Intrahepatic cholangiojejunostomy (Longmire procedure) for recurrent bilioenteric anastomotic stricture with hepatolithiasis

Interventional procedure via percutaneous transhepatic route is often performed, as an initial treatment, in patients with benign bilioenteric anastomotic stricture. However, surgical management is required in most cases in which radiological intervention is unsuccessful. In this report, we describe a case of a 67-year-old woman with recurrent bilioenteric anastomotic stricture, accompanying bilateral hepatolitiasis after several times of transhepatic interventions. The patient underwent intrahepatic cholangiojejunostomy (Longmire procedure) and cholangioscopic lithotomy after resection of an atrophic left lateral segment resulting from hepatolithiasis. Although the damaged hilar bile duct had to be isolated and divided from the corresponding vasculature for re-anastomosis, it was quite impossible due to severe inflammatory change at the hepatic hilus. We, therefore, anastomosed the intact biliary stump on the cut surface of the left lateral segment to the jejunal loop with a stent tube. The patient's postoperative course was uneventful and she exhibited no evidence of cholangitis during follow-up period of 1 year after surgery. At present, the indications for intrahepatic cholangiojejunostomy for biliary obstruction, are quite limited, but biliary surgeons should keep this procedure in mind at the time of biliary reconstruction for benign proximal bile duct stricture, particularly in cases of multiply operated hilum.     

Helicobacter pylori may survive ampicillin treatment in the remnant stomach

Helicobacter pylori (H. pylori) is a Gram-negative curved rod-like or spiral bacterium that chronically infects the human gastric mucosa, and is a major risk factor for gastritis, gastric and duodenal ulcer and adenocarcinoma of the stomach. After partial gastrectomy, some patients may have persistent H. pylori infection for five years or more. In this study, we detected three bacteria, i.e., Klebsiella pneumoniae, Enterobacter aerogenes, and Escherichia coli, in the gastric juice of patients with a remnant stomach. Some of these bacteria produced beta-lactamase. These findings are potentially important since such bacteria could provide H. pylori with the chance to acquire drug resistance and to transfer drug resistance genes. This could be one reason why H. pylori is difficult to eradicate in the remnant stomach.     

Endoscopic internal biliary drainage in a child with malignant obstructive jaundice caused by neuroblastoma

We describe a 13-year-old girl who underwent insertion of a Flexima biliary stent for obstructive jaundice due to compression of the extrahepatic bile duct by an enlarged lymph node secondary to neuroblastoma. This novel endoscopic internal biliary drainage procedure was safe and effective even for a child, and improved her quality of life. We further review other treatment options available for malignant obstructive jaundice in children.     

Screening for genetic heterogeneity in the interferon sensitivity determining region of the hepatitis C virus genome by polymerase chain reaction with melting curve analysis

BACKGROUND: Although mutations in the interferon (IFN) sensitivity determining region (ISDR) of hepatitis C virus (HCV) have been reported to be useful as a predictive viral factor for IFN therapy in patients infected with HCV-1b, such laboratory research has not been favorably translated into the clinic. To promote such translation, we attempted the establishment of a rapid and simple polymerase chain reaction (PCR) combined with melting curve analysis (MCA) to screen for mutations in the ISDR and for the monitoring of HCV quasispecies. METHODS: A PCR-MCA protocol was established using in-house primers and hybridization probes designed according to the results of direct sequencing of 34 HCV-1b samples. Then, the performance of PCR-MCA was verified by comparing with mutation profiles obtained by direct sequencing and sequencing after cloning. RESULTS: The MCA assay revealed that melting temperature (Tm) was inversely correlated with the number of nucleotide (nt) and amino acid substitutions in the ISDR deduced on the basis of the results of direct sequencing. A boundary Tm of 58.0 degrees C allowed us to discriminate HCV genomes into two groups: one with a Tm >58.0 degrees C had no or a low number of nt substitutions, while the other genomes with a Tm <58.0 degrees C had a high number of nt substitutions, corresponding to wild-type in the former and mutant-type in the latter in respect of a clinical setting for IFN therapy. Moreover, this MCA assay provided precise discrimination of Tm between clones, reflecting the degree of the genetic complexity of HCV genomes. CONCLUSIONS: This study indicates that the MCA assay is useful to rapidly and simply screen the mutational status of the ISDR of HCV, as well as in using the ISDR as one of the targets for discriminating the genetic complexity of HCV genomes. The MCA assay could also be applicable as a convenient and useful screen of the genetic heterogeneity of clones relating to HCV quasispecies.     

Three Cases of Sebaceous Glands in the Esophagus

Abstract: Three cases of patients with sebaceous glands in the esophagus are described in this study. Case 1: This patient had suffered from heart burn for several months. An endoscopy disclosed a slightly elevated rounded granular yellowish lesion 5 mm in diameter in the middle esophagus. Multiple rounded yellowish lesions ranging from 1 to 2 mm in size were also recognized at the immediate distal site. A biopsy revealed normal squamous esophageal epithelium with sebaceous glands making up the underlying elevated lesions. Case 2: This patient had suffered with difficulty in swallowing for a month. An endoscopy disclosed multiple rounded granular yellowish lesions ranging from 1 to 2 mm in diameter in the middle esophagus. A biopsy revealed sebaceous glands (similar to case 1). Case 3: This patient had suffered from epigastric discomfort for a year. An endoscopy disclosed multiple rounded granular yellowish lesions ranging from 1 to 2 mm in diameter in the middle esophagus. A biopsy revealed sebaceous glands.     

Molecular epidemiological investigation of vero toxin-producing Escherichia coli (VTEC) isolated from diarrhea patients and dairy cattle

To elucidate the source and route of VTEC infection, we performed pulse field gel electrophoresis (PFGE) an 50 isolates from human diarrhea typed as serotypes O157, O111, and O26, which were very frequently isolated from patients with VTEC infection between 1986 and 1997, and 32 isolates from dairy cattle, a total of 82 isolates. The isolates were genetically analyzed based on the electrophoresis patterns of DNA, and a phylogenetic tree was prepared. The isolates were classified based on similarity > or = 89. The following results of the molecular epidemiological investigation were obtained. 1) Based on the electrophoresis patterns of DNA obtained by PFGE, 34 of the 49 O157 isolates (69.4%) were divided into groups 1-9, 15 of the 18 O111 isolates (83.3%) were divided into groups 1-3, and 12 of the 15 O26 isolates (80%) were divided into groups 1-3. Of the grouped isolates, group 8 of O157, groups 2 and 3 of O111, and group 3 of O26 included isolates from human diarrhea and dairy cattle, but the other groups included isolates from only one of the two sources. 2) With regard to regional investigation, groups 6 and 9 of O157 included human diarrhea-derived isolates from Yokohama and Ehime, and group 8 included a human diarrhea-derived isolate from Yokohama and a dairy cattle-derived isolate from Tokushima. Group 3 of O111 included a human diarrhea-derived isolate from Ehime and a dairy cattle-derived isolate from Hokkaido. Group 3 of O26 included human diarrhea-derived isolate from Ehime and dairy cattle-derived isolate from Sagamihara and Hokkaido. Since the above findings showed that although the frequency was low, isolates from human diarrhea and dairy cattle were included in the same groups, it was demonstrated that dairy cattle are closely related to the human infectious disease of the intestinal tract as a source of infection. However, classification using the PFGE method is difficult due to diversity of the electrophoresis pattern of DNA. It is necessary to investigate the classification by a combination of the PFGE method with phage typing, ribotyping, and RAPD-PCR, and to investigate more numbers of patient-derived and animal-derived isolates.     

Nitrotyrosine immunoreactivity in gerbil hippocampal CA1 region after transient forebrain ischemia

We examined whether or not nitration of tyrosine residues takes place in the gerbil hippocampal CA1 region after transient forebrain ischemia. The nitration of tyrosine residues to produce nitrotyrosine is a footprint of peroxynitrite, a reaction product of nitric oxide (NO) with superoxide. Nitrotyrosine immunoreactivity had been detected in the CA1 region from the early stage in a reperfused brain at 30 min after transient ischemia until DNA fragmentation and neuronal death appeared at 4 days after transient ischemia. In electron microscopy, we detected, prominently, nitrotyrosine immunoreactivity after transient ischemia in the cytoplasm of the CA1 neurons. Therefore, it is considered that the nitration of tyrosine residues by peroxynitrite may be closely related to apoptosis after transient ischemia.     

An elderly colon cancer patient with hepatic, lunge and peritoneal metastases was treated by hepatic arterial infusion and systemic chemotherapy-a case report

A-75 year-old man, diagnosed as ascending colon cancer with large bowel obstruction, multiple hepatic, lunge metastases and peritoneal dissemination, was treated with neoadjuvant chemotherapy (FOLFOX4: 2 courses) and subsequent ileocecal resection. Postoperative systemic chemotherapy with hepatic arterial infusion (HAI) of 5-FU was performed in the following fashion: FOLFOX4, FOLFIRI with or without bevacizumab or cetuximab was administered every 4 weeks and a weekly HAI twice every 4 weeks. By those treatments, the patient could maintain a 30-month long NC effect and a good performance status.     

Long-term Use of Golimumab in Daily Practice for Patients with Rheumatoid Arthritis

Objective To evaluate the effectiveness and drug retention rate of golimumab (GLM) for long-term use in daily practice for patients with rheumatoid arthritis (RA). Methods Patients with RA who started GLM therapy with a minimum follow-up period of 52 weeks were included. The patients were divided into a biologic-naïve group and switch group. The disease activity score (DAS) 28-erythrocyte sedimentation rate (ESR) (DAS28-ESR), grip power, and Japanese version of the health assessment questionnaire (J-HAQ) score were assessed. In addition, the treatment continuation rate was evaluated at the final follow-up. Patients Sixty-five patients [58 women and 7 men; median (range) age, 69 (61-74) years; median (range) disease duration, 9 (5-16) years] were included. Twenty-eight patients were biologic-naïve (naïve group), and 37 were switched to biologics (switch group). Results The median (range) follow-up period was 134 (58-162) weeks. The DAS28-ESR improved from a median (range) of 4.31 (3.52-5.25) to 2.65 (2.28-3.77) in the naïve group and from 4.27 (3.19-4.89) to 2.89 (2.49-3.88) in the switch group. The grip power improved in both groups (p<0.01); however, the J-HAQ score showed no marked improvement in either group. The continuation rates were 22/28 (78.6%) in the naïve group, and 26/37 (70.3%) in the switch group at the final follow-up. Conclusion We herein report for the first time that the long-term use of GLM improves the grip power. Improving the grip power may help prevent sarcopenia and frailty in the future. Given the efficacy and high continuation rate, we suggest that GLM would be a well-tolerated treatment option for RA.     

Correlation between α1–Adrenoceptors in Biopsy Specimens and Endoscopic Color Changes of Human Gastric Ulcer

α₁–Adrenoceptors were measured in the scar tissue (U) and marginal normal mucosa (C) of human gastric ulcers by radio-binding assay using [³H]-prazosin as the ligand. The specific radioactivity binding was calculated for the membrane-rich fractions of the U and C regions along with U/C ratio, and the relationship between the scar color tone and α–adrenoceptor binding levels was studied by conventional endoscopy and pharmacoendoscopy The U/C ratio for red scars (mean: 92.2%) increased as redness decreased. White scars had a mean U/C ratio of 135.6%. For pharmacoendoscopic classes P₁ and P₂, which remained red after spraying epinephrine onto the scar, the mean U/C ratio was 86.8%. For the P₃ class, which turned pale after the application of epinephrine spray, the mean U/C ratio was 172.0%. The recurrence of peptic ulcers is more frequent when red scars ocAcur, assessed by conventional endoscopy, in the P₁ and₂ classes, evaluated by pharmacoendoscopy, than in white scars (P₃ class). As the α₁–adrenoceptor binding of [³H]-prazosin appears to be proportional to the maturity of vasculature tissue, the present data suggest this latter factor plays a key role in the recurrence of gastric ulcers and that pharmacoendoscopy allows for a more accurate prognosis of ulcer relapse than conventional endoscopy