NASOGALLBLADDER DRAINAGE FOR MIRIZZI’S SYNDROME

The authors experienced a case of Mirizzi’s syndrome successfully treated with endoscopic nasogallbladder drainage (ENGBD). The patient was a 63‐year‐old man. He was admitted with abdominal pain and jaundice. Laboratory data indicated leukocytosis and elevation of serum bilirubin level. Abdominal ultrasound showed marked swelling of gallbladder and debris in the gallbladder, therefore, the authors strongly suspected Mirizzi’s syndrome. He had past history of acute myocardial infarction and treated with anticoagulation therapy. Then, the authors couldn’t perform surgical removal or percutaneous transhepatic drainage, and tried endoscopic transpapillary drainage. Endoscopic retrograde cholangiopancreatography revealed smooth stricture in the superior portion of common bile duct and occlusion of the cystic duct, and ENGBD was then performed. After ENGBD, his complaints, laboratory data, swelling of gallbladder and stricture of common bile duct were all remarkably improved.     

Laparoscopic choledochotomy with primary closure

Background: Thirty-three patients were candidates for laparoscopic choledochotomy. The indications for this operation are described. Methods: The procedure was completed 32 times (97%). We had 29 successful common bile duct (CBD) clearances, three negative explorations, and one failed clearance which needed to be converted to laparotomy. All the completed procedures ended with primary closure of the main duct. Median duration of surgery was 180 min (range 100–300), including three associated laparoscopic procedures. Results: There were three postoperative complications (9.4%), none major. Average postoperative hospital stay was 7.1 days (range 4–14). In May–June 1995 we controlled 31 out of the 32 consecutive patients (one patient was lost to follow-up) who had a successful laparoscopic choledochotomy from October 1991 to December 1994. Median follow-up was 22 months (range 5–44). Besides clinical control, 23 patients also had ultrasound (US) controls and 24 had blood tests. Eleven had intravenous cholangiotomography. Two patients died 11 and 22 months after the operation for unrelated causes and without biliary symptoms. Two patients had umbilical hernias. One had a small residual asymptomatic stone, which was removed endoscopically. None had signs of postoperative CBD stricture. At US, CBD was ≤7 mm in 15 patients, 8–10 mm in four patients, and 10–12 mm in three patients. The last group had preoperative CBD dilation, too. We could compare preoperative and postoperative CBD diameters in 22 patients: 11 had no change; in nine it decreased; and two had a slight increase (8–10 mm). Conclusions: We conclude that laparoscopic choledochotomy with primary closure is a very good operation: It has a high success rate and low morbidity. Mortality is nil so far. Medium-term results are very positive: We had no CBD stricture and only one case of asymptomatic residual stone, which could have been avoided. Our results suggest that intraductal biliary drainage is useless, and its specific complications are well known. Received: 20 October 1995/Accepted: 28 February 1996     

Lymphatic drainage of the gallbladder

Based upon detailed dissections of the lymphatic system in adult cadavers, the lymphatic drainage of the gallbladder was divided into three pathways: (1) The cholecystoretropancreatic pathway, which had two routes, one running spirally from the anterior surface of the common bile duct to the right rear, and the other running almost straight down from the posterior surface of the common bile duct. These routes converged at the principal retroportal node at the posterior surface of the head of the pancreas. (2) The cholecysto-celiac pathway; this was the route running to the left through the hepatoduodenal ligament to reach the celiac nodes. (3) The cholecysto-mesenteric pathway; this was the route running to the left in front of the portal vein to connect with the nodes at the superior mesenteric root. The cholecysto-retropancreatic pathway can be regarded as the main pathway, and the principal retroportal node appeared to be critical as the main terminal node in the visceral lymphatic system of the gallbladder. These three pathways converged with the abdomino-aortic lymph nodes near the left renal vein, and the nodes in the interaortico-caval space were considered to be of particular importance. Offprint requests to: M. Ito     

Analysis of mast cell subpopulations (MCT, MCTC) in cutaneous inflammation using novel enzyme-histochemical staining techniques

Abstract In order to gain insights into the dynamics of mast cell subpopulations in normal and diseased skin, a novel enzyme-histochemical double and triple staining method was employed that allowed the detection of metachromasia (toluidine blue) and the mast cell proteases tryp-tase and chymase within the same cell. Cryostat sections were used of skin biopsies from the following specimens: normal skin (N=4), psoriasis (N=13), atopic eczema (N=7), lichen planus (N=6), interferon α2a injection sites (N=l) of a leukemic infiltrate and corresponding normal skin of the same patient before and after treatment. (i) Equal numbers of tryptase-and chymase-positive mast cells (MCTC) were obtained in all normal and diseased specimens in papillary and reticular dermis, with threefold increases around appendages, (ii) Tryptase-positive mast cells (MCT) were absent in normal skin, but were markedly increased in a disease-specific pattern within the papillary dermis, the inflammatory infiltrate and around appendages, (iii) Marked increases of MCT were also noted at interferon injection sites within the leukemic infiltrate, but not in the normal skin of the same patient. These data suggest that disease-dependent mast cell dynamics involve only MCT in cutaneous inflammation and that MCT numbers are controlled by distinct, disease-specific local tissue factors.     

Hand and gender differences in the organization of aiming in 5-year-old children.

The aim of the present study was to analyze the organization of aiming movements in right-handed children aged 5 years, depending on gender and hand used to perform the task. We first tested the hypothesis that aiming movements are predominantly organized in a feed-forward manner before the age of six. Using a direction pre-cueing protocol, we analyzed the effect of gender and hand used to perform the task on reaction time (RT), movement time (MT), spatial accuracy (SA) and acceleration profiles (APs) in children aged 5 years. Differences in RT between the uncued and pre-cued conditions suggest that the direction is actually specified prior to the execution of the movement at the age of five. However, the results also show significant hand and gender effects on MTs, spatial error and APs. Specifically, in girls, MT and kinematics profiles vary as a function of hand and target localization, whereas this is not the case in boys. In addition, SA is lower when aiming with the non-dominant hand in boys, but not in girls. These results suggest that multiple movement strategies are already available to the child at the age of five. Girls appear to be able to change movement strategy as a function of the constraints of the task, resulting in a stability of spatial accuracy (SA). On the contrary, the functional advantage of the right hand on MT and SA generally reported in right-handed males is not present in the boys at the age of five.     

Effect of arm-shoulder fatigue on carpenters at work

Summary The purpose of the study was to analyse the effect of arm-shoulder fatigue on manual performance. Ten experienced carpenters performed three standardized tasks (nailing, sawing and screwing). Electromyographic activity was recorded from six arm-shoulder muscles and the performances were video-filmed. After 45 min of standardized arm-cranking (arm-shoulder-fatiguing exercise of approximately 70%–80% maximal oxygen consumption), the tasks were repeated. The number of work movements and the time taken for each task were recorded and the quality of the work performed was compared. After the fatiguing exercise, only nailing was perceived as being harder and more mistakes were made during nailing and sawing. Movement performance was not influenced during nailing but was slightly slower during sawing and faster during screwing. However, there were increased mean EMG amplitudes in the upper trapezius and biceps muscles during nailing, in the upper trapezius, anterior deltoid and infraspinatus muscles during sawing and in the anterior deltoid muscle during screwing. Of the muscles studied the upper trapezius and anterior deltoid muscles increased their activity most after the arm-shoulder-fatiguing exercise.     

Thoracic duct lymph and PEEP studies in anaesthetized dogs

PEEP impedes thoracic duct drainage (LF). This can be counteracted by a thoracic duct fistula. Consequently, lung oedema (LOE) should develop during PEEP more slowly with LF at atmospheric pressure (LF_AP) than with LF against jugular venous pressure (LF_JVP). In 12 anaesthetized dogs LOE was produced by Ringer's solution i.v. (2.5 ml/min per kg) for 6 h during PEEP (10 mmHg) with either LF_AP or LF_JVP. Ringer's+PEEP greatly increased aortic, pulmonary artery and wedge pressures, JVP, and cardiac output. Colloid osmotic pressures in plasma and lymph were drastically reduced, pulmonary effective filtration pressure (EFP) rose by about 20 mmHg. LF_JVP increased 7-fold, LF_AP about 19-fold, the respective loss of plasma proteins was 1.83 and 1.06 g/kg during 6 h. Thermal-dye extravascular lung water showed an increment of 68 with LF_JVP versus 43 l/h/g per mmHg with LF_AP. Final lung water content was at any EFP (12.8–31.9 mmHg) lower with LF_AP than with LF_JVP amounting 512 with LF_JVP versus 377 l/g/per mmHg with LF_AP. LF_AP decreased the development of LOE during PEEP by bypassing the PEEP-induced high JVP and thus facilitating the removal of interstitial fluid. It is hypothesized that a thoracic duct fistula might aid the treatment of patients with LOE due to ARDS and therefore requiring high levels of PEEP.     

国产房水引流物置入术治疗难治性青光眼远期疗效观察

１９９３年７月～１９９８年１月为１０３例（１０６只眼）难治性青光眼患者施行国产房水引流物（ＨＡＤ）置入术。术后平均随访３２８月。术后１年时平均眼压２２±１．４ｋＰａ。术后１～５年的手术成功率分别为８３８％,８０４％,７７１％,７１０％及６４３％。术中联合应用丝裂霉素Ｃ的病例,其术后１年时的成功率为８９５％。术后常见的并发症有持续性浅前房,局限性脉络膜脱离及眼压升高等。认为ＨＡＤ可用于治疗难治性青光眼。     

十二指肠腔内置管引流减压在毕-Ⅱ式胃大部切除术中应用疗效的观察

目的探讨防止毕-Ⅱ式胃大部切除术后十二指肠残端破裂发生的方法;方法对毕-Ⅱ式胃大部切除术中出现十二指肠残端水肿或血运差的病例,采取预防性十二指肠腔内置管引流减压的方法,收集临床资料、观察治疗效果;结果采取十二指肠腔内置管引流减压后,十二指肠残端破裂发生率明显下降;结论十二指肠腔内置管引流减压,可以预防十二指肠残端破裂的发生,并可拓宽溃疡穿孔病例采用胃大部切除术的适应证。     

Effect of continuous cisternal drainage on cerebral vasospasm

Summary The effect of continuous cisternal drainage on cerebral vasospasm was studied under strict criteria in 140 patients with ruptured intracranial aneurysms. The degree of subarachnoid haemorrhage (SAH) on the computed tomography scan was graded from I to IV. The patients were classified according to the total amount of cisternal drainage into three groups, regardless of the duration of the drainage and whether or not it was accompanied by irrigation; i.e., those with less than 500 mL (group 157 cases), those with 500–3000 mL (group 2 44 cases), and those with 3000–9500 mL (group 3 39 cases).While correlations could be found between both clinical and SAH grades with the severity of vasospasm, closer correlation could be found in the SAH grades. In analyzing the cases with subarachnoid haemorrhage grades III–IV (severe clots), the angiographic vasospasm was less severe in groups 2 and 3 than in group 1, and the incidences of permanent symptomatic vasospasm and low-density area on computed tomography were lower in groups 2 and 3 than in group 1. Regarding the surgical outcome in cases with SAH grades III–IV, the mortality rate was lower in groups 2 and 3 (22% and 19%) than in group 1 (33%). Further, the rate of good recovery was higher in groups 2 and 3 (61% and 57%) than in group 1 (28%). However, there were no differences between groups 2 and 3 in cerebral vasospasm or in surgical outcome. As a shortcoming of continuous cisternal drainage, the need for shunt operation was higher in groups 2 and 3 than in group 1.