Gastric duplication communicating with the left hepatic duct: a rare case of recurrent hemobilia in a child.

Gastric duplication is a rare anomaly, usually manifested as an abdominal mass or gastric outlet obstruction mimicking congenital hypertrophic pyloric stenosis during the first year of life. Occasionally, it communicates with the pancreatic duct and causes pancreatitis. However, communication with the intrahepatic bile duct has not been described. The authors report a rare case of gastric duplication that communicated with the left hepatic duct and caused recurrent hemobilia in a 2-year-old girl. Left hepatectomy and excision of the duplication were curative.     

Morphological investigation of the enteric nervous system in Hirschsprung's disease and hypoganglionosis using whole-mount colon preparation

BACKGROUND/PURPOSE: A suction rectal mucosal biopsy with positive staining for acetylcholinesterase is a useful test for diagnosis of Hirschsprung's disease (HD). However, hypoganglionosis has not been diagnosed by a rectal mucosal biopsy. The authors morphologically examined the enteric nervous systems in HD and hypoganglionosis patients using whole-mount preparations. METHODS: Six HD patients, two hypoganglionosis patients, and 10 with normally innervated colons were examined. Colonic specimens were incubated with the primary antibodies against protein gene product 9.5 (PGP 9.5) mixed with S-100b protein, tyrosine hydroxylase (TH), calcitonin gene-related peptide (CGRP), substance P (SP), and neurofilament protein 200 kDa (NFH). They were observed by histochemical technique using light-microscopy in whole-mount preparations. RESULTS: The aganglionic distal colon had thick nerve strands stained with PGP 9.5 mixed with S100 or NFH located in the layer between the longitudinal muscle and the circular one, and the submucosal layer. The nerve strands in the myenteric layer contained few CGRP- and SP-positive fibers and ran along the long axis of the intestine. Ganglion cells appeared along with those thick nerve strands in the transitional zone of HD. In hypoganglionosis, we found small myenteric ganglia with no thick nerve strands. CONCLUSIONS: The enteric nervous system in oligoganglionic segments of HD morphologically differed from the one in hypoganglionosis. A suction rectal mucosal biopsy would be of no use in the diagnosis of hypoganglionosis.     

Effects of bacterial endotoxin on the contraction and relaxation responses of the rabbit cavernous smooth muscles

PURPOSE: We evaluated effects of bacterial endotoxin during septicemia on contraction and relaxation responses of cavernous smooth muscles in rabbits. MATERIALS AND METHODS: We performed isometric tension studies with norepinephrine (NE), endothelium-dependent and endothelium-independent vasodilators, and nonadrenergic noncholinergic (NANC)-selective electrical field stimulation on the muscle strips of control and endotoxin (lipopolysaccharide; LPS)-treated rabbits. To determine reversibility of the LPS effects on the cavernous smooth muscle, the contraction and relaxation studies were repeated after resting the strips for 1 day at 4C. We also investigated the effect of the nonspecific nitric oxide synthase (NOS) inhibitor (NW-nitro-L-arginine methyl ester; L-NAME) and the selective immunologic NOS inhibitor (aminoguanidine) on reactivity of the strips to NE and acetylcholine. RESULTS: Contractile response to NE was significantly (p <0.01) reduced in the cavernous smooth muscles from the systemically and locally LPS-treated rabbits, compared with control group. Both aminoguanidine and L-NAME markedly improved the diminished contraction of the strips. Relaxation response to endothelium-dependent agonists (acetylcholine and bradykinin) was significantly (p <0.05) decreased in the LPS-treated groups, compared with the control group but not to endothelium-independent vasodilators (papaverine and verapamil) and NANC-selective electrical field stimulation. L-NAME completely inhibited the relaxation response to acetylcholine in the control and LPS-treated groups but aminoguanidine did not. The impaired contraction and relaxation of the strips was completely restored after resting for 1 day. CONCLUSIONS: Bacterial endotoxin may cause non-endothelial overproduction of NO and inhibition of endothelium-derived NO production, which may contribute to impairment of contraction and relaxation of rabbit cavernous smooth muscles.     

Evaluation of Tracheobronchial Diseases: Comparison of Different Imaging Techniques

Objective

To compare the clinical utility of the different imaging techniques used for the evaluation of tracheobronchial diseases.

Materials and Methods

Forty-one patients with tracheobronchial diseases [tuberculosis (n = 18), bronchogenic carcinoma (n = 10), congenital abnormality (n = 3), post-operative stenosis (n = 2), and others (n = 8)] underwent chest radiography and spiral CT. Two sets of scan data were obtained: one from routine thick-section axial images and the other from thin-section axial images. Multiplanar reconstruction (MPR) and shaded surface display (SSD) images were obtained from thin-section data. Applying a 5-point scale, two observers compared chest radiography, routine CT, thin-section spiral CT, MPR and SSD imaging with regard to the detection, localization, extent, and characterization of a lesion, information on its relationship with adjacent structures, and overall information.

Results

SSD images were the most informative with regard to the detection (3.95±0.31), localization (3.95±0.22) and extent of a lesion (3.85±0.42), and overall information (3.83±0.44), while thin-section spiral CT scans provided most information regarding its relationship with adjacent structures (3.56±0.50) and characterization of the lesion (3.51±0.61).

Conclusion

SSD images and thin-section spiral CT scans can provide valuable information for the evaluation of tracheobronchial disease.     

Malignant gastric outlet obstructions: treatment by means of coaxial placement of uncovered and covered expandable nitinol stents

PURPOSE: To assess whether coaxial placement of uncovered and covered expandable nitinol stents overcomes the disadvantages of the increased migration rate seen with covered stents and the tumor ingrowth seen in uncovered stents in the treatment of malignant gastric outlet obstructions. MATERIALS AND METHODS: Two types of expandable nitinol stent were designed: an uncovered stent and a covered stent. Under fluoroscopic guidance, the uncovered and covered stents were placed coaxially with complete overlap in 39 consecutive patients with malignant gastric outlet obstruction caused by stomach cancer. Food intake capacity was graded on a scale of 0-4. Stent patency rate was estimated by the Kaplan-Meier method. RESULTS: Technical success rate was 97% (38 of 39 patients). After stent placement, food intake capacity improved at least one grade in 36 patients. Stent migration occurred in three patients (8%), that is, partial (n = 2) or complete (n = 1) upward migration of the inner covered stent into the stomach. Two of these patients were treated by placement of an additional covered stent. During the mean follow-up period of 134 days (range, 15-569 d), 10 patients developed recurrent symptoms of obstruction with tumor overgrowth being the most common cause. Nine underwent placement of an additional covered stent with good results. The median period of primary stent patency was 157 days (mean, 278 d). The 30-, 60-, and 180-day patency rates were 97%, 91%, and 39%, respectively. Four patients (10%) died within 1 month after the procedure. CONCLUSION: Coaxial stent placement technique seems to contribute to decreasing the migration rate of the stent and decrease the rate of recurrent obstruction by preventing or delaying tumor ingrowth.     

Urologic complications of laparoscopic radical hysterectomy and lymphadenectomy

Introduction and hypothesis

The purpose of this study was to evaluate the intra- and postoperative urologic complications and management in patients with cervical or endometrial cancer treated with laparoscopic radical hysterectomy and lymphadenectomy.

Methods

We retrospectively reviewed the medical records of 146 patients with cervical or endometrial cancer who underwent total laparoscopic radical hysterectomy with lymphadenectomy between August 2002 and April 2011. The intra- and postoperative urologic complications were analyzed.

Results

Double ureteral stents were inserted prophylactically in 13 patients (8.9?%), 2 of whom had postoperative urologic complications. Nine patients (6.2?%) had postoperative urologic complications. Of four patients with ureterovaginal fistulas, two were treated conservatively with cystoscopic placement of ureteral stents and two underwent ureteroneocystostomies. Vesicovaginal fistulas occurred in two patients, both of whom underwent vesicovaginal fistula repairs. One patient noted to have a bladder injury intraoperatively had a laparoscopic repair, and one patient noted to have a ureteral injury postoperatively was treated conservatively with cystoscopic placement of ureteral stents.

Conclusions

Iatrogenic lower urinary tract injuries during laparoscopic radical hysterectomy are relatively common complications. Intraoperative prophylactic ureteral stent insertion and the early detection of urologic complications postoperatively is advised for patients who undergo laparoscopic radical hysterectomies.