No effect of perianal application of topical anaesthetic on patient comfort during nonsedated flexible sigmoidoscopy: a randomized, placebo-controlled clinical trial.

AIM: A literature review revealed no data on the effects of topical anaesthetic on patient comfort during flexible sigmoidoscopy. We therefore aimed to evaluate this in a randomized manner. METHOD: One hundred and forty-six patients who underwent flexible sigmoidoscopy were randomly allocated to one of three groups. Vaseline (n = 49), 2% lidocaine gel (n = 51) or a cream of 2.5% lidocaine plus 2.5% prilocaine (n = 46) were applied to the patients 30 min before the procedure. Demographic data and haemodynamic monitoring during procedures were recorded. Pain was assessed by visual analogue scale (VAS) and anxiety levels by the State-Trait Anxiety Inventory (STAI-I and STA-II). RESULTS: Median pre-procedural STAI-I scores were 45, 46 and 40.5 and median post-procedural STAI-I scores were 35, 34 and 33.5 for the vaseline, lidocaine, and lidocaine/prilocaine treatments, respectively. There was no statistical difference among the groups in terms of STAI-I and II scores. However, post-procedural STAI-I scores were significantly lower than pre-procedural values in each group (P < 0.001). There was no significant difference in VAS scores among the groups. In all groups there were statistically higher VAS scores during the procedure compared with the pre- and post-procedural scores (P < 0.001). CONCLUSION: Perianal application of topical anaesthetic does not influence patient comfort during sigmoidoscopy.

Thermally induced shape memory behavior, enzymatic degradation and biocompatibility of PLA/TPU blends: "Effects of compatibilization".

Poly(lactic acid) (PLA)/thermoplastic polyurethane (TPU) blends were melt-mixed and compatibilized to investigate their biocompatibility, biodegradability and thermally induced shape memory properties. The blend compositions were PLA/TPU: 80/20 (20TPU) and PLA/TPU: 50/50 (50TPU). 1,4-phenylene diisocyanate (PDI) was used in order to compatibilize the components reactively. The PDI composition was 0.5, 1, 3% by weight. Biodegradability was assessed by enzymatic degradation tests. Biocompatibility was investigated through in-vitro cell-culture experiments. Shape memory tests exhibited that 20TPU blends have higher recovery ratio than that of 50TPU blends. It was observed that the shape recovery ratio was enhanced by the addition of PDI. The highest shape recovery ratio was obtained at 3%PDI in 20TPU blends. Enzymatic biodegradability tests showed that the increasing TPU content decreased the biodegradability of the blends. It was found that compatibilization slowed down the enzymatic degradation of PLA/TPU blends. In-vitro cell-culture experiments indicated that all blends were biocompatible, and no evidence of cytotoxicity was observed.

Duct-to-duct biliary anastomosis with a "corner-saving suture" technique in living-related liver transplantation.

OBJECTIVES: Biliary complications after living-related liver transplantation (LRLT) remain a major source of morbidity for recipients. We describe our technique and early results with 32 recipients who underwent LRLT with duct-to-duct anastomoses during the last 2 years. METHODS: Between January 2003 and December 2004, 50 patients underwent liver transplantation in our center with overall patient and graft survival rate of 86.4% and 86.4%. Of 50 patients, 41 (82.0%; 17 adult and 24 pediatric) underwent LRLT, 32 (78.0%) of whom had duct-to-duct biliary anastomoses with a "corner-saving suture" technique. RESULTS: Of 32 patients in whom duct-to-duct biliary anastomoses were performed, 4 (12.5%) had an anastomotic leak with 2 eventually developing bile duct strictures within 3 months. One patient required reoperation for a bile leak. All other anastomotic leaks and strictures were treated with percutaneous drainage and balloon dilatation with excellent outcomes. There was no long-term morbidity and no graft loss owing to biliary complications. Seven patients died during follow-up (0.5 to 25 months); 43 are doing well with optimal liver function in the early posttransplantation period. CONCLUSION: According to our early results, we recommend duct-to-duct anastomosis in LRLT when calibration of the ducts show suitable results and when there is no tension on the anastomosis site. Otherwise, Roux-en-Y hepaticojejunostomy should be performed to decrease risk of biliary complications.

The role of early colonoscopy in CMV colitis of transplant recipients.

Cytomegalovirus (CMV)-associated diseases remain a major problem in transplant recipients. Early diagnosis is critical. Presentation of early CMV colitis can be mild and nonspecific in transplant recipients. Although serology is helpful in the diagnosis, sometimes it is inadequate. Because the endoscopic features of CMV colitis are specific, colonoscopy facilitates the histopathologic examination. We present the clinical properties and advantages of early colonoscopy in transplant recipients with CMV colitis. The study group included seven patients (six men, one woman of mean age, 36.7 years (range, 22 to 64 years) whose mean transplant duration was 12.3 months (range, 1 to 72 months). Six of the seven patients experienced an acute graft rejection treated with high doses of steroids; one patient had a herpes simplex virus infection. All patients were on steroid treatment with a various combinations of immunosuppressive agents, including cyclosporine, mycophenolate mofetil, and tacrolimus. All patients presented with mild diarrhea without any blood or mucous discharge. Four patients had fever exceeding 38 degrees C; two had abdominal pain. Stool examinations revealed normal findings in six patients, while one patient had white blood cells and amoebic cysts. Serum CMV IgM and CMV pp65 antigenemia were negative in five of seven patients and two had positive results. All patients showed typical colonoscopic and histopathologic findings compatible with CMV colitis. Standard ganciclovir treatment was successful in all patients. Early and rapid colonoscopy is beneficial for the early diagnosis and management of CMV colitis in transplant recipients.

Effects of selenium on endothelial dysfunction and metabolic profile in low dose streptozotocin induced diabetic rats fed a high fat diet.

Endothelial dysfunction develops as a result of oxidative stress and is responsible for diabetic vascular complications. We investigated the effects of selenium on endothelial dysfunction and oxidative stress in type 2 diabetic rats. Male Wistar rats were divided into five groups: controls, untreated diabetics, and diabetics treated with 180, 300, 500 mcg/kg selenium each day. Diabetes was induced by a single intraperitoneal injection of low dose streptozotocin to rats fed a high fat diet. Endothelium-dependent and -independent relaxations were measured in the thoracic aorta. Nicotinamide adenine dinucleotide phosphate (NADPH) oxidase and endothelial nitric oxide synthase (eNOS) mRNA expressions were analyzed using real-time polymerase chain reaction (RT-PCR). Fasting blood glucose, lipid profile, lipid oxidation, insulin and nitric oxide were measured in blood samples. Malondialdehyde, superoxide dismutase, catalase and glutathione peroxidase levels were measured in liver samples. RT-PCR showed that selenium reversed increased NADPH oxidase expression and decreased eNOS expression to control levels. Selenium also improved the impairment of endothelium-dependent vasorelaxation in the diabetic aorta. Selenium treatment significantly decreased blood glucose, cholesterol and triglyceride levels, and enhanced the antioxidant status in diabetic rats. Our findings suggest that selenium restores a normal metabolic profile and ameliorates vascular responses and endothelial dysfunction in diabetes by regulating antioxidant enzyme and nitric oxide release.

An unusual adverse effect of interferon: hypertrichosis of the eyelashes.

Hypertrichosis of the eyelashes is a rare adverse effect of interferon-alpha treatment. We present a 21-year-old man with chronic renal failure and hepatitis B virus (HBV) infection who developed hypertrichosis of the eyelashes as a complication of IFN-alpha therapy. The patient was a candidate for living related renal transplantation and was given IFN-alpha 15 million units per week for HBV DNA positivity. After 6 months of therapy, HBV DNA positivity persisted, and the dose of IFN was increased to 30 million units per week. At the end of the first half of the second 6 months of therapy, the patient suffered from bilateral hypertrichosis of the eyelashes.

The analysis of gastrointestinal amyloidosis in 78 patients with chronic renal failure.

Systemic amyloidosis is not a single disease, but the product of a variety of diseases. Amyloid proteins are insoluble fibrils that are deposited extracellularly in many organ tissues. They stain with Congo red and appear apple green under polarized light. Definitive diagnosis and classification ofamyloidosis requires histologic examination of tissue samples. Gastrointestinal tract involvement is common, and all parts of the system can be affected Immunohistochemical studies have shown that amyloid deposited in the gastrointestinal system is most often of the AA, A kappa, or A lambda types. Another type of amyloidprotein, beta-2 microglobulin (beta2M), predominantly affects the musculoskeletal system, and is usually seen in patients who have been on long-term hemodialysis. Mixed systemic amyloidosis (beta2M and AA) is seen only rarely in these patients. In this study, we attempted to answer why this is so, and examined whether or not mixed amyloidosis is related to amyloidogenesis. We studied gastrointestinal tissues from 78 chronic renal failure patients who had systemic amyloidosis with gastrointestinal involvement. A total of 115 endoscopic samples and 1 jejunal resection specimen were analysed immunohistochemically. Immunohistochemical testing using a panel of antisera directed against two major amyloid fibril proteins (AA-Monoclonal, Dako-, and beta2M-Polyclonal, Dako-) showed that all samples contained AA amyloid, but not beta2M type protein. These findings can be explained by the patients' relatively short average duration of hemodialysis and the predominance of endoscopic biopsy samples in our study.

Investigation of possible clinical and laboratory predictors of liver fibrosis in hemodialysis patients infected with hepatitis C virus.

Hepatitis C virus (HCV) infection is common in patients with end-stage renal disease. The severity of liver damage, including fibrosis, in these cases varies widely. Although many investigators have searched for noninvasive alternatives to liver biopsy for evaluating the extent of liver fibrosis, no useful noninvasive predictors have been found. Currently, liver biopsy is essential to assess the degree of fibrosis. The aim of this retrospective study was to investigate a range of clinical and laboratory parameters in HCV-infected hemodialysis (HD) patients and identify possible predictors of fibrosis. Ninety-five consecutive HD patients with HCV infection underwent liver biopsy. Each specimen was evaluated for fibrosis stage. Correlations were sought between the degree of fibrosis and the age, HD duration, time since first possible HCV exposure, body mass index, HCV RNA titer, serum ferritin level, and serum alanine aminotransferase (ALT) level. The analysis revealed no significant correlations between fibrosis stage and the parameters investigated (mean age: r =.017, P =.89; mean HD duration: r =.066, P =.576; body mass index r =.231, P =.152; HCV RNA titer: r =.015, P =.091; serum ferritin: r =.134, P =.32; serum ALT r =.108, P =.927). Links with serum ALT were reevaluated with upper normal levels arbitrarily set at 30 IU/L and 20 IU/L, but these analyses also revealed no correlations between fibrosis stage and ALT level (P =.98 and P =.449, respectively). Therefore liver biopsy is still essential for accurate assessment of liver pathology in HD patients with HCV.

Association of helicobacter pylori infection with nutritional status in hemodialysis patients.

The presence of Helicobacter pylori (HP) infection may adversely influence outcome in renal transplant candidates because of its strong association with gastrointestinal disorders. We examined the association between HP infection and nutritional parameters in symptom-free hemodialysis patients and assessed prospectively the nutritional changes in patients who received therapy for the disease. The 163 study patients, including 114 men and 69 women of mean age 41.5 +/- 12.9 years on dialysis for 67.2 +/- 47.6 months, were selected from among the group who underwent routine endoscopic evaluation according to our renal transplant protocol. Patients with active peptic ulcer, acute gastritis, chronic inflammatory disease, malignancy, or diabetes mellitus were excluded. Endoscopy results revealed normal findings in 60 (group 1), gastritis in 86 (group 2), or gastritis with HP in 17 patients (group 3). Group 3 patients received a 2-week course of triple therapy (omeprazole, amoxicillin, clarithromycin). The patient groups were compared for nutritional metrics (albumin, phosphorus, interdialytic weight gain [IDWG], body mass index [BMI]), inflammatory indices (CRP, fibrinogen), and iPTH levels. Group 3 patients were observed to be malnourished when compared with groups 1 and 2, namely abnormal values of albumin (P <.0001), phosphorus (P <.009), IDWG (P <.03), and BMI (P <.02). Repeat endoscopy revealed a 94% rate of eradication of HP with increased levels of albumin and phosphorus in group 3. Although symptom-free hemodialysis patients with HP-associated gastritis displayed a state of malnutrition; its eradication improved the nutritional status. Therefore, the presence of HP infection should be sought and its eradication mandatory for this patient population.

Colonoscopy is a useful diagnostic tool for transplant recipients with lower abdominal symptoms.

Transplant recipients are at higher risk for infection and malignancy due to therapies aimed at preventing rejection. Early detection and successful treatment of such complications is of pivotal importance for both patient and graft survival. In this study, we evaluated findings of 91 colonoscopies and colonic histopathologic findings in recipients who presented with lower gastrointestinal system complaints between January 1996 and January 2003. The study group included 79 renal and liver transplant patients. The indications for colonoscopy were diarrhea (n = 58), abdominal pain (n = 5), hematochezia (n = 19), unexplained anemia (n = 5), thickening of a colonic segment detected on computerized tomography (n = 2), screening for lymphoma (n = 1), and Kaposi's sarcoma (n = 1). During the procedures, all suspicious lesions were biopsied and specimens of normal-appearing mucosa collected when deemed necessary in relation to the clinical complaints. The endoscopic findings were classified as follows: 0 = "normal," with clear visualization of the vascular network and normal-appearing mucosa; 1 = "erythema", with tissues showing erythema, edema, hyperemia, and loss of normal vascular network; 2 = "ulcerative," with tissues exhibiting ulceration and fragility; and 3 = "coincidental findings," such as polyp or angiodysplasia. Colonoscopic and/or histopathologic abnormalities were detected in 44.5% of the 91 colonoscopy procedures. The results indicate that colonoscopy is a valuable diagnostic tool for evaluation of transplant recipients with lower gastrointestinal complaints. After an initial workup colonoscopy is important to establish an accurate diagnosis.

Successful heterotopic segmental liver transplantation from a live donor to a patient with Alagille syndrome.

Alagille syndrome is characterized by a paucity of bile ducts in the liver. The syndrome is associated with some or all the features of chronic cholestasis, cardiac disease, skeletal abnormalities, ocular defects and a distinctive facial appearance. The most common finding is chronic cholestasis, which causes intractable pruritus, xanthoma, deficiency of certain metabolic nutrients and growth retardation. Cardiac abnormalities are the most common cause of death in these patients. It is unusual to see the clinical picture of hepatic failure resulting in cirrhosis and requiring transplantation, but liver transplantation is indicated in Alagille syndrome patients who have chronic cholestasis. If the disease is diagnosed in childhood, transplantation can improve significantly the patient's prognosis and the quality of life. In recent years, auxiliary liver transplantation has gained popularity for treating both acute and chronic liver disease. Heterotopic segmental liver transplantation is an alternative treatment modality for patients who do not require native liver removal. Individuals with Alagille syndrome are good candidates for this type of treatment. J Pediatr Surg 36:667-671.

The importance of increasing the number of gastric biopsies in the diagnosis of Helicobacter pylori.

BACKGROUND/AIMS: The role of Helicobacter pylori in various gastroduodenal diseases is universally accepted. In this study, we aimed to determine the proper number and sites of the gastric biopsies in order to achieve the highest diagnostic yield through the use of a urease test and histopathology. We also compared the histological findings encountered in patients who had Helicobacter pylori (H. pylori) colonization. METHODOLOGY: Fifty patients referred for upper gastrointestinal endoscopy for dyspeptic complaints were included in the study. Our mapping protocol included 2 biopsies from antrum and 2 biopsies from corpus. We obtained 2 biopsies from each biopsy site for urease test and histopathological assessment. Golden standard positivity for the presence of H. pylori colonization was defined as concomitantly positive urease test and histologically detected bacteria found at the same biopsy site. RESULTS: Forty-three patients had H. pylori colonization. Colonization rates of H. pylori, sensitivities of urease testing, and histopathology in 4 biopsy sites were not statistically different. Sensitivity of urease testing was 81.4% for 1 biopsy and 100% for 4 cumulative biopsies. Sensitivities of histological assessment were 93% and 100% for 1 and 4 biopsies, respectively. CONCLUSIONS: Results of this study suggest that 2 biopsies for urease testing and 1 biopsy for histopathology obtained from the antrum or corpus of the stomach were sufficient to obtain the highest statistically significant diagnostic sensitivity.

Management of postoperative biliary strictures secondary to hepatic hydatid disease by endoscopic stenting.

BACKGROUND/AIMS: The cases in the present study were reviewed retrospectively with the aim to demonstrate the characteristics of these strictures as well as the effectiveness of endoscopic stenting and to discuss the possible mechanisms of stricture formation. METHODOLOGY: Thirteen cases of postoperative benign biliary strictures secondary to hepatic hydatid disease (HHD) surgery were diagnosed between 1989 and 1994. All of these cases had had surgery for HHD one or more times. Endoscopic stenting was performed in 11 of the cases. Eight cases were followed-up. RESULTS: In 3 (29%) of the 8 cases, the stents were removed after a mean period of 35.6 months, and the patients were considered cured. These cases have been followed-up for 28 months. The remaining 5 cases have been followed-up for a mean period of 14.2 months. The overall morbidity was 18%, and there were no mortalities. The postoperative benign biliary strictures secondary to HHD were long, multiple, and located proximally. Due to these properties, surgical repair was not indicated for these cases. CONCLUSION: Endoscopic stenting is a safe method in the treatment of postoperative benign biliary strictures secondary to hepatic hydatid disease.

Endoscopic treatment of bronchobiliary fistula: report on 11 cases.

BACKGROUND/AIMS: There are reports of treatment of biliary cutaneous fistulae by endoscopically placed nasobiliary drains. We report our fistulae treatment results from this method. MATERIALS AND METHODS: We treated 11 patients with bronchobiliary fistulas (BBFs) endoscopically during the last 6 years. In most cases, the BBF's were the result of Hydatid cyst operations. Six patients had simultaneous biliocutaneous fistula (BCF). RESULTS: All BBFs and BCFs closed after the nasobiliary drain placement without any complication. Three patients who developed fistula recurrence healed with endoscopic treatment. CONCLUSION: Endoscopic treatment is a viable alternative to surgical treatment.

The effect of cisapride on gallbladder contractility in type II diabetic patients.

BACKGROUND/AIMS: To investigate whether diabetics have altered gallbladder motility, and whether cisapride has any effect on gallbladder motility in these patients. The factors associated with abnormal gallbladder contractility, and with the effects of cisapride on gallbladder contractility in diabetics were also evaluated. METHODOLOGY: The gallbladder contractility parameters of 20 diabetics and 20 controls were assessed by real time ultrasonography. The same measurements were made after cisapride treatment in diabetics. RESULTS: Fasting gallbladder volume and residual gallbladder volume were statistically higher in the diabetic group than in the controls (P = 0.018 and P = 0.022, respectively). Multivariate analysis also showed a significant association between fasting gallbladder volume and existing diabetes (P = 0.0002). There was a significant positive correlation between level of hemoglobin A1c and fasting gallbladder volume (r = 0.48, P = 0.031). Responders to cisapride treatment had significantly higher hemoglobin A1c levels than nonresponders (6.6 +/- 1.3 vs. 9.1 +/- 1.8, respectively; P = 0.004). Logistic multiple regression analysis revealed that hemoglobin A1c level was the only independent factor that was predictive for efficacy of cisapride treatment. CONCLUSIONS: This study demonstrates that diabetics have impaired gallbladder contractility, and that control of diabetes is predictive for gallbladder contractility and response to cisapride therapy in these patients.