经皮内镜下胃造瘘术

１９９４年９月～１９９５年２月共行经皮内镜下胃造瘘术３７例，全部成功，平均手术时间为１５分钟，仅６例出现局部皮肤炎症反应，无任何严重并发症。结果表明：经皮内镜下胃造瘘术安全、便捷、有效，为患者提供了一个不需剖腹手术安放胃造瘘管的新方法，颇具推广价值。本文也对操作经验及注意事项进行了总结。     

PERCUTANEOUS ENDOSCOPIC GASTROSTOMY AND VENTRICULOPERITONEAL SHUNTS: A DANGEROUS COMBINATION?

Background: We report the largest European series of patients in whom both ventriculoperitoneal shunts (VPS) and percutaneous endoscopic gastrostomies (PEG) have been inserted with the aim of determining if this combination is safe or if there is an increased risk of VPS infection. Patients and Methods: The paper and electronic records of 302 patients who had a ventriculoperitoneal (VP) shunt inserted in the regional Neurosciences unit at Salford Royal NHS Foundation Trust between 2002 and 2007 were reviewed. Results: A total of 24 patients with VP shunts had 26 PEG inserted. Thirteen PEG were inserted in 11 patients with a pre‐existing VP shunt. The median age was 58 years (21–77 Yrs) with seven male and 17 female patients. In total, five patients developed a shunt infection (20.8%) compared to the overall rate of VP shunt infection for Salford Royal NHS Foundation Trust of 7% (P = 0.017). The increase in number of VP shunt infections when the procedures were done more than 10 days apart (2/14) was not significant (P = 0.25). Conclusion: In patients who need long‐term enteral feeding following a VP shunt insertion it may be prudent to delay insertion of a PEG for at least 10 days to reduce VPS infection. In stable patients who have had a VP shunt inserted on previous hospital admissions PEG insertion need not be avoided because of concern regarding cerebrospinal fluid or shunt infection.     

CLINICAL INVESTIGATION OF UPPER GASTROINTESTINAL HEMORRHAGE AFTER PERCUTANEOUS ENDOSCOPIC GASTROSTOMY

Background: Upper gastrointestinal (GI) hemorrhage after percutaneous endoscopic gastrostomy (PEG) is sometimes reported as one of the serious complications. Our purpose was to clarify the cause of upper GI hemorrhage after PEG. Patients and Methods: We retrospectively investigated the causes of upper GI hemorrhage among a total of 416 patients out of 426 consecutive patients who underwent PEG in our institution, excluding 10 patients who showed upper GI tumors on PEG placement. Results: Among 17 patients who developed upper GI hemorrhage after PEG, three and four patients showed PEG tube placement and replacement‐related hemorrhage, respectively; these lesions were vascular or mucosal tears around the gastrostomy site. Ten patients experienced 12 episodes of upper GI hemorrhage during PEG tube feeding. The lesions showing bleeding were caused by reflux esophagitis (five patients), gastric ulcer (two patients), gastric erosion due to mucosal inclusion in the side hole of the internal bolster (two patients), and duodenal diverticular hemorrhage (one patient). Anticoagulants were administered in six patients, including four patients with replacement‐related hemorrhage and one patient each with reflux esophagitis and gastric ulcer. Conclusions: Reflux esophagitis was the most frequent reason for upper GI hemorrhage after PEG. The interruption of anticoagulants should be considered for the prevention of hemorrhage on the placement as well as replacement of a gastrostomy tube.     

BURIED BUMPER SYNDROME AS A COMPLICATION OF PERCUTANEOUS ENDOSCOPIC GASTROSTOMY IN CANCER PATIENTS: THE BRAZILIAN EXPERIENCE

Background: Buried bumper syndrome (BBS) is a major complication of percutaneous endoscopic gastrostomy (PEG) in which the internal bumper migrates from the gastric lumen into the gastrostomy tract. The aim of the present study was to describe the frequency and characteristics of BBS in cancer patients. Methods: Retrospective chart review of cancer patients submitted to PEG placement. Results: Thirteen cases of BBS were diagnosed among 213 PEG procedures, with an incidence of 6.1%. The interval between PEG and BBS varied from 7 to 630 days (mean 217.5 days). All patients were treated on an outpatient basis. There were six partial, four subtotal and three total BBS. Three partial and four subtotal BBS were treated by external traction and replacement with a balloon‐tipped tube. In three cases of partial BBS the PEG tube was not removed, just repositioned. In three cases of total BBS it was necessary to redo the PEG procedure. Conclusion: BBS is an uncommon and usually late complication of PEG. Most of our cases were detected early, due to instructions provided to patients and caregivers and regular follow up. Early diagnosis permits simple treatment consisting of replacement of the original PEG tube by a balloon‐tube or repositioning the original system.     

ANALYSIS OF BURIED BUMPER SYNDROME AFTER PERCUTANEOUS ENDOSCOPIC GASTROSTOMY DUE TO USE OF A BUTTON‐TYPE KIT

Background: Buried bumper syndrome (BBS) is a rare complication of percutaneous endoscopic gastrostomy (PEG). Along with the widespread use of the button‐type kit, BBS is encountered frequently. Methods: In the present study, we examined causes and treatments for BBS among 1400 patients who had undergone PEG. Results: The causes of BBS after PEG were classified into two categories: early causes consisted of wound infection, inappropriate size of kit and severe lordosis, while late causes were inappropriate exchange of kit, rough management or weight gain. The treatments for BBS could be determined by the degree of wound infection, fistula and burial of the bumper. Conclusion: We prepared a flowchart for replacement, by which BBS can be managed safely and quickly without surgical or endoscopic intervention.     

IMPORTANCE OF THE FISTULA TRACT ANGLE IN FISTULA TRACT DISRUPTION IN PERCUTANEOUS ENDOSCOPIC GASTROSTOMY

Background : The fistula tract angle formed by percutaneous endoscopic gastrostomy (PEG) was examined. Also, the previous literature on fistula tract disruption is reviewed and the possible influence of the fistula tract angle on fistula tract disruption by non‐endoscopic catheter change is discussed. Methods : A total of 15 patients aged 24–80 years were examined.The fistula tract angle was measured as the angle of elevation between the tangent line at the orifice of the PEG stoma and the longitudinal axis of the catheter. Results : Values of the angle ranged from 56 to 90° (mean 77.6°), with four cases (27%) having angles below 70°.With one case of pan‐peritonitis after catheter insertion at 90°, laparotomy revealed that the angle of the fistula tract was low at 62° and that the catheter had broken through the tract just below the abdominal wall. Conclusion : This study suggests that the fistula tract angle might be a potential risk factor for fistula tract disruption by non‐endoscopic catheter change.     

A STUDY OF PHYSICAL EFFICACY OF DIFFERENT SNARES FOR ENDOSCOPIC MUCOSAL RESECTION

There are various types of snares for endoscopic mucosal resection (EMR). Some endoscopists may choose the snare according to their feeling, but we supposed that there were some physical reasons behind each choice. In this paper, we raise the questions, ‘What is the best snare chosen for EMR?’, and ‘Why do we have to do it?’. From the theory of dynamics, we thought that the most important element was vertical force, which we could add against mucosa through the snare. First, we made two situations; one was keeping horizontal faced position of loop of snare (we defined it as HPW; horizontal faced position weight), and the other was rising up position of it (we defined it as RPW). We inspected these forces for the representative and different seven snares, and calculated the ‘Effective Range’, which was a RPW minus a HPW in average. The results demonstrated that both the spiral snare and the smaller ‘Snare Master’ showed higher than other snares in HPW, RPW, and the Effective Range. Based on our study, we judged them as the most adequate snares for EMR in physics and logicality.     

多中心、随机、开放性观察思吉宁治疗帕金森病的临床疗效及安全性

目的研究单胺氧化酶B（MAO-B）抑制剂思吉宁治疗帕金森病（PD）的临床疗效和安全性。方法采用多中心、随机、开放性对照试验，对140例PD患者随机分为两组，分别服用思吉宁或维牛素E12周，比较两组用药第4、8、12周末UPDRS评分和用药第12周汉密尔顿抑郁量表（HMD）评分下降程度，评估其治疗效果，同时记录试验过程中可能发生的不良反应。结果思吉宁组在用药第4、8、12周末的UPDRS评分下降与维生素E组比较有统计学意义（P〈0．01）。思吉宁组在改善患者UPDRS评分方面的有效率高于维生素E组。常见不良反应为纳差、恶心等消化道症状和头晕。而失眠、体位性低血压虽少见，却容易导致停药。结论思吉宁作为MAO—B抑制剂是治疗PD的有效药物，耐受性良好。     

ENDOSCOPIC NASOBILIARY DRAINAGE: CURRENT INDICATIONS AND EVALUATION OF THE PRODUCTS

Endoscopic nasobiliary drainage (ENBD) is a well established mode of biliary decompression. Although ENBD is certainly an uncomfortable procedure with the potential risk of spontaneous dislocation or removal of the drainage catheter by disoriented patients, it has several advantages over endoscopic biliary drainage (EBD) using an indwelling stent. The current indications for ENBD are: (i) temporary drainage to treat obstructive jaundice and cholangitis caused by malignant or benign biliary stricture; (ii) urgent drainage to treat suppurative cholangitis primarily caused by common bile duct stones; (iii) temporary drainage after stone removal in patients with suspected incomplete clearance and/or with cholangitis; and (iv) biliary leaks that occur primarily after surgery, as well as other indications. Different types of nasobiliary catheters are currently available that have been designed with various diameters, shapes, and materials. However, the current catheters are not considered by most endoscopists to be sufficient. Further improvements are needed to achieve better drainage and better maneuverability.     

VALIDITY OF ACTIVITY INDICES IN ULCERATIVE COLITIS: COMPARISON OF CLINICAL AND ENDOSCOPIC INDICES

Aim: Various different clinical indices (CI) and endoscopic indices (El) have been used to evaluate the clinical disease activity of ulcerative colitis (UC). However, no standardized CI or El of UC has been established. The aim of the present study was to determine whether or not any of the CI and/or EI for assessing the disease activity of UC could be established as a standard. Methods: The most frequently used CI and EI were identified from 100 published clinical trials dealing with UC, and representative CI and El were selected. Seventy‐four patients were enrolled in this study and their CI and El were assessed prior to treatment and at 2, 4 and 8 weeks after treatment. Furthermore, changes over time and relationships among the indices were analyzed. In this study, the clinical activity index (CAI), the disease activity index (DAI), the Lichtiger index (LI) and the Seo index were selected as the representative CI, and the Baron score and the Rachmilewitz endoscopic index (REI) were selected as the representative EI. Results: A significant decrease in all the CI and El was observed after treatment, as compared with the baseline values. Moreover, there were positive relationships among the CI and between the CI and El. Conclusion: Our results demonstrated that all the CI and El examined were almost equally useful for evaluating disease activity in UC patients. Further studies may help to determine which of the indices is the most suitable for use in UC clinical trials.     

甲氨蝶呤治疗类风湿关节炎临床疗效评价—随机对照临床试验

目的：应用随机对照临床试验（ｒａｎｄｏｍｚｉｅｄｃｏｎｔｒｏｌｌｅｄｔｒｉａｌ，ＲＣＴ）方法比较在非甾类抗炎镇痛药基础上用和不用甲氨蝶呤（ＭＴＸ）对成年人活动性类风病人临床疗效的影响，方法：１３２例病人采用区组随机化方法以２：１比例分为ＭＴＸ和对照组，后者服用与ＭＴＸ外形，颜色，味道要贞的安慰剂，两组病人每周服用３粒～６粒研究药物，共１２周，结果：ＭＴＸ组有效率８８％，对照组６５％，两者有显著差别     

舒巴坦－头孢哌酮与头孢噻肟随机对照治疗细菌性感染207例多中心临床试验

本项临床试验旨在评价舒巴坦与头孢哌酮联合制剂（ｓｕｌｐｅｒａｚｏｎｅ，舒普深）的安全性与有效性。试验方法为区组随机化开放式平行对照多中心试验设计，并选用头孢噻肟作为对照药。本次试验共治疗细菌性感染２０７例，其中联合制剂组与头孢噻肟组分别为１０３与１０４例。两组痊愈率分别为７３．７９％和６６．３５％；有效率分别为９５．１５％和９０．３８％；细菌清除率分别为８４．７１％和８０．６４％。不良反应发生率分别为７．７７％和８．６５％，差异均无显著性；但临床分离到的致病菌对联合制剂敏感率为９０．９０％，显著高于对头孢噻肟的敏感率（６９．３２％）。表明该联合制剂治疗细菌性感染安全有效，可提供临床广泛应用。     

CLINICAL AND ENDOSCOPIC FEATURES OF AMYLOIDOSIS SECONDARY TO CROHN'S DISEASE: DIAGNOSTIC VALUE OF DUODENAL OBSERVATION AND BIOPSY

Aim: Recent reports have focused on the development of secondary amyloidosis (AMY) as a complication of Crohn's disease (CD). The present study was carried out to investigate the frequency of AMY secondary to CD, its clinical and endoscopic features, and the importance of duodenal biopsy in detecting this disease. Methods: This study involved 408 patients diagnosed with CD who were endoscopically and histologically examined at our hospital. At follow up, we analyzed the incidence of AMY complications, the clinical features of AMY and the methods to diagnose AMY. Results: The incidence of AMY was 2.5% (10/408). The disease type at the time of CD diagnosis was small and large bowel type (SL) in eight patients, small bowel type in one and large bowel type in one. The incidence of AMY was significantly higher in patients with SL than in patients with other disease types. The length of time from onset of CD to diagnosis of AMY was 14.1 ± 8.0 years. The cumulative incidence of AMY was 1.0% at 10 years and 5.7% at 20 years after onset. In terms of the method used to diagnose AMY, the positive rate of AMY diagnosis was 100% with endoscopic duodenal biopsy. Conclusion: The incidence of AMY as a complication of CD was low (2.5%). However, because this complication adversely affects patients' prognoses, it is important to check for the presence of AMY, particularly in the duodenum, in patients for whom more than 10 years have elapsed since the development of CD.     

CLOSURE OF GASTROTOMY IN NATURAL ORIFICE TRANSLUMINAL ENDOSCOPIC SURGERY: A FEASIBILITY STUDY USING AN EX VIVO MODEL COMPARING ENDOLOOP WITH ENDOCLIP

Background: Closure of access site is one of the key issues that will determine the development of natural orifice transluminal endoscopic surgery. Our study was designed to compare the effectiveness of gastrotomy closure using endoloop and endoclip with hand‐sewn closure as a control. Methods: Gastrotomy was carried out on 24 ex vivo porcine stomachs and the gastrotomies were randomized to be closed with either hand‐sewn, endoloop or endoclip techniques. A 2 cm gastrotomy was created with a needle knife and sphincterotome and the defects closed thereafter. We measured the time to closure of gastrotomy and the pressure at which the closure leaked. Results: Three endoloops were required for all the closures in the endoloop group. In the endoclip group, the mean (range) number of endoclips used was 10 (8–13). There was no difference in the median closure times between endoloop 28 (16–58) min and endoclip 30 (21–40) min; however, time for hand‐sewn closure was much shorter (3–5 min). All stomachs were successfully distended with air without leak at the end of the procedure and none experienced fluid leak. The endoclip closure endured a significantly higher median (range) pressure of 72.5 mmHg (15–80 mmHg) before leaking compared to that of an endoloop 25 mmHg (15–37 mmHg) (P < 0.001). The hand‐sewn gastrotomy leaked at pressure of 95 mmHg (75–130 mmHg). The majority of air leaks were from the wound site. In the endoclip group, two leaks were noted at the clip bite site. Conclusion: In a bench‐top model, endoclips seem to be better for gastrotomy closure because of their potential to endure relatively higher pressure without any prolongation of application time. Animal survival studies are needed to explore technical and wound‐closure‐related problems arising as a result of use of endoclips and endoloops for gastrotomy closure.     

CLINICAL RESULTS OF ENDOSCOPIC HEMOSTASIS USING A SHORT TRANSPARENT HOOD AND SHORT HEMOCLIPS FOR NON‐VARICEAL UPPER GASTROINTESTINAL BLEEDING

Aim: Endoscopic hemostasis using hemoclips is useful, but there are technical difficulties because the angle of the approach is tangential. A transparent hood facilitates the observation and treatment of these lesions, and a shorter hood provides a wider visible field. Endoscopic hemoclipping of hard lesions with hemoclips of the conventional size does not reliably result in sustained hemostasis because the clips slip. Short clips, however, can be easily clamped on protruded visible vessels without slip. The aim of the present study was to evaluate the efficacy of endoscopic hemostasis with a short transparent hood and short clips. Methods: Subjects were 198 patients with 214 lesions of non‐variceal upper gastrointestinal bleeding at Keio University Hospital. We used a video endoscope with a short transparent hood attached to its distal tip and carried out hemostasis using short hemoclips. Results: The short transparent hood provided a good visual field. If the lesions were in the tangential, the short hood made it possible to observe them in the frontal view and made clip hemostasis much easier. The short clip could be securely clamped against protruded visible vessels. Of 214 lesion, 211 (98.6%) had temporal hemostasis. Rebleeding occurred in 13 of 211 lesions (6.2%), and 205 of 214 lesions (95.8%) had permanent hemostasis. Nine cases were endoscopically difficult. Conclusion: Endoscopic hemostasis with a short transparent hood and short clips is useful for non‐variceal upper gastrointestinal bleeding.     

ARGON PLASMA COAGULATION FOR THE ENDOSCOPIC TREATMENT OF A NON‐RESECTABLE KLATSKIN TUMOR: IN VITRO AND IN VIVO STUDY

Background : Palliative treatment including stenting is limited in patients with Klatskin tumor. Argon plasma coagulation (APC) is a new local treatment modality for the devitalization and debulking of tumors. Argon plasma coagulation could be a candidate method for relief of biliary strictures in patients with non‐resectable Klatskin tumor in whom biliary stenting has failed. This study provides an evaluation of the technical feasibility, safety, and effect of APC as a palliative strategy in patients with non‐resectable Klatskin tumor. Methods : In vitro studies were performed in order to investigate the dimension of coagulation necrosis in 11 human gallbladders. The currents were applied in normal air conditions and a bowl filled with normal saline in five and six specimens, respectively. Argon plasma coagulation was also performed on three patients with Klatskin tumor who showed no effective drainage via percutaneous transhepatic approach with a cholangioscope. Results : A coagulation current was delivered to the specimen even if in normal saline. The maximum depth and diameter of necrosis was 3 and 6.5 mm under normal air conditions, compared with 2 and 5 mm in water conditions. No perforation of the gallbladder wall occurred in any of the lesions. The dimension of the necrosis increased with increasing impact time and energy settings. Argon plasma coagulation application was possible on tumors of patients without severe complication. Conclusion : Argon plasma coagulation seems to be applicable, effective and relatively safe in palliative treatment for advanced non‐resectable Klatskin tumor via cholangioscopy. Longer follow ups and comparative trials with other treatment modalities are, however, required.     

头孢他美匹酯与头孢克肟随机对照治疗细菌性感染的临床研究

为评价头孢他美匹酯的安全性及临床疗效，用头孢他美匹酯（每１２小时２５０～５００ｍｇ）与头孢克肟（每１２小时２００ｍｇ，疗程均为７～１０天）随机对照治疗呼吸道与泌尿道感染９９例。试验组进入临床试验病例６１例，不良反应评价病例５５例，疗效评价５１例。对照组进入试验病例５８例，不良反应评价病例５４例，疗效评价４８例。结果头孢他美匹酯与头孢克肟两组的临床有效率分别为９４．１％（４８／５１例）与９１．７％（４４／４８例），细菌清除率分别为９５．３％与９５．１％，不良反应发生率分别为９．１％与７．４％，上述结果经统计学比较差异无显著性。表明头孢他美匹酯为治疗临床常见的呼吸道、泌尿道感染的安全、有效的抗菌药物。     

注射用瑞替普酶(派通欣)治疗急性心肌梗死有效性及安全性临床研究

目的对比观察瑞替普酶(派通欣)与重组组织型纤溶酶原激活剂(rt-PA)用于急性心肌梗死溶栓治疗的效果及安全性.方法2001年11月-2002年5月,共有203例急性心肌梗死患者随机接受瑞替普酶或rt-PA溶栓治疗,观察溶栓再通率、急性期病死率、并发症及不良反应发生率.结果溶栓后90min冠状动脉造影显示梗死相关血管再通率(TIMI 2级 TIMI 3级)瑞替普酶组为89.66%,rt-PA组为69.39%(P=0.0085).35d时,瑞替普酶组的病死率为6.8%,rt-PA组的病死率为9.0%(P＞0.05);脑出血发生率瑞替普酶组为0.97%,rt-PA组为3.00%(P＞0.05);严重不良事件的发生率瑞替普酶组为7.76%,rt-PA组为10.00%(P＞0.05);冠状动脉再闭塞瑞替普酶组1.94%,rt-PA组4.00%(P＞0.05).结论瑞替普酶(派通欣)为国人治疗急性心肌梗死安全、有效的溶栓药物.     

A COMPARATIVE STUDY OF THE SAFETY AND EFFICACY OF DYSPROSIUM-165 HYDROXIDE MACRO-AGGREGATE AND YTTRIUM-90 SILICATE COLLOID IN RADIATION SYNOVECTOMY--A MULTICENTRE DOUBLE BLIND CLINICAL TRIAL

The aim of our study was to compare the safety and efficacyof a new preparation, Dysprosium-165 Hydroxide Macro-aggregate(¹⁶⁵Dy) with Yttrium-90 Silicate (⁹⁰Y) for radiation synovectomyof the knee in patients with RA and OA. A multicentre doubleblind clinical trial with subjects randomized to receive ¹⁶⁵Dyor ⁹⁰Y was undertaken in Sydney, Melbourne and Perth. Seventyknees of 59 patients were studied, using as clinical end pointmeasurements pain in the knee on walking, pain in the knee atrest and stiffness in the knee after rest. Cytogenetic damage,knee retention and extra-articular spread of the radionuclideto regional lymph nodes, liver, urine and blood were evaluated.There was no significant difference in clinical response inthe two treatment groups for either RA or OA. Chromosomal changesoccurred with equal frequency and the knee retention and extra-articularleakage of radiocolloids to regional lymph nodes and liver werecomparable in the two groups. For radiation synovectomy of theknee, ¹⁶⁵Dy is at least as safe and as effective as ⁹⁰Y andhas the advantage of a short half-life (2.334 h) and hence requiresa shorter period of post-injection immobilization and hospitalization. KEY WORDS: Radiation synovectomy, Dysprosium-165, Yttrium-90, Rheumatoid synovitis, Osteoarthritis     

MID‐TERM PROGNOSIS AFTER ENDOSCOPIC RESECTION FOR SUBMUCOSAL COLORECTAL CARCINOMA: SUMMARY OF A MULTICENTER QUESTIONNAIRE SURVEY CONDUCTED BY THE COLORECTAL ENDOSCOPIC RESECTION STANDARDIZATION IMPLEMENTATION WORKING GROUP IN JAPANESE SOCIETY FOR CANCER OF THE COLON AND RECTUM

We carried out a retrospective questionnaire survey of 792 submucosal colorectal carcinoma (CRC) cases from 15 institutions affiliated with the Colorectal Endoscopic Resection Standardization Implementation Working Group in Japanese Society for Cancer of the Colon and Rectum. In these cases, endoscopic resection (ER) and surveillance was carried out without additional surgical resection. Local recurrence or metastasis was observed in 18 cases. Local submucosal recurrence was observed in 11 cases, and metastatic recurrence was observed in 13 cases. Among the 15 cases in which the depth of submucosal invasion was measured, two cases showed depth less than 1000 µm, which has other risk factors for metastasis. Metastatic recurrence was observed in the lung, liver, lymph node, bone, adrenal glands, and the brain; in some cases, metastatic recurrence was observed in multiple organs. Death due to primary disease was observed in six cases. The average interval between ER and recurrence was 19.7 ± 9.2 months. In 16 cases, recurrence was observed within 3 years after ER. Thus, validity of ER without additional surgical resection for cases with the conditions that the depth of submucosal invasion is less than 1000 µm and the histological grade is well or moderately differentiated adenocarcinoma with no lymphatic and venous involvement was proven.