Self-expandable metallic stent for unresectable malignant strictures in the esophagus and cardia

Objective Self-expandable metallic stent (EMS) placement has been the first choice for dysphagia because of the certainty over its safety, low invasiveness, and immediate efficacy. However, there still remain some problems in relation to the EMS placement site and anticancer therapies before and after EMS placement. Methods: Consecutive 78 patients in whom EMS was placed due to the unresectable malignant stricture in the esophagus or cardia from July 1995 to August 2003 in our department were studied. Results: Gastroesophageal reflux was found in 5 of 8 patients after placement of conventional EMS for the stricture in the gastroesophageal junction. Meanwhile, acid and bile reflux into the esophagus were not detected by pH and bilirubin monitoring, respectively, in 6 patients after placement of the EMS with an anti-reflux mechanism for the stricture in the gastroesophageal junction. The median survival period of all patients after EMS placement was 123 days. The median survival period of 7 patients with radiotherapy only after EMS placement was 138 days and that of 17 patients with radiotherapy before EMS placement was 60 days, which was shorter than that of the former (p<0.05). On the other hand, the median survival period after hospital admission due to dysphagia of these 7 patients was longer than that of 17 patients with radiotherapy only before EMS placement, although, the difference was not significant. Conclusion: EMS with an antireflux mechanism is not commercially available in Japan and approval is urgently required. The indication of radiotherapy associated with EMS placement is to be studied further.     

Effect of substituting allogenic blood transfusion with autologous blood transfusion on outcomes after radical oesophagectomy for cancer.

BACKGROUND: The oncologic benefit of avoiding allogenic blood transfusion in oesophageal cancer resection has not been studied. METHODS: The medical records of 68 patients (Auto group) who underwent a potentially curative oesophageal cancer resection without allogenic blood transfusion from 1996 to 1999 receiving 800 g of autologous blood donated preoperatively, and 97 patients (Allo group) who underwent the same operation with allogenic blood transfusion from 1990 to 1995 were compared. RESULTS: There were no differences in age, gender, stage of disease, number of retrieved nodes, or perioperative hemoglobin concentration between the two groups. The survival of the 45 patients with nodal involvement in the Auto group was better than that of the 59 patients in the Allo group (p=0.0435), and the survival of the 35 patients with T3 or T4 lesions in the Auto group was better than that of the 61 patients in the Allo group (p=0.0408). According to logistic regression analysis, allogenic blood transfusion correlated with tumour recurrence in patients with either nodal involvement or a T3-4 lesion. The natural killer cell activity remained higher in the Auto group than in the Allo group (p<0.05). CONCLUSION: Avoidance of allogenic blood transfusion favorably effected the survival of patients with oesophageal cancer at risk for recurrence.     

Utility of endoscopic ultrasonography in assessing the indications for endoscopic surgery of submucosal esophageal tumors

BACKGROUND: The submucosal tumor (SMT) of the esophagus presents good indications for minimal invasive surgery, such as endoscopic or thoracoscopic resection. However, it is essential that the layer of origin be ascertained. The SMT can be detected as hypoechoic lesions in the wall of the esophagus, and the intramural location can be estimated in terms of destruction or deviation of the ultrasonic layer structure of the esophagus. METHODS: To test the efficacy of this approach, a series of patients were examined by an endoscopic ultrasonography (EUS). RESULTS: In one patient, the lesion was diagnosed as located in the muscularis mucosa, and endoscopic resection was performed. In another four patients, the lesions appeared to be in the proper muscle layer, and enucleation was carried out under thoracoscopy or open surgery. Histologically, all of the lesions were leiomyomas, and the EUS diagnosis was correct in all of the patients. CONCLUSIONS: Thus, the intramural condition of SMTs can be estimated and indications for endoscopic or thoracoscopic resection assessed by this approach.     

Effect of H. pylori on COX-2 expression in gastric remnant after distal gastrectomy

BACKGROUND/AIMS: Helicobacter pylori infection is known to induce gastritis, oxidative stress, and cyclooxygenase (COX)-2 expression in the gastric mucosa. However, the effect of H. pylori infection on remnant gastritis has not been studied. We investigated whether the severity of remnant gastritis and COX-2 expression were affected by H. pylori infection after distal gastrectomy. METHODOLOGY: The study included 97 patients with gastric cancer who underwent curative distal gastrectomy with lymphadenectomy in our department between May 1999 and April 2001. All patients underwent endoscopic examination 2 weeks before and 12 weeks after surgery. The presence of H. pylori infection was determined by urease activity, hematoxylin-eosin staining, and immunochemical staining. Histologic remnant gastritis was graded based on the degree of neutrophil infiltration using the updated Sydney System. COX-2 expression was estimated immunohistochemically. RESULTS: Both the degree of neutrophil infiltration and the level of COX-2 expression were significantly higher in patients with than without H. pylori (p<0.05). There was a significant correlation between the degree of neutrophil infiltration and the degree of COX-2 expression (p<0.001). CONCLUSIONS: H. pylori eradication may become a treatment for preventing both remnant gastritis as well as remnant gastric carcinoma after distal gastrectomy.     

Gonadotropin-inhibitory hormone neurons interact directly with gonadotropin-releasing hormone-I and -II neurons in European starling brain

Gonadotropin-inhibitory hormone (GnIH) is a hypothalamic dodecapeptide (SIKPSAYLPLRF-NH(2)) that directly inhibits gonadotropin synthesis and release from quail pituitary. The action of GnIH is mediated by a novel G-protein coupled receptor. This gonadotropin-inhibitory system may be widespread in vertebrates, at least birds and mammals. In these higher vertebrates, histological evidence suggests contact of GnIH immunoreactive axon terminals with GnRH neurons, thus indicating direct regulation of GnRH neuronal activity by GnIH. In this study we investigated the interaction of GnIH and GnRH-I and -II neurons in European starling (Sturnus vulgaris) brain. Cloned starling GnIH precursor cDNA encoded three peptides that possess characteristic LPXRF-amide (X = L or Q) motifs at the C termini. Starling GnIH was further identified as SIKPFANLPLRF-NH(2) by mass spectrometry combined with immunoaffinity purification. GnIH neurons, identified by in situ hybridization and immunocytochemistry (ICC), were clustered in the hypothalamic paraventricular nucleus. GnIH immunoreactive fiber terminals were present in the external layer of the median eminence in addition to the preoptic area and midbrain, where GnRH-I and GnRH-II neuronal cell bodies exist, respectively. GnIH axon terminals on GnRH-I and -II neurons were shown by GnIH and GnRH double-label ICC. Furthermore, the expression of starling GnIH receptor mRNA was identified in both GnRH-I and GnRH-II neurons by in situ hybridization combined with GnRH ICC. The cellular localization of GnIH receptor has not previously been identified in any vertebrate brain. Thus, GnIH may regulate reproduction of vertebrates by directly modulating GnRH-I and GnRH-II neuronal activity, in addition to influencing the pituitary gland.     

Percutaneous management of bile duct injuries after cholecystectomy

Intraoperative biliary tract injuries are relatively uncommon, but are a cause of significant morbidity and mortality. We have repaired open biliary tract injuries found postoperatively in three patients without reoperation by percutaneous intervention. In two cases, biliary stents were placed percutaneously across the injured portion of the bile duct. For this procedure, a unique coaxial guidewire technique was used. The bile leaks resolved soon after insertion of the biliary stents. In one patient, an expandable metallic biliary endoprosthesis was inserted, and the temporary stent was removed. This patient had no signs or symptoms of cholangitis or biliary obstruction at the 6-year follow-up. The other patient died of heart failure soon after reconstruction. In the last patient, a biliary drain was inserted through the injured duct via the biliocutaneous fistula. In this case, biliary drainage alone resulted in resolution of the bile leak, because the injury was partial without a stricture. This patient was well at the 3-year follow-up. Percutaneous management of bile duct injuries is an alternative in selected patients.