Hiroshi Takakuwa

Endoscopic management of biliary strictures after duct-to-duct biliary reconstruction in right-lobe living-donor liver transplantation

Background. The aims of this study were to characterize the features of the biliary strictures that occur after duct-to-duct biliary reconstruction during right-lobe living-donor liver transplantation (LDLT) and to evaluate the feasibility of correcting such stricture endoscopically by inserting an “inside stent,” that is, a short internal stent, above the sphincter of Oddi. Methods. Biliary stricture occurred in 26 (35.6%) of 73 consecutive patients who underwent right-lobe LDLT with duct-to-duct biliary reconstruction from July 1999 through October 2001 and survived for more than 3 months. Of the 26 patients who had biliary stricture, 22 were referred for endoscopic retrograde cholangiography (ERC) and 4 for percutaneous cholangiography. Results. ERC disclosed biliary stricture in 19 (86.4%) of the 22 patients who underwent the procedure. One patient had an unbranched stricture, 16 had a fork-shaped stricture, 1 had a trident-shaped stricture, and 1 had a stricture with more than three branches. Fourteen (73.7%) of the patients with strictures were treated endoscopically by inserting inside stents ranging from 7 F to 12 F in size, three underwent a Roux-en-Y hepaticojejunostomy to repair their stricture, and two were closely observed as outpatients. Of the 14 patients who were treated with the inside-stent, only 1 had acute cholangitis immediately after the procedure and underwent a Roux-en-Y hepaticojejunostomy. The other 13 patients who were treated with the inside stent have not required surgical repair for as long as an average of 586 days. Conclusion. Endoscopic placement of an inside stent is useful for treating biliary strictures in patients who have undergone right-lobe LDLT with duct-to-duct reconstruction.

Gastric aberrant pancreas : EUS analysis in comparison with the histology

BACKGROUND Histologic diagnosis of aberrant pancreas is usually difficult when tissue samples are obtained with a standard biopsy forceps. The aim of this study was to describe the endosonographic (EUS) features of gastric aberrant pancreas. METHODS EUS was performed in 10 patients with aberrant pancreas before resection. EUS features of the lesions were analyzed and compared with resected specimens retrospectively. RESULTS EUS in 5 lesions (50%) demonstrated the ectopic pancreatic tissue as located in the third and fourth sonographic layers (submucosa and muscularis propria) and in the third layer (submucosa) in the other 5 lesions. The margin appeared for the most part indistinct (80%) because of the lobular structure of the acinous tissue. The internal echo pattern in all cases was heterogeneous, mainly a hypoechoic image (acinous tissue) accompanied by scattered small hyperechoic areas (adipose tissue). An anechoic area (duct dilatation) (80%) and fourth-layer thickening (muscular hypertrophy) (80%) were commonly visualized. CONCLUSION Gastric aberrant pancreas has characteristic EUS features that correlate with specific histologic components and is variable with regard to sonographic layer of origin.

Endoscopic mucosal resection of gastric tumors located in the lesser curvature of the upper third of the stomach

Endoscopic mucosal resection (EMR) is increasingly used for the removal of small gastric tumors with surrounding mucosa 1 and is a useful therapeutic method as well as a diagnostic approach to mucosal lesions. EMR for early gastric cancers has been widely accepted as a standard procedure because of its minimal invasiveness and satisfactory postprocedure results in maintaining a good quality of life for patients. Several different EMR procedures have been reported and their usefulness is well established. 2 Strip biopsy method or lift-and-cut EMR (LC-EMR), introduced by Tada et al., 3 has been used most widely in Japan. 4 If the target lesion is located in the l esser curvature of the upper third of the stomach, LC-EMR using a double-channel endoscope is quite difficult to perform because of the tangential location of the tumor to the endoscope. 5 In this article, we describe the use of a cutting EMR (C-EMR) technique, based on the original procedure ofHirao et al.,6 for gastric tumors located in the lesser curvature of the upper third of the stomach. We prospectively evaluated its clinical usefulness in comparison with LC-EMR.

Treatment results of radiotherapy for carcinoma of the cervical esophagus

The methods and results of treatment for cancer of the cervical esophagus differ from those for cancer of the thoracic esophagus. Our objective was to retrospectively review the outcome for cervical esophageal cancer patients treated with radiotherapy. Twenty-seven patients with carcinoma of the cervical esophagus treated with definitive radiotherapy from 1988 to 2002 were enrolled in the study. Clinical stage (UICC 1997) was stage I in five, II in six, III in 12 and IV in four. Concurrent head and neck malignancy was found in six patients (22%). The mean radiation dose was 66 Gy. Concurrent chemotherapy (cisplatin and 5-fluorouracil) was performed in 23 patients. The actuarial overall survival rates at 1, 3 and 5 years were 55.6%, 37.9% and 37.9%, respectively, with a median survival of 13.9 months. In the patients with stage I, the 3-year and 5-year survival rates were 75% and 75%, respectively. With univariate analysis, only two of the possible prognostic factors were found to actually influence survival: performance status (p < 0.01) and tumor length (p < 0.01). The survival of patients with cervical esophageal cancer remains poor. It is thought that organ preservation is possible by definitive chemoradiation for early cancer.

Alcohol sclerotherapy of hepatic cysts: its effect in relation to ethanol concentration

While ultrasonically guided percutaneous aspiration and ethanol injection therapy has proved useful for non-neoplastic giant hepatic cysts that cause symptoms, the optimum quantity of ethanol injected into hepatic cysts has not been established. In eight patients with non-neoplastic giant hepatic cysts who were treated by ethanol injection, ethanol concentration in cystic fluid after treatment was estimated. Ethanol concentrations ranged from 5.9 to 47.6%. Hepatic cyst regressed almost completely in five cases; in all of which, the estimated ethanol concentrations were more than 40%. Our results suggest that it is desirable to drain cystic fluid as much as possible and to inject ethanol as little as possible, so that the estimated ethanol concentration in the cyst exceeds 40% for maximal effect and minimal side effects.

Epinephrine sprayed on the papilla for prevention of post-ERCP pancreatitis

BackgroundEpinephrine sprayed on the papilla may reduce papillary edema and thus prevent acute pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP). The aim of this study was to determine the efficacy of this technique for prevention of post- ERCP pancreatitis.MethodsPatients scheduled for ERCP were recruited into this study. We randomized the patients to have 10 ml of either 0.02% epinephrine (epinephrine group) or saline (control group) sprayed on the papilla after diagnostic ERCP and prospectively analyzed the occurrence of post-ERCP pancreatitis between the groups. We recorded duct visualization, presence of pancreatic acinarization, number of injections into the pancreatic duct, total volume of contrast used, and procedure duration.ResultsThere was no significant difference between the groups with regard to visualization of the bile duct and/or the main and accessory pancreatic ducts, presence of pancreatic acinarization, number of injections into the pancreatic duct, total volume of contrast used, and procedure duration. Overall, post-ERCP pancreatitis occurred in 4 of the 370 patients (1.1%). The incidence of pancreatitis tended to be higher in the control group (4/185) than in the epinephrine group (0/185) (P = 0.1230).ConclusionsEpinephrine sprayed on the papilla tended to prevent post-ERCP pancreatitis, although it was not statistically significant because of the low incidence of pancreatitis. Further studies on the efficacy of this technique in patients at high risk for pancreatitis, and on other volumes and/or concentrations of epinephrine, are warranted.

Endophthalmitis with brain, lung, and liver abscesses associated with an occult colon cancer

TO THE EDITOR: Septic endophthalmitis, a rare inflammatory process involving ocular tissues, can be the initial presentation of septicemia from abscess (1, 2). We encountered an unusual case of endophthalmitis with brain, lung, and liver abscesses, in which colon cancer was subsequently disclosed in the absence of any gastrointestinal symptoms on admission. The possible pathophysiological mechanism of these associations will be discussed here. A 46-yr-old woman, who had a 2-yr history of diabetes without medication, presented with a high grade fever and right visual disturbance. On physical examination, hypopyon, invisible optic disc, and absent light perception were noted in the right eye, and an enlarged liver was palpable. Adult T-cell leukemia virus, human immunodeficiency virus, and antinuclear antibodies tests were all negative. Computed tomography (CT) showed several nodular lesions, 1.5 cm in diameter, in the left lung field with plural effusion, and a heterogeneous hepatic mass, 10 cm in diameter. Echocardiography revealed no abnormalities. A diagnosis of right endophthalmitis with lung and liver abscesses was made. Therapy with insulin and ceftazidime, 4.0 g daily, and percutaneous drainage of the liver abscess were started. Right vitrectomy and lensectomy were then performed. Cultures of the eyeball contents and the abscess yieldedKlebsiella pneumoniae . Two weeks later, she was confused and disoriented with incontinence. Although cranial nerves, cerebellum, motor, and sensory examinations revealed no apparent abnormalities, acalculia, agraphia, and memory disturbance were disclosed. Brain CT revealed multiple enhanced lesions consistent with brain abscesses (Fig. 1). The antibiotic was changed to latamoxef sodium, 9.0 g daily for 1 month, with clinical improvement. Cultures of the cerebrospinal fluid (CSF) and blood were negative. One month later, she complained of watery diarrhea. Colonoscopy showed a large sigmoid cancer. Cultures of the stool yielded K. pneumoniae. After her condition improved, sigmoidectomy was performed. The patient had an uneventful recovery, and CT scans returned to normal with no evidence of abscesses. The endophthalmitis and brain abscesses in our case were most likely caused by hematogenous spread of K. pneumoniaeassociated with liver abscess and underlying diabetes. Because diabetics have impaired neutrophils functions (3, 4), diabetes can be an important predisposing factor of endophthalmitis with other septic lesions. Although brain abscess is considered lethal (5), large doses of broad-spectrum antibiotic therapy is effective, particularly during the phase of encephalitis (6). Because the average concentration of latamoxef sodium in CSF is greater than those of other antibiotics (7), ceftazidime was changed to latamoxef sodium, resulting in a favorable outcome. The liver abscess could result from K. pneumoniaebacteremia after the organism entered into the portal route from the surface of colon cancer. The mucosal disruption by colon cancer exposing the underlying blood vessels to the fecal flora can be the most likely mechanism of bacteremia (8, 9). Because blood samples were obtained after administration of antibiotics, blood cultures were negative. Our case was interesting in view of the unusual presentation of colon cancer with a favorable outcome. An aggressive approach in the diagnosis and therapy by both internists and ophthalmologists is definitely required. The isolation of K. pneumoniaefrom eyeball contents needs further investigations of the gastrointestinal tract for the presence of occult neoplasms.

Fibrolamellar carcinoma of the liver with a mixture of ordinary hepatocellular carcinoma: a case report.

Fibrolamellar carcinoma (FLC) of the liver is a rare variant of hepatocellular carcinoma (HCC), and only 13 cases have been reported in Japan up to 1997. We described a histologically unusual case of FLC. A 52-yr-old man was admitted to our hospital for work-up of hepatic mass. Laboratory examinations revealed no abnormalities except elevated serum alpha-fetoprotein (AFP) (2098 ng/ml). A diagnosis of HCC was made by imaging findings, and left lobectomy of the liver was performed. Histologically, the tumor was composed of areas of FLC mixed with ordinary HCC and those of pure ordinary HCC. Staining for AFP was positive in the HCC component and negative in the FLC component. Some cases of such mixed tumors have been reported in Europe and the United States, but not in Japan. We regarded our case as the first of the mixed tumor in Japan.

Bleeding stercoral ulcer with visible vessels: effective endoscopic injection therapy without electrocoagulation

endoscopic ultrasonography, and long term outcome in a large surgical series. Gastrointest Endosc 1998;47:42-9. 2. Sugiyama M, Atomi Y, Hachiya J. Intraductal papillary tumors ofthe pancreas: evaluation with magnetic resonance cholangiopancreatography. Am J Gastroenterol 1998;93: 156-9. 3. Tajiri H, Kobayashi M, Niwa H, Furui S. Clinical application of an ultra-thin pancreatoscope using a sequential video converter. Gastrointest Endosc 1993;39:371-4. 4. Kaneko T, Nakao A, Nomoto S, Furukawa T, Hirooka Y, Nakashima M, et al. Intraoperative pancreatoscopy with the ultrathin pancreatoscope for mucin-producing tumors of the pancreas. Arch Surg 1998;133:263-7.

Malignant lymphoma in the ileocecal region causing intussusception

A 67-year-old female was admitted with diarrhea. Preoperatively, we diagnosed intussusception due to malignant lymphoma in the ileocecal region by image and colonoscopic examinations. We resected the right hemicolon for the tumor, which was located mainly in the cecum, causing intussusception. The stenotic terminal ileum free of the tumor was invaginated within the cecum with infiltrating tumor, thus showing the appearance of an anthill. The growth of the tumor corresponded with Woods constrictive type, in which intussusception rarely occurs.