Reoperative surgery in cholelithiasis

From 1965 to 1980, reoperations for residual or recurrent stones were performed on 78 out of 962 Japanese patients with cholelithiasis. The majority of patients who required reoperation had intrahepatic stones. Most of the causes of reoperation were residual stones due to incomplete removal or the non-detection of intrahepatic stones at the previous surgery. Very careful examination of the intrahepatic biliary trees should be done in patients with biliary tract diseases, because in many, the first operation was done during their youth. To remove the intrahepatic calculi completely, hepatic lobectomy should be considered as a final procedure. The causes of reoperation of common duct stones were residual in 60 per cent and recurrent in 40 per cent. Definitive surgery should be done at the first or at least the second operation to avoid irreversible hepatic disorders which have untoward effects on the prognosis. It is important not only to remove the stones but also to relieve the bile stasis in the biliary tract.     

Successful remission using metyrapone in an elderly patient with Cushing disease accompanied by generalized edema

An 82-year-old woman was referred to our hospital because of hypoalbuminemia and generalized edema. Hypercortisolemia was subsequently found as the levels of serum cortisol and plasma adrenocorticotropic hormone (ACTH) sampled in a fasting morning were 140 pg/mL and 41.9 μg/dL, respectively. These hormones were not suppressed after taking low-dose dexamethasone the previous night and increased to a mild extent in response to administration of corticotrophin-releasing hormone, suggesting presence of pituitary adenoma producing ACTH (Cushing's disease). However, intrasella localization of pituitary adenoma could not be determined by magnetic resonance imaging. Soon after administration of metyrapone was started in an attempt to reduce her cortisol levels, the patient suffered from severe pneumonia. The pulmonary infection and peripheral edema were improved with decreases in cortisol levels by continuing metyrapone administration with antibiotics and finally she was discharged from the hospital on foot. Metyrapone is a useful therapeutic choice to achieve a remission of cortisol levels in the elderly patients with Cushing's disease in association with serious hypercortisolemia impending severe infection.     

Effect of granulocyte and monocyte adsorption apheresis on urinary albumin excretion and plasma endothelin-1 concentration in patients with active ulcerative colitis

BACKGROUND/AIM: Increases in microalbuminuria and endothelin (ET-1) are involved in the development of ulcerative colitis (UC) and in its progress. Because granulocyte and monocyte adsorption apheresis has proven to be useful in the treatment of UC, we examined whether urinary albumin excretion and plasma ET-1 concentrations are altered and whether granulocyte and monocyte adsorption apheresis affects the concentrations of these two factors in patients with active UC. METHODS: Twenty patients with active UC and 20 age-matched healthy volunteers (our hospital staffs) were included in this study. UC patients were randomly divided into two treatment groups: a granulocyte and monocyte adsorption treatment group (n = 10) and a conventional treatment group (n = 10). The urine albumin/creatinine ratio, plasma ET-1 concentration and tumor necrosis factor (TNF)-alpha were determined before and after treatment and compared between 2 treatment groups. The 10 adsorption treatment patients underwent 5 consecutive weekly apheresis sessions, each of 60 min duration at a flow rate of 30 ml/min. RESULTS: The urine albumin/creatinine ratio in UC patients (6.4 +/- 2.2 mg/mmol) were higher than that in healthy subjects (1.0 +/- 0.7 mg/mmol, p < 0.01). In addition, the plasma ET-1 level in UC patients (3.5 +/-1.5 pg/ml) was higher than that in healthy subjects (0.8 +/- 0.4 pg/ml, p < 0.01). Plasma TNF-alpha was detected in UC patients (18.8 +/- 8.4 pg/ml), but not in healthy subjects. The urine albumin/creatinine ratio was highly correlated with the plasma ET-1 level (r = 0.62; p < 0.01) and plasma TNF-a level (r = 0.66, p < 0.01). Granulocyte and monocyte adsorption apheresis reduced the urine albumin/ creatinine ratio from 6.6 +/- 2.4 to 1.8 +/- 0.6 mg/mmol (p < 0.01), reduced the plasma ET-1 level from 3.7 +/- 1.6 to 1.4 +/- 0.6 pg/ml (p < 0.05) and reduced the plasma TNF-alpha from 19.2 +/- 8.6 to 3.8 +/- 1.2 pg/ml (p < 0.01). Conventional treatment did not affect these factors. CONCLUSION: Our data suggest that increases in the urine albumin/creatinine ratio, ET-1 and TNF-alpha play an important role in active UC and that granulocyte and monocyte adsorption apheresis is effective in ameliorating such increases.     

Brief Questioning by Nursing Staffs before Endoscopic Examination May Not Always Pick Up Clinical Symptoms of Endoscopic Reflux Esophagitis

The clinical features of patients reflux esophagitis without any symptoms have not been clearly demonstrated. This study evaluated the clinical features of patients with endoscopy-positive reflux esophagitis, who did not complain of symptoms, as detected by brief questioning by nursing staffs. Eight thousand and thirty-one patients not taking medication for gastrointestinal disease, were briefly asked about the presence of heartburn, dysphagia, odynophagia and acid regurgitation by nursing staffs before endoscopy for assessment of esophagitis utilizing the Los Angeles Classification. Endoscopically, 1199 (14.9%) patients were classified as positive for reflux esophagitis. The endoscope positive subjects who complain heartburn were 539/1199 (45.0%).The endoscope positive subjects who do not complain symptoms were 465 in 1199 positive reflux esophagitis (38.8%). We compared endoscopic positive subjects without any complain by brief question by nursing staffs to endoscopic positive subjects with heartburn. Male gender, no obesity, absence of hiatus hernia, and low-grade esophagitis were associated with endoscopy-positive patients who do not complain of symptoms. The results of this study indicated correct detection of clinical symptoms of reflux esophagitis might be not easy with brief questioning by nursing staffs before endoscopic examination.     

Lymphokine-activated killer cell activity of peripheral blood,spleen, regional lymph node,and tumor infiltrating lymphocytes in gastric cancer patients

Lymphokine-activated killer (LAK) cell activity of peripheral blood mono-nuclear cells (PBM), spleen cells (SPC), regional lymph node cells (LNC), and tumor-infiltrating lymphocytes (TIL), induced by activation with in-terleukin 2 (IL 2) for 4 days, was evaluated in patients with gastric carcinoma. TIL exhibited the lowest LAK activity and the cytotoxicity of LNC was significantly lower than that of either PBM or SPC. There was no difference between PBM and SPC. Then, there were significant correlations of LAK activity among PBM, SPC, and LNC, whereas poor correlations were observed in the cytotoxicity between TIL and PBM, SPC, or LNC. Phenotypic analysis of each cell population was performed before and after activation with IL 2. Before culture, the cells mediating natural killer (NK) activity such as CD16⁺, CD56⁺, and CD57⁺ cells were few in LNC and TIL. However, CD56⁺ and CD57⁺ cells in TIL were increased after culture. Then, CD4⁺ Leu8⁺ and CD8⁺ CD11⁺ cells, which identify suppressor cell function, were not elevated in LNC or TIL, as compared to that in PBM or SPC. Further, the proportions of OKIa1⁺ and CD25⁺ cells expressing T-cell activation and IL 2 receptor were uniformly increased in all cell populations after culture. These results indicate the differential reactivity of each lymphocyte population to IL 2 and fundamental dysfunction of LNC and, especially TIL, suggesting the specific influence of the local tumor environment on the lymphocyte function in the area in patients with gastric carcinoma. © Wiley-Liss, Inc.     

CARCINOGENESIS: Bilioenterostomy enhances biliary carcinogenesis in hamsters

The aim of this study was to examine whether the type of bilioenterostomyenhances biliary carcinogenesis in the hamster model. Syrianhamsters were divided into the following groups; simple laparotomy(control group), cholecystoduodenostomy with dissection of theextrahepatic bile duct on the distal end of the common duct(CDDB group) and cholecystoileostomy with dissection of theextrahepatic bile duct on the distal end of the common duct(CIDB group). Following these procedures, all hamsters receivedN-nitrosobis(2-oxopropyl)amine. The diameter of the extrahepaticbile duct and plasma levels of cholecystokinin (CCK) were measuredand the number of neoplastic lesions was counted microscopically.Proliferative effect of the procedures on the biliary epitheliumwas examined by proliferative cell nuclear antigen. In the CDDBgroup the extrahepatic bile duct was significantly dilated andcarcinogenesis of the gall-bladder and extrahepatic bile ductswas enhanced. In the CIDB group the CCK bioactivity was stimulatedand intrahepatic biliary duct, but not gall bladder and extrahepaticbile duct, carcinogenesis was promoted more than that observedin the CDDB group. Proliferation of the biliary duct epitheliumwas enhanced in both the CDDB and CIDB groups. Cholecystoduodenostomyenhanced intra- and extrahepatic bile duct carcinoma, whereascholecystoileostomy promoted only intrahepatic bile duct carcinoma.Some factors in the intestinal juice seem to play a role inthe promotion of biliary tract carcinoma.     

Biventricular pacing using two pacemakers and triggered VVT mode in patients with atrial fibrillation and congestive heart failure: a case report

A 76-year-old female had undergone implantation of a single chamber pacemaker for sick sinus syndrome 20 years previously. She developed chronic atrial fibrillation and required repeated admission due to congestive heart failure. She had significant mitral and tricuspid regurgitation. Paradoxical movement of the intraventricular septum was severe. Due to right ventricular apical pacing, significant interventricular conduction delay was present with a paced QRS duration of 189 msec. The left ventricular pacing lead was positioned via the coronary sinus. The mode of the previously implanted pacemaker was set at VVT. Biventricular pacing could be achieved even in intrinsic beats by VVT mode. The battery life time was improved. This method is useful in patients with conventional pacemakers.     

Long-lasting change in 5-HT2A receptor-mediated behavior in rats after a single footshock

To investigate the long-term functional change in the 5-HT(2A) receptor after acute stress, we examined the effect of single footshock on head shake behavior induced by the 5-HT(2A) receptor agent (+/-)-2,5-dimethoxy-4-iodoamphetamine hydrochloride (DOI) in rats. Head shakes were evoked in a dose-dependent manner by 0.1-10 mg/kg of DOI, and the maximal response was attenuated by a single footshock given 24 h before. This suggests that there is a decrease in the number of functionally effective 5-HT(2A) receptors. The single footshock-induced reduction in head shakes evoked by DOI was observed immediately and 24 h after footshock, and lasted until 1 and 2 weeks after footshock. Because there were no changes in the [3H]ketanserin binding of the frontal cortex 1 week after footshock, decreases in head shakes were not due to the down-regulation of 5-HT(2A) receptors evoked by footshock.     

Skin problems among fiber-glass reinforced plastics factory workers in Japan

Two surveys, one in winter the other in summer time, examined the skin problems of the entire manual workers (N=148) from 11 small-to-medium sized fiber-glass reinforced plastics (FRP) factories located in Kyushu, Japan. The workers were exposed to unsaturated polyester resin, including styrene and auxiliary agents such as cobalt naphthenate, hardeners such as methyl ethyl ketone peroxides, glass fiber and dust including shortened glass fiber and plastic particles. Eighty-seven workers (58.8%) reported having skin problems (mainly itching or dermatitis) since they started to work in FRP manufacturing and 25 workers had consulted a physician because of their skin problems; one worker was forced to take sick leave because of his severe dermatitis. History of allergic diseases and shorter occupational period (duration of employment) in a FRP factory were associated with greater probability of having a history of work-related skin symptoms. Workers in factories where dust-generating and lamination sites were located in different buildings were significantly less likely to have a history of skin problems than those in factories where the two sites were located in the same building. Of the 67 workers examined in both seasons closed to double the prevalence of dermatitis was found in summer (23.3%) than winter (13.4%).