPase and ecto-ADPase are not separate enzymes but are expressed by one enzyme, ATP diphosphohydrolase.

Gastric bleeding after endoscopic injection sclerotherapy for esophageal varices may be fatal

Among 457 Japanese cirrhotic patients with esophageal varices, 28 (6%) bled from the upper gastrointestinal tract after the initial session of endoscopic injection sclerotherapy (EIS); 13 bled during the course of repeated EIS and 15 bled mainly from gastric lesions after eradication of the varices. Of these 28 patients, bleeding from gastritis occurred in 13 (46%), from esophageal varices in 10 (36%), from gastric varices in 4 (14%) and from gastric ulcer in one (4%). Six of 13 patients with gastritis-related bleeding and 3 of 4 patients with gastric variceal bleeding died of uncontrollable hemorrhage complicated liver failure, while 9 of 10 patients with esophageal variceal bleeding were controlled and reinjection was feasible. Ten (36%) of the 28 patients, with Child's grade B or C and severe ascites, died, mainly following bleeding from gastric lesions. This study shows that bleeding from gastric lesions after EIS can be uncontrollable and fatal in patients with poor liver function.

Comparative effects of 5% ethanolamine oleate versus 5% sodium morrhuate for sclerotherapy of oesophageal varices

Forty-five cirrhotic patients with oesophageal varices were randomized to receive endoscopic injection sclerotherapy with either 5% ethanolamine oleate (EO), or 5% sodium morrhuate (SM). In the EO group, there was a statistically significant higher rate of disappearance of red colour signs on the varices a week after the initial session of sclerotherapy than in the SM group (91.3% vs 45.5%, P less than 0.05). A jet-like bleeding from injection sites at the second session of sclerotherapy occurred in three patients in the SM group and they experienced blurred vision. There was no such occurrence in the EO group. Oesophageal bleeding requiring blood transfusion during the course of repeated sclerotherapy occurred only in the SM group (five patients): bleeding was from a partly thrombosed varix and in four was from oesophageal ulcers. We found that EO administered intravariceally is more efficacious than SM for sclerotherapy of oesophageal varices.