Endoscopic cholangiopancreatography in hepatic clonorchiasis--a follow-up study

Cholangiographic changes of the biliary system in 16 patients with proven hepatic clonorchiasis, diagnosed by positive stool or bile ova isolates, were studied. All patients presented with epigastric pain. Other symptoms included jaundice in 31% (5 of 16) and fever in 12.5% (2 of 16). Praziquantel given at 25 mg/kg for three doses in 1 day were administered. Three consecutive stool tests were performed 3 months after treatment and were negative in 87.5% (14 of 16). ERCP studies were repeated at a mean interval of 31.6 months (range, 8 to 69 months). Measurements of the bile ducts on retrograde cholangiograms before and after treatment were compared using the paired Student's t test. Filling defects and blunting of the terminal bile ducts seen on the initial cholangiogram, interpreted as the presence of adult worms, disappeared after treatment. However, there was no significant change between pre- and post-treatment measurement of bile duct caliber. Bile duct dilation, irregularities, and ductal proliferation persisted despite eradication of the parasite.

Reliability and characteristics of current perception thresholds in the territory of the infraorbital and inferior alveolar nerves

AIMS

To estimate the intra- and interrater reliability of current perception threshold (CPT) evaluation, especially within the infraorbital nerve territory (ION) and inferior alveolar nerve territory (IAN) of the orofacial region, and to characterize the CPTs of ION and IAN in the normal population.

METHODS

Electrical stimulation (at 2,000 Hz, 250 Hz, and 5 Hz) was applied to ION and IAN to allow for CPT evaluation in 200 subjects, all of whom were healthy, had no systemic diseases, and were free from symptoms and history of neuropathic conditions. Twenty-five of the subjects were evaluated 3 times by 2 examiners to test reliability, and the remaining subjects were evaluated once for normative data.

RESULTS

The intraclass correlation coefficient of CPTs within examiner and between examiners ranged from 0.46 to 0.95. There were no significant differences between right and left sides in CPT evaluation within the ION and IAN territory. Gender and age did not affect the CPT values for ION and IAN in the normal population. There were significant differences between each of the 3 frequency-dependent (2,000 Hz, 250 Hz, 5 Hz) measures within ION and IAN (P < 0.001).

CONCLUSION

Evaluation of CPTs within ION and IAN revealed good intra- and interrater reliability. The study also provided normative data of CPTs of ION, IAN, and the between-site and within-site ratios of CPTs of ION and IAN. This should prove useful in the diagnosis of orofacial neuropathy.

Validation of a new immunoblot assay for the diagnosis of Helicobacter pylori in the Asian population

BACKGROUND

Performance of commercial serological tests for Helicobacter pylori varies in different populations, largely due to strain heterogeneity and variations in antigenic preparations. Currently available serology tests often show sub-optimal accuracy when used for Asian patients.

AIM

This study evaluated a recombinant antigen-based immunoblot for the diagnosis of H. pylori infection in Chinese patients, and compared it with a conventional ELISA test.

METHODS

Dyspeptic patients referred for diagnostic endoscopy were recruited. The gold standard for H. pylori infection was based on two or more positive results among rapid urease test, histology and (13)C-urea breath test. Serological diagnosis of H. pylori infection was conducted by an ELISA test (pylori DTect; Diagnostic Technology) and an immunoblotting against a novel recombinant antigen (C1S; Genelab), which was constructed by immunological screening of the genomic DNA library of H. pylori.

RESULTS

A total of 87 patients were evaluated and H. pylori infection was diagnosed in 40 (46%) by the reference tests. The sensitivities of the ELISA and immunoblot were 80% (95% CI: 64--91%) and 90% (95% CI: 76--97%), whilst the specificities were 96% (95% CI: 86--96%) and 87% (95% CI: 74--95%), respectively. The respective likelihood ratios of the two tests were 18.6 and 7.0.

CONCLUSIONS

Satisfactory performance is obtained by the use of the new recombinant antigen-based immunoblot for diagnosing H. pylori infection in Chinese patients.

Somatic beta-catenin mutation in gastric carcinoma--an infrequent event that is not specific for microsatellite instability

We screened 90 cases of gastric carcinoma (GCA) samples for beta-catenin exon 3 mutation and assessed its possible relationship with microsatellite instability (MSI). Three mutations were detected in two samples, including a single mutation in an intestinal type and double mutations in a diffuse type GCA. One of the mutations found in the diffuse type GCA sample was a non-sense mutation at codon 68 (CAG-->TAG). This novel mutation was predicted to disrupt the binding of beta-catenin to alpha-catenin and may be related to the diffuse type morphology. The other two mutations were missense mutations involved or related to the GSK-3beta phosphorylation site, which have been reported previously. No MSI can be demonstrated in the two cases with beta-catenin mutation. Our results suggested that beta-catenin mutation was infrequent in GCA and appeared not specific for MSI.

Association between cyclo-oxygenase-2 overexpression and missense p53 mutations in gastric cancer

Wild-type p53 competitively binds to the promoter region of COX-2 in vitro and inhibits its transcription. We examined the association between p53 mutation and COX-2 expression in gastric cancer. COX-2 over-expression was seen in 19 (48.7%) cases. These tumours had more lymph-node metastasis (P = 0.048) and tended to have a poorer survival (P = 0.07). Missense mutations of p53 were detected in 20 (51.3%) patients and had a significantly stronger COX-2 expression than tumours without p53 mutation (P = 0.016). Our results suggest a link between p53 mutation and COX-2 overexpression in gastric cancer.

Randomized trial of low-dose misoprostol and naproxen vs. nabumetone to prevent recurrent upper gastrointestinal haemorrhage in users of non-steroidal anti-inflammatory drugs

BACKGROUND

Prophylactic misoprostol or non-steroidal anti-inflammatory drugs (NSAIDs) with low gastric toxicity (nabumetone) has been shown to reduce mucosal injury.

AIM

To compare nabumetone vs. co-therapy of naproxen with low-dose misoprostol for secondary prevention of upper gastrointestinal bleeding in NSAID users.

METHODS

NSAID users presenting with upper gastrointestinal bleeding were enrolled if they required long-term NSAIDs. After ulcer healing, they were randomized to receive: naproxen (500-1000 mg/day) and misoprostol (200 microg b.d.), or nabumetone (1000-1500 mg/day) and placebo misoprostol for 24 weeks. The primary end-point was recurrent upper gastrointestinal bleeding. The secondary end-point was the proportion of patients suffering from major gastrointestinal events including ulcer bleeding, symptomatic ulcers and severe dyspepsia.

RESULTS

A total of 90 patients were included in the intention-to-treat analysis (misoprostol/naproxen 45, nabumetone 45). Recurrent bleeding occurred in 10 patients (22.2%) receiving misoprostol/naproxen compared with three (6.7%) receiving nabumetone (relative risk 3.33, 95% CI: 0.98-11.32, P=0.069). The proportion of patients suffering from major gastrointestinal events at 24 weeks was 31.1% in the misoprostol/naproxen group and 28.9% in the nabumetone group.

CONCLUSIONS

Misoprostol/naproxen is not superior to nabumetone for secondary prevention of upper gastrointestinal bleeding. Neither low-dose misoprostol nor nabumetone is adequate for high-risk NSAID users.

Is it safe to reuse disposable laparoscopic trocars? An in vitro testing

BACKGROUND

The reuse of disposable laparoscopic instruments carries a risk of transmitting infectious diseases such as hepatitis and HIV. We evaluated the safety of reusing disposable trocars by studying the chances of their harboring infectious viruses after resterilization in an in vitro setting.

METHODS

Disposable laparoscopic trocars were exposed to horse blood contaminated with high or low viral concentrations of herpes simplex virus type 1 (HSV1) and attenuated polio virus type 1 at room temperature for 2 h. HSV1 was chosen as the surrogate for lipid viruses that include hepatitis B and HIV virus; polio virus represented the nonlipid viruses that cause infections in immunocompromised patients and are more resistant to sterilization. The trocars were subsequently cleaned and resterilized by low-temperature steam and formaldehyde at 80 degrees C for 3 h. Viral cultures were then repeated after sterilization.

RESULTS

A cytopathic effect (CPE) was demonstrated at both concentrations for HSV1 in all trocars before but not after sterilization. For the polio virus, CPE was evident in 50% of the trocars (two of four) exposed to high viral concentration after sterilization.

CONCLUSION

Disposable trocars are difficult to resterilize and may harbor infectious viruses after their initial use. Therefore, the reuse of disposable trocars in laparoscopic surgery cannot be recommended.

Transhepatic balloon sphincteroplasty for bile duct stones after total gastrectomy

Previous upper gastrointestinal surgery with the construction of a Roux-en-Y jejunal loop may prevent endoscopic access to the second part of the duodenum. We report a technique of percutaneous transhepatic balloon sphincteroplasty to facilitate the removal of common bile duct (CBD) stones. A 67-year-old woman presented with a 1-week history of right upper quadrant abdominal pain and fever, deranged liver function tests, and dilated intrahepatic ducts. The patient had previously had a total gastrectomy with Roux-en-Y reconstruction for a high-grade B-cell lymphoma of the stomach. Peroral endoscopic access to the biliary tree was unsuccessful. Percutaneous transhepatic cholangiography confirmed the presence of CBD stones. Over a period of 8 weeks, sequential dilatation of the percutaneous tract was undertaken. After a further 2 weeks, percutaneous choledochoscopy was performed. Several large stones were visualized and then fragmented. The choledochoscope would not pass through to the duodenum due to postinflammatory stenosis of the papilla, so the papilla was dilated with an endoscopic balloon. The remaining fragments were pushed through, and the duct was thoroughly irrigated with saline. Repeat cholangiography confirmed a clear CBD. Balloon catheter sphincteroplasty and biliary stone extrusion into the duodenum is a novel technique that enabled clearance of the CBD in an elderly patient who may otherwise have required open surgical exploration.

Neck ultrasound in staging squamous oesophageal carcinoma - a high yield technique

AIM

This study evaluates the use of neck ultrasound in staging squamous oesophageal carcinoma.

MATERIALS AND METHODS

A prospective analysis of the clinical, neck ultrasound (US) and thoraco-abdominal computed tomography (CT) findings in 121 patients with squamous oesophageal carcinoma at presentation was performed. The relationship between malignant neck nodes, mediastinal and abdominal adenopathy, location and size of the primary tumour was analysed.

RESULTS

Ten of 121 patients (8%) had clinically palpable neck nodes which were deemed malignant in six (5%) following US and fine-needle aspiration for cytology. Of those 111 patients with no palpable neck nodes, 31 (28%) had malignant nodes shown on US. The more cephalad the location of the primary tumour, the higher the frequency of malignant neck nodes which were found in 80%, 52%, 29% and 9% of cervical, upper thoracic, mid-thoracic and lower thoracic oesophageal tumours, respectively. Eleven (29%) of the 38 patients with malignant neck nodes shown on US had no CT evidence of additional adenopathy in the mediastinum or upper abdomen. Neck US altered TNM staging in 22/121 (18%) patients at presentation.

CONCLUSION

Neck US frequently detects clinically impalpable metastatic nodes leading to altered TNM staging in patients with squamous oesophageal carcinoma. We advocate its routine use when staging squamous oesophageal carcinoma.

Beta-endorphin infusion during exercise in rats: blood metabolic effects

Beta-endorphin (betaE) bolus (0.05 mg x kg(-1)) infusion (0.05 mg x kg(-1) x h(-1)) was previously shown in rats to attenuate the decline in plasma glucose during exercise.

PURPOSE

The present investigation compared betaE and saline infusion in rats without a bolus of betaE to determine whether 1) the attenuation in the glucose decline was attributable to the type of administration (bolus betaE + continuous betaE infusion vs continuous betaE infusion), and 2) whether circulating catecholamines or FFAs were in part involved in the glucose decline.

METHODS

Forty untrained Sprague-Dawley rats were randomly assigned to one of four treatments: 1) betaE infusion at rest (betaR), 2) betaE infusion during exercise (betaX), 3) saline infusion at rest (SR), and 4) saline infusion during exercise (SX). Infusions (betaE or saline) with running (22 m x min(-1), 0% grade) lasted 90 min.

RESULTS

A 2 x 2 ANOVA indicated betaE infusion significantly attenuated the decline in plasma glucose due to exercise at 90 min (SX = 4.16 +/- 0.1 vs betaX = 4.61 +/- 0.1 mM). BetaE infusion elevated plasma betaE about 2.5-fold at rest compared with SR and two-fold after exercise (betaX) compared with SX. BetaE infusion had no effect at rest on any of the other variables measured. Exercise significantly increased catecholamines, FFAs and glucagon compared with resting levels. BetaE infusion enhanced the glucagon response to exercise (SX = 577 +/- 67.5 vs betaX = 913 +/- 153 ng x L(-1), P < 0.02). Epinephrine and norepinephrine and FFAs were similar with betaE infusion either at rest or during exercise compared with saline infusion.

CONCLUSION

These results suggest that betaE infusion independent of the betaE bolus can attenuate the decline in glucose during exercise by enhancing glucagon levels and the betaE infusion did not influence circulating catecholamines or FFA's response to exercise.

Effect of intravenous omeprazole on recurrent bleeding after endoscopic treatment of bleeding peptic ulcers

BACKGROUND

After endoscopic treatment of bleeding peptic ulcers, bleeding recurs in 15 to 20 percent of patients.

METHODS

We assessed whether the use of a high dose of a proton-pump inhibitor would reduce the frequency of recurrent bleeding after endoscopic treatment of bleeding peptic ulcers. Patients with actively bleeding ulcers or ulcers with nonbleeding visible vessels were treated with an epinephrine injection followed by thermocoagulation. After hemostasis had been achieved, they were randomly assigned in a double-blind fashion to receive omeprazole (given as a bolus intravenous injection of 80 mg followed by an infusion of 8 mg per hour for 72 hours) or placebo. After the infusion, all patients were given 20 mg of omeprazole orally per day for eight weeks. The primary end point was recurrent bleeding within 30 days after endoscopy.

RESULTS

We enrolled 240 patients, 120 in each group. Bleeding recurred within 30 days in 8 patients (6.7 percent) in the omeprazole group, as compared with 27 (22.5 percent) in the placebo group (hazard ratio, 3.9; 95 percent confidence interval, 1.7 to 9.0). Most episodes of recurrent bleeding occurred during the first three days, which made up the infusion period (5 in the omeprazole group and 24 in the placebo group, P<0.001). Three patients in the omeprazole group and nine in the placebo group underwent surgery (P=0.14). Five patients (4.2 percent) in the omeprazole group and 12 (10 percent) in the placebo group died within 30 days after endoscopy (P=0.13).

CONCLUSIONS

After endoscopic treatment of bleeding peptic ulcers, a high-dose infusion of omeprazole substantially reduces the risk of recurrent bleeding.

EUS-guided injection of cyanoacrylate for bleeding gastric varices

BACKGROUND

Bleeding gastric varices is a highly fatal condition. Recurrent bleeding after hemostasis achieved by endoscopic methods is common, and obliteration of gastric varices is difficult to assess. Our aim was to investigate the use of endosonography (EUS) in monitoring cyanoacrylate injection to obliterate gastric varices.

METHODS

Patients who presented with bleeding gastric varices were treated with bolus injection(s) of cyanoacrylate (0.5 mL cyanoacrylate mixed with 0.7 mL Lipiodol) until bleeding was controlled; 47 patients received "on-demand" injection only in response to recurrent bleeding (on-demand group). Another group of 54 patients underwent biweekly EUS followed by repeated injection of cyanoacrylate (repeated-injection group) until all gastric varices were obliterated. The primary outcome was recurrent bleeding-free interval and survival rate.

RESULTS

The two groups of patients were comparable demographically. Although the rates of early (</=48 hour) bleeding recurrence were similar with repeated or on-demand injection (7.4% versus 12.8%, p = 0.5), late recurrence of bleeding (>48 hour) was significantly reduced in the repeated-injection group (18.5% versus 44.7%, p = 0.0053, odds ratio 0.28 (95% CI [0.12, 0. 69]). Cumulative probability of recurrent bleeding-free interval was higher in the repeated-injection than the on-demand group (log-rank test, p = 0.0053). There was a numeric trend toward improved survival in the repeated-injection group.

CONCLUSION

Gastric varices obliteration with cyanoacrylate under EUS monitoring reduces recurrent bleeding and may improve survival.

Atrophy and intestinal metaplasia one year after cure of H. pylori infection: a prospective, randomized study

BACKGROUND & AIMS

Helicobacter pylori-infected gastric mucosa evolves through stages of chronic gastritis, intestinal metaplasia (IM), glandular atrophy (GA), and dysplasia before carcinoma develops. We studied if H. pylori eradication would alter the course of premalignant histologic changes in the stomach.

METHODS

Volunteers from the Yantai County in China underwent upper endoscopy with biopsy specimens obtained from the antrum and corpus. H. pylori-infected subjects were randomized to receive either a 1-week course of omeprazole, amoxicillin, and clarithromycin (OAC) or placebo. At 1 year, endoscopies with biopsies were repeated.

RESULTS

A total of 587 H. pylori-infected subjects were randomized to OAC (n = 295) and placebo (n = 292). At 1 year, H. pylori was eradicated in 226 subjects assigned to OAC. In the placebo group, 245 patients remained H. pylori infected. Analysis of paired samples obtained from the same patients showed that acute and chronic gastritis decreased in both the antrum and corpus after H. pylori eradication (P<0.001) and activity of IM decreased in antrum (P = 0.014). In the H. pylori-infected group, antral biopsy specimens had more pronounced acute gastritis (P = 0.01), whereas corpus specimens showed increased acute and chronic gastritis (P<0.001) and a marginal increase in GA (P = 0.052). When histologic changes were compared between the 2 groups, decrease in acute and chronic gastritis was more frequent after H. pylori eradication (P<0.001) but changes in IM were similar. In the H. pylori-infected group, increase in GA was seen in the corpus (P = 0.01).

CONCLUSIONS

At 1 year, H. pylori eradication is beneficial in preventing progression of pathologic changes of the gastric mucosa.

Interaction of Helicobacter pylori eradication and non-steroidal anti-inflammatory drugs on gastric epithelial apoptosis and proliferation: implications on ulcerogenesis

BACKGROUND

Apoptosis is associated with loss of gastric mucosal integrity and may play an important role in ulcer development.

AIM

To examine how Helicobacter pylori and NSAIDs interact to effect apoptosis and proliferation of the gastric mucosa.

METHODS

Patients presenting with musculoskeletal pain requiring NSAID treatment and without previous exposure to NSAID or pre-existing ulcers were recruited. Patients were divided into three groups: (A) H. pylori-infected; (B) H. pylori-eradicated; and (C) non-infected patients. They were given naproxen for 8 weeks. Patients with non-ulcer dyspepsia and H. pylori infection who were given anti-Helicobacter therapy were recruited as controls (D). Endoscopy was performed at baseline and 8-weeks after receiving naproxen. Gastric antral biopsies were obtained to assess apoptosis by terminal uridine deoxynucleotidyl nick end-labelling (TUNEL) and proliferation by Ki67 immunostaining.

RESULTS

A total of 55 patients were studied. H. pylori-positive patients had a higher apoptosis and proliferation index at baseline than non-infected patients (P < 0.0001), and eradication of H. pylori resulted in a significant reduction in these parameters. The NSAID induced apoptosis in non-infected subjects (P=0.03) whilst apoptosis was reduced in H. pylori-positive patients receiving NSAID (P=0.02). After 8 weeks of NSAID, post-treatment apoptosis was significantly higher in patients with persistent H. pylori infection than in non-infected patients (P=0.01).

CONCLUSIONS

Eradication of H. pylori prior to NSAID therapy significantly reduces the level of apoptosis in the gastric mucosa, which may contribute to maintaining mucosa integrity and preventing ulcer development.

Laser-assisted removal of a foreign body impacted in the esophagus

BACKGROUND AND OBJECTIVE

We reported the use of Holmium-YAG laser in the management of a foreign body impacted in the esophagus.

STUDY DESIGN/PATIENTS AND METHODS

Esophagoscopy was performed on a man with a denture impacted in the esophagus. The denture was disimpacted into the stomach and fractured with Holmium-YAG laser before removal.

RESULTS

The denture was successfully removed in three pieces without complications.

CONCLUSION

Holmium-YAG laser can be used to fragment foreign bodies to aid in their removal.

Surgery in the acute management of bleeding peptic ulcer

The management of bleeding peptic ulcers is an increasing challenge in an ageing population. Endoscopic therapy reduces the need for emergency surgery in bleeding peptic ulcers, and ulcers that fail endoscopic therapy are often 'difficult' ulcers, highly demanding for most gastric surgeons. Mortality in patients requiring eventual salvage surgery is high. Planned urgent surgery is preferable to emergency surgery in elderly patients. Initial endoscopic control offers an opportunity for selecting high-risk ulcers for early surgery. Such a logical approach has, however, not been supported by evidence in the literature. At surgery, an aggressive approach is recommended. Post-operative bleeding is more common after lesser surgery, and this complication is often fatal. When re-bleeding occurs, a selective approach is suggested as emergency surgery carries with it a substantial mortality. Large chronic ulcers with exigent bleeding are less likely to respond to endoscopic re-treatment. Expedient surgery is advised for these patients.

Prevalence and patterns of nocturnal bruxofacets on stabilization splints in temporomandibular disorder patients

The purpose of this study was to investigate the prevalence of nocturnal bruxism, the characteristics of bruxofacets, and the reduction of symptoms in temporomandibular disorder (TMD) patients. The study involved the observation of bruxofacets on a stabilization splint. Twenty-six patients (22 women and 4 men, 16-54 years of age) with signs and symptoms of TMD were given an initial examination before using a splint, and then at intervals of one, three, six and ten weeks after a stabilization splint was first used. In 88% of the patients (n = 23) active shiny facets or scratches caused by nocturnal bruxism appeared on the occlusal surface of splints within ten weeks. In 52% of the 23 patients these facets were created by bilateral mandibular excursions, in 35% by small lateral movements, and in 13% by unilateral excursions. Subjective pain and the Craniomandibular Index in patients had decreased after ten weeks (p < 0.001), but a reduction of symptoms did not differ according to the patterns of the bruxofacets. It was concluded that most TMD patients have a parafunctional habit, namely bruxism. Further research is needed to produce more convincing evidence of a true cause-and-effect relationship between nocturnal bruxism and TMD.

Helicobacter pylori infection is associated with milder gastro-oesophageal reflux disease

BACKGROUND

We have previously demonstrated a negative relationship between the prevalence of Helicobacter pylori and gastro-oesophageal reflux disease (GERD).

AIM

To study the effects of H. pylori infection on the severity of GERD.

METHODS

Ethnic Chinese patients with frequent heartburn and/or endoscopic oesophagitis were studied. Endoscopic examination was performed to assess the severity of oesophagitis (modified Savary-Miller grading) and the presence of hiatus hernia. Biopsies were taken for rapid urease testing and confirmation of Barrett's oesophagus. Risk factors which may affect the severity of oesophagitis (age, sex, smoking, drinking, diabetes mellitus, hiatus hernia, H. pylori status and body mass index) were evaluated by a multiple regression model. The cagA status of H. pylori infected GERD and age-and-sex matched controls were determined by Western blot. Age-and-sex matched non-reflux patients were recruited as controls for comparison.

RESULTS

Two hundred and twenty-five patients with GERD were studied, of whom 77 (34%) were infected with H. pylori. Oesophagitis and Barrett's oesophagus were found in 140 patients (62%) and six patients (3%), respectively. H. pylori infected patients had significantly less severe oesophagitis compared to the uninfected group (P=0.022). All patients with Barrett's oesophagus were uninfected. Factors that predicted severe oesophagitis included age over 60 years (P < 0.001) and hiatus hernia (P < 0.001). H. pylori infection was the only factor that showed a negative correlation with severe oesophagitis (P=0.011). The prevalence of the cagA positive strain in endoscopy-negative GERD, erosive oesophagitis and control subjects was 70, 76 and 78%, respectively (P=0.75).

CONCLUSIONS

H. pylori infection is associated with milder GERD.

Diagnostic and therapeutic fistuloscopy: an adjuvant management in postoperative fistulas and abscesses after upper gastrointestinal surgery

BACKGROUND AND STUDY AIMS

Postoperative fistulas and abscesses pose difficult management problems. We report our experience in the use of fistuloscopy in postoperative fistulas and abscesses after upper gastrointestinal surgery.

PATIENTS AND METHODS

From June 1993 to January 1997, nine patients (seven men, two women; mean age 65) with postoperative fistulas and abscesses were treated with therapeutic fistuloscopy. Diagnostic fistuloscopy was carried out using a 5-mm choledochoscope under fluoroscopic guidance. Therapeutic procedures included mechanical debridement, irrigation, and sealing of fistula with fibrin sealant and gelatin sponge.

RESULTS

The patients were suffering from duodenal stump fistula (three cases), gastrojejunostomy dehiscence after gastrectomy (three cases), gastropleurocutaneous fistula (two cases), and subphrenic abscesses (two cases). Fistuloscopy was performed 4-19 days (mean 12 days) after the diagnosis of the fistula. The median number of sessions required was 2 (range 1-4). The average daily fistula output prior to fistuloscopy was 154 ml (range 30-560 ml), and all fistulas healed in an average of 18.7 days (range 2-46 days) after index fistuloscopy. No procedure-related complications occurred. The mean hospital stay was 61 days. During a mean follow-up period of 12 months, no recurrent abscesses or fistulas developed.

CONCLUSIONS

Fistuloscopy provides a new means of managing patients with postoperative fistula and abscess formation.

Total activation change of visual and motor area due to various disturbances

Brain activation is affected by gradient acoustic noise and various disturbances as well as by other primary tasks. Therefore, we have studied the effects of various disturbances of two different levels of difficulty, that is, weak and strong difficulty levels for primary visual and motor tasks. In the case of visual task with motor and mental disturbances, we found it decreased as motor and mental disturbance difficulty-level increased, compared with the case of without motor and mental disturbances. To the contrary, in the case of motor activity, the total activation of motor cortex with weak and with strong mental disturbance increased as mental disturbance difficulty-levels increased. Therefore, one can conclude that when mental disturbance is added, the visual cortex and motor cortex have an opposite result and when the difficulty-level of the disturbance is increased, the primary tasks are affected more significantly. Although the current observation is preliminary and requires more careful experimental study, it appears that various disturbance effects on brain functions (such as motor and visual cortical responses) produce significant differences in data observations.

Eradication of Helicobacter pylori prevents recurrence of ulcer after simple closure of duodenal ulcer perforation: randomized controlled trial

OBJECTIVE

In this randomized trial, the authors sought to determine whether eradication of Helicobacter pylori could reduce the risk of ulcer recurrence after simple closure of perforated duodenal ulcer.

BACKGROUND DATA

Immediate acid-reduction surgery has been strongly advocated for perforated duodenal ulcers because of the high incidence of ulcer relapse after simple patch repair. Although H. pylori eradication is now the standard treatment of uncomplicated and bleeding peptic ulcers, its role in perforation remains controversial. Recently a high prevalence of H. pylori infection has been reported in patients with perforations of duodenal ulcer. It is unclear whether eradication of the bacterium confers prolonged ulcer remission after simple repair and hence obviates the need for an immediate definitive operation.

METHODS

Of 129 patients with perforated duodenal ulcers, 104 (81%) were shown to be infected by H. pylori. Ninety-nine H. pylori-positive patients were randomized to receive either a course of quadruple anti-helicobacter therapy or a 4-week course of omeprazole alone. Follow-up endoscopy was performed 8 weeks, 16 weeks (if the ulcer did not heal at 8 weeks), and 1 year after hospital discharge for surveillance of ulcer healing and determination of H. pylori status. The endpoints were initial ulcer healing and ulcer relapse rate after 1 year.

RESULTS

Fifty-one patients were assigned to the anti-Helicobacter therapy and 48 to omeprazole alone. Nine patients did not undergo the first follow-up endoscopy. Of the 90 patients who did undergo follow-up endoscopy, 43 of the 44 patients in the anti-Helicobacter group and 8 of the 46 in the omeprazole alone group had H. pylori eradicated; initial ulcer healing rates were similar in the two groups (82% vs. 87%). After 1 year, ulcer relapse was significantly less common in patients treated with anti-Helicobacter therapy than in those who received omeprazole alone (4.8% vs. 38.1%).

CONCLUSIONS

Eradication of H. pylori prevents ulcer recurrence in patients with H. pylori-associated perforated duodenal ulcers. Immediate acid-reduction surgery in the presence of generalized peritonitis is unnecessary.

Aeromonas infection in acute suppurative cholangitis: review of 30 cases

OBJECTIVES

Aeromonads, though not common pathogens in biliary sepsis, caused substantial mortality in patients with impaired hepatobiliary function. Our aim was to study the pathogenic role of Aeromonas in acute suppurative cholangitis.

METHODS

Between 1996 and 1998, the medical records of patients with a diagnosis of biliary sepsis were reviewed. Those who fulfilled the diagnostic criteria for acute suppurative cholangitis and had positive bile or blood cultures for Aeromonas species were studied.

RESULTS

One thousand and forty-five patients were confirmed to have acute suppurative cholangitis. Of these, 30 patients (2.9%) had Aeromonas species isolated from bile; four were complicated by aeromonas septicaemia with simultaneous recovery of the bacteria from blood. All except two isolates were A. hydrophila. Twenty-four patients (80%) had bile duct stones, four (13%) had cholangiocarcinoma and two (7%) pancreatic cancer. Twenty-five cases (83%) had previous exploration of the biliary tract. There was substantial resistance to piperacillin (58%), ceftazidime (30%) and imipenem (15%). Most patients improved after biliary decompression. Only three patients (10%) died, two had terminal malignancy and one had end-stage liver failure. No excess mortality was attributable to Aeromonas infection in biliary sepsis.

CONCLUSIONS

Previous instrumentation facilitated ascending Aeromonas infection of the biliary tract from the gastrointestinal tract. Unlike early reports, our results showed that aeromonads did not adversely affect the clinical outcome of acute suppurative cholangitis with successful drainage of biliary obstruction.