Application of the OTSC system for the closure of fistulas, anastomosal leakages and perforations within the gastrointestinal tract.

Until recently there has been no technique available which reproducibly and safely allowed endoscopic closures of penetrating defects within the digestive tract. With the new "over the scope clipping system" (OTSC system®), which regarding design and function is similar to a bear-trap, a method is available for the endoscopic closure of fistulas and perforations. Here, we present a series of 10 patients, in whom different penetrating defects within the digestive tract could be closed in 9 of 10 cases successfully by the OTSC system®: fistulas (esophagotracheal, esophagopleural, gastrocutaneous and colovesical), perforations (after mucosectomy, after papillotomy and PEG misplacement) and anastomosal leakages (after gastrotomy and gastrectomy). In another case we demonstrate our first experience with the OTSC system® for the prevention of perforations during deep endoscopic R 0 resection of a T 1(sm1)G1 sigmoideal cancer after initial R 1 resection.

Removal of over the scope clips (OTSC) with an Nd:YAG Laser.

Until recently there has been no technique available which reproducibly and safely allows endoscopic closures of penetrating defects within the digestive tract. With the new "over the scope clipping system" (OTSC system), which regarding design and function is similar to a bear-trap, a method is available for the endoscopic closure of fistulas and perforations. The OTSC-systems are designed for permanent placement. However, in the case of misplacement or the need to remove the clip after healing of the defect, a technique for destroying and removing the clip should be available. We demonstrate for the first time the successful removal of the deeply penetrating OTSC system by using the Nd:YAG-Laser in 3 cases: (i) after closure of an oesophageal fistula, (ii) after closure of a perforation of the distal common bile duct in the roof of the papilla and (iii) after clip misplacement in a case of a wide oesophagomediastinal fistula resulting in a severe oesophageal stenosis. Clinically relevant thermal lesions were not observed after the procedure. If clinically necessary, the OTSC-system can be safely removed by the Nd:YAG Laser in centres for interventional endoscopy. Because of the small number of cases the method must still be considered as experimental and requires further validation. This will be possible with the help of a newly established OTSC registry ( www.endodo.de ).

[Gangliocytic paraganglioma--a rare cause of an upper gastrointestinal bleeding]. / Gangliozytisches Paragangliom--eine seltene Ursache für eine obere gastrointestinale Blutung.

INTRODUCTION: Gangliocytic paraganglioma is a rare tumour, occurring nearly exclusively in the descending part of the duodenum. It is regarded as a mostly benign tumour but of unknown malignant potential, which rarely metastasises to local lymph nodes or distantly. CASE REPORT: Here we report on a 62-year-old female patient with a marked microcytic anaemia with a haemoglobin concentration of 3.4 mg/dL. Oesophagogastroduodenoscopy showed an ulcerous periampullary tumour in the duodenum with a diameter of approximately 5 cm. Endoscopic ultrasonography showed no evidence of tumour infiltration of the tunica muscularis and of locoregional lymph node metastasis. Therefore, complete endoscopic resection of the tumour was achieved after ligating the tumour base by an endoloop using a dual channel endoscope. In a second step, the tumour base was resected by endoscopic submucosal dissection (ESD) and revealed no residual tumour. The histological evaluation showed a gangliocytic paranganglioma consisting of three specific cell types: epithelioid cells arranged in typical carcinoid-like patterns, spindle cells wrapped around nests of epithelioid cells and ganglion cells. All cell types expressed neuron-specific enolase (NSE) as a neuroendocrine marker. Synaptophysine was expressed mainly by the epithelioid and ganglion cells while the protein S 100 was expressed mainly by the spindle cells, which surround the epithelioid cell nests as a sustentacular network. The proliferation rate determined by Ki67 staining was only < 5 %. CONCLUSION: Gangliocytic gangliocytomas of the duodenum can be safely removed by endoscopic submucosal dissection as long as there is no evidence of infiltration of the tunica muscularis or of local lymph node metastasis. Because of the unknown malignant potential, these patients have to be controlled by regular ultrasonographic and endosonographic procedures.

["Endoscopy in a stone quarry"--multiple pigment stones 6 weeks after delivery]. / "Endoskopieren im Steinbruch"--ausgeprägtes Pigmentsteinleiden 6 Wochen post partum.

A 29-year-old African woman without any history of diseases was referred to our clinic because of recurrent abdominal pain. 6 weeks earlier she had delivered a healthy baby. Laboratory data revealed hypochromic microcytic anemia, elevated cholestatic liver enzymes, and an elevated bilirubin level of 2.2 mg/dl. Abdominal sonography showed choledocholithiasis. The endoscopic retrograde cholangiography showed the presence of more than 100 small stones in the intra- and extrahepatic bile ducts. An endoscopic papillotomy was performed and multiple small black stones were removed from the bile duct by basket into the duodenum. Because of the hypochromic microcytic anemia, the detection of pigment stones and the ethnic background of the patient we suspected a hemoglobinopathy. Hemoglobin electrophoresis showed 97 % HbC. The molecular genetic analysis revealed a homozygous mutation in codon 6 GAG > AAG for the beta globin chain (HbCC). HbC is a structurally abnormal hemoglobin with typical aggregates and tetragonal crystal formation which results in mild chronic hemolytic anemia. The cholezystectomy after 6 weeks was performed without complications.

Anthracyline-reduced sequential combination chemotherapy for younger patients with good-prognosis aggressive B-cell non-Hodgkin's lymphoma.

INTRODUCTION: Anthracyline-based chemotherapy is the treatment of choice for patients with aggressive B-cell non-Hodgkin's lymphoma (NHL). However, anthracyclines have been associated with long-term cardiac toxicity. METHODS: We conducted a study using a sequential combination chemotherapy with a reduced cumulative dose of anthracyclines in younger patients with good-prognosis aggressive NHL. Chemotherapy consisted of one cycle of vincristine, ifosfamide, etoposide, and dexamethasone, followed by three cycles of epirubicin, cyclophosphamide, vincristine, and dexamethasone, and a fifth cycle containing carboplatin, etoposide, and dexamethasone. 86 patients were treated, 65 without and 21 with additional rituximab. Consolidating involved-field irradiation was applied in patients with stage I/II, bulky disease, or localized residual lymphoma. RESULTS: Complete and partial remissions were achieved in 67 and 27% of patients, respectively, and the 3-year event-free and overall survival estimates were 75 and 87%. The survival estimates were substantially better in patients who received rituximab. Main toxicity was grade 3/4 leukocytopenia in 89% patients with neutropenic fever in 30%. Two patients died of septic shock. CONCLUSION: The treatment appears to be effective in this group of patients. The hematological toxicities, particularly after the first and fifth cycle, require the use of G-CSF and/or a dose reduction in selected patients.

A facilitated method for endoscopic interventions at the bile duct after Roux-en-Y reconstruction using double balloon enteroscopy.

Endoscopic retrograde cholangiography (ERC) after Roux-en-Y reconstruction and modified BII surgery or duodenopancreatectomy is considerably more difficult than ERC under normal anatomic conditions. If the common bile in the afferent loop cannot be reached by a common lateral-viewing duodenoscope because of excessive intestinal length, it has recently become possible to use double balloon enteroscopy (DBE) for ERC to reach the common bile duct. Cannulating the bile duct via DBE in these postoperative settings remains one of the most difficult ERCP manipulations because of the lack of an Albarran lever and the use of extra long ERCP accessories. Here, we report on a facilitated method for endoscopic interventions at the bile duct in postoperative settings with a long afferent loop using DBE. For facilitation of interventions the enteroscope can be exchanged for a 110-cm-long conventional gastroscope after incision of the overtube in three quarters of its circumference. Care has to be taken that the pressure line for the balloon remains intact. The huge benefit of this facilitated method is the use of standard endoscopic material like guides, catheters and papillotomes.

[Pancreaticomediastinal fistula as a rare cause of recurrent pleural effusions]. / Pankreatikomediastinale Fistel als seltene Ursache rezidivierender Pleuraergüsse.

A 45-year-old male with chronic alcoholism was transferred to our hospital with progressive dyspnoea, bilateral pleural effusions and ascites. Serum concentrations of lipase and CRP were increased. Pleural effusions recurred despite repeated thoracentesis, antibiotic therapy and total parenteral nutrition. A CT scan of chest and abdomen showed a lipomatous pancreas without signs of necrosis. Endosonography (EUS) demonstrated as signs of chronic pancreatitis an increased lobularity of the parenchyma without calcifications and two small cystic lesions in the pancreatic head. The pleural fluid lipase levels were markedly increased compared to a low lipase concentration in ascites. As an explanation for the pleural effusions ERCP showed a retroperitoneal fistula in the head/body region into the mediastinum and a stenosis of the pancreatic duct in the pancreatic head. For the ascites an inflammatory pathogenesis due to the exacerbation of chronic pancreatitis had to be assumed because the analysis showed an exudate with leukocytosis. After papillotomy via the pancreatic duct a 10 French wide 9 cm long stent was inserted into the pancreatic duct bridging the pancreatic fistula. Within 10 days pleural effusions had completely receded. After three weeks pancreaticography showed a total regression of the fistula and the stent was exchanged. After 6 weeks the pancreatic stent was removed with a lasting remission of the pleural effusions.

[Acute generalized cat scratch disease in myelodysplastic syndrome]. / Akute generalisierte Katzenkratzkrankheit bei myelodysplastischem Syndrom.

In patients with normal immunity, cat scratch disease typically develop a papule at the portal of entry and no other cutaneous features. A 73 year old male patient with a myelodysplastic syndrome developed generalized petechial, papular and, vasculitic skin lesions in association with cat scratch disease. After the diagnosis was established by identifying the causative organism in a lymph node biopsy, the patient was treated with erythromycin for three weeks resulting in progressive clearance of the skin lesions. Apart from the soluble IL-2 receptor, no other serologic inflammatory parameters were elevated. IgG antibodies against Bartonella henselae and Bartonella quintana increased only slightly during acute exacerbation of the disease, but significantly increased some months later. The diagnosis was established by the positive staining of the lymph node biopsy using the Warthin-Starry stain.

Simple, cost-effective technique for portable digital eletrocorticography.

We revised 16 patients submitted to epilepsy surgery using a new method of digital, real-time, portable electrocorticography. Patients were operated upon over a period of 28 months. There were no complications. The exam was useful in 13 cases. The low installation and operational costs, the reliability and simplicity of the method, indicate it may be useful for defining the epileptogenic regions in a variety of circumstances, including surgery for tumors, vascular malformations, and other cortical lesions associated with seizure disorders.

Prognostic factors in mesial temporal lobe epilepsy surgery.

Eighty-four patients submitted to anterior temporal lobectomy were evaluated retrospectively in order to correlate the different type of simple partial seizure (SPS) and their prognostic implications in patients with mesial temporal sclerosis. The patients were divided in two groups following the classification of Engel; Group 1 (53 patients) included patients Class I (without seizures or of good outcome) and Group 2 (31 patients) included Classes II, III and IV (with seizures or of bad outcome). The two groups were compared and results showed no statistical difference in relation to the demographic aspects as sex, side of surgery, age at onset of seizures and time of the patients' postoperative follow-up. Statistical analysis revealed no relationship between type of SPS and outcome. SPS did not show a statistical value in localizing the side of pathology. However, when the two groups were compared statistically in terms of patients' ages at the time of surgery, and the time elapsed from the onset of the seizures to the surgical intervention, it was observed that Group 1 (of good outcome) had seizures for smaller interval (p <0.05) and was operated at an earlier age (p<0.02) than Group 2 (of bad outcome). The presence or the type of SPS can not be used as a prognostic measure; surgical therapy must be considered as soon as clinical resistance is demonstrated.

The fiber-type-specific effect of inactivity and intermittent weight-bearing on the gastrocnemius muscle of 30-month-old rats.

OBJECTIVE: To characterize single skeletal muscle fiber contractile properties from the gastrocnemius muscle that occur during inactivity and intermittent weight-bearing in 30-month-old animals. DESIGN: Randomized control trial. SETTING: A controlled laboratory environment. SUBJECTS: Eighteen 30-month-old male Fisher 344 Brown Norway F1 Hybrid rats were randomly assigned to control (C), hindlimb unweighted (HU), and hindlimb unweighted with intermittent weight-bearing (HU-X) groups. INTERVENTIONS: The HU and HU-X rats were suspended for 7 days. The HU-X animals were unsuspended for four 15-minute bouts of weight-bearing. MAIN OUTCOME MEASURES: Single skeletal muscle fiber contractile properties (diameter, peak active force [P0], peak specific tension [P0/CSA], and maximal shortening velocity [V0] by fiber type) were determined from the deep portion of the lateral head of the gastrocnemius muscle (RG). RESULTS: In comparison to C animals, the ratio of gastrocnemius weight to body weight decreased by 18% and 14% following HU and HU-X, respectively. Diameter and P0 of type I fibers from the RG were reduced after HU. Attenuation of the decline in diameter and P0 was observed in type I fibers from the RG with HU-X. P0 was reduced in type IIa fibers and type I-IIa fibers with HU. Attenuation of the decline in P0 by intermittent weight-bearing in type IIa fibers and type I-IIa fibers did not occur. CONCLUSIONS: Inactivity altered the contractile properties of single skeletal muscle fibers from the gastrocnemius muscle of 30-month-old animals. The inactivity-induced alterations were present in the three fiber types. Therapeutic intervention of weight-bearing attenuated the inactivity-induced changes in the type I fibers from the gastrocnemius, but not the other fiber types.

[Neuroleptic malignant syndrome: case report with recurrence associated with the use of olanzapine]. / Síndrome neuroléptica maligna. Relato de caso com recorrência associada ao uso de olanzapina.

The neuroleptic malignant syndrome (NMS) consists in an idiosyncratic reaction to neuroleptic drugs, probably related to a blockage of dopamine receptors in basal ganglia. Research criteria for diagnosing NMS from DSM-IV require severe rigidity and fever accompanied by 2 of 10 minor features including diaphoresis, dysphagia, tremor, incontinence, altered mentation, mutism, tachycardia, elevated or labile blood pressure, leukocytosis and elevation of creatine phosphokinase. From a clinical point of view, the NMS may range a large spectrum of presentations. Haloperidol is the most frequent drug associated with this syndrome. We report the case of a 30 year-old man who developed NMS at two different occasions, the first related to haloperidol and chlorpromazine and the second related to olanzapine, to our knowledge without previous mention in the indexed literature.

Assessment of satisfaction with the communication process during consultation of cancer patients with potentially curable disease, cancer patients on palliative care, and HIV-positive patients.

The aim of this study was to evaluate the attitudes of cancer patients towards the medical interview and to determine their psychosocial satisfaction subsequent to the dialogue. The answers given by patients with curable cancer were compared to those given by cancer patients whose treatment intent was palliative and to the replies of patients infected with the human immunodeficiency virus (HIV), a nonmalignant but also incurable state. The subject population comprised a total of 139 patients. Patients had to complete a questionnaire with a total of 34 items. The answers to the questions were rated on a 5-point scale with response options ranging from 1 to 5 or consisting of true-false statements. Cancer patients, palliative and curative, and HIV-positive patients considered their physicians to be honest (x = 4.34, x = 4.58, and x = 4.30, respectively; p = 0.104), and they emphasized that he/she took enough time answering their questions (x = 4.00, x = 4.30 and x = 4391, respectively; p = 0.12). Cancer patients treated with potentially curable disease were more frequently afraid of being informed about additional diagnostic examinations and about the disclosure of results as compared to cancer patients on palliative care (p < 0.05 for both questions). Patients with HIV-infection considered themselves less informed about the treatment they received as compared to curative cancer patients (x = 3.73 and x = 4.28, respectively; p < 0.046). Only 8.0% of the tumor patients on palliative care, but 63.6% of the HIV-positive patients realized that their medication was given with the objective to relieve symptoms (p < 0.001). When asked about additional goals of treatment, 48% of the palliative cancer patients and 15.1% of the HIV-positive patients checked "cure" (p < 0.002). In conclusion, particularly patients with curable cancer were afraid of information they might receive during the medical interview. Cancer patients considered themselves better informed compared to patients with HIV-infection. This is in significant contrast with the actual, measurable knowledge about their disease in the latter group. It is indeed surprising that only a small minority of incurable cancer patients realized that the goal of the medical care they received was relief of symptoms, the principle objective of palliation.

The intracarotid amobarbital procedure (Wada test) with two protocols combined, Montreal and Seattle.

The intracarotid amobarbital procedure was carried out in 8 male and 7 female candidates to temporal lobectomy, and a female candidate to frontal lesionectomy, aged 18-50 (mean 32.5) years. Language and memory were tested after injection in each hemisphere. Both were measured by the Montreal procedure. In 9 patients language and memory were evaluated with the Seattle procedure too. In 12 patients the left hemisphere was dominant for language; three had bilateral dominance. In 1 patient the Seattle procedure demonstrated the dominant hemisphere by relatively slowness of speech during the drug effect in the left hemisphere. Memory was defined to be in the left hemisphere in 12 patients, in the right in 2, bilateral in 1 and in another lateralization was not possible. In 1 patient memory dominance was determined by the Montreal protocol alone because of lack of cooperation. These early results indicate that the methods may be complementary for determination of language and memory dominance in epilepsy surgery candidates.

Epilepsy surgery without invasive EEG. Early results of a new program.

A total of 42 patients were submitted to a clinical, behavioural and neuropsychological evaluation with the objective of eventual surgical treatment of epilepsy refractory to the usual clinical therapies. Prolonged video-EEG monitoring, MRI hippocampal volume measurement, lateralization of speech and memory using the amobarbital (Wada) test were used. Of 18 operated cases, 12 were submitted to temporal lobectomy, with a follow-up of 6-30 months; 8 patients had significant improvement in seizures control; 2 patients had partial improvement in seizure frequency and intensity; 2 patients had no improvement in seizure control. One patient underwent right frontal lobectomy with total remission of seizures and 5 had callosotomy with varying degrees of success. There was no mortality. Morbidity included one subdural hematoma, one transient hemiparesis, one episode of mania, one lobar pneumonia and frequent immediately post-operative muscular tension headaches. These early results indicate good results of temporal lobectomy patients investigated through a non-invasive presurgical evaluation.

[Digital EEG with brain mapping in Alzheimer's dementia and Parkinson's disease. A prospective controlled study]. / Eletrencefalograma digital com mapeamento em demência de Alzheimer e doença de Parkinson: estudo prospectivo controlado.

In order to evaluate the EEG activity during wakefulness in senile dementia of the Alzheimer type (AD) and Parkinson's disease (PD), a prospective controlled study was performed. We compared 6 AD and 11 PD patients with a control group of 12 patients with mild to moderate major chronic depression (DSM-III-R, 1987). The median of the frequencies and the power of the posterior dominant activity was obtained in the three groups using spectral analysis. The posterior activity had a frequency of 8.79 +/- 0.52 (mean +/- sd) in the control group, 6.65 +/- 0.80 (mean +/- sd) in the AD group and 7.69 +/- 1.39 (mean +/- sd) in the PD group. The experimental hypothesis that patients with AD and PD differ from controls in relation to the background activity (defined as abnormal < 8) was confirmed by the chi square test (p = 0.01) and the t test showed that the mean of the frequency of the posterior power was significantly lower in AD (p = 0.01) and PD (p = 0.05) patients, compared with the controls. The results indicate that this abnormality could be correlated with the degree of cortical damage and natural history of these disorders.

[Lateralization of the epileptogenic area by magnetic resonance imaging in temporal lobe epilepsy]. / Lateralização da área epileptogênica através de ressonância magnética na epilepsia do lobo temporal.

We studied 5 patients with medically refractory temporal lobe epilepsy using special methods of MRI, in order to localize the epileptogenic area. Coronal sequences were obtained with 5 mm sections from the posterior margin of the brainstem to the base of the frontal lobe using: "Inversion recovery T1" (TR = 2500 msec, TE = 26 msec, T1 = 600 msec) to analyse loss of internal structure and atrophy of the hippocampus, and morphology of the temporal lobe; and Spin-echo T2w (TR = 250 msec, TE = 120 msec) looking for abnormal high intensity signal. In two cases with left focal EEG the MRI showed atrophy, loss of internal structure and abnormal high intensity signal in the hippocampus, and atrophy of the anterior temporal lobe, ipsilaterally. One case with independent bilateral foci at the EEG showed atrophy, loss of internal structure and abnormal high intensity signal in the right hippocampus. Other case with right focal EEG showed bilateral atrophy of the anterior temporal lobes. Another case was normal. We conclude that this methodology can facilitate the surgical indication in temporal lobe epilepsy.

Lateralizaçäo da área epileptogênica através de ressonância magnética na epilepsia do lobo temporal / Lateralization of the epileptogenic area by magnetic resonance imaging in temporal lobe epilepsy

Métodos especiais de MRI foram utilizados em 5 pacientes com epilepsia do lobo temporal refratários ao tratamento clínico, com a finalidade de localizar a área epileptogênica. Imagens coronais com espessura de 5mm foram obtidas da borda posterior do tronco cerebral até a base do lobo frontal, utilizando-se as sequências "Inversión Recovery T1" (TR=2500 msec, TE=26 msec, T1=600 msec) para avaliar perda de estrutura interna e atrofia do hipocampo e morfologia do lobo temporal; Spin-echo T2w (TR=2500 msec, TE=120 msec) visando a avaliar sinais de alta intensidade anormais. Em 2 casos com focos esquerdos no EEG, a MRI mostrou atrofia, perda de estrutura interna e aumento de sinal no hipocampo, e atrofia do lobo temporal anterior, ipsilateralmente. Um caso com focos bilaterais independentes no EEG teve atrofia, perda da estrutura interna e aumento de sinal no hipocampo direito. Um caso com EEG focal direito mostrou atrofia em ambos os lobos temporais anteriores. Outro caso näo mostrou anormalidades. Concluimos que esta metodologia pode facilitar a indicaçäo cirúrgica em epilepsia do lobo temporal