ENDOSCOPIC SNARE PAPILLECTOMY FOR TUMORS OF THE MAJOR DUODENAL PAPILLA

Safer procedures for performing endoscopic papillectomy on papillary tumors should be established. Fourteen patients underwent endoscopic papillectomy between January 2000 and February 2007. Before papillectomy, tumors were slightly elevated by submucosal injection of glycerol, followed by semi‐circular mucosal incision of the anal border of the lesion in five cases. In nine cases, balloon‐catheter‐assisted endoscopic snare papillectomy was performed. All patients routinely underwent endoscopic nasobiliary drainage tube placement in the bile duct. A pancreatic stent was inserted only in patients with non‐patent minor papilla. The rate of positive margins was lower in patients who received balloon‐catheter‐assisted papillectomy than in patients who received papillectomy without a balloon catheter. Of three patients with local recurrence, only one patient required surgery. Post‐procedural complications included hemorrhage in eight patients, pancreatitis in one patient, and perforation in one patient. No perforation occurred after submucosal injection and mucosal incision. In three of four patients with early hemorrhage, bleeding was noticed as hemobilia through the nasobiliary drainage tube; this appears to be useful for early diagnosis of bleeding. No pancreatitis occurred in patients with patent minor papilla, suggesting that pancreatic stent placement is unnecessary in patients with patent minor papilla.     

Morphology of the human and dog spleen with special reference to intrasplenic microcirculation

The terminal structure of splenic arterial capillaries, studied by scanning transmission electron microscopy, provided a three-dimensional view of the microarchitecture of human and dog spleens. There are reports that the terminal arterial capillaries end “openly” in the cord, however, our microphotographs indicate the possibility of a closed circulation in humans and dogs. In the human spleen, we found two types of arterial capillaries, one with a flat and continuous endothelium, and the other with discontinuous rod-shaped endothelial cells and a sheath-like structure. The microarchitecture and the termination of these arterial capillaries differ markedly among species. An abstract of this paper appeared in the Proceedings of the 19th Congress of the European Society for Surgical Research. (Zurich, 1984)     

The influence of age on N-isopropyl-p-[123I]iodoamphetamine accumulation in the human heart

Variations in heart intensity in the 30 min and 4 hr chest images of the radiolabelled lipophilic amine, N-isopropyl-p-[123I]iodoamphetamine (123I-IMP) were observed in 130 patients with lung diseases, aged 23 to 85 yrs. The heart intensity had a significant positive linear correlation with age (r = 0.43 at 30 min, 0.66 at 4 hr). The ratio of 4 hr heart intensity to 30 min heart intensity also had a positive linear correlation (r = 0.59), suggesting slower clearance of the radioactivity from the heart in older than in younger patients during this interval. Other parameters including sex, EKG findings, liver function, blood pressure, the presence of diabetes mellitus and smoking history had no relationship to heart intensity. A significant difference between heart intensities in bronchogenic carcinoma and pneumonia patient groups might be probably due to the age difference between the two groups. Therefore heart intensity in the 4 hr 123I-IMP image may reflect certain metabolic and/or myocardial change(s) with aging.     

Abnormality of the hepatic vein waveforms in cirrhotic patients with portal hypertension and its prognostic implications

Background and Aim:  We investigated the prognostic significance of changes in the Doppler hepatic vein (HV) waveforms in cirrhotic patients with portal hypertension and the mechanisms of these changes.
Methods:  A total of 103 consecutive patients were included in this study and their HV waveforms were classified into four types: type I, triphasic waveform; type II, biphasic waveform; type III, biphasic waveform with reduced phasic oscillations; and type IV, a flat waveform.
Results:  Type I was observed in 34, type II in 40, type III in 23, and type IV in six patients. The 5-year survival rates were 90%, 89%, 41%, and 0% in type I, II, III, and IV, respectively. Five variables including the Child–Pugh score, albumin, bilirubin, ascites, and HV waveform significantly correlated with the survival in a univariate analysis. A multivariate analysis only identified the HV waveform (type III and IV) to be an independent prognostic value. Even in Child–Pugh class B patients, the 5-year survival rate for type III or IV was as poor as 26% in comparison to 92% for type I or II. In contrast, in Child–Pugh class C patients, the 5-year survival rate for type I or II was as good as 63% in comparison to 25% for type III or IV. Furthermore, the changes in HV waveforms correlated with the extent of hepatic fibrosis, the increase in portal perfusion per liver volume, or the decrease in portal vascular resistance.
Conclusions:  Analyzing the HV waveforms was thus found to be a simple method for accurately assessing the prognosis in cirrhotic patients with portal hypertension.     

NATURAL ORIFICE TRANSLUMENAL ENDOSCOPIC SURGERY FOR PREOPERATIVE STAGING IN A PANCREATIC CANCER PATIENT

Background: Many experimental studies have shown the technical feasibility of natural orifice translumenal endoscopic surgery (NOTES). We report the first clinical application of natural orifice transgastric endoscopic peritoneoscopy in Japan for preoperative staging in a patient with pancreatic cancer. Methods: A submucosal tunnel was created for safe peritoneal access and secure closure of the gastric‐incision site. Results: Transgastric peritoneoscopy provided an excellent view and allowed approach to various areas of the abdominal cavity. After confirmation of operative curability, the patient underwent an open standard operation without complication. Conclusions: Natural orifice transgastric endoscopic peritoneoscopy for cancer staging using the submucosal tunnel technique appears to be feasible and safe.     

Frequencies of mild factor V, VII and X deficiencies in a Japanese population.

We investigated the frequencies of coagulation factor deficiencies in a Japanese population. We measured factor II, V, VII and X activity in 100 healthy individuals. A specific factor deficiency was determined according to the factor activity and the ratio of the factor activity to that of other coagulation factors. Seven samples showed factor activity less than the mean -2SD of standardized factor activity (factor II: three; factor V: one; factor VII: one; factor X: one and factor V+factor VII: one). The samples with low factor II and factor VII activity were determined not to be due to deficiency because the ratios of these factor activities to other factor activities were within the range of the mean +/- 2SD. We measured activity ratios in the remaining 97 samples and identified one sample with factor V deficiency and two with factor VII deficiency. Thus, six samples with coagulation factor deficiency were identified (factor X: one; factor V: two; factor VII: two and factor V + factor VII: one). These results suggest that the Japanese population has relatively high frequencies of mild factor V, factor VII and factor X deficiencies, in which activity is reduced to approximately 50% (36-64%) of normal plasma.     

Assessment of time-resolved, dynamic, contrast-enhanced MRDSA using radial sliding-window reconstruction.

Sliding-window reconstruction (SWR) has been recently introduced for rapid imaging that improves temporal resolution while maintaining signal-to-noise ratio (SNR) and spatial resolution. We assessed the quantity of 2-dimensional contrast-enhanced magnetic resonance digital subtraction angiography (2D CE-MRDSA) with non-Cartesian radial SWR in phantom and clinical studies. In phantoms, we compared the quantitative properties of time-intensity curves (TIC) obtained with dynamic 2D CE-MRDSA using SWR in a radial acquisition with those obtained by Cartesian acquisition. We calculated the mean variance and standard deviation among signal intensities in TICs and used SWR to study 2D CE-MRDSA in 5 patients with angiographically proven arteriovenous malformations. Using a 3-point grading scale, we individually scored vascular visualization capability and calculated time delay (TD) from the TIC in the feeding artery (FA), nidus, and draining vein (DV). The maximum signal intensity variance in Cartesian SWR was 6.58 +/- 2.27% among time-intensity curves and was 0.87 +/- 0.77% radial SWR. Signal intensity in radial SWR decreased significantly (P<0.001) compared with the Cartesian SWR. In clinical study, the mean rating on 2D CE-MRA of the feeding artery was 2.3, nidus, 2.6, and draining vein, 2.6. Mean delay time between DV and FA was 1.8 s. The radial SWR technique is useful for demonstrating the hemodynamic features of vascular malformations in the head with 2D CE-MRDSA.     

Evaluation of the diaphragm in patients with COPD (emphysema dominant type) by abdominal ultrasonography]

The aim of this study was to clarify whether the diaphragm in patients with COPD (emphysema dominant type) can be evaluated by abdominal ultrasonography. We therefore established a method for diaphragm scanning: The dome of the right hemidiaphragm was detected by epigastric right oblique scan passing through the right edge of the inferior vena cava and the zone of apposition. Diaphragmatic flattening, correlation between the flattening and %FEV1.0, diaphragmatic motion, and the inspiratory time cycle were also measured. We studied 14 patients with COPD (emphysema dominant type) and 12 healthy control subjects. RESULTS: (i) Diaphragmatic flattening was recognized in patients with COPD and the radius of the right hemidiaphragmatic curvature (index of diaphragmatic flattening) correlated with %FEV1.0. (ii) Motion of the anterior diaphragm was poor in patients with COPD. (iii) Expiration time was prolonged in patients with COPD. CONCLUSION: Flattening and motion of the diaphragm, as well as the prolonged expiratory time were possible to evaluate by abdominal ultrasonography. Diaphragmatic flattening reflects %FEV1.0. Based on these observations we believe that abdominal ultrasonography may be useful to avoid underdiagnosis of COPD.