Endoscopic submucosal dissection using sodium hyaluronate for large superficial tumors in the colon

Endoscopic submucosal dissection is becoming popular for large superficial gastric cancer in Japan. However, it is considered difficult in the colon because the colonic wall is much thinner than the gastric wall. We use several devices to overcome this difficulty and have made it feasible in the colon as well. Submucosal injection of sodium hyaluronate is used to maintain sufficient thickening of the submucosal tissue and a small‐caliber‐tip or regular cylindrical transparent hood is used to open up the incised mucosa as a substitute for countertraction. In this method, not only the lateral margin, but the vertical margin of the resection can also be determined precisely because submucosal incision is carried out under direct visualization of the submucosal tissue.     

Gastric Ulcer Hemorrhage Treated by Endoscopic Hemostasis with Histoacryl

Abstract: We report a case of hemorrhagic gastric ulcer in which endoscopic injection of Histoacryl effectively achieved hemostasis. The patient was an 86-year-old woman with complaints of hematemesis and melena, and emergent endoscopic examination revealed fresh bleeding from the gastric ulcer. Neither endoscopic injection of Aethoxysklerol and ethanol nor clipping stopped the active bleeding, while the injection of Histoacryl produced an immediate hemostatic effect. Unfortunately, she died of pneumonia and heart failure seven days after this treatment. Autopsy revealed Histoacryl polymer localized in the gastric wall, but the gastric ulcer that had caused the massive bleeding was covered with exudate and the site of arterial rupture was unclear. The significant hemostatic effect of Histoacryl injection and the histological findings in this case suggest that this procedure may be useful for managing refractory hemorrhagic gastric ulcer.     

A case of gastric mucosal bridge with Beh?et's disease]

A 69-year-old man visiting our hospital with an epigastralgia and tarry stool was diagnosed as having Beh?et's disease on the basis of repetitious aphthous stomatitis, erythema nodosum and arthralgia in 1991. The next year, he suffered from double active ulcers in the antrum of the stomach, and he had been operated on for intestinal perforation. In 1994, endoscopic examination revealed the gastric mucosal bridge between the double ulcers. The double ulcer healed after an eradication therapy of H. pylori, but the gastric mucosal bridge has remained there on the gastrointestinal endoscopy. The gastric mucosal bridge with Beh?et's disease has not been reported in Japan, being considered to be very rare.     

Effects of primary and secondary low-grade respiratory syncytial virus infections in a murine model of asthma

BACKGROUND: Respiratory syncytial virus (RSV) infection is known to develop and exacerbate asthma in young children. In adult, RSV causes recurrent but asymptomatic infections. However, the impact of asymptomatic RSV infection on adult asthma is yet to be determined. The present study is designed to determine the effects of primary and secondary low-grade RSV infections on allergic airway inflammation in a murine model of allergic asthma. METHODS: A low-grade RSV (2 x 10(3) plaque-forming units/mouse) was inoculated, and this caused neither pulmonary inflammation nor symptoms but induced significant IFN-gamma production in thoracic lymph nodes. To investigate interaction between low-grade virus and Dermatophagoides farinae (Df), airway hyper-responsiveness, lung inflammation and cytokine production from thoracic lymph nodes were compared after primary and secondary low-grade RSV infections in four groups of mice; control, Df allergen-sensitized, RSV-infected and Df-sensitized RSV-infected mice. A direct comparison between low- and high-grade RSV infections was also performed in primary infection. To investigate the role of IL-5 during secondary RSV infection, anti-IL-5 monoclonal antibody (anti-IL-5 mAb) was injected in mice and similar parameters were compared in four groups of mice. RESULTS: Primary high-grade RSV infection increased allergen-induced airway inflammation, while primary low-grade RSV infection attenuated allergen-induced airway inflammation concomitant with significant IFN-gamma production in lung-draining lymph nodes. In marked contrast, secondary low-grade RSV infection increased both IFN-gamma and IL-5 production, resulting in exacerbation of allergen-induced airway inflammation. Anti-IL-5 mAb treatment in secondary low-grade RSV infection and Df allergen-sensitized mice attenuated virus and allergen-induced airway inflammation. CONCLUSIONS: Low-grade RSV infection per se does not cause pulmonary inflammation, whereas it induces a significant immunological response in the allergen-sensitized host. These results indicate that subclinical and recurrent RSV infection may play an important role in exacerbation and maintenance of asthma in adults, wherein IL-5 is critically involved.     

Surveillance colonoscopy after ureterosigmoidostomy

Twenty-two patients underwent surveillance colonoscopy for 2 to 54 months (average, 22 months) after ureterosigmoidostomy. The distance between site of ureterocolonic anastomosis and anal verge ranged from 13 to 30 cm (average, 18.3 cm) in right side and from 20 to 37 cm (average, 29.5 cm) in left side. The form of implanted site could be classified into 3 types which were flat, sessile and pedunculated types. Endoscopic biopsies performed on eleven polyp-like regions of ureterocolonic anastomosis revealed inflammation in 10 cases (90%) and adenoma without malignancy in one case (10%). The mucosa more than 5 cm away from implanted site showed findings of inflammation without constitutional abnormality in more than 60% of all patients. The periodical surveillance colonoscopy at intervals of approximately one year seemed to be useful for early detection of the tumors of the colon after ureterosigmoidostomy.     

Acute humoral rejection and C4d immunostaining in ABO blood type-incompatible liver transplantation.

Complement C4d deposition in graft capillaries has been reported to be associated with antibody-mediated rejection in kidney and other solid organ transplantation. The correlation of C4d deposits and humoral rejection in liver transplants, however, is not well understood. We investigated the C4d immunostaining pattern in 34 patients whose liver biopsy was taken within the first 3 postoperative weeks for suspected acute rejection after ABO blood type-incompatible liver transplantation. The staining pattern was classified as positive (portal stromal staining), indeterminate (endothelial staining only), and negative (no staining). Positive C4d immunostaining was seen in 17 (50%) patients and was significantly associated with high (x64 or more) postoperative antidonor A/B antibody (immunoglobulin M (IgM)) titers (88 vs. 35%, P = 0.002) and poorer overall survival rate (41 vs. 88%, P = 0.007). Ten of 11 (91%) cases with histological acute humoral rejection (periportal edema and necrosis (PEN) or portal hemorrhagic edema) were positive for C4d, all of which showed high postoperative antibody titers. The other histologies associated with C4d positivity was purulent cholangitis (n = 4), coagulative hepatocyte necrosis (n = 1), acute cellular rejection (n = 1), and hepatocanalicular cholestasis (n = 1). Full clinical recovery was observed in only 6 of 17 (35%) C4d-positive patients, and tended to be associated with a lower rejection activity index (RAI). In conclusion, our study indicates that C4d deposits in the portal stroma can be a hallmark of acute humoral rejection in ABO-incompatible liver transplantation, and allograft damage can be reversible in a minority of cases.     

Subconjunctival mucosa-associated lymphoid tissue (MALT) lymphoma arising in Tenon’s capsule

Purpose We report the first case of subconjunctival mucosa-associated lymphoid tissue (MALT) lymphoma arising in Tenon’s capsule (fascia bulbi). Methods A 75-year-old woman presented with painless swelling of the superior bulbar conjunctiva in her left eye. During the biopsy of the bulbar lymphoid lesion, it was noticed that the conjunctiva was movable and that the lesion was located in the subconjunctiva. The tissues were studied by conventional light microscopy, immunohistochemistry, flow cytometry, and gene rearrangement analysis. Results Histopathological examination revealed that a diffuse lymphoid infiltrate consisting of small-sized lymphoid cells was present in Tenon’s capsule but not in the substantia propria of the conjunctiva. Immunohistochemical and flow cytometric studies documented tumor cells of B-lymphocyte lineage. Molecular analysis demonstrated positive immunoglobulin heavy chain gene rearrangement. The final diagnosis was subconjunctival MALT lymphoma arising in Tenon’s capsule. Conclusion Ophthalmologists and pathologists need to distinguish the subconjunctival lymphoma that arises in Tenon’s capsule from the conjunctival lymphoma in the substantia propria during diagnosis of epibulbar lymphoid tumors. This material is not under consideration for presentation and has not been previously presented. The authors received no specific financial support for this study and have no financial interest in any company or product discussed in it.     

Clonidine premedication modifies responses to adrenoceptor agonists and baroreflex sensitivity

PURPOSE: To evaluate the effects of clonidine on responses to adrenoceptor agonists and baroreflex sensitivity, we examined arterial blood pressure (AP) responses to phenylephrine and heart rate (HR) responses to isoproterenol and baroreflex sensitivity (HR response to AP changes due to phenylephrine or nitroglycerin). METHODS: We studied 60 anaesthetized patients who either did or did not receive 5 micrograms.kg-1 clonidine po before they were anaesthetized. After induction of general anaesthesia, the patients received 3 micrograms.kg-1 phenylephrine, 0.02 microgram.kg-1 isoproterenol, or 2-3 micrograms.kg-1 nitroglycerin, and haemodynamic measurements were taken. Baroreflex sensitivity was expressed as the slope of the linear regression line (msec.mmHg-1; in msec of R-R interval change vs mmHg change in systolic arterial pressure) following the administration of phenylephrine and nitroglycerin. RESULTS: Patients who received clonidine had greater augmented responses in AP to phenylephrine and in HR to isoproterenol (47.2 +/- 15.6% vs 23.7 +/- 11.9% for increase in systolic AP and 59.8 +/- 22.6% vs 26.2 +/- 11.0% for increase in HR, P < 0.05 respectively). There were no differences between the baroreflex sensitivities in the pressor (phenylephrine) test groups (3.77 +/- 1.08 vs 4.41 +/- 1.66 msec.mmHg-1). In contrast, the slopes of depressor (nitroglycerin) test groups were decreased in patients receiving clonidine (1.98 +/- 0.73 vs 3.68 +/- 1.72 msec.mmHg-1, P < 0.05). CONCLUSION: The results suggest that premedication with clonidine might enhance critical hypotension during anaesthesia and surgery, but restoration both of AP and HR decrease can be achieved effectively by phenylephrine and isoproterenol i.v., respectively.     

Giant intraatrial septal aneurysm originating from a branch of the left coronary artery

We present the case of a 38-year-old woman who had a large intraatrial aneurysm occupied by old thrombosis. The aneurysm was successfully removed, and the atrium was repaired. Pathohistological findings indicated that the inflow artery of the aneurysm had an anomalous origin from the left main coronary artery, and its pathogenesis was unknown. It is occasionally difficult to distinguish a large coronary aneurysm from a mediastinal tumor because this aneurysm is a rare entity, even more so in an atrial septum. A giant coronary aneurysm should be considered an alternative diagnosis in the event of a mediastinal mass. Surgery is recommended for a large coronary aneurysm.