Hironobu Takada

3479 Non-invasive gastrointestinal anastomosis with magnet rings.

Patients with inoperable GI cancers and strictures or stenoses often require intestinal bypass. These patients usually have advanced disease and are poor surgical candidates. In addition, surgical intervention often result in substantial mortality and morbidity as well as hospitalization and recovery time. Non-invasive methods of performing GI anastomosis may help improve their outcome and quality of life. We present cases to illustrate the use of magnet compression anastomosis. METHODS: Discshaped magnets of 1.5 cm in diameter and 0.7 cm thick are used. Two magnets are placed within the GI tract, one magnet each in the respective portion of the GI tract to be anastomosed. The magnets are placed orally, rectally, or endoscopically and are then maneuvered into the desired locations either endoscopically or percutaneously with an external magnet. Once the magnets are in place, the magnetic force attracting the two magnets then serve to compress the walls of the two respective gastrointestinal tracts together. Over the course of one to four weeks, an anastomosis is formed between the two adjoining segments of the gastrointestinal tract. CASES: Both cases 1 and 2 are patients with advanced antral gastric cancer with multiple metastases, who were not surgical candidates but who were unable to eat because of marked gastric outlet obstruction. One magnet was placed in the stomach and the other magnet was placed in the third portion of the duodenum. Promptly after magnet placement, the two magnets could be seen fluoroscopically compressing the stomach wall and the duodenal wall between them. After two weeks, the anastomoses were formed and the magnet pair passed spontaneously in the stool.Well-functioning anastomoses were confirmed by X ray. Case 3: This is a patient with sigmoid colon cancer with colon stricture. An anastomosis between ascending colon and distal sigmoid would provide bypass of the stricture. The 2 magnets were placed orally and endoscopically at ascending and distal colon. Ten days after, the anastomosis was completed and the two magnets passed spontaneously in the stool. The anastomosis functioned very well and the patient has had no obstructive symptoms for 6 months. CONCLUSION: Magnet compression anastomosis does not require surgical intervention or anesthesia, and still forms a well functioning anastomosis for bypassing neoplastic strictures and stenoses. It may become an additional clinical tool for providing palliative relief of gastrointestinal strictures and stenoses in patients with irreversible end-stage disease.

Silent infection of Giardia lamblia causing bleeding through vitamin K malabsorption.

weighed 45.3 kg. Her pulse rate was 84 b.p.m. and regular. Her blood pressure was 118 systolic, 52 diastolic. The palpebral conjunctiva was anemic. Her heart revealed a clicking sound caused by an artificial valve. Massive subcutaneous bleeding was noted. The lower extremities (legs) were also dotted with many petechiae. The laboratory report showed a red blood cell count of 1 830 000/mm, a white blood cell count of 9300/mm, a hemoglobin level of 5.6 g/100 mL, and hematocrit of 17.1%.The percentage prothrombin time was less than 12.5%. Because she was still taking warfarin potassium, the cause of bleeding was thought to be the anticoagulant therapy.There was no liver dysfunction, no dietary change, or a change of medication that may have affected blood coagulation. Therefore, we speculated a vitamin K absorption disorder might be the cause. The blood vitamin K concentration 5 h after oral administration of 30 mg menatetrenone was 5.84 ng/mL, which was significantly less than the normal range of 322 ± 45 ng/mL. A stool examination disclosed Giardia lamblia cysts. Pathology of the duodenal mucosa obtained by the use of endoscopy disclosed many Giardia lamblia trophozoites (Fig. 1a), although the duodenal mucosa was endoscopically normal. We diagnosed this case as bleeding because of vitamin K malabsorption caused by these parasites. We started administration of metronidazole to eradicate Giardia lamblia. After 3 weeks, her blood coagulation was normalized even after the administration of warfarin potassium. A stool examination and a pathological examination were negative for parasites after treatment (Fig. 1b). The blood vitamin K concentration 5 h after oral administration of 30 mg menatetrenone was 57.11 ng/mL, which was still below the normal range, but was significantly improved. She was discharged 5 weeks after admission, and the anticoagulant therapy was well controlled for at least 12 months. Giardiasis is well known to cause malabsorption.The mechanism by which giardiasis induces malabsorption remains unclear. Several hypotheses for the mechanism of malabsorptions were suggested, such as a physical barrier to absorption, pancreatic insufficiency that induces malabsorption, and the deconjugation of bile salts within the intestinal lumen. None of these hypotheses, however, fully explain the selective malabsorption that occurred in our case. While G. lamblia infection may be quite common, the majority of the cases are asymptomatic, and so we are inclined to pay little attention to this parasitic infection. In the present case, association of Giardia infection and coagulopathy is confirmed by the fact that the coagulopathy was recovered, and the vitamin K malabsorption was SILENT INFECTION OF GIARDIA LAMBLIA CAUSING BLEEDING THROUGH VITAMIN K MALABSORPTION