Cholestatic hepatocellular carcinoma diagnosed by deposits of Lipiodol and treated by combination of endoscopic retrograde biliary drainage and transcatheter arterial embolization

Cholestatic hepatocellular carcinoma, which grows into the bile duct and causes obstructive jaundice, is rare and difficult to diagnose. A case is presented in which cholestatic hepatocellular carcinoma was detected by deposit of Lipiodol. This is also the first case that was successfully treated by endoscopic retrograde biliary drainage and transcatheter arterial embolization.     

HLA‐haploidentical nonmyeloablative stem cell transplantation: induction to tolerance without passing through mixed chimaerism

There are few reports of unmanipulated HLA‐haploidentical nonmyeloablative stem cell transplantation (NST) using only pharmacological acute graft‐vs.‐host disease (GVHD) prophylaxis. We present here a successful case of unmanipulated HLA‐haploidentical NST for mediastinal large B cell lymphoma that was resistant to autologous peripheral blood stem cell transplantation (PBSCT). The conditioning regimen consisted of fludarabine, busulfan and rabbit anti‐T‐lymphocyte globulin (ATG) in addition to rituximab. GVHD prophylaxis was performed using tacrolimus and methylprednisolone 1 mg/kg. The patient had rapid engraftment, with 100% donor chimaerism in the lineages of both T cells and granulocytes on day +12, but developed no GVHD clinically. The patient is still in complete remission past day +1020, with no sign of chronic GVHD without receiving immunosuppressive agents. HLA‐haploidentical NST may be performed without utilizing mixed chimaerism.     

Multiple Early Gastric Carcinoma in Cases Treated Endoscopically

Multiple gastric carcinoma was endoscopically diagnosed in 14 patients (13.6%) with 33 lesions (27.3%), out of 103 cases of early gastric carcinoma treated by endoscopic surgery. The sex ratio of these patients was 11 males to 3 females, and their mean age was 61.7 years old. In 79% of the patients the macroscopic type of the lesions was the same. Twelve of 33 lesions were metachronous lesions diagnosed by endoscopy using the dye contrast method. All of the metachronous lesions were evaluated as invading only as far as the mucosa. Almost all of the metachronous lesions were located at a height similar to that of the initial lesion or in a more oral direction. Eleven of 12 metachronous lesions were less than 2 cm in diameter, including 5 minute cancer lesions which were less than 5 mm in size. All these lesions were treated again endoscopically without gastrectomy. These results suggest that an annual endoscopy using the dye contrast method permits early detection of gastric carcinoma at a stage at which it can be treated endoscopically.     

Severe bullous emphysema and hypercapnia successfully treated by bronchoscopic lung volume reduction

Patients with severe COPD may develop hypercapnic respiratory failure requiring mechanical ventilation and are at risk of becoming ventilator-dependent. We describe a patient with uncontrollable hypercapnic respiratory failure on mechanical ventilation whose respiratory condition and life were improved after bronchoscopic lung volume reduction. Further discussion of the possibility of bronchoscopic lung volume reduction in patients who require mechanical ventilation due to hypercapnic respiratory failure is warranted.     

Endoscopically Resected Colorectal Sessile Tumors with Nodular Surface Aggregates

Twenty colorectal sessile tumors, with nodular surface aggregates, were endoscopically resected in 20 patients. Among 17 tumors less than 19 mm in diameter, 16 were completely resected in one session and one required piecemeal resection to achieve complete removal. All three lesions measuring over 30 mm were resected piecemeal, and one of these lesions was concurrently heat-probe treated. Thus, all lesions were completely resected endoscopically. Histologically, tubular adenoma was identified in nine resected specimens, tubulovillous adenoma in eight, serrated adenoma in one, and carcinoma in adenoma in two. None of the malignant lesions had invaded the submucosa. Adenomas showing severe atypia and carcinomas in adenomas accounted for 55% of all lesions. These findings indicate that endoscopic mucosal resection is the treatment of choice for sessile tumors with nodular surface aggregates; lesions which cannot be managed by this procedure should be surgically resected.     

ENDOTOXIN CLEARANCE BY EXCHANGE BLOOD TRANSFUSION IN SEPTIC SHOCK NEONATES

ABSTRACT. The role of exchange transfusion with fresh whole blood in septic shock infants was evaluated. Endotoxin was positive in 8 of 10 infants and completely removed from 6 by exchange transfusion. All 6 infants with negative endotoxins after exchange transfusions survived, but 2 with positive reactions died despite the exchange transfusion. Staphylococcus aureus was cultured in the blood from 2 infants with negative reactions and one of them survived. These findings suggested that the clearance of endotoxin has an important role in exchange transfusion among septic shock neonates.     

Gastrointestinal perforation in very low-birthweight infants

BACKGROUND: Spontaneous isolated gastrointestinal perforation (SIP) in very low-birthweight infants has been reported as a different disease entity from necrotizing enterocolitis (NEC). The objective of this study was to investigate the incidence and risk factors of NEC and SIP. METHODS: The authors reviewed the medical records of very low-birthweight infants who were admitted to Toho University Perinatal Center, Tokyo, Japan, between 1 January 1991 and 31 December 2002. The diagnosis of NEC was made with the finding of bloody gastric fluid or stool, abdominal distention, and abnormal abdominal X-ray findings such as pneumatosis intestinalis or fixed dilated intestinal loops. SIP was defined at laparotomy as the presence of an isolated gastrointestinal perforation surrounded by normal appearing bowel. RESULTS: A total of 556 very low-birthweight infants were included in this study. Of those, 15 infants were excluded because of major anomalies. Out of 541 infants, 14 were diagnosed to have NEC or gastrointestinal perforation. In total, 13 infants had gastrointestinal perforation and 10 were confirmed as SIP. Two SIP suggestive cases were included in SIP cases. There was only one case of NEC (0.2%) during 12 years in the authors' institute. Eight SIP cases had antenatal nonsteroidal anti-inflammatory drugs (NSAID). The treatment with antenatal NSAID was significantly associated with the incidence of SIP (p<0.001). CONCLUSION: The authors experienced only one proven case of NEC (0.2%), 12 cases of SIP (2.2%) among 556 very low-birthweight infants admitted during 12 years. Antenatal NSAID were strongly associated with SIP.     

Transoral vs. Endoscopic Endonasal Approach for Clival/Upper Cervical Chordoma

The surgical results of 18 cases of clival/upper cervical chordoma treated in the last decade via the endoscopic endonasal approach (EEA, 9 cases) and the transoral-transpalatal approach (TO-TPA, 9 cases) were compared. Each group showed the same incidence of subdural invasion, with 5 cases each. The superior (frontal base) and lateral surgical fields were wider by EEA, but the inferior view lower than the cranio-vertebral junction (CVJ) was wider by TO-TPA. Gross total removal was achieved in 3 cases in the EEA group, but in only 1 case in the TO-TPA group. Differences in radicality might be due to the extent of the lateral and subdural overview. However for large tumors extending below the CVJ, TO-TPA was the only viable approach for surgical removal. Surgical complications were higher in the EEA (4 cases) than the TO-TPA group (1 case), and were mainly caused by aggressive management of subdural invasion in the EEA group. Post-operative oral intake was earlier and the operative time was shorter in the EEA group. The surgical results were more radical and less invasive in the EEA group than the TO-TPA group. However in tumors extending below the CVJ, the surgical field in EEA was limited, indicating the need to use the transoral route or a combination of routes. A higher complication rate following subdural management was a negative factor that requires improvement in the EEA group and two-staged EEA followed by a transcranial approach may be considered for the cases with subdural invasion.