Surgical resection for accessory spleen torsion: A case report

INTRODUCTION

Accessory spleen torsion is extremely rare, and surgery is often the emergency or elective treatment of choice.

PRESENTATION OF CASE

A 20-year-old female with no specific medical history presented to our outpatient clinic with a chief complaint of abdominal pain. The patient was diagnosed with accessory spleen torsion by computed tomography. However, the abdominal symptoms and inflammatory reaction based on blood tests were mild, so a conservative treatment was selected. Subsequently, blood tests were normalized, and imaging studies showed that the accessory spleen was shrinking. Contrast-enhanced examination showed contrast enhancement in a portion of the infarcted accessory spleen region, indicating that the accessory spleen torsion had been released. Surgical resection was performed to prevent possible future re-torsion and hemorrhage of the accessory spleen.

DISCUSSION

The removed specimen seemed to be normal accessory spleen tissue with clear infarcted foci edges. This artery showed evidence of luminal organization and untwisting of the occluded artery.

CONCLUSION

This accessory spleen torsion was treated conservatively; however, the patient was referred for surgical treatment.

Risk factors for umbilical incisional hernia after laparoscopic colorectal surgery

BACKGROUND

Laparoscopic colorectal surgery (LCRS) requires a small laparotomy at the umbilicus. The wound is small and inconspicuous, but if the patient develops an umbilical incisional hernia (UIH), the wound is visible and the patient suffers from symptoms of discomfort. However, the incidence of UIH after LCRS and its risk factors are not well understood. The purpose of this study was to investigate the risk factors for UIH after LCRS for colorectal cancer.

METHODS

This was a single-centre retrospective study of 135 patients with colorectal cancer, conducted at our hospital from April 2013 to March 2019. The diagnosis of UIH was based on computed tomography and physical examination findings. Preoperative patient data such as enlargement of the umbilical orifice (EUO), subcutaneous fat thickness (SFT) and intraperitoneal thickness (IPT) were collected and analysed using univariate and multivariate analyses for the presence of risk factors for UIH.

RESULTS

A total of 135 patients who underwent LCRS were analysed. The incidence of UIH was 20.7%. Univariate analysis revealed significantly high body mass index (BMI) ≥ 25 (P = 0.032), EUO (P < 0.001), SFT ≥18 mm (P = 0.011), and IPT ≥61 mm (P < 0.01) in the UIH group. Multivariate analysis revealed significant differences in EUO (P < 0.001), SFT ≥18 mm (P = 0.046) and IPT ≥61 mm (P = 0.022).

CONCLUSION

EUO was the most important risk factor for UIH, followed by IPT and SFT. These findings are predictive indicators of the development of UIH after LCRS and can be assessed objectively and easily with preoperative computed tomography.

Laparoscopic left-sided mesocolic leaf flap repair for pelvic reconstruction after sacral tissue necrosis. A case report

Radical surgical procedures for malignant diseases of the pelvis result in a large pelvic defect that requires soft tissue reconstruction. The mesentery can be used for pelvic floor reconstruction when debridement with intestinal resection is required. A 75-year-old woman was diagnosed with sacral necrosis, infection and sepsis after carbon ion radiotherapy for sacral chordoma. She underwent sacral debridement three times, which resulted in a large pelvic defect of 14 × 13 cm. Surgery was performed to completely resect the necrotic tissue. We performed extended debridement of sacrum and adjacent tissue around the rectum and anus. Since it was impossible to preserve the anus, laparoscopic left hemicolectomy, abdominosacral resection, and left-sided mesocolic leaf repair for the pelvic defect, and reconstructed the pelvis and buttocks using a gluteal thigh flap were performed. Indocyanine green fluorescent (ICG) imaging was used to detect the margin of the pelvic floor and necrotic tissue and the blood flow of the left-sided mesocolic leaf flap. Left-sided mesocolic leaf reconstruction is useful for large pelvic defects. ICG imaging enabled the detection of the resection margins and the blood flow of the mesocolic leaf.

Drug sensitivity profile of minor KRAS mutations in colorectal cancer using mix culture assay: The effect of AMG-510, a novel KRAS G12C selective inhibitor, on colon cancer cells is markedly enhanced by the combined inhibition of MEK and BCL-XL

Colorectal cancer with a Kirsten rat sarcoma 2 viral oncogene homolog (KRAS) gene mutation is considered to be resistant to anti-EGFR agents. G12D is the most common KRAS mutation in colorectal cancer, followed by G12V and G13D. According to clinical and basic research data, patients with colorectal cancer exhibiting G12D and G12V KRAS mutations are resistant to anti-EGFR agents; however, this is not true of G13D and other minor mutations, which are still not well understood. The current study focused on minor KRAS mutations (G12A, G12C, G12S, Q61H and A146T) and evaluated whether these were resistant to anti-EGFR antibodies using a mix culture assay. The results demonstrated that all KRAS mutations, including minor mutations, were resistant to two anti-EGFR agents: Cetuximab and panitumumab. The combined effect of MEK and BCL-XL inhibition on colorectal cancer cells with KRAS minor mutations were subsequently evaluated. The combined effect of MEK and BCL-XL inhibitors was confirmed in all KRAS minor mutations. The sensitivity of AMG510, a novel KRAS G12C selective inhibitor, was also assessed. The mix culture assay revealed that AMG510 selectively exerted an antitumor effect on colon cancer cells with a G12C KRAS mutation. The combination of MEK and BCL-XL inhibition markedly enhanced the effect of AMG510 in colon cancer cells. The current study suggested that AMG510 may have potential clinical use in combination with MEK and BCL-XL inhibitors in the treatment of patients with colorectal cancer exhibiting the G12C KRAS mutation.

Impact of barometric pressure on adhesive small bowel obstruction: a retrospective study

Background

Adhesive small bowel obstruction (ASBO) is one of the most common causes of postoperative morbidity. According to Boyle’s law, decreased barometric pressure expands the volume of intestinal gas. We aimed to elucidate the relationship between barometric pressure and ASBO.

Methods

We divided 215 admissions of 120 patients with ASBO into three groups: the fasting group, which responded to fasting (n = 51); the decompression group, which was successfully treated with gastrointestinal decompression (n = 104); and the surgery group which required emergency or elective surgery to treat ASBO (n = 60). We compared and examined clinical backgrounds, findings on admission, and barometric pressure during the peri-onset period (29 days: from 14 days before to 14 days after the onset of ASBO).

Results

There were significant differences among the three groups regarding gender, history of ASBO, hospital length of stay, and barometric pressure on the onset day of ASBO. Barometric pressure on the onset day was significantly higher in the fasting group than in the decompression group (p = 0.005). During pre-onset day 5 to post-onset day 2, fluctuations in the barometric pressure in the fasting and decompression groups showed reciprocal changes with a symmetrical axis overlapping the median barometric pressure in Matsumoto City; the fluctuations tapered over time after onset. In the fasting group, the barometric pressure on the onset day was significantly higher than that on pre-onset days 14, 11, 7, 4, 3, and 2; post-onset days 3 and 10; and the median pressure in Matsumoto City. Conversely, in the decompression group, the barometric pressure on the onset day was lower than that on pre-onset days 14, 5–2; post-onset days 1, 2, 7, 8, 11, 13, and 14; and the median pressure in Matsumoto City. In the surgery group, the barometric pressure on the onset day was equivalent to those on the other days.

Conclusions

ASBO with response to conservative treatment is vulnerable to barometric pressure. Additionally, ASBO that is successfully treated with fasting and decompression is associated with a different barometric pressure on the onset day and reciprocal fluctuations in the barometric pressure during the peri-onset period.

Pathological complete response by advanced hepatocellular carcinoma with massive macrovascular invasion to hepatic arterial infusion chemotherapy: a case report

Background

Advanced hepatocellular carcinoma (HCC) with macrovascular invasion has an extremely dismal prognosis. We report a rare case of multiple HCC with tumor thrombosis in the portal vein and inferior vena cava that was initially treated with hepatic arterial infusion chemotherapy (HAIC); later resection revealed pathological complete response.

Case presentation

A 75-year-old man presented with HCC in his right liver, with tumor thrombosis growing to the right portal vein and the inferior vena cava, and bilateral intrahepatic liver metastases. He underwent HAIC (5-fluorouracil [170 mg/m²] + cisplatin [7 mg/m²]) via an indwelling port. Although the tumor shrank and tumor marker levels decreased rapidly, we abandoned HAIC after one cycle because of cytopenia. We resumed HAIC 18 months later because of tumor progression, using biweekly 5-fluorouracil only [1000 mg] due to renal dysfunction. However, after 54 months, the HAIC indwelling port was occluded. The patient therefore underwent a right hepatectomy to resect the residual lesion. Histopathological findings showed complete necrosis with no viable tumor cells. The patient has been doing well without postoperative adjuvant therapy for more than 10 years after initially introducing HAIC and 6 years after the resection, without evidence of tumor recurrence.

Conclusions

HAIC can be an effective alternative treatment for advanced HCC with macrovascular invasion.

Role of adenosine A1 receptors in the modulation of dopamine D1 and adenosine A2a receptor signaling in the neostriatum

Adenosine is known to modulate the function of neostriatal neurons. Adenosine acting on A(2A) receptors increases the phosphorylation of dopamine- and cAMP-regulated phosphoprotein of M(r) 32 kDa (DARPP-32) at Thr34 (the cAMP-dependent protein kinase [PKA] site) in striatopallidal neurons, and opposes dopamine D2 receptor signaling. In contrast, the role of adenosine A(1) receptors in the regulation of dopamine/DARPP-32 signaling is not clearly understood. Here, we investigated the effect of adenosine A(1) receptors on D(1), D(2) and A(2A) receptor signaling using mouse neostriatal slices. An A(1) receptor agonist, 2-chloro-N(6)-cyclopentyladenosine (100 nM), caused a transient increase, followed by a transient decrease, in DARPP-32 Thr34 phosphorylation. Our data support the following model for the actions of the A(1) receptor agonist. The A(1) receptor-induced early increase in Thr34 phosphorylation was mediated by presynaptic inhibition of dopamine release, and the subsequent removal of tonic inhibition by D(2) receptors of A(2A) receptor/G(olf)/cAMP/PKA signaling. The A(1) receptor-induced late decrease in Thr34 phosphorylation was mediated by a postsynaptic G(i) mechanism, resulting in inhibition of D(1) and A(2A) receptor-coupled G(olf)/cAMP/PKA signaling in direct and indirect pathway neurons, respectively. In conclusion, A(1) receptors play a major modulatory role in dopamine and adenosine receptor signaling.

Demonstration of reversed flow in segmental branches of the portal vein with hand-held color Doppler ultrasonography after hematopoietic stem cell transplantation

Hepatic veno-occlusive disease (VOD) is a severe complication of hematopoietic stem cell transplantation (SCT). When monitored with hand-held color Doppler ultrasonography during day -7 to +35 around SCT, reversed blood flow in the segmental branches of the portal vein was detected in nine of 56 patients who had undergone SCT. Three of nine patients had clinical evidence of VOD, but six patients did not fulfill the criteria for diagnosis of VOD initially. Two patients progressed to clinical VOD at a later date and the reversed portal flow disappeared with or without treatment for VOD in the other four patients. Monitoring for reversed portal flow with color Doppler ultrasonography may be a useful tool for the early diagnosis of VOD, and may improve prognosis by allowing early initiation of treatment.

Neuroprotective mechanisms of lidocaine against in vitro ischemic insult of the rat hippocampal CA1 pyramidal neurons

To compare neuroprotective effects of lidocaine and procaine against ischemic insult, intracellular recordings were made from rat hippocampal CA1 pyramidal neurons in slice preparations. Superfusion of the slices with oxygen- and glucose-deprived medium (in vitro ischemia) produced a rapid depolarization 6 min from the onset. When oxygen and glucose were reintroduced, the membrane depolarized further until it reached 0 mV, and thereafter the membrane showed no functional recovery. Pretreatment with lidocaine (10 microM), but not procaine (50 microM), restored the membrane potential after the reintroduction of oxygen and glucose. Lidocaine, compared to procaine, significantly inhibited the reduction in both tissue ATP content and flavoprotein fluorescence during and after in vitro ischemia. Under electron microscopy, only lidocaine well preserved the structure of mitochondria in the CA1 pyramidal cell body. Extracellular recordings revealed that procaine reduced the field postsynaptic potential whereas lidocaine augmented it. Both drugs reduced the presynaptic volley dose-dependently. Neither lidocaine nor procaine significantly affected a rapid rise of the intracellular Ca2+ level produced by in vitro ischemia in the CA1 region. All the results suggest that the neuroprotective lidocaine action is due to the protection of the mitochondria to maintain the tissue ATP content during and after in vitro ischemia.

Influence of transplanted dose of CD56+ cells on development of graft-versus-host disease in patients receiving G-CSF-mobilized peripheral blood progenitor cells from HLA-identical sibling donors

We investigated effects of variations in the cellular composition of G-CSF-mobilized peripheral blood progenitor cell (G-PBPC) allografts on clinical outcomes of allogeneic PBPC transplantation. We retrospectively analyzed transplanted doses of various immunocompetent cells from 27 HLA-identical sibling donors in relation to engraftment, incidence of graft-versus-host disease (GVHD), and survival. Significant variability was documented in both absolute numbers and relative proportions of CD34+, CD2+, CD3+, CD4(high)+, CD4+25+, CD8(high)+, CD19+, CD56+, and CD56+16+ cells contained in these allografts. Stepwise Cox regression analysis revealed that the CD56+ cell dose was significantly inversely correlated with the incidence of GVHD. Thus, there was a significantly higher incidence of grade II acute GVHD in patients receiving a lower CD56+16+ cell dose (hazard ratio (HR) 0.0090; 95% confidence interval (CI), <0.00001-3.38; P=0.031), a higher incidence of chronic GVHD in those receiving allografts with a lower CD56+16+ to CD34+ ratio (HR <0.00001; 95% CI <0.00001-0.0007; P=0.0035), and a higher incidence of extensive chronic GVHD in those receiving allografts with a lower CD56+ to CD34+ ratio (HR <0.00001; 95% CI <0.00001-0.053; P=0.0083). These results suggest that CD56+ cells in G-PBPC allografts from HLA-identical sibling donors may play an important role in preventing the development of GVHD.

Covered expandable metallic stent placement for hemostasis of colonic bleeding caused by invasion of gallbladder carcinoma

A 72-year-old Japanese man was admitted to our hospital complaining of right upper-quadrant abdominal pain, blood in his stool, and symptoms of anemia. On physical examination a hard mass, about 6 cm in diameter, was palpable in the right upper quadrant of the abdomen. Computed tomography revealed a gallbladder carcinoma which had invaded the transverse colon, with liver metastasis. We diagnosed gallbladder carcinoma, stage IVB. Colonoscopy was performed for persistent blood in the stools. This revealed an elevated lesion which appeared to be an invasion of gallbladder carcinoma, with diffuse bleeding from the right-side of the transverse colon. It proved difficult to stop this bleeding by ordinary therapeutic endoscopy. In order to achieve hemostasis we therefore inserted a covered Ultraflex metallic stent to compress the tumor. After stent placement, blood was no longer seen in the patient's stools, he became able to eat soft food and was discharged. This treatment was uninvasive and effective. Covered stent placement appears to be a new and useful method in the management of bleeding from malignant gastrointestinal tumors.

Monitoring of cytomegalovirus reactivation after allogeneic stem cell transplantation: comparison of an antigenemia assay and quantitative real-time polymerase chain reaction

Cytomegalovirus (CMV) antigenemia and quantitative real-time polymerase chain reaction (PCR) were compared for monitoring of CMV reactivation after allogeneic stem cell transplantation. The number of CMV antigen-positive cells by the antigenemia assay and the level of CMV DNA by real-time PCR correlated well. The sensitivity and specificity of the antigenemia assay was 55.4% and 95.5%, respectively, using real-time PCR as the reference standard. The probability of positive antigenemia at day 100 was 76.5%, with a median of first detection at day 37 in 51 patients, compared with a positive PCR of 84.3% and day 33, respectively. When HLA-identical sibling donor transplant recipients and other donor transplant recipients were analyzed separately, there was no difference between the two tests. However, temporal patterns of first detection of CMV antigen-positive cells and CMV DNA differed between HLA-identical and alternative recipients; patients without CMV (29%) or with sporadic positive PCR results (14%) were more common in HLA-identical sibling transplants, whereas patients with simultaneous antigenemia and positive PCR occurred more in alternative transplants (48%). Two of 51 patients (4%) developed CMV colitis despite antigenemia-guided prophylaxis, but both were successfully treated with ganciclovir. Although PCR is more sensitive than antigenemia, both tests are useful in the early detection of CMV after allogeneic stem cell transplantation.

Results of bowel plication in addition to primary anastomosis in patients with jejunal atresia

BACKGROUND/PURPOSE

Disturbed intestinal transit (DIT) associated with bowel dilation occurs in some postoperative patients with jejunal atresia. Bowel plication (BP) has been introduced to prevent the DIT, but the long-term results of BP are unclear.

METHODS

The authors reviewed the preoperative and operative records and postoperative clinical courses (for 2.3 to 7.0 years; mean period, 3.7 years) of 19 jejunal atresia patients, 4 of whom had undergone additional BP with primary anastomosis after dilated bowel resection or tapering jejunoplasty at neonatal surgery. The degree of DIT was evaluated by the clinical symptoms, weight gain, whether reoperation was performed, and duration from the operation to receiving an oral feeding volume of at least 130 mL/kg/d. The patients then were assigned 4 grades (0 to 3). To determine the presence or absence of bowel dilation at the BP site, the plain abdominal x-rays were reviewed.

RESULTS

(1) Within 2 months after surgery, 4 patients without BP underwent operation because of severe DIT. The degree of postoperative DIT in patients who had received additional BP at neonatal surgery was less than that in patients without BP (mean grade, 0.50 v. 2.08). (2) The preoperative clinical features, operative method, and postoperative weight gain were almost similar in patients with and without BP. (3) On abdominal x-ray the bowel dilation remained 6 to 12 months after the operation, but was not observed over 1 year after the operation.

CONCLUSIONS

In this preliminary study, the addition of BP after tapering jejunoplasty or resection of dilated bowel may be effective in preventing early postoperative DIT. Further study is necessary to evaluate the long-term results of additional BP at neonatal surgery. J Pediatr Surg 36:1752-1756.

Identification and characterization of two novel mutations (Q421 K and R123P) in congenital factor XII deficiency

The factor XII genes of two unrelated factor XII-deficient Japanese families were screened, and two novel mutations were identified. A heterozygous mutation (Q421K) was identified in the gene of a cross-reacting material (CRM)-negative patient with reduced FXII activity (entitled Case 1). No mutations were discovered in the other allele. Case 2 was a CRM-negative patient with severe FXII deficiency. In this case, a homozygous mutation (R123P) was discerned. Expression studies in Chinese Hamster Ovary (CHO) cells demonstrated accumulation of mutant Q421 K factor XII in the cell, and insufficient secretion, while the R123P mutant showed lower levels of accumulation than wild-type, and no evidence of secretion in culture supernatant. In the presence of proteasome inhibitor, all types of FXII (wild-type. Q421K, R123P) accumulated in the cells. Protease protection experiments using the microsomal fraction of these cell lines demonstrated that while 20% wild-type FXII (total wild-type:100%) and 10% R123P mutant (total R123P-type: 40%) were resistant to treatment with trypsin, 50% Q421K-type FXII (total Q421K-type:130%) remained resistant to digestion. From these results, we conclude that Q421K is less susceptible to proteasome degradation than wild-type, but is unable to exit the ER efficiently, resulting in insufficient secretion phenotype. In contrast, R123P is susceptible to proteasome degradation and is not secreted.

Detection of hepatic oxidative DNA damage in patients with hepatoblastoma and children with non-neoplastic disease

BACKGROUND

The authors have revealed a significant association between hepatoblastoma and low birth weight. This study was done to explore the evidence that liver cells were oxidatively damaged, based on the hypothesis that oxidative damage to DNA is involved in the development of hepatoblastoma in children of low birth weight.

PROCEDURE

Oxidative DNA damage in the liver was examined by immunohistochemically detecting the presence of a DNA repair product, 8-hydroxy-2'-deoxyguanosine (8-OHdG), in five patients with hepatoblastoma and 14 children with non-neoplastic disease.

RESULTS

Positive staining for 8-OHdG was observed in all five patients with hepatoblastoma. Distribution of 8-OHdG positivity was diffuse in the intralobular area in one patient and was restricted to the periportal area of the lobules in four patients. There was no apparent correlation between birth weight of the patients, histological findings in the liver, and the distribution of 8-OHdG positivity. In children with non-neoplastic disease, 8-OHdG was detected in nine of 14 patients, and 8-OHdG was positive in the intralobular area of the liver parenchyma except in one patient.

CONCLUSIONS

These results suggest that the cause of oxidative DNA damage in patients with hepatoblastoma may be different from the cause, extensive parenchymal damage to the liver, in children with non-neoplastic disease, but the 8-OHdG formation is not specific to hepatoblastoma patients of low birth weight. Further studies to elucidate the true reason for the high incidence of hepatoblastoma in children of low birth weight are necessary.

Effects of recombinant human endostatin on a human neuroblastoma xenograft

New antitumor agents must be added to the current neuroblastoma treatment regimens to improve the clinical results. We investigated whether recombinant human endostatin (rhEndostatin), an antiangiogenic agent, is effective against human neuroblastoma in the human neuroblastoma xenograft model designated TNB9. When tumors on the back of nude mice grew to a weight of 90-95 mg, rhEndostatin 10 mg/kg/day was administered subcutaneously every day for 10 consecutive days. Mean relative tumor weight in mice administered rhEndostatin (n=5) was significantly less than that in controls (n=12) on days 2, 4, and 6 after the start of administration (p<0.01 on day 2, p<0.05 on days 4 and 6), and regression of tumor growth (TRW<1.0) was marked on day 2. The maximum inhibition rate (MIR) by rhEndostatin was 46.4%, indicating inefficacy, but it may not be appropriate to apply Battelle Columbus Laboratories criteria to this experimental model because rhEndostatin is a protein. After day 8, tumors in the experimental group increased in weight and were not statistically significantly different from those in controls. Recombinant human endostatin was used in tumors in the arterial system of the mouse in this experiment because eventually rhEndostatin, not recombinant mouse endostatin, may be used to treat advanced neuroblastoma in the clinical setting. The results show that there is little cross-reactivity of rhEndostatin with the human and mouse models and indicate that rhEndostatin could become an effective agent for the treatment of human neuroblastoma.

Magnetic resonance angiography of portal collateral pathways after hepatic portoenterostomy in biliary atresia: comparisons with endoscopic findings

BACKGROUND/PURPOSE

This study was undertaken to assess the usefulness of magnetic resonance angiography (MRA) in detecting varices and to investigate the possibility of avoiding routine endoscopy after surgery for biliary atresia (BA).

METHODS

The subjects are 21 patients who have undergone periodical MRA since 1996. The esophageal and gastric vessels were investigated as the sites of potential development of collateral vessels. The collateral vessels on MRA were compared with endoscopic findings.

RESULTS

(1) Detection of collateral vessels: of 21 patients examined, 9 patients had 12 varices. MRA depicted collateral vessels in all of the 12 varices (sensitivity, 100%). However, all MRA findings, but one was compatible with endoscopic findings (specificity, 92.9%). Outside of a series of these 21 patients, there were 3 additional patients who had undergone endoscopic treatments previously with success, and in whom esophageal vessels were not depicted on MRA, but endoscopy showed remnant varices. (2) Time-dependent relationship between the appearance of collateral vessels and varices: of 4 varices that appeared after the start of MRA, 3 esophageal varices were found endoscopically simultaneously with or after delineation of collateral vessels on MRA. In the remaining patient, varices were found enodscopically 6 months before the MRA delineation, because a simultaneous MRA was not performed in this case. All these varices were in the early stage.

CONCLUSIONS

MRA was highly sensitive and specific in detecting esophagogastric collateral vessels of the portal venous system. An endoscopic examination is unnecessary until collateral vessels are seen on MRA after surgery for BA.

Inflammatory pseudotumor of the liver: case report and review of the literature

Inflammatory pseudotumor is a rare lesion that generally is considered to be benign in biological behavior, although some may recur or metastasize. The authors report on a patient with inflammatory pseudotumor of the liver whose preoperative radiologic findings resembled those of focal nodular hyperplasia. The biological investigation showed a polyclonality of the cells and diploidy of the DNA content and suggested benign characteristics of the lesion. J Pediatr Surg 36:663-666.

Life-threatening mediastinal teratoma in a neonate

This report describes a newborn with a large mediastinal teratoma (MT) presenting with severe respiratory distress (RD) at birth. At operation, there was no space for dissection because the huge cystic and solid tumor completely occupied the left hemithorax. After evacuation of the cystic component, the tumor was removed successfully. To our knowledge, only 16 newborn infants with MT presenting with RD have been reported. Operative morbidities occurred in one-half of the cases. We have reviewed the literature to discuss the potential risks of this entity.

Effects of brushing with a dentifrice for sensitive teeth on tubule occlusion and abrasion of dentin

By using a dentifrice or toothpaste for sensitive teeth, the brushing-induced effects on dentinal tubule occlusion and abrasion of human sound dentin were investigated with a scanning electron microscope and a scanning laser microscope. The dentifrice contained diatomaceous earth and silica as abrasives and strontium chloride hexahydrate as an active ingredient. Thirty dentin pieces of human premolar teeth with an average of 20% occluded dentinal tubules were attached to resin plates and exposed to the oral cavities of five adult subjects for 2, 4, and 8 weeks. Brushing with and without dentifrice was performed 1 min per day, respectively. Brushing with the dentifrice gradually decreased the mean average of occluded tubules from about 91 to 77% during 2 to 8 weeks, although there were no significant differences among the individual values. However, the mean abrasive loss of the dentin surfaces brushed with dentifrice significantly increased from about 52 to 143 microm in depth. The brushed surfaces of the dentin showed a rough topography with numerous toothbrush scratches but no organic pellicle was found. On the other hand, brushing without dentifrice caused about 99% of the dentinal tubules to occlude in 2 and 4 weeks and 100% in 8 weeks. The brushed dentin surfaces at 8 weeks were entirely covered with organic pellicle containing fine mineral granules derived from saliva, and the abrasive loss was about 1.4 microm in mean depth. Such results indicate that brushing with abrasive dentifrices for sensitive teeth remarkably erodes dentin, and suggest that the brushing should cause the dentinal tubules to open again for a certain period of time.

Risk of contralateral manifestation in children with unilateral inguinal hernia: should hernia in children be treated contralaterally?

PURPOSE

This study was done to identify risk factors for metachronous manifestation of contralateral inguinal hernia in patients with unilateral inguinal hernia.

METHODS

Characteristics of 156 patients with metachronous contralateral hernia were compared with those of 156 patients with unilateral hernia who were ascertained not to have presented with contralateral hernia.

RESULTS

There was a tendency for the hernia to be more often on the left side in 88 of 156 patients (56.4%) with contralateral manifestation compared with 70 of 156 patients (44.9%) in the control group (P =.054). The age at hernia repair of the patients with contralateral manifestation, 1 to 120 months (median, 14 months), was significantly younger than the 1 to 149 months (median, 20 months) of the control patients (P =.016). More patients with contralateral manifestation had a family history of inguinal hernia, and the percentage, 24.4%, was significantly higher than the 14.7% in the control group (P =.046). A univariate analysis with the Cox regression models found that hernia on the left side and a positive family history were significantly associated with the metachronous manifestation of contralateral hernia (hazard ratio [HR], 1.40; P =. 037 and HR, 1.59; P =.013, respectively).

CONCLUSION

The risk of metachronous manifestation of contralateral hernia is high in patients with left-side hernia and in those with a family history, and the incidence of contralateral hernia is at most 10% in these patients. The authors think that the incidence is still too low to justify routine exploration and surgery for a patent processus vaginalis. Contralateral exploration should therefore be reserved for high-risk patients in whom second anesthesia and surgery have to be avoided.

Antitumor effects of fotemustine and busulfan against a human neuroblastoma xenograft

We examined whether or not fotemustine, a new nitrosourea derivative, and busulfan, an agent already clinically used, are effective against human neuroblastoma, using a human neuroblastoma xenograft model designated TNB9. The maximum inhibition rate (MIR) of fotemustine against the TNB9 model was 44.6% with a total dose of fotemustine of 75 mg/kg, indicating that fotemustine is not effective against TNB9. The MIR of busulfan against the same model was 26.7% when a total dose of 135 mg/kg was administered orally to nude mice. Busulfan was also suspended in carboxy-methylcellulose, and was administered intraperitoneally. The MIRs were 19.4% and 36. 4% when busulfan was administered intraperitoneally at a total dose of 40 mg/kg and 60 mg/kg, respectively. The total doses of 40 mg/kg and 60 mg/kg did not show any adverse effects on mice, but were found to be ineffective against TNB9, indicating that busulfan might not be an effective chemotherapeutic agent against human neuroblastoma.

A novel female-specific member of the CYP3A gene subfamily in the mouse liver

Expression of a female-specific CYP3A in the adult mouse liver was observed on immunoblotting analysis. To characterize this cytochrome P450, we determined the primary structure of its cDNA and examined its expression profile. This cytochrome P450 consisted of 504 amino acids and showed 92, 68, 88, and 69% amino acid sequence identity with mouse CYP3A11, 3A13, 3A16, and 3A25, respectively, and was designated as CYP3A41, a new mouse CYP3A gene. In the female liver, levels of CYP3A41 mRNA expression were comparable to those of CYP3A11, the major CYP3A enzyme in the adult mouse liver. Expression of CYP3A41 mRNA was detected immediately after birth in the livers of animals of both sexes, but increased with age in females, whereas it was gradually reduced in males, resulting in predominantly female-specific expression in livers. Lesser amounts of CYP3A41 mRNA were detected in the kidneys of female mice, with traces in the stomach, ovary, and heart of female mice and in the testis of male mice. Gonadectomy and sex hormone treatment indicated that estradiol and testosterone were able to induce and suppress the expression of CYP3A41 mRNA in the liver, respectively. Among the classical CYP3A inducers, dexamethasone, rifampicin, and 3-methylcholanthrene did not affect the level of CYP3A41 mRNA in the liver of either sex. On the other hand, pregnenolone 16alpha-carbonitrile and phenobarbital suppressed CYP3A41 level to half that of untreated female mice. These observations indicated that CYP3A41 is a female-specific CYP3A and one of the major CYP3A forms in the female mouse liver.

A case of well-differentiated, fetal-type hepatoblastoma with very low serum alpha-fetoprotein

Serum alpha-fetoprotein (AFP) is elevated in 96.6% of infants and children with hepatoblastoma and hepatocarcinoma. Serum AFP was of normal level in only one case of immature-type hepatoblastoma, and very low in only one case of fetal-type hepatoblastoma among 43 cases reviewed in 1986. Recently, a case of hepatoblastoma with very low serum AFP was encountered in the authors' surgical department. In October 1998, a 55-month-old girl was admitted. Her birth weight was 717 g. A large space-occupying lesion (SOL) located in the left lobe of the liver was seen by magnetic resonance imaging (MRI), and her serum AFP level was 322 ng/mL with a subfractionation pattern of the "benign liver disease" type based on reactivity with lens culnaris hemagglutinin and concanavalin A. The patient underwent successful left lobectomy, and histological examination showed that the tumor, weighing 268 g, was hepatoblastoma of the well-differentiated, fetal type. Immunohistochemistry findings for AFP were negative. A hepatic mass in infants and children with low serum AFP level indicates the presence of either well-differentiated or immature hepatoblastoma, or fibrolamellar hepatocellular carcinoma. Subfractionation of AFP may contribute to the differential diagnosis of these subtypes.

Incidence of intrahepatic biliary cysts in biliary atresia after hepatic portoenterostomy and associated histopathologic findings in the liver and porta hepatis at diagnosis

BACKGROUND/PURPOSE

The association of intrahepatic biliary cysts in biliary atresia (BA) after hepatic portoenterostomy has drawn the attention of many pediatric surgeons and has become an important subject in clinical management, but the incidence and causes of this association are not well known.

METHODS

During the last 14 years, we operated on 33 BA patients by hepatic portoenterostomy. Five patients could not be followed up over a 1-year period, so the remaining 28 patients had their intrahepatic structure investigated by periodic magnetic resonance imaging (MRI), and were confirmed at autopsy. The authors also reviewed the preoperative conditions of these patients and the histopathologic changes in the liver biopsy and the porta hepatis specimens taken at portoenterostomy.

RESULTS

(1) Intrahepatic biliary cysts were found in 6 of the 28 patients studied (21%). Of 16 patients who were operated on after 1989 and are undergoing follow-up by MRI, 4 (25%) had cysts. (2) Five of the 6 patients with cysts had episodes of cholangitis before or at the time of discovery of the cysts, and 4 of them have had their jaundice reappear since the discovery of the cysts. (3) The intralobular spaces (ILS) with fibrosis and the number of bile ducts had increased in the group with cysts compared with those in the group without cysts. (4) The bile duct maximum size in the porta hepatis (PH) was similar in the groups with and without cysts, but a denudation of the mucosal lining cells in the duct, and a fibrosis and inflammation around the duct had increased in the group with cysts compared with those in the group without cysts. (5) Statistically, the fibrosis found in the ILS and the inflammation around the bile duct found in the PH were induced as a correlative factor affecting cyst formation.

CONCLUSIONS

The association of intrahepatic biliary cysts in BA after portoenterostomy is frequent. The fibrous change in the ILS and the inflammatory process around the bile ducts might be potential causes of cyst formation.

Basement membranes, microfibrils and beta amyloid fibrillogenesis in Alzheimer's disease: high resolution ultrastructural findings

It is known that beta amyloid fibrils are deposited at the basement membrane of the cerebromicrovasculature in the brains of patients with Alzheimer's disease, and the assembly of the fibrils may be in continuation with the core of senile plaques. The fibrils accumulate in a manner similar to that in which microfibrils accumulate in the glomerular basement membrane of the rat kidney during long-term experimental diabetes, and in the alveolar-capillary basement membrane of the normal lung. beta amyloid fibrils in-situ are known to be about 10 nm wide tubular structures and they closely resemble connective tissue microfibrils. Our recent high resolution ultrastructural studies combined with immunogold labeling demonstrated that beta amyloid fibrils in-situ are indeed microfibril-like structures, and the beta protein is associated with their surface in the form of loose assemblies of 1 nm wide flexible filaments. Thus, the result of this study indicates that in-situ a major component of the beta amyloid deposit is the microfibril-like structure. The elucidation of the mechanism of cerebral beta amyloid fibrillogenesis in Alzheimer's disease may therefore require understanding the mechanism of 'normal' microfibrils biogenesis.

[Cranial fasciitis of a neonatal case with massive intra- and extracranial extension]

We report a neonatal male case of cranial fasciitis in childhood. He was born with a large skull tumor in his left fronto-parietal region. The day after his birth, he was admitted to our hospital. On inspection, the mass was firm, non mobile, and had two humped peaks. The size of the mass was 7 x 5 x 4 cm, and it was located on the left coronal suture and fontanelle. The overlying skin was normal. Skull X-rays revealed osteolytic defect and linear bone remnant skirted the outer rim of the tumor. CT scan showed a slightly high-density large frontal mass with a low density area in the center of it and marked enhancement. MR images revealed a large mass with massive intra- and extracranial extension. Cerebral angiography showed the remarkable vascularization of the tumor. Preoperatively, the branches of the external carotid artery were partly embolized. On surgery, the profusely bleeding, elastic hard, yellowish-white mass arising from the dura was partially removed with the surrounding bone. A small mass remained subdurally. The boundary of the mass and the dura was not well demarcated. After the operation, no neurological deficits were seen. 16 months after the surgery, MRI revealed the unfolded brain with no evidence of tumor. Histological examination showed characteristic proliferation of spindle-shaped fibroblasts embedded in a collagenous stroma. Inflammatory lymphocytes and acidophils were also noted. Electron micrograph revealed a tumor cell rich in rough endoplasmic reticulum and nuclei with numerous indentations. Immunostaining confirmed that these cells were positive for vimentin but negative for smooth muscle actin, GFAP, S-100 protein, and desmin. No recurrence of this tumor has been detected at four years of follow-up.

Ultrastructure of familial amyloid polyneuropathy amyloid fibrils: examination with high-resolution electron microscopy

The ultrastructure of familial amyloid polyneuropathy (FAP) amyloid fibrils was examined with high-resolution electron microscopy and immunolabeling. Sural nerve biopsies from FAP (Met 30) patients as well as control tissues were prepared for thin-section observations. Extracellular spaces in the vicinity of myelinated and unmyelinated peripheral nerves were found to be filled with amyloid fibrils as well as with deposits of an "amorphous" material. The fibril was composed of a surface layer and a core. The surface layer was made up of heparan sulfate proteoglycan and was externally associated with a loose assembly of 0.5- to 1-nm-wide filaments. The core was a microfibril-like structure in which amyloid P component was enclosed in a tight helical structure by chondroitin sulfate proteoglycan. Immunogold labeling showed that the peripheral fine filaments were composed of transthyretin. The dimensions of the transthyretin filament suggest that its basic unit is a modified monomer. The deposited amorphous material was a mixture of individual components of the fibril. These results suggest that the main body of FAP amyloid fibrils is similar to that of recently observed fibrils of experimental murine AA and hemodialysis-associated amyloid as well as of connective tissue microfibrils. The differences in the fibrils of these various types of amyloid are in the peripheral filaments which are composed of a protein specific to each type of amyloid.

Prenatally diagnosed cystic lymphangioma in infants

BACKGROUND/PURPOSE

Prenatally diagnosed cystic lymphangioma (CL) is often associated with chromosomal anomalies, hydrops fetalis, and, in the case of cervical CL, occasionally respiratory distress just after birth. Often it is difficult to treat prenatally diagnosed CL because of the large size and associated symptoms.

METHODS

Between 1988 and 1997, 11 cases of prenatally diagnosed CL were treated. Five pregnancies were terminated electively and one aborted spontaneously (nondelivered, non-D group), and another five delivered (delivered, D group). Thirteen infants nondiagnosed prenatally were also seen in the same period (prenatally nondiagnosed, without pre-D group).

RESULTS

In the non-D group, massive CLs were diagnosed by ultrasound scan between 16 and 20 weeks' gestation. They occurred in the head and neck in all six cases, and four had associated pleural effusions or hydrops. In the D group, CL occurred in the face and neck in four cases. Three were born by cesarean section with neonatologists and surgeons standing by, then transferred to our hospital immediately after birth. Respiratory distress appeared in two cases; tracheostomy was carried out in one case. One patient with a huge CL in the chest and abdominal wall necessitated partial resection after OK-432 sclerotherapy. In the without pre-D group, there was CL in the face or neck in 10 cases, abdominal wall in two cases, and chest wall in one case. Respiratory distress was observed in three cases of cervical CL, and tracheostomy was required in two cases. One patient with hypoxic brain damage sequela died of pneumonia afterward.

CONCLUSIONS

Prenatal diagnosis permits planned delivery, prompt postnatal resuscitation, and improve prognosis. Infants with massive CL diagnosed early in pregnancy have other associated anomalies as well as hydrops fetalis, and a poor outcome or difficult management can be expected.

[Allogeneic peripheral blood stem cell transplantation in 30 patients with hematologic disorders]

Thirty patients (median age of 32 years; range, 6-61) with hematologic disorders received unmanipulated peripheral blood stem cell transplants from HLA-matched or one-antigen-mismatched related donors following myeloablative therapy for acute lymphoblastic leukemia (7), acute myelogenous leukemia (6), chronic myelogenous leukemia (8), myelodysplastic syndrome (3), or other disorders (6). Granulocyte colony stimulating factor (G-CSF) mobilized peripheral blood stem cells were collected from donors in 1 to 3 aphereses. The apheresis products contained mean counts of 11.3 x 10(8) (range, 3.8-17.2) nucleated cells/kg and 6.7 x 10(6) (range, 1.3-16.7) CD34+ cells/kg. Graft-versus-host-disease (GVHD) prophylaxis consisted of cyclosporin A plus methotrexate, or FK506 plus methotrexate. All patients received G-CSF following their transplant. Although 1 patient died of pneumonia 6 days after transplantation, the others demonstrated rapid engraftment. Median days to recovery to 500/microliter neutrophils and 20,000/microliter platelets were 13 (range, 8-21) and 14 (range, 1-23) days, respectively. The incidence of acute GVHD grade II-IV was 33%; chronic GVHD developed in 57% of the assessable patients. There were no episodes of graft failure or rejection. Nineteen patients (63%) were alive and in complete remission from 147 to 839 days following their transplant (median follow-up of 560 days). Further follow-up study will be required to assess the incidence of chronic GVHD and graft-versus-leukemia (GVL) effects.

Surgical treatment of neuroblastomas in infants under 12 months of age

BACKGROUND

Surgical treatment of neuroblastomas, both those detected by screening and those detected clinically, in infants less than 12 months of age, is controversial, because some tumors in this age group potentially have the ability to regress spontaneously.

METHODS

From January 1985 to March 1997, the authors treated 50 infants (under 1 year of age) with neuroblastoma: 23 boys and 27 girls. Forty-one cases were detected preclinically by screening when the patients were 6 to 11 months of age (median, 7 months), and nine patients were discovered to have clinical manifestations at the age of 1 to 10 months (median, 4 months).

RESULTS

The tumor was INSS stage 3 or 4 in 10 patients (24%) with screening-detected tumor and in five (56%) with clinically detected tumor, although the difference was not statistically significant. Four screening-positive patients had multifocal primary tumors, and three of them were synchronous bilateral adrenal neuroblastomas. There was no statistically significant difference between the screening-detected tumors and the clinically detected tumors in biological characteristics such as Shimada's histology, DNA ploidy, and N-myc amplification. Complete resection of the primary lesion was accomplished by either primary surgery or second look (delayed primary) surgery in 46 patients (92%), and the resection was incomplete in the remaining four. In patients with bilateral adrenal tumors, the larger one was primarily resected, and the smaller contralateral tumor was enucleated or resected by partial adrenalectomy. Surgical complications included postoperative adhesive ileus (n=2), Horner's syndrome (n=2), renal atrophy (n=1), renal failure (n=1), phrenic nerve injury (n=1), chylous ascites (n=1), chylothorax (n=1) and intussusception (n=1). One patient died of respiratory failure caused by a complication, but 49 patients (98%) were alive at the time of evaluation.

CONCLUSION

When considering surgical treatment of infants with biologically favorable neuroblastoma, the risk involved in treatment should be weighed against the risk inherent in a tumor capable of spontaneous regression, and aggressive surgery is unacceptable.

Infected duodenal duplication with unusual clinical and radiological manifestations: a case report

Infected cystic duplication of the duodenum is an unusual lesion. We report a case in which pre-operative MR imaging revealed a huge multicystic mass masquerading as a cystic lymphangioma or mesenteric cyst. The differential diagnosis of this unusual appearance is discussed.

Intraductal ultrasonography for the diagnosis of proximal invasion in extrahepatic bile duct cancer

Intraductal ultrasonography (IDUS) was performed on 22 patients with extrahepatic bile duct cancer, using the percutaneous transhepatic approach. Intraductal ultrasonography images of the proximal invasion of the bile duct cancer were defined. In addition, three patients were examined through the peroral approach, to try to diagnose whether or not the cancer invaded to the bifurcation of the hepatic duct. Intraductal ultrasonography images obtained through the percutaneous approach could be classified into three patterns, types 1, 2 and 3, according to the features of the interior surface of the bile duct and the thickness of the bile duct wall. Type 1 images, which did not show protrusions into the bile duct lumen and had a bile duct wall of even thickness, were not likely to show bile duct cancer. Type 2 images showed protrusions of the tumour into the bile duct lumen and the surfaces of the protrusions were irregular. Type 3 images showed single or multiple low echoic papillary masses in the bile duct. Using the peroral technique, we considered all three cases to be type 1 and could diagnose that cancer had not invaded to the bifurcation of the hepatic ducts. From the results of this study, we suggest that proximal invasion of extrahepatic bile duct cancer can be diagnosed using IDUS.

A high resolution ultrastructural comparison of isolated and in situ murine AA amyloid fibrils

There is an inconsistency between the ultrastructural organization of AA amyloid fibrils that have been isolated, which are composed of a slowly twisting set of two or more protofibrils, and those seen in situ, which are tubular entities with a tight helical substructure. In this study, the ultrastructure of fibrils isolated from experimental murine AA amyloid were observed at high resolution and compared with those seen in situ in the hope of clarifying the reason for this inconsistency. The fibrils in situ were composed of a microfibril-like 8-9 nm wide core covered by a layer of heparan sulfate proteoglycan (HSPG) to which 1 nm wide filaments, immunohistochemically identified as AA protein, were externally associated. Following isolation with the standard distilled water washing procedure, the HSPG layer and AA protein filaments detached from their core and dispersed into the water. The remaining denuded, variously loosened cores lost their typical appearance. In distilled water the detached 1 nm wide AA protein filaments became quite conspicuous and coiled themselves into 3 nm wide tight helices which in turn assembled into the characteristic slowly twisting sets of two parallel protofibrils similar to that previously reported as "isolated amyloid fibrils". The results emphasize that great caution must be taken in extrapolating amyloid fibril structure from isolated preparations to in situ tissue conditions.

A common genetic polymorphism (46 C to T substitution) in the 5'-untranslated region of the coagulation factor XII gene is associated with low translation efficiency and decrease in plasma factor XII level

We studied the Hga I polymorphism (46 C/T) in the 5'-untranslated region of the coagulation factor XII (FXII) gene corresponding to four bases upstream from the ATG translation initiation codon. By using allele-specific restriction analysis with restriction endonuclease Hga I, the allele frequency of 46C/T was estimated to be 0.27/0.73 in Orientals (allele number =152), and conversely, 0.8/0.2 in Caucasians (allele number =40). Because it has been reported that plasma levels of FXII were lower in Orientals than in Caucasians, we investigated the relationship between this polymorphism and plasma levels of FXII. As a result, there were significant differences in plasma FXII levels between these three allele types: C/C,170+/-38% (178+/-27%); C/T, 141+/-29% (123+/-34%); and T/T, 82+/-19% (61+/-11%) [FXII activity (FXII antigen levels)]. In heterozygotes of 46 C/T both alleles were equally transcribed in hepatocytes, as determined by reverse transcription polymerase chain reaction (RT-PCR), suggesting little influence of the polymorphism at the level of transcription or on the stability of mRNA. In in vitro transcription/translation analysis, less FXII was produced from cDNA containing 46 T than from that containing 46 C. Therefore, it is highly likely that the 46 T polymorphism in the FXII gene decreased the translation efficiency and led to low plasma levels of FXII activity and antigen, probably due to the creation of another ATG codon and/or impairment of the consensus sequence for the translation initiation scanning model.

Ultrastructural organization of hemodialysis-associated beta 2-microglobulin amyloid fibrils

Fibrils of hemodialysis-associated beta 2-microglobulin amyloid were examined by high resolution electron microscopy and immunohistochemical labeling. The amyloid containing tissues obtained through autopsy were prepared for thin section observations. In contrast to other forms of amyloid, the most conspicuous feature of these fibrils were their curved conformations. The fibril core showed ultrastructural and immunohistochemical features in common with the core of connective tissue microfibrils and of previously observed fibrils of experimental murine AA amyloidosis and familial amyloid polyneuropathy (FAP). The core was wrapped in a layer of 3 nm wide ribbon-like "double tracked" structures identified as chondroitin sulfate proteoglycan (CSPG) with immunogold labeling as well as from the results of previous in vitro experiments. Finally, the outer surface of the fibril was associated with a loose assembly of 1 nm wide filaments immunohistochemically identified as beta 2-microglobulin. This is similar to the manner in which AA protein and transthyretin filaments are associated with their respective fibrils. The results of this study provide an additional example for the concept that amyloid fibrils in general are microfibril-like structures externally associated with amyloid protein filaments. An unusual feature of the fibrils of hemodialysis-associated amyloid, however, is the presence of a peripheral layer composed of CSPG rather than of heparan sulfate proteoglycan (HSPG) as in the case of the other two amyloids above. These chondroitin sulfate chains in the outer CSPG layer may be less effective in providing rigidity to the fibril core, thus allowing for the curved conformations of beta 2-microglobulin amyloid fibrils.

A peculiar form of multiple cystic dilatation of the intrahepatic biliary system found in a patient with biliary atresia

The authors report a peculiar form of intrahepatic multiple cysts of the biliary system in a patient with biliary atresia (BA). An 11-year-old girl was admitted to our institution to be investigated for repeated cholangitis occurring after the age of 10 years. She underwent a hepaticojejunostomy, caused by Type I (cyst-type) BA, in the neonatal period. The radiological examination results showed multiple cystic dilatation of the intrahepatic biliary system with a vascular structure protruding into the cyst lumen. Such cystic dilatation with a protruding vascular structure has been noted in patients with Caroli's disease and congenital hepatic fibrosis, and ductal plate malformation is shown to be responsible for the cyst formation. The authors postulate that such malformation of the intrahepatic biliary system is related to the cyst formation in our case.

The relationship between disturbed transit and dilated bowel, and manometric findings of dilated bowel in patients with duodenal atresia and stenosis

To determine whether dilated bowel proximal to obstruction associated with duodenal atresia and stenosis is related to feeding problems after a surgical correction of obstruction, the authors reviewed retrospectively the degree of bowel dilatation and disturbed transit as well as other clinical features in 18 duodenal atresia and 12 duodenal stenosis patients. A multivariate analysis was conducted to determine the possible correlation among them. The authors also evaluated the physiological function of the dilated bowel in duodenal atresia and stenosis patients (n = 8) by manometry of dilated bowel. The results were as follows. (1) In multivariate analysis, using the degree of disturbed transit as a dependent variable and using other clinical features as independent variables, the presence of postoperative complication and the existence of bowel dilatation 2 weeks after the operation were risk factors for disturbed transit. (2) One or two episodes of phase 3 were found in six of eight measured patients during the recorded period. The most distinctive manometric finding was the low contraction amplitude of both phase 2 and phase 3. These results indicate that dilated bowel was related to disturbed transit during the postoperative period, and that the low contraction amplitude of the dilated bowel was the main pathophysiological feature. The tapering or plication of dilated bowel might be indicated in patients with a markedly dilated bowel.

MRI findings in the liver in biliary atresia patients after the Kasai operation

To evaluate liver function in biliary atresia (BA) patients after the Kasai operation, magnetic resonance imaging (MRI) was carried out 28 times in 19 BA patients. Sixteen of these were divided into three groups on the basis of the serum level of total bilirubin (t-bil), glutamic pyruvic transaminase (GPT) and gamma-glutamyltransferase (gamma-GTP) in the postoperative follow-up period (2-11 years). In group 1 (n = 7) the t-bil was continuously kept under 1 mg/100 ml. In group 2 (n = 4) the t-bil was continuously kept under 1 mg/100 ml, but GPT and gamma-GTP remained high (GPT > 100 IU/liter, gamma-GTP > 200 IU/ liter) for more than 2 years. In group 3 (n = 5) an increase in the t-bil level reappeared (1-2 mg/100 ml; n = 4, > 2 mg/100 ml; n = 1). The differences between MRI finding in the 3 groups, and the correlation between MRI findings and laboratory data (t-bil, cholinesterase; ChE, GPT and gamma-GTP), which were taken around the time of MRI examinations, were studied. The results were as follows: (1) All 19 patients had normal or high signal areas of various sizes on T1 weighted images (WI). (2) Eighteen of 19 patients had high signal areas of various sizes on T2 WI in the portal system areas and/or liver parenchyma, and these areas were enhanced by gadolinium-DTPA in about half of the patients. (3) Ten of 16 patients had atrophic change over one liver lobe. (4) MRI findings for group 1 and the other groups were significantly different, and MRI findings, except for atrophic change, were correlated with the increase or decrease in laboratory data taken around the time of MRI examinations (p < 0.05). These results indicate that a normal or high signal area on T1 WI shows functional tissue, and that a high signal area on T2 WI shows tissue damaged by inflammation and/or progressive fibrosis. MRI is useful for evaluating liver function, especially in terms of morphological features, in BA patients after the Kasai operation, and will be one method for establishing their prognosis.

Gastrointestinal angiodysplasia in congenital platelet dysfunction

We herein report three cases of repeated massive bleeding from the stomach and small bowel. One patient suffered from both thrombasthenia (type II) and von Willebrand disease (type 1) simultaneously. Two others had Bernard-Soulier's syndrome (BSS). One patient with BSS had bleeding from gastric angiodysplasia and was treated endoscopically by clipping. The other patients had massive bleeding from the small intestine, and had partial resection of the affected small intestine. Histologically, irregular dilatation and proliferation of the blood vessels were demonstrated in the submucosa in bleeding spots from a resected small intestine, and these findings were consistent with the features of acquired angiodysplasia. The development of gastrointestinal angiodysplasia may not only be associated with a dysfunction of von Willebrand factor but also with that of platelets.