Endoscopic treatment of bile duct stones with benign choledochojejunal anastomotic stenosis

[BACKGROUND AND AIMS]: Endoscopic interventions for bile duct stones (BDS) with benign choledochojejunal anastomotic stenosis (bCJS) are challenging. Therefore, we investigated endoscopic interventions for BDS with bCJS. [METHODS]: Seventeen patients with BDS with bCJS were retrospectively analyzed. Patient characteristics, technical success, adverse events (AEs), and recurrence were evaluated. [RESULTS]: In 17 patients, the median diameters of the bile duct and BDS were both 8 mm. The median number of BDS was 3. The technical success rate was 94% (16/17). Ten patients underwent balloon dilation at the choledochojejunal anastomotic site (CAS), the median diameter of balloon dilation was 10.5 mm, and waist disappearance was achieved in 2. Six patients had fully covered self-expandable metal stents (FCSEMS) with a diameter of 10 mm placed at the CAS. BDS were removed after balloon dilation or FCSEMS removal, and 6 out of 16 patients were treated with a combination of lithotripsy and 5 with peroral direct cholangioscopy (PDCS). Regarding AEs, perforation at the CAS by balloon dilation occurred in 1 patient. The median follow-up was 3701 days. Nine out of 16 patients (56%) had recurrence. The patients treated with combination of PDCS at BDS removal (p=0.022) and waist disappearance at the CAS by balloon dilation (p=0.035) had significantly fewer recurrences. [CONCLUSIONS]: Endoscopic interventions for BDS with bCJS are useful and relatively safe; however, long-term follow-ups showed frequent recurrences. Recurrence was common in patients not treated with the combination of PDCS at BDS removal and those without waist disappearance at the CAS by balloon dilation.

Effects of adoptive T-cell immunotherapy on immune cell profiles and prognosis of patients with unresectable or recurrent cholangiocarcinoma

The identification of immune cell profiles (ICP) involved in anti-tumor immunity is crucial for immunotherapy. Therefore, we herein investigated cholangiocarcinoma patients (CCA) who received adoptive T-cell immunotherapy (ATI). Eighteen unresectable or recurrent CCA received ATI of αβ T cells alone or combined with chemotherapy. ICP were evaluated by flow cytometry. There were 14 patients with intrahepatic cholangiocarcinoma (iCCA) and four with distal cholangiocarcinoma (dCCA). After one course of treatment, nine iCCA and four dCCA had progressive disease (PD), while five iCCA had stable disease (SD). Median overall survival (OS) was prolonged to 21.9 months. No significant differences were observed in OS between the PD and SD groups of iCCA. The frequency of helper T cells (HT) in iCCA decreased from 70.3% to 65.5% (P = .008), while that of killer T cells (KT) increased from 27.0% to 30.6% (P = .005). dCCA showed no significant changes of immune cells. OS was prolonged in iCCA with increased frequencies of CD3+ T cells (CD3) (P = .039) and αβ T cells (αβ) (P = .039). dCCA showed no immune cells associated with OS. The frequencies of CD3+ T cells and αβ T cells in the PD group for iCCA decreased from 63.5% to 53% (P = .038) and from 61.6% to 52.2% (P = .028), respectively. In the SD group, the frequency of HT decreased from 65.8% to 56.9% (P = .043), whereas that of KT increased from 30.1% to 38.3% (P = .043). In conclusions, ATI affected ICP and prolonged OS. Immune cells involved in treatment effects differed according to the site of cholangiocarcinoma.

Biliary stones or ulcers at the choledochojejunal anastomotic site involving the jejunal mucosa at stent removal may be recurrent factors in patients with benign choledochojejunal anastomotic stenosis undergoing endoscopic biliary stenting using fully-covered self-expandable metal stents

BACKGROUND

Temporary fully-covered self-expandable metal stent (FCSEMS) placement is performed for benign choledochojejunal anastomotic stenosis (bCJS). However, recurrence may develop after stricture resolution. We investigated endoscopic biliary stenting using FCSEMS for bCJS.

METHODS

Sixteen bCJS patients with FCSEMS placement were retrospectively analyzed. FCSEMS was removed endoscopically after 2 months. Technical success, stricture resolution, recurrence, and adverse events were evaluated.

RESULTS

The technical success rate for FCSEMS placement was 94% (15/16). Biliary stones were detected and extracted in 4 patients. FCSEMS removal was successfully performed on 14 patients, excluding 1 with stent migration. At FCSEMS removal, stricture resolution was noted in 14 patients; however, 4 had anastomotic ulcers. The median follow-up was 319 days. Three patients with a history of repeated plastic stent placement had no recurrence. Four out of 15 patients (27%) had recurrence, and three had no recurrence after additional interventions. Biliary stones before first FCSEMS placement (p=0.003) or anastomotic ulcers at FCSEMS removal (p=0.018) were associated with recurrence.

CONCLUSIONS

Although FCSEMS placement was useful for stricture resolution, recurrence was detected in patients with biliary stones before first FCSEMS placement or anastomotic ulcers at FCSEMS removal. Anastomotic ulcers are a risk factor for recurrence and only detected by endoscopy.

Relationship between midgut malrotation and anatomy of the hepatoduodenal ligament: a rare anatomical variation in a deceased donor

INTRODUCTION

Anatomical variations around the hepatoduodenal ligament greatly influence surgical procedures and the difficulty of operations. Here, we report the case of a deceased donor with midgut malrotation (MgM) and anatomical variation. We also present an anatomical comparison between MgM and normal cases.

CASE REPORT

The donor, a male in his 60s, was diagnosed with MgM based on preoperative computed tomography. Intraoperatively, the liver graft was harvested from the proper hepatic artery (PHA), but its length was too short for reconstruction. Therefore, the hepatic artery was reconstructed at both the left and right hepatic arteries.

METHODS

The length of the proper hepatic artery (l-PHA) and main trunk of the portal vein (l-PV) was compared between MgM and control groups (n = 9) using computed tomography. The ratio of PHA (r-PHA) and PV (r-PV), which was calculated as the l-PHA or l-PV divided by the patient's height, was also compared.

RESULTS

The r-PV was 1.3% in the MgM group and 1.6% in the control group (P = .09). The r-PHA was 0.23% in the MgM group and 0.92% in the control group (P < .01). Thus, the PHA was significantly shorter in the MgM group. Additionally, anatomical variations of the hepatic artery were confirmed in four cases.

CONCLUSION

Preoperative radiological evaluation is not always adequate for identifying anatomical abnormalities in deceased donors. MgM is a rare but important anomaly because of the possibility of associated anatomical variations of the hepatic artery.

A novel triple secured technique for pancreatic reconstruction following pancreaticoduodenectomy for a soft pancreas

BACKGROUND/AIMS

Soft pancreases are susceptible to developing pancreatic fistula following pancreaticoduodenectomy. To reduce the incidence of pancreatic fistula after pancreaticoduodenectomy in patients with a soft pancreas, we developed a triple secured technique. In this study, we describe the details of this technique and also report on the postoperative outcomes.

METHODOLOGY

The triple secured technique employed an ultrasonic dissector for pancreatic transection with skeletonizing and ligating of the small pancreatic branch ducts, duct-invagination or duct-to-mucosa anastomosis for main pancreatic duct management, and, finally, four large stitches between the pancreatic stump parenchyma and the jejunal seromuscular layer to prevent minor pancreatic leakage. A total of 28 consecutive patients with a soft pancreas who underwent pancreaticoduodenectomy using our technique were included in this study.

RESULTS

Postopetrative complications occurred in 16 patients. Grade B pancreatic fistula developed in 6 patients. However, no grade C pancreatic fistula occurred in this series. Neither any reoperation nor in-hospital mortality was observed in this series.

CONCLUSIONS

Our triple secured technique after pancreaticoduodenectomy was feasible and safe, with an acceptable rate of grade B pancreatic fistula and no grade C pancreatic fistula for patients with a soft pancreas.

Evaluation of eligibility criteria in living donor liver transplantation for hepatocellular carcinoma by α-SMA-positive cancer-associated fibroblasts

The eligibility criteria of liver transplantation (LT) for hepatocellular carcinoma (HCC) must clearly confirm the prognosis not only from pathological diagnosis but also from pre-operative imaging diagnosis. In the present study, we evaluated published eligibility criteria for LT based on both pre-operative imaging diagnosis and pathological diagnosis using living donor liver transplantation (LDLT) recipients at our hospital by α-smooth muscle actin (SMA)-positive cancer-associated fibroblasts (CAFs) in HCC. The Up-to-seven (Up-to-7), Asan and Tokyo criteria were evaluated, in both overall survival and HCC disease-free survival, to be statistically significantly beneficial criteria to define post-LDLT prognosis. Recipients only within Up-to-7 criteria based on both pre-operative imaging diagnosis and pathological diagnosis survived without HCC recurrence. Recipients with proliferation of α-SMA-positive CAFs in HCC had significantly poorer prognosis. All survival recipients without HCC recurrence, who were above the Up-to-7 criteria in pathological diagnosis, had no proliferation of α-SMA-positive CAFs. As a result of multivariate analysis, the significant independent factors defining prognosis of recipients after LDLT for HCC were Up-to-7 criteria and proliferation of α-SMA-positive CAFs. The ideal eligibility criteria for LDLT with HCC is Up-to-7 criteria and α-SMA-positive CAFs was considered to be an important factor in HCC recurrence. LDLT should be limited to recipients within Up-to-7 criteria or without proliferation of α-SMA-positive CAFs.

Duodenal adenocarcinoma with neuroendocrine features in a patient with acromegaly and thyroid papillary adenocarcinoma: a unique combination of endocrine neoplasia

A 67-year-old woman with familial clustering of thyroid papillary adenocarcinoma was diagnosed with acromegaly due to pituitary macroadenoma. She had multiple skin vegetations, but had no parathyroid and pancreas diseases. Before transsphenoidal surgery, she was further diagnosed as having a duodenal tumor and multiple hypervascular liver nodules. Biopsy specimens from the duodenal tumor and liver nodules were diagnosed histologically as moderately differentiated adenocarcinoma. Immunohistochemically, the tumor cells were positive for chromogranin, synaptophysin and somatostatin receptor 2a, suggestive for neuroendocrine features. After surgery, the patient was not in biochemical remission, and octreotide treatment was initiated. The duodenal cancer was treated with chemotherapy (neoadjuvant cisplatin and S-1). After 24 months, the patient's insulin-like growth factor I level had been normalized, and her liver tumors had not progressed macroscopically. This is a rare case of acromegaly associated with multiple endocrine tumors, not being categorized as conventional multiple endocrine neoplasia. Octreotide treatment might have had beneficial effects on our patient's duodenal adenocarcinoma and liver metastases, both directly via SSTR2a and indirectly via GH suppression, thereby contributing to their slow progression.

Prevention of intrahepatic metastasis of liver cancer by suicide gene therapy and chemokine ligand 2/monocyte chemoattractant protein-1 delivery in mice

BACKGROUND

The prognosis of patients with hepatocellular carcinoma (HCC) remains poor, largely as a result of intrahepatic metastasis. Using a mouse model of intrahepatic metastasis, we investigated whether chemokine ligand 2/monocyte chemoattractant protein-1 (CCL2/MCP-1) could potentiate the antitumor effects of the herpes simplex virus thymidine kinase/ganciclovir (HSV-tk/GCV) system.

METHODS

Mouse hepatoma cells infected with recombinant adenovirus vectors expressing HSV-tk, CCL2/MCP-1 and LacZ at multiplicities of infection of Ad-tk/Ad-MCP1 = 3/0.03 (T/M(Low)), 3/3 (T/M(High)) and Ad-tk/Ad-LacZ = 3/3 (T/L) were injected into BALB/c mice.

RESULTS

Intrahepatic tumor growth was significantly lower in T/M(Low) mice. By contrast, no tumor suppression was observed in T/M(High) mice. The tumor-specific cytolytic activities of splenocytes from T/M(Low) and T/M(High) mice were comparable. Immunohistochemical analysis of liver tissues showed similar infiltration by Mac-1(+) and T cells in these animals, whereas the proportions of classical activated (M1) monocytes/macrophages were significantly higher in T/M(Low) mice. In addition, interleukin-12 production was elevated in these tissues. Vascular endothelial growth factor-A expression and CD31(+) microvessels were increased in T/M(High) mice.

CONCLUSIONS

Collectively, these results demonstrate that an adequate amount of CCL2/MCP-1, together with the HSV-tk/GCV system, may induce T helper 1-polarized antitumor effects without inducing tumor angiogenesis in the microenvironment of intrahepatic HCC progression.

Frequency of CD45RO+ subset in CD4+CD25(high) regulatory T cells associated with progression of hepatocellular carcinoma

The purpose of this study was to assess the properties of CD4+CD25(high/low/negative) T cell subsets and analyze their relation with dendritic cells (DCs) in patients with hepatocellular carcinoma (HCC). In HCC patients, the prevalence of CD45RO+ cells in CD4+CD25(high) T cells was increased and associated with higher frequencies of plasmacytoid DCs. Larger proportions of this T cell subset were detected in the patients with larger tumor burdens. These results suggest that increased frequencies of the CD45RO+ subset in CD4+CD25(high) Tregs in HCC patients may establish the immunosuppressive environment cooperatively with tolerogenic plasmacytoid DCs to promote disease progression of liver cancer.

Prolonged recurrence-free survival following OK432-stimulated dendritic cell transfer into hepatocellular carcinoma during transarterial embolization

Despite curative locoregional treatments for hepatocellular carcinoma (HCC), tumour recurrence rates remain high. The current study was designed to assess the safety and bioactivity of infusion of dendritic cells (DCs) stimulated with OK432, a streptococcus-derived anti-cancer immunotherapeutic agent, into tumour tissues following transcatheter hepatic arterial embolization (TAE) treatment in patients with HCC. DCs were derived from peripheral blood monocytes of patients with hepatitis C virus-related cirrhosis and HCC in the presence of interleukin (IL)-4 and granulocyte-macrophage colony-stimulating factor and stimulated with 0·1 KE/ml OK432 for 2 days. Thirteen patients were administered with 5 × 10⁶ of DCs through arterial catheter during the procedures of TAE treatment on day 7. The immunomodulatory effects and clinical responses were evaluated in comparison with a group of 22 historical controls treated with TAE but without DC transfer. OK432 stimulation of immature DCs promoted their maturation towards cells with activated phenotypes, high expression of a homing receptor, fairly well-preserved phagocytic capacity, greatly enhanced cytokine production and effective tumoricidal activity. Administration of OK432-stimulated DCs to patients was found to be feasible and safe. Kaplan-Meier analysis revealed prolonged recurrence-free survival of patients treated in this manner compared with the historical controls (P = 0·046, log-rank test). The bioactivity of the transferred DCs was reflected in higher serum concentrations of the cytokines IL-9, IL-15 and tumour necrosis factor-α and the chemokines CCL4 and CCL11. Collectively, this study suggests that a DC-based, active immunotherapeutic strategy in combination with locoregional treatments exerts beneficial anti-tumour effects against liver cancer.

Tumor cell apoptosis induces tumor-specific immunity in a CC chemokine receptor 1- and 5-dependent manner in mice

The first step in the generation of tumor immunity is the migration of dendritic cells (DCs) to the apoptotic tumor, which is presumed to be mediated by various chemokines. To clarify the roles of chemokines, we induced apoptosis using suicide gene therapy and investigated the immune responses following tumor apoptosis. We injected mice with a murine hepatoma cell line, BNL 1ME A.7R.1 (BNL), transfected with HSV-thymidine kinase (tk) gene and then treated the animals with ganciclovir (GCV). GCV treatment induced massive tumor cell apoptosis accompanied with intratumoral DC infiltration. Tumor-infiltrating DCs expressed chemokine receptors CCR1 and CCR5, and T cells and macrophages expressed CCL3, a ligand for CCR1 and CCR5. Moreover, tumor apoptosis increased the numbers of DCs migrating into the draining lymph nodes and eventually generated a specific cytotoxic cell population against BNL cells. Although GCV completely eradicated HSV-tk-transfected BNL cells in CCR1-, CCR5-, or CCL3-deficient mice, intratumoral and intranodal DC infiltration and the subsequent cytotoxicity generation were attenuated in these mice. When parental cells were injected again after complete eradication of primary tumors by GCV treatment, the wild-type mice completely rejected the rechallenged cells, but the deficient mice exhibited impairment in rejection. Thus, we provide definitive evidence indicating that CCR1 and CCR5 and their ligand CCL3 play a crucial role in the regulation of intratumoral DC accumulation and the subsequent establishment of tumor immunity following induction of tumor apoptosis by suicide genes.

[Unresectable pancreatic cancer in the Hokuriku area]

To clarify the diagnosis and treatment for unresectable pancreatic cancer from April 2001 when gemcitabine was released, we conduct a retrospective survey in the Hokuriku area. We analyzed clinical data of 254 patients. Seventy-two percent of the patients was treated by any method, and 90.7% of those were treated with a protocol including gemcitabine. Gemcitabine was administered a standard protocol (1000 mg/m(2) for 3 consecutive weeks with one week rest) in 62.2% patients, and dose of gemcitabine was reduced or schedule was changed in others. The median survival time was 8.2 months in the therapy group, and were is no differences between gemcitabine monotherapy, multi-drug therapy including gemcitabine and radiation combining gemcitabine in survival time. Multivariable analysis clarify patient's age, performance status, ascites, pleural effusion, and any therapy were prognostic factors. This investigation revealed chemotherapy for unresectable pancreatic cancer with gemcitabine have been spread around the Hokuriku area, in addition various ways have been tried.

Augmentation of tissue ATP level during digestion using preoxygenated perfluorocarbon results in high islet yield-new strategy for islet isolation

BACKGROUND

Recently, preservation using oxygenated perfluorocarbon (the two-layer method) has shown beneficial effects on islet yield and viability. In this paper, we apply this concept on isolation processes to examine the effectiveness of oxygenation.

METHODS

Rat pancreata were digested using four different methods: (groups 1A, 1B, 2A, and 2B) with or without oxygenated perfluorocarbon in groups 1 and 2, respectively. Adenosine was added into the collagenase solution in subgroup A whereas it is not added in subgroup B.

RESULTS

Tissue oxygen tension in group 1 was about 0 during digestion; whereas it rapidly reached about 300 mm Hg and was maintained in group 2. Tissue ATP level just after laparotomy (control) was 4.2 +/- 0.7 micromol/g dry weight. The ATP levels after digestion were 0.12 +/- 0.03 in group 1A (P < 0.01 vs control); 0.70 +/- 0.10 in group 1B (P < 0.01 vs control); 0.30 +/- 0.18 in group 2A (P < 0.01 vs control); and 2.90 +/- 0.80 in group 2B (P = 0.19 vs control). Islet yields (IEQ/pancreas) were 1600 +/- 400 in group 1B; 1400 +/- 400 in group 1B; 1300 +/- 400 in group 2A; and 2400 +/- 100 in group 2B. The amount in group 2B was significantly greater than that in the other three groups.

CONCLUSIONS

Oxygen provision by preoxygenated perfluorocarbon itself showed no beneficial effect on islet yield. However, if oxygen provision was associated with adenosine administration into the pancreas, tissue ATP levels after digestion were well maintained, and a greater number of islets were retrieved.

Successful Islet Transplantation From a Single Pancreas Harvested From a Young, Low-BMI, Non–Heart-Beating Cadaver

BACKGROUND

Young donors, donors with low body mass index (BMI), and non-heart-beating (NHB) donors are considered nonideal for islet transplantation. In this report, we successfully used a pancreas from a young, low-BMI, NHB donor for islet transplantation.

METHODS

The donor was a 15-year-old adolescent boy whose cause of death was rupture of a primary brain tumor. According to Japanese regulations, his pancreas was procured after cardiac arrest. Warm ischemic time was 3 minutes and cold ischemic time was 300 minutes. The pancreas was digested by the automated method of Ricordi, followed by purification using continuous Euro-Ficoll gradients on a Cobe 2991 device. The recipient was a 35-year-old woman with unstable type 1 diabetes mellitus. Her pretransplant C-peptide level was null. She suffered frequent hypoglycemic unawareness. Her pretransplant M value, which is a good marker for glucose instability, was 125. Islet yield was 252,816 IEQ. There were no signs of contamination. Viability of islets assessed by FDA/PI staining was 83%. Stimulation index was 2.7.

RESULTS

The patient received 5160 IEQ/kg of islets via the portal vein under local anesthesia. There were no transplant-related complications. Although she required minimal exogenous insulin, her C-peptide level increased to 0.7 ng/mL at postoperative day (POD) 14. Her M value at POD 15 to 19 decreased dramatically to 23.6, indicating good glycemic control. At 3 months posttransplant, episodes of hypoglycemia disappeared.

CONCLUSIONS

Although an additional transplant is mandatory to wean patients from insulin, this case shows the possibility of using marginal donors, such as a young, low-BMI, NHB donor, for pancreas islet transplantation.

Effect of Relative Humidity on the Photocatalytic Activity of Titanium Dioxide and Photostability of Famotidine

Titanium dioxide (TiO2) has been widely used as a pharmaceutical excipient and is also known to be a strong photocatalyst. An investigation into the relationship between the photocatalytic activity of TiO2 and the photostability of famotidine, which is known as an H2-blocker, is presented. The photocatalytic activity of the anatase form of TiO2, as measured by the four-probe method, is approximately 1.5 times higher than that of the rutile form. Discoloration of famotidine in a binary system containing TiO2 depends significantly on both the wavelength of the irradiating light and the crystal form of the TiO2, with the degree of discoloration of anatase higher than that of the rutile form. Discoloration of famotidine also depends on relative humidity. The relationship between discoloration rate constant and water vapor pressure is linear. These results demonstrate that famotidine is easily discolored by the photocatalytic activity of TiO2 and suggest that the solid-state photocatalytic activity of TiO2 is strongly affected by relative humidity.

Protection against experimental small intestinal ischaemia-reperfusion injury with oxygenated perfluorochemical

BACKGROUND

Intestinal ischaemia-reperfusion (IR) injury frequently occurs in abdominal surgery. Perfluorochemical (PFC) can be used to oxygenate intestinal organs directly and allows adenosine 5'-triphosphate (ATP) production within the submerged organs during ischaemia. This study was designed to evaluate the protective effect of PFC in IR injury, focusing on cytokine production in rat small intestine.

METHODS

The superior mesenteric artery was occluded in rats for 60 min and the small bowel placed in an intestinal bag containing either normal saline (group 1), oxygenated saline (group 2) or oxygenated PFC (group 3). The arterial clip was subsequently removed, allowing reperfusion. The number of rats that survived for 7 days, tissue ATP levels, biochemical variables, tissue lipid peroxidation (LPO), bacterial cultures and histological changes were examined after reperfusion.

RESULTS

The use of oxygenated PFC in group 3 improved survival compared with the other groups. Serum creatine phosphokinase and lactate dehydrogenase levels in groups 1 and 2 reflected small intestinal damage, and plasma levels of tumour necrosis factor alpha and interleukin 6 were raised. In contrast, oxygenated PFC decreased these levels, and reduced LPO, bacterial translocation and augmented apoptosis of the small intestine after reperfusion.

CONCLUSION

An intestinal bag containing oxygenated PFC showed protective effects during bowel ischaemia.

Intestinal obstruction in autosomal dominant polycystic kidney disease

A 42-year-old woman with autosomal dominant polycystic kidney disease (ADPKD) was admitted to our hospital on April 29, 1999, with complaints of abdominal pain. A diagnosis of intestinal obstruction was reached on the basis of clinical findings and X-ray evidence. A computed tomography scan of the abdomen showed massively enlarged kidneys, especially the right kidney, which seemed to compress the small intestine. The patient underwent percutaneous aspiration of the largest cysts on the surface of the right kidney. The symptoms, in this rare case of intestinal obstruction by an enlarged kidney in ADPKD, were alleviated the day after the aspiration procedure.

[Efficacy of the urine antibody test for detection of Helicobacter pylori: comparison with serum antibody tests]

A urine-based enzyme-linked immunosorbent assay kit (URINELISA) for detection of the antibody for H. pylori has recently been developed. We evaluated the diagnostic capability of the URINELISA test in comparison with two serum IgG antibody kits (HM-CAP and Helico G) for H. pylori infection. The subjects of this study were 173 patients. H. pylori was detected by means of culture, immunohistochemical staining and rapid urease test of endoscopically obtained biopsy specimens. A positive diagnosis of H. pylori was when at least one of three tests was positive and a negative diagnosis when all three were diagnosed as H. pylori positive and 23 as negative. We also examined the diagnostic potential of the antibodies in urine and in serum by using the results of the bioptic methods as the gold standard. The sensitivity of both URINELISA and HM-CAP was 93.3% and that of Helico G 94.7%, while their respective specificities were 47.8%, 65.2% and 52.2%. The URINELISA kit thus showed high sensitivity but relatively low specificity. The latter was due to sampling errors in the bioptic procedure because the subjects of this study included many elderly patients with atrophic gastritis. The level of the antibody in urine decreased markedly after 2 months of eradication therapy. We conclude that the URINELISA kit is as effective as serum antibody kits for the diagnosis of H. pylori infection.

[Percutaneous endoscopic gastrostomy (PEG) for the management of dysphagia: experiences in the neurosurgical care unit]

This report concerns percutaneous endoscopic gastrostomy (PEG) administered in the neurosurgical care unit to a patient with dysphasia. This reliable nutrition route has the major advantage of minimal surgical invasion and can be expected to become a standard nutritional method. Since patients with neurological disorders account for the majority of those who need PEG, neurosurgeons need to be aware of the importance of PEG.

[Clinical effect on tumor regression and tissue concentration of peplomycin treated with peplomycin emulsion in hydroxypropylcellulosum]

Peplomycin emulsified in hydroxypropyl cellulosum (HPC-PEP) was prepared for intravesical chemotherapy. Clinical efficacy of HPC-PEP and tissue concentration of peplomycin (PEP) were studied in 12 patients with bladder tumor. Histopathology showed transitional cell carcinoma; 2 in grade 1,8 in grade 2, and 2 in grade 3. The total volume of 30 ml HPC-PEP was prepared from a mixture of 2% HPC and 90 mg PEP in 15 ml saline, and was intravesically administered through a urethral catheter and retained for two hours. Clinical evaluation 7 days after the initial instillation demonstrated good tumor regression in 2, good response in 5, and no change in 5. The mean PEP level in tumor tissue was 0.36 microgram/gr after 7 days and 0.19 microgram/gr even after 14 days. These clinical observations and tissue levels of PEP suggest that HPC-PEP might be useful as an intravesical instillation agent for bladder tumor.

[Studies of enzymuria and proteinuria: Report 2; Relationship between glomerular filtration rate and urinary enzymuria and proteinuria]

Urinary splitting enzymes and proteins including N-acetyl-b-D-glucosanimidase (NAG), beta 2 microglobulin (beta 2MG), and alpha 1 microglobulin: (alpha 1MG), which are established to be useful in the evaluation of renal dysfunction, especially renal tubular impairment, were measured to determine the extent of renal tubular impairment in relation to the degree of glomerular dysfunction in patients with renal deterioration. In healthy volunteers, urinary NAG, alpha 1MG and beta 2MG levels were 3.5 +/- 1.4 (mean +/- SD) U/g creatinine, 2.5 +/- 2.0 mg/l and 88 +/- 75 micrograms/l, respectively. While serum beta 2MG level (SBMG; microgram/ml) was between 2.0 and 2.9, among the patients with renal dysfunction, NAG, alpha 1MG and BMG levels showed 8.6 +/- 5.5, 9.8 +/- 5.8 and 785 +/- 1,264, respectively, and further elevated to 10.1 +/- 5.0, 16.5 +/- 0.7 and 525 +/- 440, respectively with a SBMG level over 3.0. Thus glomerular function was deteriorated, urinary alpha 1MG level elevated to significantly higher with a parallel to renal dysfunction. In patients with more severe renal dysfunction, the corresponding urinary NAG and alpha 1MG levels became significantly higher. However, urinary beta 2MG level was significantly higher in patients with moderate renal dysfunction compared to healthy volunteers only when SBMG level was more than 2.0. Therefore, it was more valuable to measure urinary alpha 1MG with NAG or beta 2MG at SBMG level of less than 1.9 and to determine urinary NAG and alpha 1MG at greater than 2.0. These results indicated that the measurement of the levels of urinary splitting enzymes and proteins is valuable in the evaluation of proximal tubular impairment, even when the degree of glomerular impairment is minimal.(ABSTRACT TRUNCATED AT 250 WORDS)

[Study on urinary splitting enzymes and proteins. III. Effect of non-ionic contrast medium on renal function]

Renal toxicity of non-ionic contrast medium (iohexol) for drip infused pyelography (DIP) was studied in a randomized trial of nine patients with normal renal function. Urine samples were collected before and immediately after DIP, and analyzed for albumin, an index of glomerular permeability; gamma-glutamyl transpeptidase (gamma-GTP), a brush-border enzyme; N-acetyl-beta-glucosaminidase (NAG), a lysosomal enzyme; alpha 1 microglobulin (alpha 1MG) and beta 2 microglobulin (beta 2MG), an index to tubular proteinuria; and creatinine. The urinary excretion of enzymes and proteins was compared with urinary creatinine. Urinary excretion of gamma-GTP and NAG increased significantly (P less than 0.001, 0.02) after DIP. Urinary alpha 1 MG and beta 2-MG did not change significantly. The change of urinary albumin was mild. Our data suggest that non-ionic, low osmolal radiocontrast medium ioheol shows a lower renal tubular toxicity, and the brush-border enzyme gamma-GTP and lysosomal enzyme NAG are considered as a good index for renal tubular damage.

[Evaluation of transrectal longitudinal ultrasonography of chronic non-bacterial prostatitis]

Transrectal longitudinal ultrasonography was performed in 34 patients with chronic non-bacterial prostatitis. Prostatic stones and cystic lesions were associated with chronic non-bacterial prostatitis in 67.6% and 11.8%, respectively. The annual relapse rates of clinical symptoms were related to the presence of prostatic stones and cystic lesions. Transrectal ultrasonography plays a very important role in predicting the clinical courses of chronic non-bacterial prostatitis.

[Effect of metoprolol in patients with renal hypertension]

Eighteen patients with renal hypertension were treated with metoprolol (Seloken) for more than 3 months. Compared with the pretreatment value, the mean blood pressure decreased by 6.0, 11.2, 9.2 and 12.2 mmHg, after 2 weeks and 3, 6 and 12 months of treatment with metoprolol, respectively. All the differences observed were statistically significant (p less than 0.01). The blood pressure lowering effect of metoprolol was observed in 12 of the 17 patients (70.6%) examined. Decrease in plasma renin activity was seen in most of the responders. Although the number of patients was limited, the plasma level of metoprolol was also measured. The results indicated no sign of accumulation of metoprolol in the body. Moderate deterioration in renal function was observed in 1 patient but the treatment with metoprolol could be continued. Metoprolol administration had to be discontinued in 1 patient, who developed asthma. There were no other serious side effects.

[Clinical efficacy of flucytosine on urinary candidiasis]

An antifungal agent (Flucytosine) was used to treat urinary candidiasis in 9 patients who had an indwelling catheter and developed fungal colony counts greater than 10(4). Among 9 patients with catheter drainage, urologic underlying diseases were benign prostatic hyperplasia in 7 and a neurogenic bladder in one patient all of whom had accompanied diabetes mellitus. Only one patient was supravesically diverted from the upper urinary tract through an indwelling catheter of bilateral ureterocutaneostomy after the removal of a tumorous bladder. All patients had previously received antimicrobials. Isolated strains of Candida were Candida albicans in 6, Candida tropicalis in 2, and Candida parapsilosis in one patient. Out of 9 patients having received daily administration of 1,500 mg Flucytosine for 2 weeks, 7 patients subsequently had no yield of fungal colony after the treatment. Minimum inhibitory concentration (MIC) of this agent was determined at the range of 0.1 to 0.2 microgram/ml in 5 patients with C. albicans and 0.2 microgram/ml in both patients with C. tropicalis. Otherwise, a high MIC of over 100 micrograms/ml indicating resistance to this agent was observed in only 2 patients with C. albicans and C. parapsilosis. Three of the 7 patients had recurrent urinary Candida infection even 2 weeks after the discontinuation of this antifungal therapy despite rapid and excellent eradication of urinary candidiasis. From these results, Flucytosine may be one of the most promising antifungal agent with a low MIC in the treatment of compromised urinary Candida infection and should be occasionally supplemented with a topical instillation of amphotericin B without any serious complication in the prevention of recurrence.

[Clinical studies of varicocele. 3: A rare venous return via Santorini's plexus in a varicocele patient. Report of a case]

A 12-year-old man was referred to our clinic because of sanguineous discharge. At the out-patient department, bilateral varicocele was found. Urinalysis showed microscopic hematuria, but no other laboratory data were abnormal. Excretion urography was normal. The retrograde phlebograph showed a rare venous return via Santorini's plexus and lumbar veins. After varicocelectomy, urinalysis improved.

[Clinical studies of varicocele. 2: Radiographic examination and measurement of spermatic vein pressure in varicocele patients]

There are two types of internal spermatic veins (ISV) by radiographic examinations. In type 1, ISV is dilated with some collateral venous branches. On the other hand, ISV of type 2 is narrowed with increased collateral venous branches or abnormalities such as the circumaortic renal are seen. In these groups, pressure of renal vein and ISV were measured. As a result, renal vein pressure was about the same in type 1 as in the controls at 9.5 +/- 2.3 cmH2O but was higher in type 2 at 17.0 +/- 2.8 cmH2O. As for ISV, it was also about the same in type 2 as in the controls at 13.9 +/- 6.8 cmH2O but was markedly higher in type 2 at 33.3 +/- 3.9 cmH2O. When selective renal venography was performed, a contrast medium back-flow was seen in 9 out of 11 type 1 varicocele patients, but it was not seen in any of the cases with the nutcracker phenomenon. These results suggested that type 1 may be caused by the structural and functional disorders in the valve between the renal vein and ISV. In contrast, pathogenesis of type 2 varicocele may be due to an abnormality of the ISV in the embryo.

[Comparison of urinary and seminal N-acetyl-beta-glucosaminidase isoenzymes]

N-acetyl-beta-glucosaminidase (NAG) and its isoenzymes were measured in the urine and seminal plasma of healthy volunteers. Urinary NAG level was 2.62 +/- 1.30 U/L (mean +/- standard deviation), 1.99 +/- 0.77 U/g creatinine and seminal NAG level was 2370 +/- 1007 U/l. Urinary NAG level was 2.59 +/- 1.44 U/l, 1.93 +/- 0.80 U/g creatinine in males and 2.67 +/- 1.15 U/l, 2.08 +/- 0.78 U/g creatinine in females, and there was no significant sex difference. NAG isoenzymes in the urine and seminal plasma were divided into two major peaks, A and B. The A:B ratio was 78.0 +/- 6.5: 21.9 +/- 6.5 in the urine and 24.7 +/- 3.2: 75.2 +/- 3.2 in the seminal plasma, and was significantly different. Urinary NAG isoenzyme was 80.3 +/- 6.7: 19.6 +/- 6.7 in males and 74.1 +/- 4.3: 25.9 +/- 4.3 in females, and there was no significant difference between the sexes. These results indicated that urinary and seminal NAG can be differentiated by measuring the isoenzymes. Furthermore, the comparison of seminal NAG isoenzymes before and after vasectomy indicated that seminal NAG may be affected not only by the sperm but also by the prostatic fluid.

[Studies of enzymuria and proteinuria: Report 1: N-acetyl-beta-glucosaminidase in urological diseases]

N-Acetyl-beta-glucosaminidase (NAG) exists in renal tubules and seminal tract. We measured the NAG level in patients with urinary tract and seminal tract diseases and evaluated its clinical significance. The urinary NAG level was high in renal tubular function disorders such as glomerulonephritis, diabetic nephropathy and hydronephrosis. In these patients, NAG-isoenzyme studies indicated that the A-type isoenzyme decreased while the B-type isoenzyme increased. On the other hand, in the seminal tract disease patients, the urinary NAG level was high in benign prostatic hypertrophy with a catheter indwelling and in prostatitis. Urinary and seminal NAG-isoenzymes were measured in normal subjects. The isoenzyme patterns for urinary NAG and seminal NAG differed. The urinary NAG isoenzymes were measured in acute prostatitis patients, we found that the A-type isoenzyme decreased and the B type increased. In conclusion, when the A/B ratio of the NAG-isoenzyme is close to 24.9/75.0 in the urine, the presence of urological diseases in which seminal plasma could be mixed in, especially prostatic diseases, should be suspected.

[Clinicopathological examinations of sinus reactions of lymph nodes from tumor-bearing patients]

The sinus reaction of lymph nodes from tumor-bearing patients was classified into 5 categories, normal (N), sinus histiocytosis (SH), mixed sinus reaction (M), sinus catarrh (SC) and not classified (NC), according to the definition of Thoresen (1982). As a result, at the low stage, 93.8% were N and SH, while at the high stage, 97.0% were M, SC and NC. The same results were also obtained, when the transfer of the lymph nodes was taken into consideration. On the other hand, when the lymph nodes were studied from the distant lymph nodes area (DLA) and regional lymph node area (RLA) according to the position of the pathogen, SC was the most with DLA, since all cases were at the high stage. With RLA, SH was the most at 47.6% at the low stage, while at the high stage. SC and NC indicated 66.0%. Therefore, the sinus reaction can be used to estimate the degree of the response to the cancer and the diagnosis of tumor-bearing patients.

[Changes in N-acetyl-beta-glucosaminidase (NAG) in prostatitis patients]

NAG was measured before and after treatment and compared in 11 acute prostatitis patients, 13 chronic prostatitis patients and 10 healthy volunteers. Urinary NAG before treatment was 34.1 +/- 18.4 U/l in the acute prostatitis patients and was significantly higher than that in the healthy volunteers, which was 5.1 +/- 1.2 U/l. It was 8.5 +/- 3.2 U/l in the chronic prostatitis patients. Urinary NAG after treatment decreased and was 7.6 +/- 4.4 U/l and 6.7 +/- 1.7 U/l in the acute and chronic prostatitis groups, respectively. These results suggest that urinary NAG is useful in evaluating the changes in the condition of prostatitis and in diagnosing prostatitis, especially acute prostatitis.

[Renal papillary necrosis cured with endourological treatment]

We recently experienced a case of renal papillary necrosis which we removed by endourological treatment. A 58-year-old female diabetic patient complaining of left flank pain, fever and chills was admitted to our clinic. She had no past history of analgesic abuse or atypical vasculitis. Physical examination revealed a body temperature of 38 degrees C and tenderness in the left costovertebral angle. Pyuria was noted, and urine cultures grew more than 100,000 colonies of Escherichia coli per cubic millimeter. DIP revealed a diminished renal function, hydronephrosis, distorted middle and lower calyces and filling defect in the dilated ureter. However, there was no evidence of obstruction or ureteral reflux. Retrograde pyelography confirmed distortion and irregularity of the calyces and hydronephrosis due to a shadow defect which was movable during radiographic examinations. Laboratory studies revealed anemia, leucocytosis and hyperglycemia, but no elevation of BUN. Therefore, the patient was diagnosed as renal papillary necrosis. We succeeded in its endourological removal through nephrostomy with a choledochoscope (Olympus Co.) under epidural anesthesia. After surgery, the patient made a satisfactory recovery.

[Urinary tract infection : clinical significance of antibody-coated bacteria]

More attention should be directed to upper urinary tract infections as they cause renal parenchymal damage. Recently, many reports on antibody-coated bacteria (ACB) in urological diseases have been made. We performed ACB tests in 68 cases of urological infectious diseases. The tests were made according to Thomas' method. Anti-human immunoglobulin IgG, IgA, and IgM rabbit sera were used. The results were compared using the chi-square analysis. ACB-positive were 0 approximately 15% of the cases of acute cystitis, 33 approximately 67% of the cases of chronic cystitis, 30 approximately 60% of the cases of prostatitis and urethritis, and 60 approximately 90% of the cases of pyelonephritis. The percentage was higher in the patients who had indwelling catheters than in those who did not. The ACB test was suggested to be helpful in diagnosing upper urinary tract infection in the female patients who did not have indwelling catheters. But there was the danger of making an incorrect diagnosis with this test on male patients who had indwelling catheters, and those with prostatitis or urethritis, and on female patients with indwelling catheters.

Urinary tract infection and blood P1 antigen: preliminary report

A clinical study was made on the relationship between the blood type P1 antigen and urinary tract infection (UTI). The blood type P1 antigen could be detected in 3 out of 11 healthy Japanese volunteers (27.2%), and in 54% of the UTI patients as a whole. Classified by the type of infection, it could be detected in 3 out of 4 patients with upper UTI (75%) and in 11 out of 22 patients with lower UTI (50%). These incidences were higher than that of healthy volunteers, the difference being statistically significant. The relationship between the annual frequency of UTI and the positive detection of P1 antigen was examined. The patients who had been exposed to UTI twice or more a year proved to have a higher detection rate (61%), than the other group of patients, the difference being statistically significant. Two of the patients with E. coli detected as a clinical isolate proved to have the P1 antigen.

[Clinical study on cefmenoxime (CMX) in urology]

Basic and clinical studies were made on Cefmenoxime (CMX), a new cephalosporin antibiotic, and the following results were obtained. The serum concentration of CMX was examined in four healthy adults after administration of 250 mg of CMX by intramuscular injection, intravenous injection and one-hour intravenous drip infusion (cross over). In the case of intramuscular injection, the peak value of 5.9 micrograms/ml was obtained 30 minutes after administration, and the half-life in serum was 1.41 hours. In the case of intravenous drip infusion, injection, a concentration value of 11.1 micrograms/ml on the average was obtained after 15 minutes of administration, and the half-life in serum was 1.26 hours. In the case of intravenous drip infusion, the concentration was 12.4 micrograms/ml upon completion of drip infusion, and CMX disappeared from serum at a half-life of 0.94 hour. The urinary recovery up to 6 hours was from 60 to 70% in each The efficacy rate of this preparation was 100% for 4 cases of acute simple cystitis. The efficacy rate of CMX was 70% for 10 cases of complicated urinary tract infection; the 3 cases in which CMX was not effective were patients with a residual catheter and Pseudomonas persisting or appearing as superinfection. It was noted that Serratia, which was resistant to the conventional cephalosporin antibiotics, became negative. No subjective side effects due to the administration of this preparation were observed. As for abnormal laboratory findings, a slight and transient rise in transaminases was observed in one case. On the basis of the above-mentioned results, it was concluded that CMX is an effective preparation for the treatment of urinary tract infections.