Japanese multicenter experience of endoscopic necrosectomy for infected walled-off pancreatic necrosis: The JENIPaN study.

BACKGROUND AND STUDY AIMS: Only a few large cohort studies have evaluated the efficacy and safety of endoscopic necrosectomy for infected walled-off pancreatic necrosis (WOPN). Therefore, a multicenter, large cohort study was conducted to evaluate the efficacy and safety of endoscopic necrosectomy and to examine the procedural details and follow-up after successful endoscopic necrosectomy. PATIENTS AND METHODS: A retrospective review was conducted in 16 leading Japanese institutions for patients who underwent endoscopic necrosectomy for infected WOPN between August 2005 and July 2011. The follow-up data were also reviewed to determine the long-term outcomes of the procedures. RESULTS: Of 57 patients, 43 (75 %) experienced successful resolution after a median of 5 sessions of endoscopic necrosectomy and 21 days of treatment. Complications occurred in 19 patients (33 %) during the treatment period. Six patients died (11 %): two due to multiple organ failure and one patient each from air embolism, splenic aneurysm, hemorrhage from a Mallory - Weiss tear, and an unknown cause. Of 43 patients with successful endoscopic necrosectomy, recurrent cavity formation was observed in three patients during a median follow-up period of 27 months. CONCLUSIONS: Endoscopic necrosectomy can be an effective technique for infected WOPN and requires a relatively short treatment period. However, serious complications can arise, including death. Therefore, patients should be carefully selected, and knowledgeable, skilled, and experienced operators should perform the procedure. Further research into safer technologies is required in order to reduce the associated morbidity and mortality.

Endoscopic ultrasound-guided celiac ganglia neurolysis vs. celiac plexus neurolysis: a randomized multicenter trial.

BACKGROUND AND STUDY AIMS: No prospective comparison of endoscopic ultrasonography-guided direct celiac ganglia neurolysis (EUS - CGN) vs. EUS-guided celiac plexus neurolysis (EUS - CPN) has been reported. The aim of the current study was to compare the effectiveness of EUS - CGN and EUS - CPN in providing pain relief from upper abdominal cancer pain in a multicenter randomized controlled trial. PATIENTS AND METHODS: Patients with upper abdominal cancer pain were randomly assigned to treatment using either EUS - CGN or EUS - CPN. Evaluation was performed at Day 7 postoperatively using a pain scale of 0 to 10. Patients for whom pain decreased to ≤ 3 were considered to have a positive response, and those experiencing a decrease in pain to ≤ 1 were considered to be completely responsive. Comparison between the two groups was performed using intention-to-treat analysis. The primary endpoint was the difference in treatment response rates between EUS - CGN and EUS - CPN at postoperative Day 7. Secondary endpoints included differences in complete response rates, pain scores, duration of pain relief, and incidence of adverse effects. RESULTS: A total of 34 patients were assigned to each group. Visualization of ganglia was possible in 30 cases (88 %) in the EUS - CGN group. The positive response rate was significantly higher in the EUS - CGN group (73.5 %) than in the EUS - CPN group (45.5 %; P = 0.026). The complete response rate was also significantly higher in the EUS - CGN group (50.0 %) than in the EUS - CPN group (18.2 %; P = 0.010). There was no difference in adverse events or duration of pain relief between the two groups. CONCLUSIONS: EUS - CGN is significantly superior to conventional EUS - CPN in cancer pain relief. CLINICAL TRIAL REGISTRATION: http://www.umin.ac.jp/ctr/index.htm (ID: UMIN-000002536).

Cystic lymphangioma of the colon: endosonographic diagnosis with through-the-scope catheter miniprobe and determination of further management. Report of a case.

Lymphangioma of the colon is rare. There are several reports that endoscopic ultrasound is useful for diagnosis of colonic lymphangioma. We report a case of lymphangioma of colon diagnosed by catheter endosonography and review the literature on endoscopic ultrasound in cystic lymphangioma of the gastrointestinal tract. A 70-year-old female was found to have two submucosal lesions in the colon by colonoscopy. Endoscopic ultrasound revealed that these lesions were anechoic, multicystic, and confined to the submucosa, and the underlying muscularis propria was intact. These findings were consistent with cystic lymphangioma. If typical endosonographic images of an anechoic, septated lesion within colonic submucosa are obtained, further workup or treatment may not be necessary if the patient is asymptomatic.

Adherence of cyanoacrylate which leaked from gastric varices to the left renal vein during endoscopic injection sclerotherapy: a histopathologic study.

We report a case involving leakage of cyanoacrylate (CA) to the inferior vena cava (IVC) through a gastrorenal shunt and left renal vein. A 72-year-old man with liver cirrhosis was admitted to our hospital to undergo emergency treatment for massive hemorrhage of gastric varices. Endoscopic injection sclerotherapy (EIS) using CA was performed on the varices. Radiographic fluoroscopy revealed that most of the injected CA had adhered firmly to the gastric varices, but a certain portion of the CA had flowed to the IVC through the gastrorenal shunt and left renal vein. At that point, the patient did not complain of any symptoms. However, 6 months later, he died of hepatic failure and an autopsy was performed. Histopathologic examination of the wall of the IVC and renal vein, to which CA had adhered, revealed that the CA was covered with endothelial cells of the vessel and no nearby thrombus was present. Long-term anticoagulant therapy may not be indicated in cases of leakage of CA from the gastric varices to other veins, since the leaked CA may be readily covered with endothelium without thrombus formation as in our patient. It is possible for CA to flow to the IVC and have a fatal impact. Our patient was fortunate, and for safe EIS it is important that these complications are prevented.

Anti-tumor immunity against CT26 colon tumor in mice immunized with plasmid DNA encoding beta-galactosidase fused to an envelope protein of endogenous retrovirus.

Endogenous retroviral gene products have been recognized as being expressed in human cancerous tissues. However, these products have not been shown to be antigenic targets for T-cells, possibly due to immune tolerance. Since carcinogen-induced colon tumor CT26 expresses an envelope protein, gp70, of an endogenous ecotropic murine leukemia virus that is comparable to human tumor-associated antigens, we examined whether a DNA vaccine containing the gp70 gene induces protective immunity against CT26 cells. Injection of mice with plasmid DNA (pDNA) encoding gp70 alone failed to induce anti-gp70 antibody (Ab) or anti-CT26 cytotoxic T lymphocyte (CTL) responses. However, immunization with pDNA encoding the beta-galactosidase (beta-gal)/gp70 fusion protein induced anti-gp70 Ab and anti-CT26 CTL responses and conferred protective immunity against CT26 cells. These results indicate that beta-gal acts as an immunogenic carrier protein that helps in the induction of immune responses against the poorly immunogenic gp70. Considering these results, it is possible that potential tolerance to the endogenous retroviral gene products expressed by human tumors may be overcome by DNA vaccines that contain an endogenous retroviral gene fused to genes encoding immunogenic carrier proteins.

Injection of plasmid DNA into the gastric mucosa induces mucosal and systemic immunity.

Nearly all mucosal surfaces participate in a common mucosal immune system, and application of an antigen to one mucosal surface elicits local as well as distant mucosal immune responses. However, whether the gastric mucosa is a part of this network has not been examined directly. We show here that the injection of plasmid DNA encoding beta-galactosidase into the gastric wall caused transfection of gastric mucosal epithelial cells, induced systemic and mucosal antibody responses at both local (digestive tract) and distant (genital and respiratory tracts) sites, and induced cytotoxic T lymphocyte responses in the spleen and the mesenteric and iliac lymph nodes.

EUS analysis of collateral veins inside and outside the esophageal wall in portal hypertension.

BACKGROUND: The relation between esophageal varices and venous collaterals outside the esophageal wall in patients with portal hypertension remains unclear. We investigated this relationship with endoscopy and endoscopic ultrasound (US). METHODS: Twenty-two patients with untreated varices were examined. The collaterals were studied with a 20 MHz US catheter probe. Collaterals were divided into two groups: (1) periesophageal collateral veins adjacent to the muscularis externa of the esophagus and (2) paraesophageal collateral veins external to the esophageal wall but without contact with the muscularis externa. Periesophageal and paraesophageal collateral veins were scored as mild or severe according to stage of development. RESULTS: Varix form as defined endoscopically was significantly larger in the severe periesophageal collateral veins group than in the mild periesophageal collateral veins group (p < 0. 01). In contrast, varix form did not differ significantly between the mild and severe paraesophageal collateral veins groups. Perforating veins were detected in the distal esophagus in 18 of 22 patients (81.8%) by means of US. The prevalence of perforating veins increased in relation to varix form. Two types of perforating veins were found on the basis of connection with periesophageal and paraesophageal collateral veins. The frequency with which perforating veins were connected to periesophageal collateral veins was 81.8%; the frequency of connection to paraesophageal collateral veins was 27.3%. CONCLUSION: Periesophageal collateral veins play a more important role in the formation of esophageal varices than do paraesophageal collateral veins.

Mixed connective tissue disease with severe pulmonary hypertension and extensive subcutaneous calcification.

The results of the autopsy of a 38-year-old female with mixed connective tissue disease who had suffered from painful subcutaneous calcification in her buttocks and extremities for 14 years and died from rapidly progressive pulmonary hypertension are reported. On autopsy, her heart and lungs revealed changes of severe pulmonary hypertension with intimal thickening and plexiform lesions in the small pulmonary arteries which had resulted in the collapse of both lungs and caused marked dilatation and hypertrophy of the right ventricle of the heart. Microscopic examinations of the subcutaneous calcified tissues indicated that the calcification may have been caused by repeated panniculitis.

[A case of right atrial myxoma: M-mode and pulsed-Doppler echocardiographic findings before and after operation].

There are some reports concerning operations of right atrial myxoma. But precise effect on systemic hemodynamics before and after operation of right atrial myxoma has not been reported. We studied hemodynamics of a 54 year-old male with right atrial myxoma before and after removal of myxoma by M-mode and two-dimensional echocardiography. He was admitted to our hospital because of dyspnea on effort and orthostatic dizziness. On two-dimensional echocardiography the apical four chamber view showed an abnormal huge mass echo with cystic change (6.9 x 4.4 cm) moving between the right atrium and the orifice of tricuspid valve. From this finding emergent operation was undertaken with the possible diagnosis of right atrial myxoma, and the mass was found to be a benign myxoma histopathologically originating from the right side of atrial septum. Left ventricular dimensions (Dd, Ds) and the dimension of left atrial chamber were enlarged after the operation by M-mode echocardiography. Among the left ventricular inflow parameters, rapid filling peak velocity (E) increased with no change in presystolic peak velocity (A) and A/E improved from 1.63 to 0.95. This improvement of left ventricular diastolic function was supposed to be induced through the increased preload. After the operation his manifestations of dyspnea and dizziness have disappeared. It should be emphasized that an increase in preload after the removal of right atrial myxoma is very important to keep left ventricular diastolic and systolic function.

Protective effects of trifluoperazine on the microcirculation of cold-stored livers.

Previous studies have shown a protective effect of trifluoperazine (TFP), a calmodulin inhibitor, upon the microcirculation of cold-stored kidneys. The present study points to similar beneficial effects of TFP on the microcirculation of cold-stored livers; 25 canine livers were preserved for 24 hr with Euro-Collins' solution (EC) (n = 8), University of Wisconsin solution (UW) (n = 7), or UW + TFP (n = 10). The stored livers underwent heterotopic transplantation (HLTX); hepatic-artery and portal-vein pressure and flow were monitored; oxygen consumption and extraction were measured before HLTX and at 15-min intervals after reperfusion, for 1 hr. Mean hepatic-artery and portal-vein flow (HAF & PVF) prior to donor hepatectomy were 172 and 530 cc/min, respectively. Poor HAF and PVF occurred in EC-HLTX (mean 35, 175 cc/min, respectively). The damaged EC-flushed livers could not compensate to the decreased hepatic blood flow by increased oxygen extraction (oxygen consumption and extraction, 8.7 vol.% and 48%, respectively). Light and electron microscopy showed severe liver necrosis and periportal hemorrhages. Improved hepatic-artery and portal-vein flows were seen in UW HLTX (105 and 254 cc/min), and oxygen consumption and extraction were 16.4 vol.% and 66%, respectively. Liver biopsy taken just before reperfusion revealed well-preserved liver architecture. Liver biopsy obtained 1 hr after reperfusion revealed marked edema of the portal triad, sinusoid congestion, and hemorrhage. Electron-microscopy biopsies obtained during reperfusion at 15-min intervals revealed severe vasospasm of the terminal hepatic arterioles and progressive damage to the liver microcirculation. The addition of TFP to the UW-flush solution resulted in excellent protection of the liver microcirculation. Marked increase in hepatic-artery and portal-vein blood flow was noted after reperfusion (mean 167 and 421 cc/min, respectively (P 0.02 vs. UW: P 0.001 vs. EC). The recovery of metabolic activity was evident by the high oxygen consumption and extraction (25.8 vol.% and 80%, respectively). And serial liver biopsies obtained after reperfusion have shown excellent protection of liver architecture and the absence of hepatic arteriolar vasospasm. Taken together, these data suggest that the addition of TFP to the UW solution protects the liver microcirculation by rendering the hepatic microcirculation insensitive to vasospastic stimuli during reperfusion, thus permitting better metabolic recovery after transplantation.

[A case report of tricuspid valve endocarditis due to Staphylococcus aureus with successful surgical treatment].

A 14-year-old boy had previously received right temporal lobectomy under the diagnosis of a malignant brain tumor. About one month after lobectomy, ventriculo-peritoneum shunt and ventriculo-atrium shunt were placed because hydrocephalus was progressed. The patient subsequently had a high fever probably due to wound infection of the shunt operation. Several blood cultures demonstrated Methicillin Resistant Staphylococcus Aureus (MRSA). Several sensitive antibiotics were administered for about 30 days, however these drugs were not effective. According to echocardiography, moderate tricuspid regurgitation and a large vegetation at the tricuspid valve were detected and isolated tricuspid valve endocarditis was diagnosed. Surgical intervention was necessary because of recurrent pulmonary emboli. After tricuspid valve replacement with a Björk-Shiley mechanical valve (31 mm), fever subsided and the patient was discharged on the 38th postoperative day. It is concluded that the surgical indications of the tricuspid valve endocarditis are as follows: 1. recurrent pulmonary emboli, 2. refractory right heart failure, 3. resistance against antibiotics.