A New Assessment of Esophageal Varices by Endoscopic Ultrasonography Using a 15/20-Megahertz Ultrasonic Probe

Abstract: We examined esophageal varices using the new technique of endoscopic ultrasonography (EUS) that employed a high-resolution 15/20 MHz ultrasonic probe. EUS employing the direct contact method, in which the forceps-channel probe was in direct contact with the lumen, was used in patients with esophageal varices (58 cases) and in control patients without varices (32 cases). Findings were also compared with additional EUS employing the conventional balloon method which was performed on 21 of the patients with esophageal varices. The direct contact method visualized all the varices (endoscopic Grade 1 varices; 2.0 ± 0.7 mm in diameter (mean ± SD) and 11.9 ± 3.1 cm in length, endoscopic Grade 2 or 3 varices; 5.8 ± 3.2 mm in diameter and 16.3 ± 3.0 cm in length). In the 21 patients who underwent EUS by the two different methods, varices were displayed by both methods in 9 cases (7 endoscopic Grade 2 varices, and 2 Grade 3 varices). In the other 12 cases (8 endoscopic Grade 1 varices, and 4 Grade 2 varices) varices were displayed only by the direct contact method, and not by the balloon method. The direct contact method can be regarded as a useful technique for the evaluation of esophageal varices.     

Neonatal erythema infectiosum

A report is presented of a patient with neonatal erythema infectiosum who developed petechiae, transient thrombocytopenia and transient cardiac failure due to transplacental transmission of human parvovirus B19 (HPV B19) infection. It is suggested that the thrombocytopenia was caused by platelet-associated IgG produced by the patient, and that the cardiac failure may have been caused by direct entry of HPV B19 into the cardiac tissue.     

Neonatal Dubin-Johnson Syndrome with Severe Cholestasis: Effective Phenobarbital Therapy

ABSTRACT. We described Dubin-Johnson syndrome (DJS) with severe cholestasis in a 20-day-old Japanese boy. Although neonatal DJS has been sporadically reported, DJS with severe cholestasis has not to our knowledge been described in the English literature. The ratio of urinary coproporphyrin isomer I to urinary total coproporphyrin in our patient was high (93%). Liver histology showed cytoplasmic pigment granules in the liver cells. Administration of phenobarbital (PB) significantly decreased the levels of bilirubin and bile acids in the serum. There was a significant elevation of 1β-hydroxylated bile acids in the urine. It is predicted that severe cholestasis in neonatal DJS may cause metabolic abnormalities in both bilirubin and bile acids transport.     

Spontaneous peripelvic extravasation of urine due to an inflammatory aneurysm of the abdominal aorta

A 71-year-old man presented complaining of severe left flank pain. A computed tomography scan of the abdomen disclosed a left peripelvic extravasation of urine and a 4.0-cm abdominal aortic aneurysm with a significant amount of perianeurysmal thickening and prominent left hydroureter. The patient was diagnosed as having an inflammatory aneurysm of the abdominal aorta (IAAA) with peripelvic extravasations of urine. We report the results of a patient with IAAA with ureteral obstruction successfully treated with steroid therapy and a ureteral stent.     

The effects of transjugular intrahepatic portosystemic shunt on portal hypertensive gastropathy

In addition to variceal bleeding, haematemesis may occur due to haemorrhagic gastritis in patients with portal hypertension. This has been known as portal hypertensive gastropathy (PHG). We have evaluated the effects of the transjugular intrahepatic portosystemic shunt (TIPS) on portal venous pressure (PVP) and endoscopic gastric mucosal changes observed in patients with portal hypertension. We performed TIPS in 12 patients with complications due to portal hypertension as follows: variceal bleeding in nine patients (bleeding from oesophageal varices in seven and gastric varices in two), refractory ascites in three and haemorrhage from severe PHG in one. Endoscopic examinations were performed before and after TIPS for all patients. Changes of PVP and gastric mucosal findings on endoscopy were analysed. Before TIPS, PHG was seen in 10 patients. Portal venous pressure decreased from an average of 25.1 ± 8.8 to 17.1 ± 6.2 mmHg after TIPS ( P < 0.005). On endoscopy, PHG improved in nine of 10 patients. Oesophagogastric varices improved in eight of 11 patients. In one patient with massive haematemesis, haemorrhage from severe PHG completely stopped after TIPS. Because TIPS effectively reduced PVP, this procedure appeared to be effective for the treatment of uncontrollable PHG.     

Dynamic Left Ventricular Arterial Pressure Gradient and Sick Sinus Syndrome with Heterozygous Fabry''s Disease Improved Following Implantation of a Dual Chamber Pacemaker

A 63-year-old woman with heterozygous Fabry's disease, sick sinus syndrome, sinus pauses, congestive heart failure, syncope, and a dynamic pressure gradient between the left ventricle and systemic arteries underwent implantation of a dual chamber (DDD) pacemaker. Following pacemaker implantation, the pressure gradient has been reduced and congestive heart failure controlled for the past 3 years.     

Indications and Timings of Re-operation for Residual or Recurrent Hemifacial Spasm after Microvascular Decompression: Personal Experience and Literature Review

We reviewed reports about the postoperative course of hemifacial spasm (HFS) after microvascular decompression (MVD), including in our own patients, and investigated treatment for delayed resolution or recurrence of HFS. Symptoms of HFS disappear after surgery in many patients, but spasm persists postoperatively in about 10–40%. Residual spasm also gradually decreases, with rates of 1–13% at 1 year postoperatively. However, because delayed resolution is uncommon after 1 year postoperatively, the following is advised: (1) In patients with residual spasms after 1 year postoperatively (incomplete cure) or who again experience spasm ≥ 1 year postoperatively (recurrence), re-operation is recommended if the spasms are worse than before MVD. (2) When re-operation is considered, preoperative magnetic resonance imaging (MRI) findings and intraoperative videos should be reviewed to ensure that no compression due to a small artery or vein was missed, and to confirm that adhesions with the prosthesis are not causing compression. If any suspicious findings are identified, the cause must be eliminated. Moreover, because of the risk of nerve injury, decompression of the distal portion of the facial nerve should be performed only in patients in whom distal compression is strongly suspected to be the cause of symptoms. (3) Cure rates after re-operation are high, but complications such as hearing impairment and facial weakness have been reported in 10–20% of cases, so surgery must be performed with great care.     

Efficacy of Monitoring Patient’s Position during Neurosurgical Procedures: Introduction of Real-time Display and Record

There are many reports on position-related complications in neurosurgical literature but so far, continuous quantification of the patient’s position during the surgery has not been reported. This study aims to explore the utility of a new surgical table system and its software in displaying the patient’s body positions during surgery on real-time basis. More than 200 neurosurgical cases were monitored for their positions intra-operatively. The position was digitally recorded and could be seen by all the members in the operating team. It also displayed the three-dimensional relationship between the head and the heart positions. No position-related complications were observed during the study. The system was able to serve as an excellent indicator for monitoring the patient’s position. The recordings were analyzed and even used to reproduce or improve the position in the subsequent operations. The novel technique of monitoring the position of the head and the heart of the patients and the operating table planes are considered to be useful during delicate neurosurgical procedures thereby, preventing inadvertent procedural errors. This can be used to quantify various surgical positions in the future and define safety measures accordingly.