MEDIASTINAL EMPHYSEMA AFTER ESOPHAGEAL ENDOSCOPIC SUBMUCOSAL DISSECTION: ITS PREVALENCE AND CLINICAL SIGNIFICANCE

Aims: To assess the prevalence and clinical significance of mediastinal emphysema (ME) after esophageal endoscopic submucosal dissection (ESD). Methods: A total of 105 patients in whom assessment of ME was prospectively carried out with multi‐detector row computed tomography (MDCT) after esophageal ESD were included in this study. ME was graded as follows: Grade‐0, no ME; Grade‐I, bubbles around the esophagus; Grade‐II, ME around the thoracic aorta; Grade‐III, ME extending around the heart or beyond the mediastinum into the neck; and Grade‐IV, ME with pneumothorax or subcutaneous emphysema. MDCT grading was compared with the finding of conventional chest X‐ray images (CXR) and clinical symptoms. Results: CXR revealed the presence of ME in 6.6% of the subjects. On MDCT, ME was recognized in 62.9% (Grade‐0, 37.1%; I, 46.7%; II, 10.5%; III, 5.7%; and IV, 0%), most (83.8%) being Grade‐I or 0. CXR was able to visualize ME of Grade‐II or greater. Exposure of the muscularis propria layer and location of the lesion were significant risk factors for development of ME of Grade‐II or greater (P = 0.008 and P = 0.03, respectively). The duration of a fever of 37°C or higher was longer and the serum C‐reactive protein level was higher in patients with a higher grade of ME. Conclusions: MDCT revealed the occurrence of ME in 62.9% of the patients who had undergone esophageal ESD, most of which, however, was clinically silent. Exposure of the muscular layer during ESD and location of the lesion were independent risk factors for the development of ME.     

Large Duodenal Tumor with Positive K-ras Mutation Mimicking Lateral Spreading Tumor of the Colon — a Case Report

Abstract: A 69-year-old woman was referred to our hospital with discomfort on swallow ing. Endoscopic examination revealed a large elevated tumor with multiple nodules at the end portion of the duodenal bulbus. The diagnosis obtained by biopsy was tubular adenoma with severe atypia. Upper gastrointestinal series and CT showed a tumor ap proximately 3.5 cm in diameter and the possibility of malignancy could not be ruled out. Partial duodenectomy was performed. Macroscopically the tumor measured 4.7X 3.1 cm. Endoscopic appearance and operational specimen of the tumor mimicked so-called lateral spreading tumor (LST) of the colon, which spreads horizontally and cir-cumferentially along the wall. Microscopically the tumor involved the mucosal and sub-mucosal layers, with no invasion of the muscular layer. Pathological diagnosis of the resected specimen was a borderline lesion between well-differentiated adenocarcinoma and adenoma with severe atypia. Using polmerase chain reaction and hybridization protection assay (PCR-HPA), we identified a point mutation at codon 12 of the K-ras onco-gene from glycine (GGT) to alanine (GCT). The tumor stained negative for p53 on immunohistochemistry, and PCR non radioisotopic single strand conformational polymor phism (non RI PCR-SSCP) for the analysis of exons5–8 of the p53 gene was also negative. This case seemed to be a duodenal epithelial tumor mimicking colonic LST with a rather benign nature despite its large size. (Dig Endosc 1999; 11: 70–75)     

Questionnaire survey on female urinary frequency and incontinence

BACKGROUND: Urinary incontinence is a well-known bothersome symptom in women, which may cause physical and psychological problems. We conducted a questionnaire survey on female urinary incontinence to investigate the disease's impact on the quality of life (QoL), the reasons women don't seek medical attention and the information they wished to obtain. PATIENTS AND METHODS: From March to October 2002, a member of the Professional Women's Coalition for Sexuality and Health distributed a questionnaire about urinary frequency and urinary incontinence to women who were attending the lectures hosted by the group. RESULTS: We analysed 262 questionnaires: 158 people belonged to the Stress Urinary Incontinence (SUI) Group, 36 to the Overactive Bladder (OAB) Group, 22 to the Urinary Frequency (UF) Group and 18 to the Normal Group. 'Going out' was most influenced in all three groups with symptoms in their daily life. Compared with the Normal or SUI Group, the QoL in those belonging to the OAB and UF Groups was more deteriorated. The medical institution check-up rate in the SUI Group was the lowest at 7.1%, bringing down the overall consultation rate to 13.5%. More than 70% of respondents who didn't have a check-up said that they did not think it was a problem serious enough to require consultation. CONCLUSIONS: Urinary incontinence and frequency impairs women's QoL. It is important to provide information on these diseases and to provide medical treatments that cater to the needs of individual patients.     

Perioperative and Long-term Outcomes of Carotid Endarterectomy for Japanese Asymptomatic Cervical Carotid Artery Stenosis: A Single Institution Study

As the recently developed medical treatments for asymptomatic cervical carotid artery stenosis (ACCAS) have shown excellent stroke prevention, carotid endarterectomy (CEA) should be carried out for more selected patients and with lower complication rates and better long-term outcomes. We have performed CEA for Japanese ACCAS patients with a uniform surgical technique and strict perioperative management. In this study, we retrospectively investigated the perioperative complications and long-term outcomes of our CEA series. A total of 147 CEAs were carried out in 139 Japanese ACCAS patients. All patients were routinely checked for their cardiac function and high risk coronary lesions were preferentially treated before CEA. All CEAs were performed under general anesthesia using a shunt system. The postoperative cerebral blood flow was routinely measured under continued sedation to prevent postoperative hyperperfusion. The 30-day perioperative morbidity rate was 2.04%, including a perioperative stroke rate of 0.68%. There were no perioperative deaths. With regard to the long-term outcomes of the 134 followed-up patients, 9 patients were dead and 5 patients suffered from strokes, including 2 patients with ipsilateral hemispheric ischemia. The annual rates of death, all stroke and ipsilateral ischemic stroke were 1.15%, 0.64%, and 0.25%, respectively. These results showed that the perioperative morbidity and mortality rates of our CEAs were lower than those in the previous large trials. Furthermore, the long-term outcomes of this series were favorable to those reported in the latest medical treatment trials for ACCAS patients. CEA may be useful for preventing ischemic stroke in Japanese ACCAS patients.     

Analysis of urgent colonoscopy for acute lower intestinal bleeding

Background: Urgent colonoscopy is often performed to diagnose and stop acute lower intestinal bleeding, but its usefulness has yet to be clarified. The aim of this study was to clarify the present role of urgent colonoscopy for this purpose. Methods Urgent colonoscopy was defined as colonoscopy performed within 48 h of the occurrence of hematochezia. All patients investigated by urgent colonoscopy from September 1996 to March 2000 who were hospitalized in Shimane Medical University Hospital or Shimane Prefectural Central Hospital, Japan, were enrolled in this study. The endoscopic data and medical records of all the investigated patients were reviewed retrospectively to clarify the role of urgent colonoscopy for diagnosing and treating patients with hematochezia. Results A total of 152 patients were enrolled and 137 (90.1%) were successfully diagnosed endoscopically. Ischemic colitis was the most frequent disease found (32.9%), followed by postpolypectomy hemorrhage (9.2%), hemorrhoids (8.6%) and rectal ulcer (7.2%). Endoscopic hemostasis was employed to treat postpolypectomy hemorrhage and bleeding rectal ulcers with favorable results. Conclusions Urgent colonoscopy is useful for the diagnosis of hematochezia. Endoscopic hemostasis is frequently required to treat postpolypectomy hemorrhage and bleeding rectal ulcers.     

The Transport Mechanism of an Organic Cation,Disopyramide, by Brush-border Membranes. Comparison Between Renal Cortex and Small Intestine of the Rat

Abstract— The characteristics of disopyramide uptake in brush-border membrane vesicles isolated from rat renal cortex and small intestine were investigated. Transport of disopyramide into an osmotically reactive intravesicular space was observed with notable binding to the membrane surface. An outwardly directed H⁺ gradient stimulated disopyramide uptake, resulting in a transient uphill transport in both brush-border membranes. As for the renal brush-border membrane, the H⁺ gradient itself appeared to be the driving force for this stimulation of uptake. These findings suggest that disopyramide-H⁺ antiport is the mechanism of disopyramide action in renal cell membrane. The initial uptake was saturable (K_m and V_max of 680 μm and 1·25 nmol (mg protein)^?1/30 s, respectively). The stimulation of disopyramide uptake by an outward H⁺ gradient in rat intestinal brush-border membrane was due to an interior negative H⁺-diffusion potential. A K⁺-diffusion potential (interior negative) enhanced disopyramide uptake. These results suggest that there are different mechanisms of disopyramide uptake for renal and intestinal brush-border membrane vesicles.