Endoscopic tissue shielding method with polyglycolic acid sheets and fibrin glue to prevent delayed perforation after duodenal endoscopic submucosal dissection.

Delayed perforation after duodenal endoscopic submucosal dissection (ESD) occurs at a high rate because the duodenal wall is very thin and the artificial ulcer after resection is exposed to bile and pancreatic juice. We investigated the application of the combination of a polyglycolic acid (PGA) sheet and fibrin glue. PGA sheets comprise materials widely used in surgery for absorbable thread. Fibrin glue is a heated blood product and is used for hemostasis during operations. We developed a combined method using both materials. We have used this method in two cases. One case involved an elevated lesion located in the lower duodenal angle of the duodenum. The other involved an elevated lesion in the second portion of the duodenum. About 1 week after ESD, the PGA sheets remained covering the ulcer and delayed perforation did not occur. We were able to easily carry out this method for several parts of the duodenum. This method may be helpful for the prevention of delayed perforation after duodenal ESD.

[A case of probable autoimmune hepatitis from which the persistence of hepatitis A IgM antibody, and the improvement was pathologically obtained by ursodeoxycholic acid medication].

We present a 68 years old woman who was referred to our department due to impaired liver function. Hepatitis A IgM antibody and anti-nuclear antibody were positive, IgG, and gamma-globulin were elevated. Percutaneous liver biopsy was performed and autoimmune hepatitis was suspected pathologically. Oral administration of ursodeoxycholic acid was started and liver function was normalized three months later. The improvement of a hepatitis image was examined by percutaneous liver biopsy one year later. Although hepatitis A IgM antibody was positive throughout the course, hepatitis A virusemia was not considered the cause of persistent positive hepatitis A. IgM antibody could not be clarified. There was a possibility of a non-specific reaction and abnormalities in antibody production control were considered possible. We present this case and discuss the previous literature.

[Case of primary malignant fibrous histiocytoma of the diaphragm discovered by liver function disorder].

We present the case of a 67-year-old man with primary malignant fibrous histiocytoma (MFH) of the diaphragm. He was admitted to our hospital with anorexia and loss of body weight. High serum levels of AST, ALT, ALP and gamma-GTP were observed. Several imaging studies disclosed a large tumor on the right side of the diaphragm to the right lobe of the liver. The entire tumor was resected, and histopathological examination of the specimen revealed the characteristics of MFH. MFH originating from the diaphragm is very rare, and we present the case of this patient in addition to a discussion of previous literature.

Neutrophils enhance invasion activity of human cholangiocellular carcinoma and hepatocellular carcinoma cells: an in vitro study.

BACKGROUND AND AIM: Tumor-mesenchymal interactions are involved in the mechanism of tumor invasion in several types of carcinoma. Mutual interactions between carcinoma cells and neutrophils, however, have been poorly understood. In the present study we examined the effect of neutrophils on invasion activities of carcinoma cells in vitro. Role of hepatocyte growth factor (HGF) as a mediator was also evaluated. METHODS: Using a Matrigel invasion chamber, invasion activities of HuCC-T1 human cholangiocellular carcinoma cells and HepG2 hepatocellular carcinoma cells in response to recombinant HGF or neutrophils were evaluated. RESULTS: Recombinant HGF dose-dependently increased invasion activities of HuCC-T1 and HepG2 cells. Neutrophils significantly enhanced invasion activities of these cells, which were suppressed to the respective basal levels with anti-HGF antibody. The carcinoma cells did not secrete HGF. Neutrophils cultivated in tumor condition medium (TCM) of HuCC-T1 or HepG2 cells secreted a significant level of HGF protein without increasing HGF mRNA expression. Treatment with heat or ultrafiltration of TCM of HuCC-T1 or HepG2 cells suggested carcinoma cell-derived HGF inducer(s) to be certain protein(s) with a molecular weight of more than 30 000. CONCLUSIONS: The present study suggests the presence of mutual interactions between HuCC-T1/HepG2 carcinoma cells and neutrophils in tumor invasion via paracrine regulation mediated by neutrophil-derived HGF.

Effects of obstructive jaundice on neutrophil production and acquisition of chemotactic activity in the bone marrow.

BACKGROUND AND AIMS: Increased numbers and enhanced functions of peripheral neutrophils have been observed in obstructive jaundice. However, the effects of obstructive jaundice on the bone marrow, that is neutrophil production and acquisition of neutrophil chemotactic activity, have been poorly understood. In the present study, differentials of bone marrow cells and chemotactic activity of bone marrow neutrophils were evaluated in bile duct-obstructed rats. METHODS: Male Wistar rats underwent either bile duct obstruction for 10 days or bile duct obstruction for 4 days followed by 6 days' internal biliary drainage. Differentials of peripheral blood and bone marrow cells were sequentially determined. Chemotactic activity of peripheral and bone marrow neutrophils was evaluated with a modified Boyden method using interleukin-8 (recombinant rat Gro-beta) as a chemoattractant. RESULTS: Numbers of peripheral neutrophils significantly increased after bile duct obstruction. Significant increases in the myeloid/erythroid (M/E) ratio of bone marrow cells were observed after bile duct obstruction. The neutrophil proliferative pool (promyelocytes and myelocytes) increased initially, followed by an increased neutrophil storage pool (metamyelocytes, bands, and segmented neutrophils). The M/E ratio as well as the neutrophil proliferative and storage pools normalized after internal biliary drainage. Chemotactic activity was enhanced in both peripheral and bone marrow neutrophils after bile duct obstruction, and enhanced chemotaxis was alleviated with internal biliary drainage. CONCLUSION: The present results strongly suggest the principal role of the bone marrow in increasing the number of neutrophils and their chemotactic activity during obstructive jaundice.

Neutrophil chemotaxis in bile duct-obstructed rats, and effect of internal biliary drainage.

BACKGROUND/AIMS: Our previous studies demonstrated enhanced neutrophil chemotaxis in bile duct-ligated, obstructive jaundice rats. In the present study, we produced a reversible obstructive jaundice model in rats. The efficacy of the present model in producing sufficient bile flow blockade and subsequent internal biliary drainage was assessed. Furthermore, the effect of internal biliary drainage on neutrophil chemotaxis was evaluated. METHODOLOGY: Bile duct was obstructed with a polyester tape attached with a stainless steel coil. Internal biliary drainage was performed by removing the tape. Rats were subjected to either 10 days' bile duct obstruction or 4 days' bile duct obstruction followed by 6 days' internal biliary drainage. Some animals underwent conventional bile duct ligation and dissection for 4 or 10 days. Neutrophil chemotaxis was evaluated with a modified Boyden method using interleukin-8 (recombinant rat Gro-beta) as chemoattractant. RESULTS: The present technique produced sufficient obstructive jaundice as evidenced by increases in serum alanine aminotransferase and total bilirubin throughout the observation period, the values of which were insignificant with those induced by the conventional method. Internal biliary drainage effectively normalized these values. Similarly, neutrophil chemotaxis was enhanced with both procedures, and increased neutrophil chemotaxis was significantly decreased after drainage. CONCLUSIONS: The present reversible obstructive jaundice method is as efficacious as the conventional method for producing obstructive jaundice, and internal biliary drainage could be readily available. With the present model, neutrophil overactivity in obstructive jaundice was effectively alleviated by internal biliary drainage. The result may support the role of preoperative biliary drainage in the prevention of postoperative septic complications.

Diagnosis of common bile duct calculi with intraductal ultrasonography during endoscopic biliary cannulation.

BACKGROUND: Choledocholithiasis can be difficult to diagnose, even with direct cholangiography. We examined the role of biliary intraductal ultrasonography in detecting common bile duct stones that had been overlooked during endoscopic retrograde cholangiopancreatography. METHODS: Eighty consecutive patients who underwent endoscopic retrograde cholangiography for suspected choledocholithiasis with negative results were evaluated with intraductal ultrasonography (20 MHz) for the presence of biliary concrements. The diagnostic criterion for stones was a strong-echo structure with acoustic shadowing. Materials of low amplitude echoes without acoustic shadowing were considered sludge. RESULTS: Intrabile duct scanning was successful in all patients. Of the 80 patients, 20 (25%) had ultrasonic evidence of common bile duct stones. The stones measured 5 mm or less on ultrasound and their presence was confirmed macroscopically during endoscopic (17 patients) or laparoscopic (three patients) bile duct clearance. Another 37 patients (46%) had biliary sludge alone and have been followed up uneventfully. CONCLUSIONS: Biliary intraductal ultrasonography may become a useful adjunct to establish the diagnosis of occult bile duct concrements and a guide to appropriate therapeutic selection during endoscopic biliary cannulation.

The effect of biliary decompression on antibiotic biliary excretion.

BACKGROUND/AIMS: Raised biliary pressure may affect antibiotic biliary excretion. We evaluated whether biliary decompression for patients with biliary obstruction could improve antibiotic biliary excretion. METHODOLOGY: Eight patients with common bile duct obstruction undergoing endoscopic nasobiliary drainage were evaluated. During endoscopic cannulation, biliary pressure above the obstruction and antibiotic concentrations in the bile and peripheral blood were determined 60 min after the intravenous antibiotic (panipenem) administration. RESULTS: Biliary pressure was initially elevated above normal in all the patients, but normalized after biliary drainage for 5 to 7 days. At the initial endoscopic retrograde cholangiopancreatography, the aspirated bile contained low or undetectable levels of the antibiotic, but the mean bile panipenem concentration and the mean bile/plasma ratio of panipenem concentrations significantly improved after biliary decompression. CONCLUSIONS: The results suggest an important role of biliary pressure in determining antibiotic transfer into the bile.