Comparison of antiemetic efficacy between single and repeat treatment with dexamethasone in patients receiving carboplatin-based combination chemotherapy

A retrospective study was carried out to compare the preventive effects of single and repeat treatment with dexamethasone (DEX) on delayed nausea and emesis in patients who had received carboplatin (CBDCA)-based combination chemotherapy. Sixty-four patients were evaluated. Efficacy was assessed using the nausea and emesis score, food intake score and the requirement for antiemetic medication. These forward scores were categorized as three-grade during the first 5 days after chemotherapy. Acute nausea and emesis were well controlled in both groups on day 1. Mean values of the nausea and emesis score on day 3 evening and the food intake score on day 4 morning in the repeat-treatment group was 1.31 ± 0.93 and 3.46 ± 1.03, respectively, which were significantly better when compared with the single-treatment group (2.00 ± 1.52; P = 0.028 and 2.79 ± 1.12; P = 0.018, respectively). Multivariate logistic regression analysis revealed that less frequent dispensing of antiemetic medication was significantly associated with the repeat-treatment group (adjusted odds ratio, 0.153; 95% confidence interval, 0.026-0.734; P = 0.018). These results suggest that repeat-dose DEX may be more effective than single-dose DEX for the prevention of delayed nausea and emesis after CBDCA-based combination chemotherapy.

Double balloon endoscopy in two hundred fifty cases for the diagnosis and treatment of small intestinal disorders

Double balloon endoscopy is based on a new insertion mode in which two balloons at the distal ends of both an endoscope and an overtube are operated in combination. We have performed 419 enteroscopic examinations in 250 patients using the Fujinon double balloon endoscopy system between September 2000 and October 2005. Total enteroscopy was successfully achieved by the combination of both oral and anal approaches in 55 out of 71 cases in whom total enteroscopy was intended. Of 250 patients, ulcerative and/or erosive lesions were found in 49 cases and tumors/polyps were found in 49 cases. We also found 26 cases of vascular lesion, including angiodysplasia. Endoscopic treatments, including hemostasis using either clipping devices or electro coagulation, polypectomy, endoscopic mucosal resection, balloon dilation, and stent placement was successfully carried out. Double balloon enteroscopy is both feasible and useful technique for the diagnosis as well as treatment of small intestinal disorders.

Endoscopic thermal ablation therapies for hepatocellular carcinoma; multi-center study

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Background: Differences of efficacy between radiofrequency ablation (RFA) and microwave coagulation (MWC) for hepatocellular carcinoma (HCC) is still unknown. So we performed multi-center study to assess factors contributing to survival among patients treated by endoscopic thermal ablation for single HCC. Methods: 396 patients in six institutions with single HCC who were firstly treated by endoscopic thermal ablation were enrolled in this study and assessed retrospectively. Among 396 patients, 347 were treated under general anesthesia and 49 were treated local anesthesia. 144 were treated by MWC and 252 were treated by RFA. 383 were ablated laparoscopically and 13 were done thoracoscopically. 230 HCCs were located superficial position of liver and 166 were deep position. Classification with Child-Turcotte-Pugh score, the Japan Integrated Staging score, and the Cancer of the Italian Program scoring system were performed. All patients were analyzed survival rates by Kaplan-Meier method and differences among groups were compared by the log-rank test. Results: Five year survival rates of all 396 patients were 63% and ten year survival rates were 42%. Differences between general and local anesthesia were not significant (p = 0.28). Differences between MWC and RFA were not significant (p = 0.77). Location of HCCs were not significant (p = 0.89). Differences among groups classified by Child-Turcotte-Pugh score were significant (p = 0.017). Classification by the Japan Integrated Staging score was not significant (p = 0.24). However, classification by the Cancer of the Italian Program scoring system were significant (p = 0.001). Conclusions: Endoscopic thermal ablation therapies for HCC was effective. Differences of efficacy between RFA and MWC were not found.

No significant financial relationships to disclose.

Contamination with hepatitis B virus DNA in gastrointestinal endoscope channels: risk of infection on reuse after on-site cleaning

BACKGROUND AND STUDY AIMS

The incidence of viral contamination in the air, water and suction/accessory channels of gastrointestinal endoscopes was examined in order to evaluate the risk of infection.

MATERIALS AND METHODS

After endoscopic examinations, including biopsy procedures, in 17 patients who were positive for hepatitis B virus surface antigen and eight patients who were positive for hepatitis C virus antibody, the endoscopes were cleaned on site by suctioning and flushing the air and water channels with an enzyme detergent. First samples were then collected by flushing 5 ml of sterile water through each channel. After mechanical reprocessing, second samples were collected in the same way. Virological studies were carried out with real-time polymerase chain reactions for hepatitis B virus DNA and hepatitis C virus RNA.

RESULTS

Hepatitis B virus DNA was detected in five of the first samples recovered from the suction/accessory channels of the endoscopes (titers of 1.3 x 10 (4) to 2.5 x 10 (5) copies/ml), while no contamination was detected after reprocessing ( P = 0.0445). The first samples from one water channel and three air channels were also positive for hepatitis B virus DNA, but were negative after reprocessing ( P > 0.5, P = 0.227, respectively). No hepatitis C virus RNA was detected in any of the samples.

CONCLUSIONS

These results indicate that all of the channels were potential sources of viral infection.

Single Burr Hole Surgery for the Spheno-Orbital Fibrous Dysplasia Using Intraoperative Computed Tomography

Total removal of spheno-orbital fibrous dysplasia was achieved through intraoperative CT-assisted surgery via a burr hole. A 32-year-old man had persistent headache. Radiological studies demonstrated a small osteolytic lesion in the sphenoidal bone underneath the superior orbital fissure. Intraoperative serial CT scans showed the depth and width of the tumor within the complicated structure of the skull base. The lesion was successfully removed by CT-guided minimally invasive surgery.

Pericryptal fibroblast sheath in intestinal metaplasia and gastric carcinoma

BACKGROUND AND AIMS

In the progression of chronic gastritis, gastric mucosal cells deviate from the normal pathway of gastric differentiation to an intestinal phenotype which is closely related to gastric carcinoma. However, to date, it has not been elucidated whether the intestinal metaplasia is merely a change in the epithelium or whether the underlying mesenchyme also changes from gastric type to intestinal type. We have investigated the relationship between intestinal metaplasia and the pericryptal fibroblast sheath (PCFS) in the mesenchyme. In addition, we also examined PCFS in gastric carcinoma.

METHODS

We determined the existence of PCFS in the intestinal metaplastic mucosa and carcinoma of both human and Cdx2 transgenic mouse stomach. PCFS was determined using the antibody against alpha-smooth muscle actin and electron microscopic observations.

RESULTS

PCFS formed an almost complete layer around the small and large intestinal crypts while it did not exist around the normal gastric glands in both mice and humans. PCFS was seen around the glands of intestinal metaplastic mucosa in both Cdx2 transgenic mouse and human stomachs. However, PCFS was virtually absent in the intestinal-type gastric adenocarcinoma area.

CONCLUSION

We successfully demonstrated that the epithelium as well as the mesenchyme changed from the gastric type to the intestinal type in intestinal metaplasia and that PCFS disappeared in intestinal-type gastric carcinoma.

A case of inflammatory fibroid polyp causing small-bowel intussusception in which retrograde double-balloon enteroscopy was useful for the preoperative diagnosis

We showed a newly developed method, retrograde double-balloon enteroscopy, to be useful for preoperative diagnosis in a case of inflammatory fibroid polyp accompanied by small-bowel intussusception. A 64-year-old woman was admitted to our hospital with small-bowel intussusception. Results of radiographic and ultrasonographic examination were suggestive of a small-bowel mass. Retrograde double-balloon enteroscopy was performed in an attempt to make a preoperative diagnosis. Endoscopic observation, in combination with histological findings derived from endoscopic biopsy, was suggestive of an inflammatory fibroid polyp. The patient then underwent laparotomy with minimal incision, which revealed a polypoid mass leading to a jejunojejunal intussusception, without bowel necrosis, and a partial small-bowel resection was performed. The pathological diagnosis was an inflammatory fibroid polyp.

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.

Successful en-bloc resection of large superficial tumors in the stomach and colon using sodium hyaluronate and small-caliber-tip transparent hood

En-bloc resection is desirable for accurate histopathological assessment of tissue specimens obtained using endoscopic mucosal resection (EMR). A new EMR method using sodium hyaluronate and a small-caliber-tip transparent hood has been developed. This is a peeling-off method using a needle-knife for mucosal and submucosal incisions. Long-lasting submucosal thickening resulting from an injection of sodium hyaluronate, and good visualization of the submucosal tissue with the aid of a small-caliber-tip transparent hood, make the cutting procedures easy and safe. A large superficial gastric cancer and a large villous tumor of the sigmoid colon were endoscopically resected using this method. En-bloc endoscopic resection was successful in both patients. The gastric lesion was an well-differentiated intramucosal adenocarcinoma, completely resected in a specimen measuring 97 x 50 mm. The colonic lesion was an intramucosal well-differentiated adenocarcinoma in adenoma, completely resected in a specimen measuring 70 x 55 mm in diameter. No significant complications were noted in either patient. The new method of EMR using sodium hyaluronate and the small-caliber-tip transparent hood is a promising method for endoscopic en-bloc resection of large superficial neoplastic lesions, both in the stomach and the colon.

Improvement of the automatic endoscopic reprocessor: self-cleaning disinfecting connectors between endoscope and reprocessor

BACKGROUND AND STUDY AIMS

We have previously pointed out a defect of automatic endoscopic reprocessors, i. e. the contamination of the connecting part between the endoscope and the reprocessor. We evaluated a newly designed connector (MH-861; Olympus, Tokyo, Japan) with a self-cleaning and disinfection mechanism, which enabled cleaning and disinfection of both the connector itself and its interface with the suction and air/water valves during a reprocessing cycle, which was not previously possible.

METHODS

Ten upper gastrointestinal endscopes were examined in the study. Swabs were taken from the suction and air/water valves for microbiological culture before and after reprocessing by the washer-disinfector. The numbers of contaminated endoscopes before and after reprocessing with the new connector were compared.

RESULTS

Before the procedure there were five contaminated endoscopes and none after the procedure. When the new connector was used, the difference in cleaning and disinfection of the connecting parts was significant (P = 0.0325).

CONCLUSIONS

We conclude that the newly developed connector permits effective cleaning and disinfection by automatic reprocessors.

Effectiveness of a transforaminal surgical procedure for spinal extradural arachnoid cyst in the upper lumbar spine

Spinal extradural arachnoid cysts are relatively rare, and the pathogenesis is still unclear. Here, we report a 24-year-old woman with a Type I lesion by Nabors' classification (extradural arachnoid cyst without spinal nerve root fiber involvements), who complained of low back pain and right thigh pain, treated surgically using a transforaminal approach. Magnetic resonance imaging (MRI) and myelography showed a large extradural cystic lesion close to the L1 nerve root sleeve, accompanied by moderate L1 nerve root compression and a communication between the extradural cyst and the subarachnoid space. Resection of the cyst wall and closure of the ostium were easily performed by this approach. This procedure resulted in the relief of both low back pain and right thigh pain. Histological examination showed clusters of meningothelial cells, which was a typical feature of arachnoid cysts. Postoperative MRI demonstrated that both the cystic lesion and nerve root compression had disappeared. This transforaminal procedure proved useful for the treatment of a lesion located around a lumbar spinal nerve root.

An unusual reduction technique prior to surgical treatment for traumatic spondylolisthesis in the lower cervical spine

Traumatic spondylolisthesis in the lower cervical spine is rare and only a few cases have been reported. We present a 56-year-old man who had severe C6-C7 spondylolisthesis without major neurological complications, caused by a traffic accident. Plain CT images showed a pedicular fracture on the right side and a laminar fracture on the left side at C6, but magnetic resonance images revealed no spinal cord compression. Application of a halo brace and maintaining the neck in slight flexion without traction resulted in reduction of the spondylolisthesis to nearly normal alignment. Anterior fusion using an autogeneous bone graft and a plate was easily performed without loss of correction. We suggest that preoperative reduction using a halo brace in slight flexion without longitudinal skull traction is useful and effective for severe traumatic spondylolisthesis in the lower cervical spine.

Evaluation of a prototype long-lasting insecticide-treated mosquito net under field conditions in rural Burkina Faso

Insecticide measurements and standard World Health Organization bioassays on random samples of new unwashed, traditionally washed and up to 18 months field-used 'long-lasting' deltamethrin treated mosquito nets demonstrated a rapid reduction of efficacy under field conditions. The technology of 'long-lasting' insecticide-treatment needs much improvement.

Safe percutaneous canalization of the biliary tree using a sheath in patients with malignant biliary stenosis

BACKGROUND

Percutaneous canalization of the bile duct is essential for radiologic interventions of the biliary tract. This study discusses technical considerations for safe approaches for canalization of the bile duct when using a sheath.

METHODS

During early and late periods, percutaneous canalization was performed in 104 patients and 79 patients with malignant biliary stenosis, respectively. The late period differed from the early period in that the bile duct was canalized with a previously placed sheath to prevent catheter dislodgement during the procedure.

RESULTS

During the early and late periods, catheter dislodgement during canalization occurred in three of 104 patients (3%) and none of 79 patients (0%), respectively. The success rate of canalization without cholangioscopy in the late period (99%) was better than that in the early period (89%; p < 0.05).

CONCLUSION

Placement of a sheath into the biliary tree increases the safety and success of canalization in patients with malignant stenosis.

Paraparesis due to spinal leiomyosarcoma lesion in the thoracic spine accompanied by two leiomyosarcoma lesions in the back and the thigh over an interval of 4 years

We present an 83-year-old man who developed three different leiomyosarcoma lesions in the thigh, back, and thoracic spine. The pathology of the thigh tumour was pleomorphic leiomyosarcoma. MRI after 4 years showed a vertebral bone lesion associated with spinal cord compression at T7 and a paravertebral mass lesion at T9-T10. Surgical treatment for the spinal lesion which caused paraparesis improved the neurological symptoms. The pathological features of the lesions in the back and spine were identical and rather distinct from those of the previous thigh lesion. Spinal leiomyosarcoma causing paraparesis and the two other with soft-tissue leiomyosarcoma lesions with different pathological features in a single patient over a period of 4 years is an extremely rare occurrence.

A combination of heparin and an intermittent pneumatic compression device may be more effective to prevent deep-vein thrombosis in the lower extremities after laparoscopic cholecystectomy

BACKGROUND

The purpose of this study was to clarify the effect of a combination of heparin and an intermittent pneumatic compression device on thrombogenesis and platelet activation in the upper and lower extremities after laparoscopy.

METHODS

A blinded study was performed on 30 patients. Patients were randomly injected with either heparin or physiological saline solution (PSS) subcutaneously. The intermittent compression boot was used during surgery. Plasma D-dimer (D-D), a marker of thrombogenesis, and b-thromboglobulin (b-TG), a marker of platelet activation, were measured in the upper and lower extremities.

RESULTS

In the heparin group, D-Ds in the upper and lower extremities increased significantly 24 h after surgery, but they were significantly lower than those of the PSS group. b-TG in the lower extremities of patients in the PSS group increased significantly 24 h after surgery.

CONCLUSION

A combination of low-molecular-weight heparin and intermittent pneumatic compression may be more effective to prevent deep-vein thrombosis in the legs.

Endoscopic transpapillary bile duct biopsy with the combination of intraductal ultrasonography in the diagnosis of biliary strictures

BACKGROUND

When endoscopic retrograde cholangiopancreatography (ERCP) guided bile duct biopsy fails to demonstrate malignancy, it remains unclear how to manage patients with presumably malignant strictures.

AIMS

To evaluate the value of intraductal ultrasonography (IDUS) when bile duct biopsy is negative.

METHODS

Sixty two patients with strictures of the bile duct were studied prospectively. During ERCP, IDUS was performed using an ultrasonic probe (diameter 2.0 mm; frequency 20 MHz). Following IDUS, a bile duct biopsy was performed using forceps (diameter 1.8 mm). The IDUS images of the tumour were classified as polypoid lesions, localised wall thickening, intraductal sessile tumours, sessile tumour outside of the bile duct, or absence of apparent lesion. The bile duct wall structures at the site of the tumour as well as the maximum diameter of the tumour were also analysed. The IDUS findings were compared with the histological findings or clinical course.

RESULTS

When the IDUS images showed a polypoid lesion (n=19), localised wall thickening (n=8), intraductal sessile tumour (n=13), and sessile tumour outside of the bile duct (n = 20), the sensitivities of the biopsy were 80%, 50%, 92%, and 53%, respectively. Multiple regression analysis showed that the presence of sessile tumour (intraductal or outside of the bile duct: p<0.05), tumour size greater than 10.0 mm (p<0.001), and interrupted wall structure (p<0.05) were independent variables that predicted malignancy.

CONCLUSION

When biopsy fails to demonstrate evidence of malignancy, the presence of sessile tumour (intraductal or outside of the bile duct), tumour size greater than 10.0 mm, and interrupted wall structure on IDUS images are factors that can predict malignancy.

Meningeal Rosai-Dorfman disease: report of three cases and literature review

Rosai-Dorfman disease is a well-recognized clinicopathological entity, which in rare cases affects the central nervous system, where it mimics meningioma. We describe three cases and review the literature. Histological and immunohistochemical confirmation is essential for definitive diagnosis. In addition to emperipolesis (lymphophagocytosis), reactivity for S-100 and CD68 and nonreactivity for CD-la immunostaining are characteristic features of this histioproliferative disease. In contrast to meningioma, this tumor usually occurs in young males and infiltrates the brain parenchyma.

The validity of upright myelography for diagnosing lumbar disc herniation

Although computed tomographic (CT) myelography and magnetic resonance imaging (MRI) are used for assessing lumbar disc herniations (LDH), they cannot provide images when patients are standing or walking, whose CT myelograms and MRI images show only slight disc bulging. The purpose of this study was to evaluate the usefulness of upright myelography. We examined by myelography in both an upright and a lying position for 50 patients with LDH at L4-5 and L5-S1 to assess the difference in disc bulge size. Lateral myelogram was used for evaluating the difference quantitatively. In 29 patients with damage at L4-5, 21 (72.4%) had increased disc bulging when upright, and 22 (75.9%) showed subligamentous LDH. In 21 patients with damage at L5-S1, fewer patients showed increased disc bulging when upright than showed unchanged disc bulging. This upright myelographic technique could show increased disc bulging in patients with mild compression at L4-5 whose sciatica increased in an upright position. Upright myelography seems to be the only method for assessing patients with LDH, especially at the L4-5 level, whose neurological symptoms develop during standing or walking.

Cholangiographic findings of early-stage extrahepatic bile duct carcinoma

BACKGROUND

To clarify the cholangiographic findings of early-stage (T1, tumor confined to the mucosal or fibromuscular layer) extrahepatic bile duct carcinoma.

METHODS

Cholangiographic images were retrospectively analyzed without other information in 55 patients with extrahepatic bile duct carcinoma who underwent surgical treatment. Tumor stages were T1 (n = 10). T2 (n = 17), and T3 (n = 28). Cholangiographic findings were classified as "diffuse sclerosis," "stenosis," "papillary polypoid filling defect," or "nodular polypoid filling defect". "Papillary polypoid filling defect" was the term used when the width of the base was smaller than the width of the polypoid filling defect.

RESULTS

T1 patients showed papillary polypoid filling defects (n = 8) or nodular polypoid filling defects (n = 2) on cholangiography. When cholangiography showed papillary polypoid filling defects, 8 of the 14 resected patients showed T1 stage tumor histologically.

CONCLUSIONS

In this study, 57% (8/14) of resected patients with papillary polypoid filling defects showed T1 stage tumor. No T1 stage tumor showed stenosis or diffuse sclerosis.

Radiographic evaluation of posterolateral lumbar fusion for degenerative spondylolisthesis: long-term follow-up of more than 10 years vs. midterm follow-up of 2-5 years

Although posterolateral fusion of the lumbar spine without instrumentation has been widely performed for spinal instability caused by degenerative spondylolisthesis in the lumbar spine, few long-term follow-up studies have been reported. We studied ten patients who underwent posterolateral fusion for degenerative spondylolisthesis in the lumbar spine without instrumentation in our hospital, five of whom were followed up for more than 10 years and the other five for 2-5 years. We used radiography to examine their fusion status, instability and degenerative changes at the fusion level, change in the slip, change in lumbar lordosis, and instability and degenerative changes one level above and one level below the fusion. In most of the ten patients, radiographic evaluation demonstrated solid fusion, minimal degenerative changes, and preservation of lumbar lordosis and spinal mobility. Posterolateral lumbar fusion for degenerative spondylolisthesis in the lumbar spine seems promising for obtaining not only good radiographic features but also good clinical results lasting over more than 10 years.

Severe central fracture-dislocation of the hip migrated deep into the pelvis complicating ileal rupture and ipsilateral comminuted femoral fracture: CT characteristics

A case of severe central fracture-dislocation of the hip migrated deep into the pelvis complicating ileal rupture and ipsilateral comminuted fracture of the proximal femur was described. Plain CT images of the pelvis were distinctive and quite useful for evaluating the severity of the injury. Osteomyelitis of the proximal femur occurred soon after resection of the femoral head and suturing of the peritoneum though laparotomy. Complete closure of the peritoneal laceration and rapid totally diverting colostomy would be recommendable in order to avoid infectious complications in such a severe central fracture-dislocation of the hip.

Successful en bloc resection of a large superficial gastric cancer by using sodium hyaluronate and electrocautery incision forceps

BACKGROUND

The advisability of endoscopic mucosal resection (EMR) for treatment of large superficial gastric cancers has been challenged. For more reliable en bloc resection, a new method of EMR was developed that uses a viscous substance, sodium hyaluronate, and two newly designed devices.

METHODS

A large superficial gastric cancer was treated with this new EMR technique. Sodium hyaluronate was injected into the submucosa and mucosal incisions were made with a needle-knife. The newly developed incision forceps and flat-ended transparent hood were used for submucosal incisions.

RESULTS

The large cancer was successfully resected endoscopically as a single piece of mucosa 6 cm in diameter without complication. Histopathologic evaluation of the specimen confirmed that the resection was curative.

CONCLUSIONS

EMR with sodium hyaluronate along with two new devices may be a reliable method for en bloc resection of large superficial gastric lesions.

Utility and limitations of intraductal ultrasonography in distinguishing longitudinal cancer extension along the bile duct from inflammatory wall thickening

BACKGROUND

We wanted to distinguish wall thickening caused by cancer extension from that caused by inflammation after placing a biliary catheter on intraductal ultrasonography (IDUS).

METHODS

We studied 51 patients with biliary tract malignancies who had undergone placement of biliary drainage catheters before IDUS. IDUS was performed from a transhepatic (n = 34) or transpapillary (n = 17) route with a thin-caliber ultrasonic probe (2.0 mm in diameter, 20-MHz frequency). At the hepatic side of the tumor, the thickness, asymmetry, outer margin, inner margin, and internal echoes of the bile duct wall were reviewed prospectively and correlated with the histologic findings of the surgically resected specimens in all cases.

RESULTS

When IDUS showed wall thickening in a semicircular fashion, notched outer margin, rigid inner margin, papillary inner margin, and heterogeneous internal echoes, each finding had a positive predictive value for diagnosing cancer extension (100%, 100%, 83%, 100%, and 90%, respectively). When these factors were used as the diagnostic criteria of cancer extension, IDUS accurately demonstrated suitable surgical margins in 76% of all patients and 71% of patients with bile duct carcinoma.

CONCLUSION

Wall thickening in a semicircular fashion, notched outer margin, rigid or papillary inner margin, and heterogeneous internal echoes are specific for cancer extension. However, surgical margins can be inaccurately assessed in some patients.

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.

Intraductal ultrasonography for hepatocellular carcinoma with tumor thrombi in the bile duct: comparison with polypoid cholangiocarcinoma

BACKGROUND AND AIM

Tumor thrombi in the bile duct caused by hepatocellular carcinoma (HCC), and cholangiocarcinoma show polypoid lesions on cholangiographic findings. This study prospectively compared the images of intraductal ultrasonography between HCC and polypoid cholangiocarcinoma.

METHODS

In five patients with tumor thrombi in the bile duct caused by HCC, a 2.0 mm diameter ultrasonic probe with a frequency of 20 MHz was inserted into the bile duct via the transpapillary route (n = 4) or the transhepatic route (n = 1). The images were compared to that of 65 patients with cholangiocarcinoma.

RESULTS

In all patients with HCC, intraductal ultrasonography showed a 'polypoid tumor with a narrow base'. In 16 of 65 patients with cholangiocarcinoma, it showed a 'polypoid tumor with a narrow base'. When intraductal ultrasonography showed a 'polypoid tumor with a narrow base', the findings of a positive 'nodule within a nodule' (40 vs 0%; P < 0.05), and the absence of a 'papillary-surface pattern' (80 vs 13%; P < 0.05) were more highly associated with tumor thrombi caused by HCC than to polypoid-type cholangiocarcinoma.

CONCLUSIONS

Intraductal ultrasonography was useful to distinguish between tumor thrombi caused by HCC and polypoid-type cholangiocarcinoma.

Looping technique for transpapillary selective biopsy of the left hepatic duct

PURPOSE

Because biopsy forceps tend to turn towards the right hepatic duct during endoscopic retrograde cholangiopancreatography (ERCP), selective access to the left hepatic duct is difficult.

METHODS

In this study, we managed to insert biopsy forceps selectively into the left hepatic duct, by using a looping technique, in three patients. Biopsy forceps were inserted into the right hepatic duct by the conventional method. The elevator of the endoscope was kept down, and the shaft of the biopsy forceps was then advanced to the duodenal cavity until it formed a loop between the endoscope and the papilla. During the procedure, the tip of the forceps was kept at the hepatic hilus.

RESULTS

In this condition, we were able to slowly rotate the tip of the forceps and direct the forceps towards the left. Sufficient material from the left hepatic duct was obtained in all patients.

CONCLUSIONS

The looping technique was useful for selective access to the left hepatic duct.

Use of an autologous cortical bone graft sandwiched between two intervertebral spacers in posterior lumbar interbody fusion

Various intervertebral spacers with or without posterior instrumentation use pedicle screw fixation in posterior lumbar interbody fusion (PLIF). Recently we harvested an autologous cortical bone graft from a spinous process by en bloc resection and inserted it between two intervertebral spacers during PLIF surgery. Due to better balance, this procedure provides greater mechanical strength, larger contact area, and better bilateral restoration of disc height than PLIF using intervertebral spacers only, and there is no need to take a bone graft from the iliac crest. This technique appears to result in effective spinal fusion in PLIF surgery.

Acyclic neutral carrier-based polymer membrane electrode for a stimulant, phentermine

Groups of dioxadicarboxylic diamides, which were developed as potential ionophores for inorganic cations, were found to act as ionophores for a stimulant, phentermine. Especially, N,N-dioctadecyl-N',N'-dipropyl-3,6-dioxaoctanediamide, which was originally developed as a lead ionophore and is commercially available from Fluka as lead ionophore I, was suitable for making a phentermine-selective electrode. The electrode constructed using this ionophore and bis(2-ethylhexyl) sebacate as a solvent mediator in a poly(vinyl chloride) membrane matrix discriminated between phentermine and analogous compounds more effectively than an electrode based on dibenzo-18-crown-6, a representative ionophore for organic ammonium ions. Moreover, the present electrode showed remarkably little interference by inorganic cations, such as Na+ and K+, as well as lipophilic quaternary ammonium ions including (C2H5)4N+ and (C3H7)4N+. The electrode exhibited a near-Nernstian response to phentermine in the concentration range of 2 x 10(-6) to 1 x 10(-2) M with a slope of 54.8 mV per concentration decade in 0.1 M MgCl2. The lower limit of detection was 7 x 10(-7) M. This electrode was applied to determine phentermine in a cationic-exchange resin complex of this stimulant, which is the general dosage form in medical use.

Fibrous adhesive entrapment of lumbosacral nerve roots as a cause of sciatica

STUDY DESIGN

Report of seven patients with fibrous adhesive entrapment of lumbosacral nerve roots as a cause of sciatica, whose radiographic findings were negative and who experienced relief from sciatica immediately after the entrapment was released.

OBJECTIVES

To describe a new clinical entity of fibrous adhesive entrapment of lumbosacral nerve roots with negative radiographic findings.

SETTING

Orthopaedic department, Japan.

METHODS

Clinical evaluation and post-operative outcome in seven patients with entrapment of lumbosacral nerve roots because of fibrous adhesion confirmed intraoperatively.

RESULTS

Radiographic examinations by magnetic resonance imaging (MRI), myelography, and computed tomographic (CT) myelography demonstrated neither disc herniations nor spinal stenosis in all seven patients, and differential nerve root block was effective for relieving sciatica and low back pain. We confirmed, intraoperatively, entrapment of the nerve root by fibrous adhesion, and all seven patients were relieved from sciatica and low back pain postoperatively.

CONCLUSION

This study presented seven patients with sciatica caused by fibrous adhesive entrapment of lumbosacral nerve roots who underwent decompression and release of fibrous adhesion. Radiographic examinations, such as MRI, myelography and CT myelography, showed no compressive shadows and also differential nerve root block was effective for its diagnosis. This study seems to be the first report of patients with entrapment of lumbosacral nerve roots caused by fibrous adhesion, whose radiographic findings were negative.

Epinephrine irrigation for the prevention of pancreatic damage after endoscopic balloon sphincteroplasty

BACKGROUND AND AIM

Endoscopic balloon sphincteroplasty (EBS) is an alternative to sphincterotomy for the treatment of bile duct stones. The purpose of this study was to determine if epinephrine irrigation of the papilla can prevent the pancreatic damage associated with EBS.

METHODS

A total of 173 patients with bile duct stones were treated by EBS. After conventional endoscopic retrograde cholangiography, EBS was performed by using a biliary dilatation catheter (balloon diameter: 8 mm). The duct was then cleared by using Dormia baskets or retrieval balloon catheters. Mechanical lithotripsy was performed before extraction when the stones were greater than 8 mm in diameter. In 81 patients, the dilated orifice was irrigated with 40-120 mL (50 +/- 37 mL) of 1:1,000,000 epinephrine (epinephrine group). In the remaining 92 patients, epinephrine irrigation was not performed (control group). Acute pancreatitis was defined by a serum amylase concentration fivefold greater than the upper limits of normal in association with abdominal pain.

RESULTS

After EBS, serum amylase concentrations were significantly increased in both groups. However, the degree of hyperamylasemia was less in the epinephrine group than in the control group (617 +/- 611 vs 1037 +/- 1491 IU/L, P < 0.05). The incidence of pancreatitis was lower in the epinephrine group than in the control group (1.2 vs 7.6%, P < 0.05).

CONCLUSIONS

Epinephrine irrigation is a simple and useful method to prevent post-EBS pancreatic damage and pancreatitis.

A new-type titanium intervertebral spacer and its insertion device used in posterior lumbar interbody fusion

We have recently developed a new-type trapezoid mesh cage (TPM cage) together with an insertion device, which for use as a new titanium mesh intervertebral spacer in posterior lumbar interbody fusion (PLIF). The TPM cage has sufficient mechanical strength, a large contact area that gives good long-term stability, and preserves the initial disc height to provide good balance. The insertion device for the TPM cage is useful not only for handling the implant but also for controlling the implant insertion direction. The TPM cage and its insertion device are promising for use in PLIF.

Reduction of blood loss using tranexamic acid in total knee and hip arthroplasties

There have been several attempts to reduce postoperative blood loss in patients undergoing total arthroplasty. Benoni et al. reported the usefulness of tranexamic acid in total knee arthroplasty (TKA). We investigated its effect in TKA and total hip arthroplasty (THA). Blood loss was significantly reduced in patients given tranexamic acid in both the TKA and THA groups, and no severe complications, such as venous or pulmonary thrombosis, were noted in any of the patients who received the agent. Administration of tranexamic acid seems to be useful for reducing postoperative blood loss in TKA and THA.

Multiple bile duct biopsies using a sheath with a side port: usefulness of intraductal sonography

OBJECTIVE

We clarified the number of biopsies required to determine malignancy of the biliary tract on the basis of the type of bile duct tumor.

SUBJECTS AND METHODS

Patients with a biliary tract malignancy (n = 33) and a benign biliary stenosis (n = 3) underwent biopsy via the percutaneous transhepatic route. We performed intraductal sonography using a 20-MHz probe with a 2.0-mm diameter. The sonographic findings were prospectively classified as polypoid, circular, or semicircular. The tip of a long 9-French sheath with a side port was wedged into the stenosis, and six specimens were obtained with a 1.8-mm-diameter forceps with serrated cups.

RESULTS

When cholangiography or intraductal sonography showed a polypoid lesion, the sensitivity of two biopsies was 100% (6/6). When cholangiography showed a stenotic lesion, the sensitivity of nine biopsies (96%, 26/27) was superior to that of two biopsies (74%, 20/27; p < 0.05). When intraductal sonography showed a circular lesion, the sensitivity of three biopsies (100%, 14/14) was superior to that of a single biopsy (64%, 9/14; p < 0.05). When it showed a semicircular lesion, the sensitivity of nine biopsies (92%, 12/13) was superior to that of two biopsies (54%, 7/13; p < 0.05).

CONCLUSION

Bile duct biopsy using a sheath with a side port has a high sensitivity. However, the number of biopsies required depends on the cholangioscopic and intraductal sonographic appearance of the tumor.

Transpapillary intraductal US prior to biliary drainage in the assessment of longitudinal spread of extrahepatic bile duct carcinoma

BACKGROUND

The utility of intraductal US via the transpapillary route prior to biliary drainage in the assessment of longitudinal extension of extrahepatic bile duct carcinoma was investigated.

METHODS

In 19 patients with extrahepatic bile duct carcinoma who underwent surgical resection, an ultrasonic probe (diameter, 2.0 mm; frequency, 20 MHz) was inserted into the bile duct via the transpapillary route prior to biliary drainage. Longitudinal cancer extension along the bile duct was prospectively determined and compared with the histologic findings in the resected specimens.

RESULTS

Results on the hepatic side were as follows: Intraductal US demonstrated more extensive longitudinal cancer spread than cholangiography in 9 of 19 patients with one instance of overdiagnosis. The accuracy of intraductal US in assessing the extent of spread (84%) was superior to that of cholangiography (47%) (p < 0.05). Results on the duodenal side were as follows: In patients with suprapancreatic bile duct cancer (n = 14), intraductal US demonstrated more extensive longitudinal cancer spread than cholangiography in 8 of 14 patients. The accuracy of intraductal US in assessing the extent of the spread (86%) was superior to that of cholangiography (43%) (p < 0.05).

CONCLUSIONS

Transpapillary intraductal US prior to biliary drainage is useful in demonstrating longitudinal extension of bile duct cancer. However, the surgical margins were inaccurate in some patients.

Intraductal ultrasonography for evaluating the patency of biliary metallic stents: correlation with cholangioscopic findings

BACKGROUND

This is the first study to correlate intraductal ultrasonography (IDUS) with cholangioscopy in evaluating the patency of biliary metallic stents.

METHODS

The findings of IDUS (probe 2.0 mm in diameter and 20-MHz frequency) through a percutaneous transhepatic (n = 24) or transpapillary (n = 2) approach were retrospectively reviewed without other information. Criteria for IDUS are as follows: type 1, the inside of the stent is free; type 2, the inner edge is smooth; type 3, the inner edge is irregular; type 4, the inside of the stent is totally occupied; type 5, the solid echo is connected to the outside mass; type 2+D, a hypoechoic line is seen between the bile duct wall and the inside solid component and the inner edge of the bile duct wall is smooth; type 3+D, an irregular hypoechoic line is seen between the bile duct wall and the inside solid component.

RESULTS

In the control group (n = 11), IDUS showed type 1 (n = 9) or type 2 (n = 2). In the occluded group (n = 15), when IDUS showed type 3 or 5, the patients (n = 5) required additional stents (n = 3), microwave coagulation of the tumor (n = 1), or transient external drainage (n = 1). When IDUS showed type 4 (n = 5), after washing, the findings changed to type 2+D (n = 4). When IDUS after washing showed a smooth inner edge (type 2+D), the patients were treated without additional stents more frequently than the other groups (eight of nine vs. two of six), a significant distinction (p < 0.05).

CONCLUSION

IDUS is useful in assessing the patency of metallic stents. When the inside of the stent is totally occupied, however, examination after washing is necessary.

Percutaneous recanalization of the bile duct along an endoscopic naso-biliary catheter

Percutaneous recanalization of the bile duct is essential for placing biliary stents and carrying out other interventions. This prospective study was performed to establish safe approaches for percutaneous recanalization of the bile duct when it had previously resulted in failure. Between July 1995 and July 1999, percutaneous recanalization of the bile duct was attempted in 58 patients with a malignant biliary stenosis. When recanalization failed, an endoscopic naso-biliary drainage (ENBD) catheter was placed across the stenosis. The procedure was again attempted along the ENBD catheter. In the period of the study, four patients underwent successful recanalization after ENBD, although attempts prior to ENBD had been unsuccessful. As a result, the success rate of recanalization in the period was 100% (58/58). When recanalization fails, the use of an ENBD catheter may provide access to the biliary tree, and the biliary stenosis can be recanalized safely.

Pitfalls in endoscope reprocessing: brushing of air and water channels is mandatory for high-level disinfection

BACKGROUND

Endoscopic transmission of pathogens has been reported. Guidelines have been formulated concerning the risk of infection via contaminated suction and accessory channels. Contamination of the other 2 channels for air and water has not been demonstrated. These channels were examined to clarify whether they require cleaning.

METHODS

Endoscopes used for examinations were divided into 2 groups. Group A endoscopes (n = 20) were brushed along the air and water channels. Group B endoscopes (n = 22) were not. After machine reprocessing, specimens were obtained for bacterial culture. The residual protein was measured in the 2 channels by using amido black 10B dye, and results were compared between the 2 groups.

RESULTS

With regard to the air channel, there were no contaminated endoscopes detected in either group. For the water channel, 1 endoscope in group B was positive whereas there were none positive in group A. With regard to quantification of residual protein, brushing diminished the level in both the air and the water channels.

CONCLUSION

The air and water channels can become contaminated. Brushing every channel is mandatory for high-level disinfection. A redesign of the fundamental structure of endoscopes is proposed.

Total enteroscopy with a nonsurgical steerable double-balloon method

BACKGROUND

Deep insertion of an enteroscope by use of a push technique is difficult. A new method of enteroscopy was developed, a double-balloon method, to improve the access to the small intestine.

METHODS

The new method uses 2 balloons, one attached to the tip of the endoscope and another at the distal end of an overtube. By using these balloons to grip the intestinal wall, the endoscope can be inserted further without forming redundant loops in the small intestine. This method was tried with a standard upper endoscope in 3 patients and with a longer enteroscope in 1 patient.

RESULTS

Despite its short length the upper endoscope was successfully inserted as far as 30 to 50 cm beyond the ligament of Treitz in the 3 patients. In the fourth patient the longer enteroscope was successfully inserted beyond the ileo-cecal valve.

CONCLUSIONS

The double-balloon method facilitates endoscopic access to the small intestine.

Comparison of intraductal ultrasonography with percutaneous transhepatic cholangioscopy for the identification of residual bile duct stones during lithotripsy

BACKGROUND

An imaging modality that can be used to identity small stones after a biliary lithotripsy is required. Intraductal ultrasonography was evaluated by using percutaneous transhepatic cholangioscopy as the gold standard.

METHODS

Lithotripsy, under percutaneous transhepatic cholangioscopy guidance, was performed in 20 patients. A thin-caliber ultrasonic probe (2.0 mm in diameter and 20 MHz frequency) was inserted into the bile duct through the percutaneous tract after lithotripsy, and residual stones were identified. This was followed by percutaneous transhepatic cholangioscopy.

RESULTS

In the extrahepatic bile ducts, intraductal ultrasonography provided images of all the stones demonstrated on cholangioscopy (n = 11). The sensitivity was superior to that of cholangiography (P < 0.005). However, in the intrahepatic bile ducts, intraductal ultrasonography only visualized the stones located in the cannulated lobe. Extrahepatic stones smaller than 5.0 mm in diameter or in a common hepatic duct larger than 15.0 mm in diameter were missed by cholangiography, but were visualized by the use of intraductal ultrasonography (P < 0.05).

CONCLUSIONS

Intraductal ultrasonography is equivalent to cholangioscopy in the extrahepatic bile ducts. Cholangiography and intraductal ultrasonography should be used in combination to image intrahepatic and extrahepatic stones.

Ropeway-type bile duct biopsy forceps with a side slit for a guidewire

BACKGROUND

Transpapillary procurement of bile duct biopsy specimens is an effective diagnostic technique in cases of biliary structure. The utility of new ropeway-type bile duct biopsy forceps with a side slit for a guidewire was investigated in this study.

METHODS

The 12 patients in this study had bile duct cancer (n = 3), cancer of the head of the pancreas (n = 4), gallbladder cancer (n = 1), and benign bile duct stenosis (n = 4). After endoscopic retrograde cholangiography, a guidewire was placed in the bile duct across the stenosis. The new forceps (1.8-mm diameter clamshell-type biopsy forceps without needle) was then introduced through the intact papilla along the guidewire.

RESULTS

In all patients, sufficient tissue for histopathologic evaluation was obtained without complication. In one patient, biopsy specimens were selectively obtained of the left hepatic duct, which was impossible with conventional forceps. In another patient, histologic examination of specimens obtained by using this new forceps showed adenocarcinoma, whereas specimens obtained with a conventional forceps did not contain adenocarcinoma. However, in another patient, biopsy specimens obtained with a conventional forceps contained adenocarcinoma that was not evident in specimens obtained with the new forceps. Dislodgement of the guidewire during procurement of biopsy specimens occurred in 1 patient. In the other 11 patients, an endoscopic biliary drain was inserted over the guidewire.

CONCLUSION

The new ropeway-type biopsy forceps is useful for selectively obtaining biopsy specimens of the bile duct. With this system, access for subsequent endoscopic biliary drainage is maintained.

Hyperechoic lines as a sonographic confirmatory sign during percutaneous transhepatic biliary drainage

BACKGROUND

In ultrasonically guided percutaneous transhepatic biliary drainage, we often can recognize hyperechoic lines at the tip of the needle when the duct is penetrated successfully. We evaluated the frequency of this phenomenon and analyzed whether it was a useful sign for confirming successful bile duct puncture.

METHODS

In 65 patients with biliary tract diseases, 84 catheters were placed in the course of 108 attempts at puncture. Results of puncture and the presence of hyperechoic lines were investigated prospectively.

RESULTS

When the ultrasonographic findings showed hyperechoic lines, successful puncture was significantly more frequent than when the findings did not show hyperechoic lines (53/55, 96%, vs. 31/59, 53%; p < 0.0001). When we judged the hyperechoic lines as the sign of successful puncture, the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 63%, 93%, 96%, 48%, and 71%, respectively.

CONCLUSION

Hyperechoic lines are a useful confirmatory sign of successful puncture. However, absence of these lines was not invariably associated with unsuccessful puncture.

Limitations of three-dimensional intraductal ultrasonography in the assessment of longitudinal spread of extrahepatic bile duct carcinoma

We investigated the utility and limitations of three-dimensional intraductal ultrasonography (3D-IDUS), for the assessment of the extent of longitudinal cancer spread to the hepatic side by extrahepatic bile duct carcinoma. In eight patients with extrahepatic bile duct carcinoma. 3D-IDUS was used to assess longitudinal cancer extension to the hepatic side prior to resection. When the linear dimension of 3D-IDUS showed bile duct wall thickening that was connected to the tumor and which became thin at a point, it was determined to be the front formation of longitudinal cancer extension. The findings were examined in relation to histologic information from the resected specimen. Although 3D-IDUS showed front formation of wall thickening in two patients, it accurately reflected the histological margin of the longitudinal cancer extension in only one patient. In the other patient, the wall thickening was longer than the histological margin. When 3D-IDUS showed bile duct wall thickening without front formation (n = 2), the wall thickening was longer than the histological margin of the longitudinal cancer extension. Even when 3D-IDUS did not show wall thickening (n = 4), one of these patients showed cancer spread histologically. As a result, the accuracy in assessing longitudinal cancer extension by 3D-IDUS was only 50%. Even if the linear dimension of 3D-IDUS demonstrated front formation of thickening of the bile duct, it reflected not only cancer extension but also inflammatory wall thickening.

Access for percutaneous transhepatic cholangioscopy in patients with nondilated bile ducts using nasobiliary catheter cholangiography and oblique fluoroscopy

BACKGROUND

Percutaneous transhepatic biliary drainage is required for percutaneous transhepatic cholangioscopy. However, puncture of nondilated bile ducts under ultrasonographic guidance is difficult.

METHODS

In 10 patients with no ultrasonographic evidence of intrahepatic bile duct dilatation, percutaneous transhepatic biliary drainage was performed under fluoroscopic guidance using cholangiography obtained via a nasobiliary drainage catheter. Direct puncture was performed by means of a left ventral approach using oblique C-arm fluoroscopy.

RESULTS

Bile duct puncture was successful in all patients. There were no procedure-related complications. Subsequent cholangioscopy was successful in all patients.

CONCLUSIONS

Direct puncture using nasobiliary drainage cholangiography and oblique fluoroscopy is a useful method when cholangioscopy is necessary in patients with nondilated bile ducts.