Hideyuki Kin

Increased neutrophil chemotaxis in obstructive jaundice: an in vitro experiment in rats.

Background and Aims: Changes in neutrophil functions in obstructive jaundice have been poorly understood. An in vitro experimental study was performed to evaluate the effect of obstructive jaundice on the functions of macrophages (secretion of neutrophil chemoattractants) and neutrophils (chemotaxis and superoxide anion generation).

Effect of obstructive jaundice on neutrophil chemotactic activity: An in vivo assessment in zymosan-induced peritonitis model in rats

The effect of obstructive jaundice on local neutrophil accumulation in response to inflammatory stimulus was investigated in rats. Obstructive jaundice was produced by bile duct ligation for 7 days. Zymosan (200 mg) was injected intraperitoneally and 4h later myeloperoxidase activity in the peritoneal fluid was measured to quantify neutrophil recruitment. Zymosan‐induced neutrophil recruitment was significantly greater (more than two‐fold) in bile duct‐ligated rats than in sham‐ligated or normal animals. Depletion of peritoneal cells significantly suppressed neutrophil recruitment after zymosan injection in all three groups, with no significant differences between the groups. In normal rats, replacement of their peritoneal cells by those from bile duct‐ligated rats did not enhance zymosan‐induced neutrophil recruitment. In contrast, bile duct‐ligated rats treated with peritoneal cell replacement from normals showed significantly increased neutrophil recruitment after zymosan injection. In vitro neutrophil chemotaxis in response to formyl‐Met‐Leu‐Phe was significantly enhanced in bile duct‐ligated rats, compared with that in sham‐ligated animals. The results suggest that local neutrophil recruitment in response to inflammation may be enhanced in obstructive jaundice and that increased neutrophil chemotactic activity, not macrophage activity, may play a prime role in the mechanism.

PANCREATIC PLEURAL EFFUSION SUCCESSFULLY TREATED BY ENDOSCOPIC PANCREATIC DUCT DRAINAGE COMBINED WITH EXTRACORPOREAL SHOCK‐WAVE LITHOTRIPSY: REPORT OF A CASE

A 52‐year‐old man was admitted with complaints of dyspnea. Physical examination revealed that the breath sounds were reduced at the left lung. The results of the abdominal examination were normal. Chest radiography showed massive left‐sided pleural effusion. His white blood cell count was 4600/mm 3 , serum amylase 666 IU/L, serum C‐reactive protein (CRP) 3.7 mg/dL. Thoracentesis yielded bloody fluid with a protein level of 3.7 g/dL and amylase level of 6250 IU/L. Computed tomography showed dilatation of the pancreatic duct with calcifications of the pancreas, mediastinal pancreatic pseudocysts and bilateral pleural effusion. Magnetic resonance cholangiopancreatography demonstrated dilated pancreatic duct with pancreatic calculi and pancreaticopleural fistula. Initial endoscopic retrograde cholangiopancreatography showed obstructing pancreatic calculi of the main pancreatic duct at the head; however, insertion of a naso‐pancreatic drain was unsuccessful. A naso‐pancreatic drain could be placed beyond the site of obstruction following three extracorporeal shock‐wave lithotripsy (ESWL) sessions. Pleural effusion was resolved and the chest tube was removed 5 days following placement of the drain. The naso‐pancreatic drain was replaced with a pancreatic stent 20 days later. Endoscopic retrograde cholangiopancreatography after a total of nine ESWL sessions showed a significant reduction of pancreatic calculi at the head. The pancreatic stent was removed 70 days following stent placement and there has been no recurrence during a follow‐up period of 2 years. We suggest that endoscopic treatment combined with ESWL is a first‐line treatment for pancreatic pleural effusion resulting from obstructing pancreatic calculi, and operation should be reserved as a second‐line treatment.

Endoscopic Bilateral Hepatic Drainage with Self‐Expandable Metallic Stents for Malignant Hilar Stricture

Endoscopic insertion of self‐expandable metallic stents is considered to be safer and less invasive than percutaneous stenting for patients with malignant biliary strictures. However, the technique of implantation of multiple self‐expandable metallic stents by endosocpic means has not yet been fully established. We evaluated the technical feasibility of endoscopic negotiation of bilateral hepatic ducts with subsequent placement of multiple self‐expandable metallic stents in parallel. Bilateral hepatic ducts were negotiated with guidewires, and self‐expandable metallic stents were sequentially introduced and deployed over the prepositioned guidewires in seven patients with irre‐sectable malignant hilar strictures. Insertion and deployment of self‐expandable metallic stents into both the right and left hepatic ducts were successful in six of the seven patients. The remaining patient was eventually treated with bilateral hepatic drainage using two wallstents; one was inserted endoscopically and the other percutaneously. The patients were followed up for 36–349 days (mean; 227). In two patients, stent occlusion due to sludge formation occurred 119 and 178 days after the treatment. However, endoscopic reintervention was easily performed with a favorable clinical outcome in both patients. Endoscopic bilateral hepatic drainage of multiple, self‐expandable metallic stents in parallel is considered to be a simple, safe, and reliable for irresectable malignant hilar stricture. (Dig Endosc 1999; 11: 225–230)

Endoscopic Intraductal Radiation Therapy for Unresectable Cholangiocarcinoma Using a Remote Afterloading Device

Abstract: The transpapillary technique of intracavitary irradiation has not gained wide acceptance due mainly to the development of the instruments used being in a relatively early stage. Intracavitary irradiation using a new high‐dose rate remote afterloading 192‐iridium brachytherapeutic device was performed utilizing an endoscopic transpapillary technique in four patients with cholangiocarcinomas obstructing the bile ducts. Via a prepositioned 10‐Fr nasobiliary catheter, a 12 Gy dose was administered at a distance of 1.0 cm from the radiation source at each procedure. Irradiation lasted several minutes (7.8 minutes on average). The procedure was repeated at 3‐day intervals, and the total dose ranged from 24 to 36 Gy. Cholangiography, performed immediately after completion of a series of irradiation treatments, disclosed various degrees of recanalization of the bile duct, and transpapillarily obtained biopsy specimens showed disappearance of tumor cells. All patients tolerated the radiation procedure well, and no procedure‐related complications were observed. The present preliminary experience suggests that transpapillary intracavitary irradiation has become technically feasible. Further experience in a larger series may demonstrate a role for this therapeutic modality in the treatment of unresectable cholangiocarcinoma.

The Effect of Biliary Pressure on Antibiotic Excretion into Bile

Abstract: Biliary obstruction has been recognized to inhibit excretion of antibiotics into bile. In the present study, using cefpirome sulfate (CPR), we sought to determine the effect of biliary pressure on antibiotic transfer into bile in patients undergoing endoscopic retrograde cholangiopancreatography (ERCP). Thirty‐six patients with a variety of biliopancreatic diseases (free of renal disease or hypoproteinemia) received a single intravenous dose of CPR (1 g) prior to ERCP. Under fluoroscopy a diagnostic catheter with a metal ball tip was advanced into the middle portion of the extrahepatic bile duct or, in cases of common bile duct obstruction, above the obstruction. Biliary pressure was measured via the same catheter using duodenal pressure as a reference. Subsequently, bile was aspirated, and blood was withdrawn simultaneously. The mean interval between CPR administration and the bile and blood samplings was 67±12 minutes. The bile CPR concentration and the bile/serum ratio of CPR concentrations showed a significant inverse correlation with biliary pressure, but the serum CPR concentration did not. The bile CPR concentration and the bile/serum ratio of CPR concentrations differed significantly between the group with normal biliary pressures, below 10 mmHg, and that with biliary pressures exceeding 10 mmHg. The serum CPR concentrations of the two groups were similar. These results suggest that biliary pressure plays an important role in determining antibiotic transfer into bile.

Benign Strictures of the Intrahepatic Bile Ducts Managed with Percutaneous Transhepatic Cholangioscopy: A Case Report

Benign strictures of the intrahepatic bile ducts were detected, by percutaneous transhepatic cholangioscopy combined with forceps biopsies, in a patient who presented symptoms suggesting cholangitis. The patient was successfully treated by non‐operative stricture dilation techniques, with the aid of cholangioscopy. In this paper, the usefulness of percutaneous transhepatic cholangioscopy for the management of benign biliary strictures is discussed.