A radioanatomical study of 3rd segment terminal branches of the maxillary artery in the pterygopalatine fossa.

This study describes the clinical anatomical topography and relationship of the terminal branches of the maxillary artery to the bony wall of the maxillary sinus in the pterygopalatine fossa (PPF) to estimate the bleeding risk during surgical interventions. Using contrasted computer tomography records, (i) the route of the maxillary artery in the infratemporal fossa, (ii) the number of the arteries in the critical PPF surgery plane, (iii) the diameter of the largest artery in the area and (iv) its relation to the posterior wall of the maxillary sinus were examined. Furthermore, measurements were extended with (v) the minerality of the bony posterior wall of the maxillary sinus on bone-window images. For statistical analyses Student's t- and Fisher-test were applied. 50 patients (n = 50, 100 cases including both sides) were examined in this study. The maxillary artery reached the pterygomaxillary fissure on the lateral side of the lateral pterygoid muscle in 56% of the cases (n = 32), in 37% (n = 23) on its medial side and in 7% (n = 4) on both sides. The number of arteries at the level of the Vidian canal in the PPF varied between 1 and 4 with a median of 2. The diameter of the biggest branch was 1.2-4.7 mm, the median diameter was 1.90 mm. In 41% (n = 30) of the cases the biggest artery directly contacted the posterior wall of the maxillary sinus, and the mineral density of the posterior wall was decreased in 14.3% (n = 12) of all investigated cases. The present description and statistical analysis of the vasculature of the PPF optimizes operative planning-like clip size or the type and direction of the surgical approach-in this hidden and deep head/neck region.

Mesalamine did not prevent recurrent diverticulitis in phase 3 controlled trials.

BACKGROUND & AIMS: No therapy has been proven to prevent the recurrence of diverticulitis. Mesalamine has shown efficacy in preventing relapse in inflammatory bowel disease, and there is preliminary evidence that it might be effective for diverticular disease. We investigated the efficacy of mesalamine in preventing recurrence of diverticulitis in 2 identical but separate phase 3, randomized, double-blind, placebo-controlled, multicenter trials (identical confirmatory trials were conducted for regulatory reasons). METHODS: We evaluated the efficacy and safety of multimatrix mesalamine vs placebo in the prevention of recurrent diverticulitis in 590 (PREVENT1) and 592 (PREVENT2) adult patients with ≥1 episodes of acute diverticulitis in the previous 24 months that resolved without surgery. Patients received mesalamine (1.2 g, 2.4 g, or 4.8 g) or placebo once daily for 104 weeks. The primary end point was the proportion of recurrence-free patients at week 104. Diverticulitis recurrence was defined as surgical intervention at any time for diverticular disease or presence of computed tomography scan results demonstrating bowel wall thickening (>5 mm) and/or fat stranding consistent with diverticulitis. For a portion of the study, recurrence also required the presence of abdominal pain and an increase in white blood cells. RESULTS: Mesalamine did not reduce the rate of diverticulitis recurrence at week 104. Among patients in PREVENT1, 53%-63% did not have disease recurrence, compared with 65% of those given placebo. Among patients in PREVENT2, 59%-69% of patients did not have disease recurrence, compared with 68% of those given placebo. Mesalamine did not reduce time to recurrence, and the proportions of patients requiring surgery were comparable among treatment groups. No new adverse events were identified with mesalamine administration. CONCLUSIONS: Mesalamine was not superior to placebo in preventing recurrent diverticulitis. Mesalamine is not recommended for this indication. ClinicalTrials.gov ID: NCT00545740 and NCT00545103.

Management of peptic ulcer bleeding in different case volume workplaces: results of a nationwide inquiry in hungary.

The aim of this study was to conduct a national survey to evaluate the recent endoscopic treatment and drug therapy of peptic ulcer bleeding (PUB) patients and to compare practices in high and low case volume Hungarian workplaces. A total of 62 gastroenterology units participated in the six-month study. A total of 3033 PUB cases and a mean of 8.15 ± 3.9 PUB cases per month per unit were reported. In the 23 high case volume units (HCV), there was a mean of 12.9 ± 5.4 PUB cases/month, whereas in the 39 low case volume units (LCV), a mean of 5.3 ± 2.9 PUB cases/month were treated during the study period. In HCV units, endoscopic therapies for Forrest Ia, Ib, and IIa ulcers were significantly more often used than in LCV units (86% versus 68%; P = 0.001). Among patients with stigmata of recent haemorrhage (Forrest I, II), bolus + continuous infusion PPI was given significantly more frequently in HCV than in LCV units (49.6% versus 33.2%; P = 0.001). Mortality in HCV units was less than in LCV units (2.7% versus 4.3%; P = 0.023). The penetration of evidence-based recommendations for PUB management is stronger in HCV units resulting lower mortality.

[Pyoderma gangrenosum treated successfully with visilizumab in patients with ulcerative colitis]. / Refrakter pyoderma gangraenosum sikeres visilizumabkezelése colitis ulcerosás betegben.

UNLABELLED: Pyoderma gangrenosum is a misleading designation for an idiopathic ulcerating cutaneous disease. The activity of pyoderma gangrenosum may or may not follow the activity of the inflammatory bowel disease. Visilizumab (Nuvion, PDL Bio Pharma, USA), a humanized IgG2 monoclonal antibody that binds to the human CD3 epsilon chain expressed on human T cells, induces the rapid production of selective chemokines, and reduces the CXCR3-mediated chemotaxis of the resting peripheral blood lymphocytes. In activated, but not resting T cells, visilizumab leads to rapid apoptosis. CASE REPORT: During a period of 20 years, a 40-year-old male took part in more than 30 courses of treatment for a dermatological condition misdiagnosed as crural eczema, mycosis and infected wounds. This ulcerative process was very severe in both crural regions. Ulcerative colitis was diagnosed a decade ago. He has been steroid-dependent since 1997. In 2005, pyoderma gangrenosum was diagnosed. In 2006, the patient participated in the visilizumab study and received 2x375 mcg study drug (5 mcg/kg/dose) intravenously. Six months after visilizumab administration, his leg ulcers healed. After the administration of visilizumab, pyoderma gangrenosum had not relapsed. CONCLUSION: In this severe pyoderma case, visilizumab also treated the skin disease. Although the colitis later worsened, the pyoderma gangrenosum has not recurred to date in this steroid-dependent patient. Pyoderma gangrenosum may be a T cell-mediated disease. The fact that biological therapy proved dramatically effective in this patient may suggest the use of these agents as first line of therapy in such cases.

Endoscopic mucosal resection: not only therapeutic, but a diagnostic procedure for sessile gastric polyps.

BACKGROUND AND AIMS: Histological examination of specimens obtained by forceps biopsy sampling of gastric lesions is of limited accuracy, and their management on this basis is therefore controversial. Endoscopic mucosal resection (EMR) was initially developed in Japan for the resection of early gastric cancer (EGC). The potential use of EMR as a diagnostic tool has been suggested. The aims of the present study were to assess the value of forceps biopsy sampling in establishing the correct diagnosis revealed by EMR and to evaluate the efficacy of EMR. METHODS: Fifty-six subjects with sessile gastric polyps of epithelial origin, at least 0.5 cm in diameter, and not associated with polyposis syndromes, were included. Following forceps biopsy sampling, EMR was performed with an inject-and-cut technique or with cap-fitted methods. The histological results on the forceps biopsy and the resected specimens were analyzed. RESULTS: Histology on the resected specimens revealed neoplastic lesions in 34 cases, including seven EGC, and there were hyperplastic-inflammatory lesions in 21 cases. Complete agreement between the previous histological results of the forceps biopsy samples and the resected specimens was seen in only 76.7% of the lesions. Altogether, the sensitivity and specificity of the forceps biopsy procedure for diagnosing neoplastic lesions were 87.5% (95% confidence interval [CI] = 76.0-98.9%) and 65.2% (95% CI = 45.7-84.7), respectively. A clinically relevant discrimination between neoplastic and non-neoplastic lesions was not achieved in seven cases. No complications, such as perforation or massive bleeding necessitating surgical treatment, were encountered. EMR was considered complete in five patients. None of the EGC recurred during the mean 38-month (6-72) follow up. CONCLUSIONS: Forceps biopsy is not fully representative of the entire lesion, and a simple biopsy may therefore lead to a faulty differentiation between neoplastic and non-neoplastic lesions. EMR proposes diagnostic and staging advantage in assessing patients with EGC as compared to forceps biopsy, because it provides more intact mucosa and submucosa for histological analysis. Sessile gastric polyps should be fully resected by EMR for a final diagnosis and (depending on the lesion size and type) possibly definitive treatment.

Flat gastric polyps: results of forceps biopsy, endoscopic mucosal resection, and long-term follow-up.

OBJECTIVE: Histological examination of specimens obtained by forceps biopsy sampling of gastric polyps is of limited accuracy, and their management on this basis is therefore controversial. The aim of this prospective study was to assess the value of forceps biopsy sampling in establishing the correct diagnosis revealed by endoscopic mucosal resection (EMR). The complication rate of EMR was also determined. MATERIAL AND METHODS: Subjects with gastric polyps of epithelial origin, of at least 0.5 cm in diameter, and not associated with polyposis syndromes, were included in the study. Between 1994 and 2004, 56 gastric polyps in 44 patients (30 F, 14 M, mean age 67 years) met the inclusion criteria. Indigo carmine dye staining and electronic magnification were used in all cases. Following forceps biopsy sampling, 56 EMRs were performed. The histological results of the forceps biopsy and the resected specimens were analyzed. RESULTS: The initial forceps biopsies identified in situ carcinoma in 3 cases, adenoma with no dysplasia in 19, adenoma with low-grade dysplasia in 2, adenoma with moderate-grade dysplasia in 6, adenoma with high-grade dysplasia in 7, and hyperplastic lesions in 19 cases. The histological examination of the resected polyps revealed in situ carcinoma in 5 cases, carcinoid in 1, gastrointestinal stromal tumor in 1, adenoma with no dysplasia in 14, adenoma with low-grade dysplasia in 3, adenoma with moderate-grade dysplasia in 9, adenoma with high-grade dysplasia in 1, hyperplastic lesions in 21, and no diagnosis in 1 case. Complete agreement between the histological results on the forceps biopsy sample and on the ectomized polyp was seen in only 31 (55.3%) polyps. There were important disagreements in 12 cases. In 14 neoplastic and 1 hyperplastic polyps, the degree of dysplasia seen on histological examination of the forceps biopsy specimens differed from that observed for the resected specimens. Post-mucosectomy bleeding was observed in 3 patients, all of whom were successfully treated endoscopically. CONCLUSIONS: Forceps biopsy is not sufficiently reliable for the identification of gastric polyps. These lesions should be fully resected by EMR for a final diagnosis and (depending on the lesion size and type) possibly definitive treatment.

[Diagnostic and therapeutic use of endoscopic resection of gastric mucosa]. / A gyomor endoszkópos mucosaresectiója--diagnosztikus és terápiás módszer.

BACKGROUND: EMR is a widely used treatment option for gastric adenoma and early gastric cancer, but, there are no data on its use in Hungary. The aim of this study was to assess the diagnostic and therapeutic efficacy of EMR. PATIENTS: 44 patients (30 females, 14 males, mean age: 67 years) were studied between 1994 and 2005; 33 had severe concomitant diseases (liver cirrhosis or severe cardiovascular disease). Indigo carmine dye staining and electronic magnification was used in all cases, with endoscopic ultrasonography when indicated. 56 EMR-s were performed. The histological results on the biopsy and resected specimens were analyzed. RESULTS: The morphology of the lesions was type I in 20, type IIa in 35, and type IIa-IIc in 1 case. The diagnosis at first biopsy was in situ carcinoma in 3, adenoma with no dysplasia in 19, adenoma with low-grade dysplasia in 2, adenoma with moderate-grade dysplasia in 6, adenoma with high-grade dysplasia in 7, and hyperplastic lesion in 17 cases. The histology of EMR revealed in situ carcinoma in 5, carcinoid in 1, gastrointestinal stromal tumor in 1, adenoma with no dysplasia in 14, adenoma with low-grade dysplasia in 3, adenoma with moderate-grade dysplasia in 9, adenoma with high-grade dysplasia in 1, hyperplastic lesion in 21, and no diagnosis in 1 case. However, the moderate- and high-grade dysplasia was diagnosed in different cases with the two methods. EMR was considered complete in all but 1 case. A Nd YAG laser was used in this patient with in situ carcinoma, where the resection margin was not free of cancer cells. Bleeding occurred in 3 cases; 1 required transfusion and had pneumonia postoperatively. There were no gastric cancer-related deaths during the median follow-up of 33 (1-90) months. In the follow up period we could not observe gastric malignancy in the previously hyperplastic polyp cases. Among adenoma cases one recurrence was seen in the same place and one in another location. One hyperplastic residuum occurred and in one case adenoma has grown in the same place. CONCLUSION: EMR, a facile and useful diagnostic and therapeutic technique, appears very safe in terms of complications even in patients with comorbidities. Biopsy is generally unreliable to diagnose gastric adenoma. Lesions should be fully resected by EMR for a final diagnosis and (depending on the lesion size and type) possibly definitive treatment.

[Indigo carmine contrast staining in combination with high resolution electronic endoscopy]. / Indigókarmin festékkontraszt módszer alkalmazása nagy felbontóképességú elektronikus endoszkópia során.

INTRODUCTION: Chromoendoscopy is an old endoscopic technique which has a renascence in the era of high resolution electronic endoscopy. Indigo carmine, this deep blue stain is not absorbed by gastrointestinal epithelium. It pools in crevices and valleys and highlights small lesions and defines irregularities in mucosal architecture. METHOD: The indigo carmine dye contrast method was introduced in author's endoscopic laboratory in 1994 and high resolution (400 k.pixels) endoscopy in 1997. 0.1-0.5% indigo carmine solution was administered to the gastric, duodenal or colonic mucosa through the biopsy channel of the endoscope. The author found the dye method gave dramatic accentuation of abnormalities of mucosal architecture (i.e. small irregularities, ulcer scars, extent of small tumours, polyps) and was suitable to evaluate villous atrophy in the duodenum. RESULTS: Using indigo carmine and high resolution electronic endoscopy it was possible to diagnose 3 times more gastric adenomas than was in the past. In the colon it was studied the surface appearance of colonic crypts and was able to discriminate between hyperplastic polyps which had a tipical "pit" pattern ("dots") and adenomatous polyps, which had a "groove" or "sulci" pattern. After histological examination the diagnostic accuracy was proved 59/64 in adenomatous and 18/23 in hyperplastic polyps. CONCLUSION: One should improve minute endoscopical observation and it is believed the administration of indigo carmine dye and high resolution endoscopy are suitable method for that.