Successful embolization using interlocking detachable coils for a congenital extrahepatic portosystemic venous shunt in a child

The authors report the case of a 6-year-old boy with a congenital extrahepatic portosystemic venous shunt. He had hyperammonemia. The shunt was 18 mm in diameter and located between the inferior mesenteric vein and the left internal iliac vein. The flow in the shunt was very rapid. After decreasing blood flow by inflating a balloon catheter inserted into the left internal iliac vein from the femoral vein, a microcatheter was coaxially advanced to the shunt to embolize the shunt. Embolization was successfully performed with interlocking detachable coils and microcoils without any complication. This patient's hyperammonemia resolved soon after the procedure.     

A case of refractory inguinal lymphorrhea cured by lipiodol lymphangiography

We report a case of inguinal lymphorrhea cured by Lipiodol lymphangiography. The patient was a 80-year-old female who underwent an abdomino-perineal resection with lateral pelvic lymph node dissection and inguinal lymph node extraction for anal canal cancer. Histologically, the tumor was a poorly differentiated adenocarcinoma and considered to be stage IV (a2, n3 (+), P0, H3, M (-), cur C) in the Japanese classification of colorectal cancer. We recognized a lot of lymph node metastases in dissected lateral pelvic lymph node and inguinal lymph node. By hepatic arterial infusion using 5-FU (1250 mg/body weekly), the liver metastases had a complete response after 15 courses. She noticed a left inguinal lymph node swelling and an elevation of serum CEA level (79.5 ng/mL) was observed. There was no evidence of recurrence except left inguinal lymph nodes. She underwent a left inguinal lymph node dissection. Serous discharge from a surgical site persisted despite of conservative therapy such as compression. She received lymphangiography using 8 mL of Lipiodol from left dorsum of foot. We found three lymph ducts heading to left groin and observed a lot of Lipiodol leakage from ducts. We determined not only the site of leakage but we also confirmed a gradual decrease and a complete stop of lypmphorrhea in 7 days after lymphangiography. Slight lymph edema of left lower extremity appeared but gradually relieved. Lymphangiography using Lipiodol helps determine the site of leakage and may be an effective therapeutic modality for treating refractory lymphorrhea.     

The prognostic value of positive peritoneal lavage cytology and the prevention of peritoneal dissemination after colorectal surgery

Peritoneal washing cytology during surgery was done in 745 patients with colorectal cancer. The positive washing cytology rate was 49/745 (6.6%). The peritoneal recurrence rates were 12/22 (54.5%) and 8/682 (1.3%) among patients with positive and negative peritoneal washing, respectively (p < 0.0001). The 5-year survival rate is 89.4% of the patients with positive cytology and 38.2% with negative cytology. The patients with positive cytology have a significantly lower survival rate than the negative one (p < 0.0001). Eleven patients of the positive cytology received intraperitoneal administration of MMC. Peritoneal dissemination occurred in 3/11 (27.3%) of the MMC treated group and 9/11 (81.8%) in the untreated group (p = 0.030). Our results indicated that intraperitoneal administration of MMC was an effective method of preventing peritoneal dissemination after resection of colorectal cancer.     

Unique charge distribution in surface loops confers high velocity on the fast motor protein Chara myosin

Most myosins have a positively charged loop 2 with a cluster of lysine residues that bind to the negatively charged N-terminal segment of actin. However, the net charge of loop 2 of very fast Chara myosin is zero and there is no lysine cluster in it. In contrast, Chara myosin has a highly positively charged loop 3. To elucidate the role of these unique surface loops of Chara myosin in its high velocity and high actin-activated ATPase activity, we have undertaken mutational analysis using recombinant Chara myosin motor domain. It was found that net positive charge in loop 3 affected V_max and K_app of actin activated ATPase activity, while it affected the velocity only slightly. The net positive charge in loop 2 affected K_app and the velocity, although it did not affect V_max. Our results suggested that Chara myosin has evolved to have highly positively charged loop 3 for its high ATPase activity and have less positively charged loop 2 for its high velocity. Since high positive charge in loop 3 and low positive charge in loop 2 seem to be one of the reasons for Chara myosin''s high velocity, we manipulated charge contents in loops 2 and 3 of Dictyostelium myosin (class II). Removing positive charge from loop 2 and adding positive charge to loop 3 of Dictyostelium myosin made its velocity higher than that of the wild type, suggesting that the charge strategy in loops 2 and 3 is widely applicable.     

Anomalous right lobe of the liver: CT appearance

We report five cases of anomalous right lobe of the liver diagnosed by computed tomography (CT). There were three men and two women, with an average age of 67 years. The right lobe was deformed and decreased in size in all patients. Hypertrophy of the left lobe was present in all patients.     

Superiority of 10-mm-wide Balloon over 8-mm-wide Balloon in Papillary Dilation for Bile Duct Stones: A Matched Cohort Study

Background/Aims:

Endoscopic papillary balloon dilation (EPBD) is a possible alternative to endoscopic sphincterotomy (EST) for common bile duct (CBD) stones. To date, 10- and 8-mm EPBD have not been fully compared.

Patients and Methods:

Patients who underwent EPBD for CBD stones at two Japanese tertiary care centers between May 1994 and January 2014 were identified. Matched pairs with 10- and 8-mm EPBD were generated. Short- and long-term outcomes were compared between the two groups.

Results:

A total of 869 patients were identified (61 and 808 patients for 10- and 8-mm EPBD, respectively), and 61 well-balanced pairs were generated. The rate of complete stone removal within a single session was higher in the 10-mm EPBD group than in the 8-mm EPBD group (69% vs. 44%, P < 0.001), and use of lithotripsy was less frequent in the 10-mm EPBD group (23% vs. 56%, P < 0.001). The rates of post-ERCP pancreatitis were similar between the 10- and 8-mm EPBD groups (11% vs. 8%). Cumulative biliary complication-free rates were not statistically different between the two groups: 88% [95% confidence interval (CI): 79–97%] and 94% (95% CI: 88–100%) at 1 year and 69% (95% CI: 56–85%) and 80% (95% CI: 69–93%) at 2 years in the 10- and 8-mm EPBD groups, respectively. In the 10-mm EPBD group, ascending cholangitis was not observed, and pneumobilia was found in 5% of cases during the follow-up period.

Conclusions:

EPBD using a 10-mm balloon for CBD stones is safe and more effective than 8-mm EPBD. The sphincter function is highly preserved after 10-mm EPBD.     

Topic controversies in the endoscopic management of malignant hilar strictures using metal stent: side‐by‐side versus stent‐in‐stent techniques

Endoscopic management of unresectable hilar malignant biliary stricture (MBS) is currently challenging, and the best approach is still controversial. Liver volume is the key to adequate biliary drainage in hilar MBS and multiple stenting is mandatory to drain over 50% of liver volume in most cases. The self‐expandable metallic stent (SEMS) has shown superior patency to plastic stents in recent reports. There are two methods of multiple stenting for hilar MBS: stent‐in‐stent (SIS) and side‐by‐side (SBS). Advantages of SIS include multiple SEMS placement in one stent caliber at the common bile duct (CBD), which is considered physiologically ideal. The through‐the‐mesh (TTM) technique with guidewires and the SEMS delivery system can be technically difficult in SIS, although the recent development of dedicated SEMSs having a loose portion facilitating the TTM technique makes SIS technically feasible both at stent deployment and re‐interventions. Conversely, the SBS technique, if placed across the papilla, is technically simple at initial placement and re‐intervention at stent occlusion. However, SBS has potential disadvantages of overexpansion of the CBD because of parallel placement of multiple SEMS, which can lead to portal vein thrombosis. Given the limited evidence available, a well‐designed randomized controlled trial comparing these two techniques is warranted.     

Deletion of the RAG2 C terminus leads to impaired lymphoid development in mice

The recombination-activating gene (RAG)1 and RAG2 proteins comprise the lymphocyte-specific components of the V(D)J recombinase and are required for the assembly of antigen-receptor variable-region genes. A mutant truncated RAG2 protein ("core" RAG2) lacking the C-terminal 144 amino acids, together with core RAG1, is able to mediate the basic biochemical steps required for V(D)J recombination in vitro and in transfected cell lines. Here we examine the effect of replacing the endogenous RAG2 locus in mice with core RAG2. These mice generate substantial numbers of B and T cells, demonstrating that the core RAG2 protein retains significant in vivo function. However, core RAG2 mice display a reduction in the total number of B and T cells, reflecting impaired lymphocyte development at the progenitor stage associated with reduced chromosomal V(D)J recombination. We discuss potential roles of the RAG2 C terminus in mediating rearrangement of endogenous antigen-receptor loci.