Easy and accurate targeting of deep-seated hepatic tumors under laparoscopy with a forward-viewing convex-array transducer

BACKGROUND

It is technically difficult to puncture deep-seated hepatic tumors by conventional laparoscopic ultrasonography with a linear-array probe. We have developed a laparoscopic ultrasonography system with a convex-array probe.

METHODS

The laparoscopic system used had a fixed forward-viewing convex-array transducer, and a guide groove for puncture was added to the back of the unit. These characteristics enabled us to continuously monitor the position of the needle tip on the ultrasonographic image immediately after puncturing on the liver surface. We attempted tumor puncture in 11 patients with hepatocellular carcinoma under a new probe guidance.

RESULTS

The mean puncturing distance up to the tumors was 38.7 mm. All punctures were successful on the first pass and the tumors were treated with radiofrequency ablation.

CONCLUSION

Using this new equipment, puncturing hepatic tumors for treatment is relatively easy, irrespective of the position of the tumor.

Mechanisms responsible for increase in circulating inhibin levels at the time of ovulation in mares

In female mammals, inhibin is secreted by the granulosa cells and selectively inhibits secretion of FSH. Although circulating immunoreactive (ir)-inhibin levels decrease after ovulation as a result of the disappearance of its main source, they abruptly increase at the time of ovulation in mares. To investigate the mechanisms responsible for this increase, 50 ml of equine follicular fluid (eFF) was administered into the abdominal cavity of mares during the luteal phase (eFF, n = 4). One hour after treatment, plasma levels of ir-inhibin and inhibin pro-alphaC (but not estradiol-17beta) were significantly higher in eFF-treated mares than in control mares (n = 4). The hormone profiles in eFF-treated mares were similar to those in mares with the spontaneous or hCG induced ovulations. The present study demonstrates that the release of follicular fluid into the abdominal cavity when the follicle ruptures is responsible for the ovulatory inhibin surge in the mare. These findings also suggest that circulating inhibin pro-alphaC may be useful for determining the time of ovulation in the mare.

Laparoscopic adhesiolysis for recurrent small bowel obstruction: long-term follow-up

BACKGROUND

Recurrent small bowel obstruction caused by postoperative adhesions has traditionally been treated by conventional laparotomy, but laparoscopic management of acute small bowel obstruction has been reported. The aim of this study was to assess the long-term efficacy and clinical outcome of laparoscopic adhesiolysis for recurrent small bowel obstruction.

METHODS

After conservative treatment, elective laparoscopic treatment was attempted in 17 patients hospitalized for recurrent small bowel obstruction after abdominal or pelvic surgery.

RESULTS

Postoperative adhesions were identified laparoscopically in all patients. Laparoscopic treatment was possible in 14 patients (82.4%). Conversion to laparotomy was required for 3 patients (17.6%) because of intestinal perforation (n = 1) or a convoluted mass of adherent bowel (n = 2). Long-term follow-up was possible in 16 patients. Two recurrences of small bowel obstructions were noted over a mean follow-up period of 61.7 months.

CONCLUSIONS

Laparoscopic adhesiolysis is a safe and effective treatment for recurrent small bowel obstruction. Conversion to laparotomy should be considered in patients with dense adhesions.

Acute aortic dissection associated with Sheehan's syndrome

A 69-year-old woman with Sheehan's syndrome who suffered acute Stanford type A aortic dissection had received corticosteroids and thyroid hormones for over 20 years. The entire ascending aorta was replaced in emergency graft replacement. We administered twice the usual dose of methylprednisolone during cardiopulmonary bypass and twice the patient's usual dose of prednisolone from postoperative day 1 to 6. The usual 100 micrograms of levothyroxine sodium was given orally from postoperative day 1. The patient's postoperative course was uneventful. This case emphasizes the importance of early active supplementary treatment with steroids and thyroid hormones for major surgery in patients with Sheehan's syndrome.

Inhibin is an important factor in the regulation of FSH secretion in the adult male hamster

We investigated the importance of inhibin and testosterone in the regulation of gonadotropin secretion in adult male golden hamsters (Mesocricetus auratus). After castration, plasma concentrations of inhibin and testosterone were reduced to undetectable, whereas plasma follicle-stimulating hormone (FSH) and luteinizing hormone (LH) were increased. After hemicastration, plasma FSH and LH increased moderately and plasma inhibin decreased to one-half its initial level. Plasma testosterone levels in hemicastrated animals decreased 3 h after hemicastration but returned to those in sham-operated animals at 6 h. Plasma LH in the castrated hamster declined comparably to intact animals with testosterone treatment; plasma FSH also decreased but still remained at levels higher than those in intact animals. After treatment with inhibin in long-term-castrated animals, plasma FSH decreased, whereas plasma LH was not altered. Intact males treated with flutamide, an anti-androgen, showed a significant increase in plasma LH but not in FSH. On the other hand, treatment with anti-inhibin serum induced a significant elevation in plasma FSH, but not in LH. Using immunohistochemistry, we showed that the inhibin alpha-subunit was localized to both Sertoli and Leydig cells. The present study in adult male hamsters indicates that FSH secretion is regulated mainly by inhibin, presumably from Sertoli and Leydig cells, and that LH secretion is controlled primarily by androgens produced from the Leydig cells. This situation is more similar to that of primates than of rats.

Ovarian secretion of inhibin in mares

In mares, circulating immunoreactive inhibin concentrations increase during the follicular phase and decrease at the start of the LH surge. Thereafter, sharp increases in circulating immunoreactive inhibin concentrations, the 'ovulatory increase', are observed during ovulation. In the present study, the cellular sources and molecular form of ovarian inhibin were investigated to determine the mechanism responsible for this unique ovulatory increase. Three sizes of ovarian follicles (small, < 15 mm; medium, 15-30 mm; large, > 30 mm in diameter) were selected. Inhibin alpha-subunit was localized by immunohistochemistry to the granulosa cells of follicles of all sizes and the theca cells of large follicles, whereas inhibin betaA- and betaB-subunits were detected in the granulosa and theca cells of large follicles only. High concentrations of immunoreactive inhibin, inhibin pro-alphaC and inhibin A were detected in the follicular fluid of large follicles compared with small and medium follicles, whereas there were no significant differences in the concentrations of inhibin B in the follicular fluid of medium and large follicles. These results indicate that mature large follicles secrete large amounts of inhibins pro-alphaC and A, whereas small or medium follicles secrete small amounts of inhibins A, B and pro-alphaC. These findings also indicate that the large amount of inhibin pro-alphaC produced by the ovulatory follicle is the source of the ovulatory increase in the concentrations of circulatory immunoreactive inhibin observed during ovulation in

Testicular secretion of inhibin in stallions

In this study, clear seasonal changes in the circulating concentrations of immunoreactive inhibin were observed in stallions throughout the year. The highest plasma concentrations of immunoreactive inhibin were observed during the breeding season and the lowest concentrations were observed during the nonbreeding season. There was positive correlation between the circulating concentrations of immunoreactive inhibin, steroid hormones and gonadotrophins. Inhibin alpha subunit positive staining was observed in Sertoli cells and more clearly in Leydig cells. Both cell types also stained positively for inhibin betaA and betaB subunits. Immunoreactivity to 3beta-hydroxysteroid dehydrogenase and aromatase was observed in the Leydig cells only. The testes contained large amounts of inhibin pro-alphaC and small amounts of inhibins A and B, and the inhibin B content was higher than the inhibin A content. These results indicate that inhibin B is the major bioactive form of inhibin in equine testes. However, only inhibin pro-alphaC was detectable in the circulation and the inhibin pro-alphaC concentrations changed with the concentrations of immunoreactive inhibin. In conclusion, both Leydig and Sertoli cells secrete testicular inhibin in stallions. The positive correlation observed between plasma immunoreactive inhibin and inhibin pro-alphaC concentrations and testicular activity during the breeding and nonbreeding seasons indicates that the plasma concentrations of these hormones are potentially useful indicators of testicular activity in stallions.

A selective increase in circulating inhibin and inhibin pro-alphaC at the time of ovulation in the mare

The relationship between a selective increase in circulating immunoreactive (ir)-inhibin and the time of ovulation was investigated in mares. Concentrations of plasma ir-inhibin were measured every 4 h during the periovulatory period. Inhibin pro-alphaC, a precursor protein of the inhibin alpha-subunit, was also measured. The changes in ir-inhibin and inhibin pro-alphaC in circulation were parallel. Concentrations of both ir-inhibin and inhibin pro-alphaC in the plasma increased at the same time when ovulatory follicles ruptured, and the peak levels of circulating ir-inhibin and inhibin pro-alphaC were maintained for 4-8 h. There was no selective increase in plasma concentrations of estradiol-17beta during the process of ovulation. These results suggest that the selective increase in ir-inhibin and inhibin pro-alphaC was caused by the absorption of follicular fluid after the rupture of ovulatory follicles. These results also suggest that the measuring of plasma concentrations of ir-inhibin or inhibin pro-alphaC in mares might be a useful method for detecting the time of ovulation.

The role of laparoscopic US and laparoscopic US-guided aspiration biopsy in the diagnosis of multicentric hepatocellular carcinoma

BACKGROUND

Detection of small hepatocellular carcinomas has become possible with improvements in various diagnostic imaging techniques. However, intraoperative US can detect lesions not visualized by any preoperative imaging study in which case it is difficult to determine whether the lesion is a hepatocellular carcinoma.

METHODS

Nodular lesions detected by laparoscopic US in 186 patients with hepatocellular carcinoma were examined and we evaluated the diagnostic ability of laparoscopic US to detect multicentric hepatocellular carcinoma.

RESULTS

One hundred thirty-four new nodular lesions were detected by laparoscopic US in 64 (34.4%) of 186 patients. Aspiration biopsy under laparoscopic US guidance was performed on the 134 nodules, and 28 nodules in 23 (12.4%) of the 186 patients were histologically diagnosed as hepatocellular carcinoma. Of these 23 patients, 18 had been diagnosed with solitary hepatocellular carcinoma before laparoscopic US. One hundred six of the newly detected lesions were initially diagnosed as noncarcinomatous nodules, but the diagnosis of 10 of these lesions was changed to hepatocellular carcinoma during follow-up that was as long as 96 months.

CONCLUSIONS

Laparoscopic US is useful in the initial diagnosis of hepatocellular carcinoma and impacts treatment selection by more accurately defining the presence of multicentric hepatocellular carcinomas.

Prognosis of small hepatocellular carcinoma after laparoscopic ethanol injection

BACKGROUND

Most patients with hepatocellular carcinoma have underlying cirrhosis, and this impairment of liver function makes hepatectomy difficult, prompting the use of other modalities such as transcatheter arterial embolization and percutaneous ethanol injection.

METHODS

Laparoscopic ethanol injection was performed in 48 previously untreated patients with hepatocellular carcinoma smaller than 2 cm in diameter. Long-term survival was evaluated.

RESULTS

In 12 patients, hepatocellular carcinoma was not detected by trans-cutaneous ultrasonography but could be demonstrated by laparoscopic ultrasonography. Laparoscopic ethanol injection did not cause serious complications in any patient. The mean hospital stay after ethanol injection was 8.6 days (4 to 15 days). The cumulative survival rate was 86.7% at 3 years and 60.0% at 5 years. According to the Child-Pugh classification, the cumulative survival rate at 5 years was 87.9% for class A, 65.7% for class B, and 28.6% for class C.

CONCLUSIONS

The long-term prognosis for patients with small hepatocellular carcinoma treated solely by laparoscopic ethanol injection is satisfactory but still dependent on underlying liver function.

Laparoscopic cholecystectomy in gallstone patients with acute cholecystitis

It remains controversial whether patients with gallstones with acute cholecystitis should be operated on early, or whether surgery should be delayed until the acute phase subsides. To help resolve this question, we retrospectively studied 109 patients with acute cholecystitis, 56 of whom underwent laparoscopic cholecystectomy after acute cholecystitis had subsided (delayed group) and 53 of whom underwent early laparoscopic cholecystectomy--within 7 days after admission (early group). On admission, the inflammatory findings in the two groups were very similar; however, at operation, the inflammatory findings were alleviated in the delayed group, while they remained unchanged in the early group. The mean operative time for the two groups was very similar. As for intraoperative complications, there was no conversion to laparotomy in either group, and there were no major complications in either group. The total hospital stay was 37.7 +/- 14.4 days for the delayed group and 12.7 +/- 2.0 days for the early group, showing a highly significant difference (P < 0.001). Early laparoscopic cholecystectomy seems to be better than delayed treatment for patients with gallstones with acute cholecystitis.

Formation of gamma-glutamylpropargylglycylglycine from propargylglycine in human blood and erythrocytes

Gamma-Glutamylpropargylglycylglycine (gamma-Glu-PPG-Gly) was isolated as a metabolite of propargylglycine (2-amino-4-pentynoic acid, a natural and synthetic inhibitor of cystathionine gamma-lyase) from human blood incubated with D,L-propargylglycine in the presence of L-glutamate and glycine, and identified by fast-atom-bombardment mass spectrometry, indicating that human blood can metabolize propargylglycine to gamma-Glu-PPG-Gly. When whole blood was incubated with 2 mM D,L-propargylglycine in the presence of 10 mM L-glutamate and 10 mM glycine at 37 degrees C for 16h, 0.094+/-0.013 micromol of gamma-Glu-PPG-Gly was formed per ml of whole blood. When erythrocytes were incubated under the same conditions for 16h, 0.323+/-0.060 micromol of gamma-Glu-PPG-Gly was formed per ml of erythrocytes, suggesting a large contribution of erythrocytes to gamma-Glu-PPG-Gly formation in whole blood. The apparent Km value of gamma-Glu-PPG-Gly formation in human erythrocytes for D,L-propargylglycine was 0.32 mM. The observed rate of gamma-Glu-PPG-Gly formation and the Km value for D,L-propargylglycine suggest that metabolism of propargylglycine to gamma-Glu-PPG-Gly can play a definite biological role in human subjects who are loaded with propargylglycine.

Inhibin secretion in the mare: localization of inhibin alpha, betaA, and betaB subunits in the ovary

To determine the source of circulating inhibin and estradiol-17beta during the estrous cycle in mares, the cellular localization of the inhibin alpha, betaA, and betaB subunits and aromatase in the ovary was determined by immunohistochemistry. Concentrations of immunoreactive (ir-) inhibin, estradiol-17beta, progesterone, LH, and FSH in peripheral blood were also measured during the estrous cycle in mares. Immunohistochemically, inhibin alpha subunits were localized in the granulosa cells of small and large follicles and in the theca interna cells of large follicles, whereas inhibin betaA and betaB subunits were localized in the granulosa cells and in the theca interna cells of large follicles. On the other hand, aromatase was restricted to only the granulosa cells of large follicles. Plasma ir-inhibin concentrations began to increase 9 days before ovulation; they remained high until 2 days before ovulation, after which they decreased when the LH surge was initiated. Thereafter, a further sharp rise in circulating ir-inhibin concentrations occurred during the process of ovulation, followed by a second abrupt decline. After the decline, plasma concentrations of ir-inhibin remained low during the luteal phase. Plasma estradiol-17beta concentrations followed a profile similar to that of ir-inhibin, except during ovulation, and these two hormones were positively correlated throughout the estrous cycle. Plasma FSH concentrations were inversely related to ir-inhibin and estradiol-17beta. These findings suggest that the dimeric inhibin is mainly secreted by the granulosa cells and the theca cells of large follicles; granulosa cells of small follicles may secrete inhibin alpha subunit, and estradiol-17beta is secreted by the granulosa cells of only large follicles in mares.

Effect of passive immunization against inhibin on FSH secretion, folliculogenesis and ovulation rate during the follicular phase of the estrous cycle in mares

Physiological roles of inhibin in mares were investigated by means of passive immunization using an antiserum to inhibin that had been raised in a castrated goat. Eight mares were given an intravenous injection of either 100 mL (n = 4) or 200 mL (n = 4) of inhibin antiserum 4 d after a single intramuscular injection of PGF2 alpha on Day 8 after ovulation, 4 control mares were treated with 100 mL castrated goat serum in the same manner. Jugular vein blood samples were collected after treatment with the serum until 192 h post treatment. Follicular growth and ovulations were monitored by ultrasound examination at 24-h intervals. The ability of the inhibin antiserum to neutralize the bioactivity of equine inhibin was examined in vitro using a rat pituitary cell culture system. Suppression of secretion of FSH from cultured rat pituitary cells by equine follicular fluid was reversed by the addition of increasing doses of the inhibin antiserum, thereby indicating its bioactivity. Plasma levels of FSH and estradiol-17 beta were higher in mares treated with the inhibin antiserum. The ovulation rate was significantly higher in mares treated with antiserum (100 mL = 3.75 +/- 0.63; 200 mL = 4.50 +/- 0.65) than in control mares (1.25 +/- 0.25). These results demonstrate that inhibin is important in regulating FSH secretion and folliculogenesis in mares. They also show that neutralization of the bioactivity of inhibin may become a new method for the control of folliculogenesis and ovulation rate in mares.

Testicular inhibin in the stallion: cellular source and seasonal changes in its secretion

The cellular localization of inhibin alpha, betaA, and betaB subunits, 3beta-hydroxysteroid dehydrogenase (3beta-HSD), and cytochrome P450 aromatase (aromatase) in stallion testes was investigated. In addition, detailed seasonal changes in circulating immunoreactive (ir)-inhibin were investigated in correlation with testosterone, estradiol, LH, and FSH. Inhibin alpha subunit-positive staining was observed in Sertoli cells, and more clearly positive staining was noted in Leydig cells. Inhibin betaA and betaB subunits were also stained in both types of cells. Immunoreactivity of 3beta-HSD and aromatase was confined to the Leydig cells. There was no seasonal effect on the percentage of the areas within seminiferous tubules and interstitial tissues that stained positive for the inhibin alpha subunit. The highest plasma concentrations of ir-inhibin were observed in the breeding season, and the lowest levels were noted during the nonbreeding season. The circulating concentrations of ir-inhibin, steroid hormones, and gonadotropins were positively correlated with each other throughout the 2 years studied. The presence of the inhibin alpha and beta subunits in Leydig cells and Sertoli cells in the equine testis suggests that these cells may secrete dimetric (bioactive) inhibin in circulation of stallions, and that the circulating ir-inhibin may be a useful indicator of the testicular function of stallions.

[Thoracoscopic surgery for diagnosis of interstitial pneumonia special reference to medicoeconomical effect]

We compared thoracoscopic surgery (TS) and open thoracotomy for the diagnosis of interstitial pneumonia. Intraoperative blood loss and duration of postoperative chest drainage were significantly less with TS than with thoracotomy. The length of postoperative hospital stay and social insurance costs with TS was significantly less than with thoracotomy. These results show that TS for the diagnosis of interstitial pneumonia is superior to open thoracotomy in terms of surgical stress and cost.

Inhibin secretion in the stallion

To examine the physiological role of inhibin in the stallion, a heterologous radioimmunoassay (RIA) based on a bovine RIA was validated and used to measure immunoreactive (ir)-inhibin concentrations in plasma and testicular homogenates. The bioactivity of equine testicular inhibin was also examined using an assay for suppression of FSH secretion from rat anterior pituitary cells. In addition, to identify the cell responsible for secreting testicular inhibin, the localisation of inhibin in the testis was investigated by an immunohistochemical method using a polyclonal antibody against (Tyr30)-porcine inhibin alpha(1-30) NH2. In the RIA, parallel dose response curves were obtained for the bovine inhibin standard and serial dilutions of stallion plasma and equine testicular homogenates. Parallel FSH inhibition curves were also observed for the bovine inhibin standard and serial dilutions of equine testicular homogenates in the bioassay. The inhibition of FSH secretion from rat pituitary cells by equine testicular homogenates was neutralised by an antiserum against bovine inhibin in vitro. Plasma concentrations of ir-inhibin, testosterone and oestradiol-17beta in stallions decreased abruptly after bilateral gonadectomy and FSH and LH concentrations in the plasma subsequently increased. Therefore, circulating inhibin in the stallion appeared to be largely of testicular origin. The histochemical results showed for the first time that strong immunopositive staining for inhibin occurred in the Leydig cells of the testes. Sertoli cells were also stained by the inhibin antibody but the reaction was weaker than that in Leydig cells. These results indicate clearly that both Leydig and Sertoli cells are potential sources of testicular inhibin in the stallion. A clear increase in plasma ir-inhibin concentrations was observed during the natural breeding season. Similar seasonal changes in the plasma concentrations of testicular steroid hormones and pituitary gonadotrophins occurred throughout the year. In conclusion, the testes appear to be the main source of inhibin, and testicular inhibin is secreted by Leydig and Sertoli cells in stallions. The positive correlations between plasma ir-inhibin and testicular activity during both the breeding and nonbreeding seasons indicate that plasma ir-inhibin is a useful indicator of reproductive activity in the stallion.

A pilot study on modified endoscopic variceal ligation using endoscopic ultrasonography with color Doppler function

OBJECTIVE

The purpose of the study was to evaluate feasibility of modified endoscopic variceal ligation (EVL), namely the "intensive ligation" method, using endoscopic ultrasonography with color Doppler function (EUS-CD).

METHODS

Forty-five patients with esophageal varices were treated by modified EVL. Variceal hemodynamics in 38 patients were examined using EUS-CD, which showed abdominal hemodynamics in detail under physiological conditions before and after the modified procedure.

RESULTS

1) The median number of treatment sessions was 3.2, and 41 O-rings on average were required per individual patient. 2) The median nonrecurrence period after treatment was 18 months (Kaplan-Meier method). 3) Nine patients with a good response to modified EVL did not have recurrences for 16.9+/-2.8 months, and five with a poor response had recurrences at 5.8+/-2.2 months. Gastric varices were related to the response to modified EVL (p < 0.05, Mann-Whitney's U test). 4) Minor complications in modified EVL as well as standard EVL were experienced; however, we had a patient with the development of meningitis, which was a major septic complication. 5) Before modified EVL, EUS-CD demonstrated that good responders had undeveloped (grade I) gastric varices in five of nine (56%); however, poor responders had developed (grade III) gastric varices in four of five (80%) (p < 0.05, Mann-Whitney's U test]. 6) After modified EVL, EUS-CD revealed that six of nine (67%) good responders and one of five (20%) poor responders showed a decrease in color signals in supplying veins; however, none of the former (0%) and three of the latter (60%) showed an increase (p < 0.05, Mann-Whitney's U test].

CONCLUSION

Modified EVL was safe and effective, at least with regard to intermediate-term outcome, especially when treating patients with undeveloped gastric varices revealed by EUS-CD. Both good and poor responders showed no exacerbation of gastric varices after the modified procedure, ultrasonographically as well as endoscopically.

A new metabolite of propargylglycine, gamma-glutamylpropargylglycylglycine, in liver of D,L-propargylglycine-administered rats

A new metabolite of propargylglycine (2-amino-4-pentynoic acid, a natural and synthetic inhibitor of cystathionine gamma-lyase) was isolated from liver of rats intraperitoneally administered D,L-propargylglycine with ion-exchange chromatography, and identified as a glutathione analogue, N-[N-gamma-glutamyl(propargylglycyl)]glycine (gamma-Glu-PPG-Gly), by fast-atom-bombardment-mass spectrometry and reactions of the compound including acid hydrolysis, carboxypeptidase reaction, and gamma-glutamyltranspeptidase reaction. The content of gamma-Glu-PPG-Gly in rat liver increased dose-dependently with the increase of D,L-propargylglycine. When the dose of D,L-propargylglycine was 50 mg/kg of body weight, the increase of gamma-Glu-PPG-Gly was proportional to the time after the administration of D,L-propargylglycine, up to 8 h, and then gradually decreased to about 50% of the maximum at 24 h, where the maximum level of gamma-Glu-PPG-Gly at 8 h was 1.15 +/- 0.08 micromol/g of liver. The propargylglycine moiety of gamma-Glu-PPG-Gly in rat liver at 14 h after the administration of D,L-propargylglycine corresponded to 2-7% of the propargylglycine administered when the dose of D,L-propargylglycine was 3.125-200 mg/kg of body weight. The present results indicate that gamma-Glu-PPG-Gly is a major intermediate of propargylglycine metabolism in rat liver. The structural resemblance between glutathione and gamma-Glu-PPG-Gly suggests a possible involvement of propargylglycine and gamma-Glu-PPG-Gly as cysteine and glutathione analogues, respectively, in sulfur amino-acid metabolism.

[Progress and clinical usefulness of color Doppler method in diagnosing abdominal diseases]

We report the clinical usefulness of extracorporeal color Doppler ultrasonography (CDUS), color Doppler endoscopic ultrasonography (CDEUS), and recent progress in diagnosing abdominal diseases by the color Doppler method. CDUS has the advantage of being able to be performed repeatedly and noninvasively, it is thought to be useful for the evaluation of tumor vascularity and diagnosis of vascular tumor invasion and analysis of hemodynamics in abnormal vessels found in several abdominal diseases. CDEUS, which is performed under endoscopic ultrasonography (EUS), can evaluate the hemodynamics more minutely and visualize small vessels more clearly than conventional CDUS. Recent progress in the color Doppler method, such as US color angiography and the use of contrast agents is expected to lead to a higher resolution of visualization and easier detection of abdominal vessels.

Confirmation of a "safety zone" by intraoperative cholangiography during laparoscopic cholecystectomy

BACKGROUND

Creating a "safety zone" during laparoscopic cholecystectomy is defined as dissection of the cystic duct as close as possible to the gallbladder.

METHODS

In 29 out of 802 cases in which laparoscopic cholecystectomy was difficult to perform due to uncertainty about the orientation of Calot's triangle, intraoperative cholangiography was performed, using a titanium clip as a marker that designated the safety zone. The distance between the clip and the common hepatic duct or the common bile duct could be determined by evaluation of two intraoperative cholangiograms taken in different orientation.

RESULTS

If the clip was located in the safety zone, and was distant from the common hepatic duct or common bile duct, the safety of preparation around the clip was ensured. No complication was encountered in these cases with this method. Eventually, no biliary tract injury was experienced, and the overall conversion rate to open cholecystectomy was only 0.4% (3 of 802 consecutive cases).

CONCLUSIONS

This method of confirming the safety zone by intraoperative cholangiography is a useful procedure for avoiding inadvertent injury to the biliary tract.

Serovars of Erysipelothrix strains isolated from pigs affected with erysipelas in Japan

Serovars of 1,046 Erysipelothrix strains isolated from diseased pigs during a period from 1983 to 1993 in Japan were determined by an agar gel double-diffusion precipitation system using typing sera representing all the known serovars, 1 through 23 and type N, of 2 species of Erysipelothrix. A total of 943 strains could be serotyped within the serovars. The remaining 103 strains could not be determined for their serovars and were classified as untypable. Of the 938 (99.5%) strains serologically identified as Erysipelothrix rhusiopathiae, 423 (40.4%) belonged to serovar 1a, 359 (34.3%) to serovar 2, 65 (6.2%) to serovar 1b, 35 (3.3%) to serovar 6, 19 (1.8%) to serovar 5, 11 (1.1%) to serovar 21, and the remaining 26 to serovars 4, 8, 11, 12, 15, 17, or 19. Only 5 (0.5%) strains isolated from the cases of erysipelas belonged to Erysipelothrix tonsillarum and represented serovars 7 or 23.

Laparoscopic transcystic cholangioscopic lithotripsy for common bile duct stones during laparoscopic cholecystectomy

BACKGROUND AND STUDY AIMS

Following the recent introduction of laparoscopic cholecystectomy (LC) for cholecystolithiasis, treatment of concomitant common bile duct (CBD) stones has been evaluated by using laparoscopic choledochotomy, a transcystic approach, or by means of endoscopic sphincterotomy (ES) before or after LC.

PATIENTS AND METHODS

During laparoscopic cholecystectomy, we attempted lithotripsy of CBD stones using laparoscopic transcystic cholangioscopy with lithotripsy (LTCL), in 70 patients out of 950 laparoscopic cholecystectomies. Preparatory tests included laboratory values, ultrasound, and performance of endoscopic retrograde cholangiography (ERC) with placement of a nasobillary tube (without sphincterotomy).

RESULTS

Introduction of the cholangioscope into the CBD was successful in 65 patients (92.9%) and CBD clearance was completely achieved by LTCL alone in 51 (78.5%). The overall success rate was therefore 73%. The remaining 19 cases required postoperative procedures such as extracorporeal shock-wave lithotripsy without ERC or ES (successful in all). The average hospital stay period was 9.4 days for patients in whom CBD clearance was achieved by LTCL alone. This period did not differ significantly from that of patients who underwent LC alone (8.4) days. The operation time was about 70 minutes longer for the LTCL group (total time 174 minutes on average) than for the LC group (107 minutes). We did not observe any series complications during or after LTCL (mean follow-up period: 34 months).

CONCLUSION

LTCL in combination with LC allows shortening of the hospital stay and a swift return to work for patients with CBD stones. This procedure also preserves the function of the sphincter of Oddi, so that the longterm prognosis for patients is likely to be very good.

The usefulness of ultrasonic microprobe imaging for endoscopic variceal ligation

OBJECTIVES

This study investigated whether ultrasonic microprobe (UMP) imaging was useful in judging the therapeutic effect of endoscopic variceal (EVL) on varices as well as assessing varices and surrounding vessels before and after EVL.

METHODS

UMP imaging was performed repeatedly safely and easily via the biopsy channel of an endoscope in 20 patients with esophageal varices. Using this modality in combination with our method of "intensive ligation," we treated esophageal varices successfully.

RESULTS

Before EVL, UMP imaging displayed esophageal varices, periesophageal collaterals, and the azygous vein as echo-free lumens. In 15 of 20 patients, UMP imaging clearly detected the perforating vein, one of the optimal ligation sites for EVL, connecting the varix and collateral vein. Just after EVL, UMP imaging revealed a hyperechoic change ("snow ball" sign or "snow channel" sign), indicating blood flow stasis in the esophageal varices. On subsequent EVL, UMP imaging showed the cross-sectional area of varices was undetectable (occluded) or partially detectaable. After repeated EVL (2.9 treatment sessions on average), UMP imaging, as well as endoscopy, indicated that almost all varices were eradicated (undetectable). However, UMP imaging demonstrated that neither collaterals nor the azygous vein had significantly changed in size.

CONCLUSIONS

This modern diagnostic modality provided a clinical adjunct to current endoscopy when observing esophageal varices and surrounding vessels before and after EVL to determine the need for additional therapy.

Intratracheal infection of chickens with Salmonella enteritidis and the effect of feed and water deprivation

The tissue distribution of Salmonella enteritidis in intratracheally inoculated chickens and the effect of deprivation of food and water on tissue distributions of the bacteria have been investigated. Seven-week-old specific-pathogen-free chickens were inoculated intratracheally with 10(2), 10(5), or 10(8) cells and orally with 10(5) cells. The intratracheally inoculated organisms entered the blood stream immediately after inoculation and produced generalized infection. Infection by the intratracheal route resulted in colonization of S. enteritidis in the cecum that was similar to infection by the oral route. The tissue distribution of S. enteritidis was markedly affected when chickens were deprived of food and water for a short time, demonstrating an increased susceptibility of chickens to S. enteritidis infection. This suggests that stresses such as food and water deprivation are one of of the causes of the rapid dissemination of S. enteritidis among chickens in poultry houses.

Laparoscopic cholecystectomy in the elderly: analysis of pre-operative risk factors and postoperative complications

A retrospective study was conducted of two groups of patients over (group 1, n = 57) and under (group 2, n = 655) the age of 70 years who underwent laparoscopic cholecystectomy (LC). The pre-operative physical status and systemic complications, operation time, postoperative complications, postoperative hospital stay and other clinical features of the two groups were compared. The incidence of pre-operative complications in group 1 was significantly higher than that in group 2 (P < 0.05). Postoperatively no severe complication was found in any patient. Group 1 showed significantly prolonged operation time and postoperative hospital stay compared with group 2 (P < 0.05). The difference between the groups in the intra-operative treatment time and postoperative treatment is attributed to the greater prevalence of common bile duct stone in group 1 as there was little difference between the groups in the postoperative recovery after exclusion of these patients. No pulmonary complications, which are associated with LC, were observed; the postprocedure pain was slight and the period of bedrest was short. If complications associated with pneumoperitoneum can be prevented, this surgery is an excellent measure to improve the quality of life of even elderly patients with cholecystolithiasis.

Femoral vein stasis during laparoscopic cholecystectomy: effects of graded elastic compression leg bandages in preventing thrombus formation

Venous stasis of the legs during laparoscopic cholecystectomy was compared between patients without graded compression leg bandages (Group 1; n = 12) and patients with such bandages (Group 2; n = 12) by measuring mean blood flow velocity and cross-sectional area of the femoral vein using a color Doppler ultrasonography. In Group 1, when velocity and area were measured in the supine position, a significant decrease in velocity (p < .05) and a significant increase in area (p < .05) occurred after abdominal insufflation to 10 mm Hg. These changes were greater during abdominal insufflation in the reverse Trendelenburg position than during abdominal insufflation in the supine position. In Group 2, flow velocity was significantly higher (p < .05) before abdominal insufflation as compared with Group 1. After abdominal insufflation to 10 mm Hg and a postural change, velocity significantly decreased (p < .05) and area significantly increased (p < .05) in Group 2, similar to the results in Group 1. During abdominal insufflation at 5 mm Hg or lower, the use of the graded compression bandage was found to be useful for preventing femoral vein stasis. During abdominal insufflation at 10 mm Hg or in the reverse Trendelenburg position, the bandage did not prevent femoral vein stasis.

Lower-extremity venous stasis during laparoscopic cholecystectomy as assessed using color Doppler ultrasound

Lower-extremity venous stasis during laparoscopic cholecystectomy was evaluated in 16 patients by monitoring the blood velocity in the femoral vein and the femoral vein size (cross-sectional area) using color Doppler ultrasonography. The blood velocity in the femoral vein decreased significantly after the start of 10-mmHg abdominal insufflation in the supine position. When the patients were placed in a reverse Trendelenburg position during 10-mmHg insufflation, blood velocity in the femoral vein further decreased. However, velocity returned to the baseline after deflation. The cross-sectional area of the femoral vein was significantly elevated after the start of 10 mm Hg insufflation in the supine position. When patients were placed in the reverse Trendelenburg position during 10-mmHg insufflation, this parameter was further elevated, but returned to the baseline soon after deflation. These results indicate that femoral vein stasis during laparoscopic cholecystectomy can be minimized by reducing the pressure of abdominal insufflation and avoiding elevation of the patient's head as much as possible.

Evaluation of the efficacy of a bacterin against Salmonella enteritidis infection and the effect of stress after vaccination

An oil-emulsion vaccine was prepared from phage type 4 Salmonella enteritidis to assess the potential protective efficacy of S. enteritidis vaccine and the effect of stress after vaccination. Hens were vaccinated at 14 and 18 weeks of age and challenged orally at 24 weeks of age with 10(6) or 10(3) cells of a homologous S. enteritidis strain. Pullets were vaccinated at 8 and 12 weeks of age and challenged with 10(9) cells. The O antibody titers of vaccinated hens rose quickly and were unchanged after challenge. S. enteritidis was isolated from cecal droppings of significantly fewer vaccinated hens than unvaccinated control hens for 6-21 days and 2-15 days after challenge with 10(6) and 10(3) cells, respectively. S. enteritidis was also isolated from livers and spleens of significantly fewer vaccinated pullets for 1 week. Vaccinated and control hens were equally affected by exposure to environmental stress, the result being that the shedding rate of S. enteritidis in cecal droppings increased equally in both groups.

Horizontal transmission of Salmonella enteritidis and effect of stress on shedding in laying hens

Horizontal transmission of Salmonella enteritidis in laying hens and the short-term effect of stress on shedding were examined in 32 seven-month-old laying hens. Half were inoculated with 10(5) colony-forming units of S. enteritidis phage type 4, and the remaining half were left uninoculated to study horizontal transmission. Isolation of S. enteritidis from cecal droppings of all hens was attempted every morning. Uninoculated hens rapidly became infected through contaminated drinking water. Introduction of young chickens to the same rearing room and withdrawal of water and feed for 2 days coincided with a rapid increase in the shedding rate of S. enteritidis for a short period of time. The results showed that a short-term increase in the shedding rate of S. enteritidis is associated with short-term exposure to environmental stress.

Protection of mice against Clostridium chauvoei infection by anti-idiotype antibody to a monoclonal antibody to flagella

Polyclonal rabbit anti-idiotypic antibody (anti-Id) against the protective monoclonal antibody specific to the flagella of Clostridium chauvoei was produced, purified, and characterized. Anti-Id inhibited the binding of its related monoclonal antibody to the flagellar antigen, suggesting that the anti-Id bore an internal image of the flagellar antigen. When mice were immunized with anti-Id intraperitoneally, the survival rate increased significantly, compared with mice immunized with normal rabbit IgG (P < 0.01), and specific anti-flagellar antibodies were induced.

Antigenic mimicry of Clostridium chauvoei flagella by polyclonal anti-idiotypic antibodies

Polyclonal rabbit anti-idiotypic (anti-Id) antibodies against two monoclonal antibodies (MAbs) specific for the flagella of Clostridium chauvoei were produced, purified and characterised. Lack of cross-reactivity with heterologous MAbs indicated that the anti-Id antibodies were highly specific. The surface-exposed epitopes of the flagellar filament recognised with protective MAb were further distinguished by the anti-Id antibodies. Moreover, each anti-Id antibody inhibited the binding of its related MAb to flagellar antigens in a competitive enzyme-linked immunosorbent assay, suggesting that the anti-Id antibodies bore an internal image of the flagellar antigens. The survival rate of mice was increased to nearly twice that of controls by immunisation with anti-Id 41, which had been produced with a protective MAb; in contrast, anti-Id 114, produced with a non-protective MAb, failed to immunise. The results suggest that an anti-Id antibody containing an internal image of C. chauvoei flagella might be used as a vaccine.

Long-term shedding of Salmonella enteritidis in chickens which received a contact exposure within 24 hrs of hatching

Rifampicin-resistant mutant of Salmonella Enteritidis was used for the experiment of long-term excretion in chickens. Thirty-five specific pathogen free chicks within 24 hrs of hatching were placed in contact with 18 chicks inoculated orally with 4 x 10(2) CFU of S. Enteritidis HY-1 Rif within 12 hrs of hatching. After 7 weeks of the contact exposure, samples of cecal droppings were examined for the isolation of S. Enteritidis weekly or biweekly. Twenty-five out of 35 chicks (71%) survived. S. Enteritidis was isolated intermittently at least until 28 weeks after the contact exposure for male chickens and 21 weeks for female chickens although this strain could be isolated only for one or two months from cecal droppings or internal organs of young chickens and laying hens. In order to prevent S. Enteritidis infection in poultry, it was concluded that (1) the contact exposure within 24 hrs of hatching or transovarian infection should be avoided because infection of chicks within 24 hrs of hatching with S. Enteritidis causes the prolonged cecal shedding, and that (2) the isolation of S. Enteritidis from cecal droppings should be repeated because of its intermittent shedding.

Erysipelothrix tonsillarum isolated from dogs with endocarditis in Belgium

Five strains of Erysipelothrix tonsillarum were isolated from dogs with endocarditis in Belgium. The identity and validity of the species was proved by serotyping, and biochemical and pathogenicity tests. All the isolates belonged to serovar 7 (E tonsillarum serovars); they produced acid from saccharose but did not induce any clinical sign of erysipelas in swine. These results suggest that some strains of E tonsillarum are a canine pathogen.

The ability of Salmonella enteritidis isolated from chicks imported from England to cause transovarian infection

S. Enteritidis HY-1 isolated during quarantine from chicks imported from England was used. Laying hens at the age of 34 weeks were inoculated orally with 10(10) organisms (10 birds), intramuscularly with 10(9) (5 birds), and intravenously with 10(9) (5 birds). Egg production did not change in hens infected orally, although it was reduced in hens infected intramuscularly for 2-3 weeks post inoculation. For one month, internally infected eggs of which the shells were not contaminated were found: one out of 65 eggs in hens infected orally and three out of 36 eggs in hens infected intramuscularly. This experiment demonstrated the ability of S. Enteritidis isolated from chicks imported from England to cause transovarian infection.

Sero- and CPE-types of porcine enteroviruses isolated from healthy and diarrheal pigs: possible association of CPE type II with diarrhea

Porcine enteroviruses (PEV) were isolated from feces of healthy and diarrheal domestic Japanese pigs, and examined for their serotypes. Each virus of the isolates corresponded not only to the Japanese version of the reference serotype, but also to its corresponding world version of the reference serotype. Twenty-two samples (75.9%) of 29 isolates from the feces of healthy pigs exhibited a characteristic of CPE I. On the other hand, 69.2% (27/39) of all diarrheal pigs showed a characteristic of CPE II. This would suggest the PEV with CPE II has a closer association with the enteric pathogenicity than that with CPE I.

[Application of calcium phosphate ceramics to periodontal therapy. 8. Effects of orthodontic force on repaired bone with hydroxyapatite]

It has been unclear whether M.T.M. is acceptable for patients treated with bone grafts using hydroxyapatite (HAP), which is not biodegradable. Therefore we studied histological changes in bone among HAP during orthodontic tooth movement. HAP was implanted into artificial bone defects adjacent to second premolars in beagle dogs, and as a control no material was implanted Three months after implantation, the second premolars were moved with orthodontic force. Then they were observed histopathologically. The results obtained were as follows. The amount of movement of the teeth in implanted sites was less than in the controls. In the pressure zone, resorption of bone by osteoclasts was observed in both the implanted and the control sites, in addition, root resorption occurred adjacent to HAP. Furthermore multinucleated giant cells were closely attached to HAP and were surrounded by bone and connective tissue. In retention period there was ankylosis between the roots and bone around HAP. In the tension zone, additional bone from HAP was observed. Bone defects were filled with bone in the implanted sites, but with connective tissue in the controls. These results suggest that bone among HAP was resolved by osteoclasts. Clinically, HAP implantation for the pressure zone should be avoided because of the occurrence of root resorption and ankylosis. But for the tension zone it seems to be effective because HAP implantation produces more repaired bone.

Clinical analysis of 33 patients with adult T-cell leukemia (ATL)-diagnostic criteria and significance of high- and low-risk ATL

The clinical characteristics of 33 patients with adult T-cell leukemia (ATL) are described. All patients were born and have lived in Miyazaki Prefecture (southwest of Japan). Because of a wide range of clinical presentations and courses, they were subdivided into 2 groups. In the high-risk group, patients presented with high white-cell counts (WBC greater than or equal to 20,000/microliter) and over 30% of abnormal lymphoid cells (18 patients) and hypercalcemia with a low percentage of leukemic cells (5 patients). In this group the median survival time was only 3 months despite various modes of treatment. In contrast, patients of the second group exhibited a low percentage of abnormal lymphoid cells (WBC less than 20,000/microliter and/or leukemic cells less than 30%) and had no hypercalcemia (8 patients). Their clinical course was chronic with a median survival of 8 months, regardless of modalities of treatment. Two patients went through a period when the number of circulating leukemic cells was low (less than or equal to 5%) before overt leukemia appeared. Other clinical features, signs, symptoms, routine laboratory data, serum anti-ATL-associated antibody, cell membrane markers and cytogenetic studies were similar to those observed in other districts of Kyushu island.