Medical Library

Methylene-blue-aided cholangioscopy in patients with biliary strictures: feasibility and outcome analysis.

BACKGROUND AND STUDY AIMS: Chromoendoscopy using methylene blue is employed in the gastrointestinal tract to delineate neoplastic lesions. We tested the value of chromoendoscopy during choledochoscopy for characterization of local inflammation, neoplasias, and other alterations in patients with biliary strictures. METHODS: Patients with suspected biliary lesions were scheduled for endoscopic retrograde cholangiography with subsequent cholangioscopy. After initial inspection of the bile duct, 15 ml methylene blue (0.1 %) was administered via the working channel of the cholangioscope. Newly appearing circumscribed or unstained lesions were judged according to their macroscopic type and staining features. Methylene-blue-aided diagnosis was compared with either clinical follow-up of the patients or, in some cases, with the results of targeted biopsies. RESULTS: A total of 55 patients [biliary stenosis/cholestasis of unknown origin (n = 24), stenosis after orthotopic liver transplantation (n = 11), primary sclerosing cholangitis (n = 20)] were included. Methylene blue unmasked subtle mucosal changes and permitted macroscopic characterization of circumscribed lesions. Characteristic surface staining patterns were seen in chronic inflammation, dysplasia, and ischemic-type biliary lesions. Nondysplastic mucosa appeared homogeneously stained, whereas scarred strictures showed a weak uptake of methylene blue. CONCLUSION: In this prospective feasibility study, methylene-blue-aided cholangioscopy was used for the first time to define different staining patterns of the bile duct. The differences in staining patterns identified normal, dysplastic, and inflamed mucosa of the bile duct, as was proved by follow-up or, in some cases, histology. Whereas homogeneous staining predicted the presence of normal mucosa, absence of staining of circumscribed lesions, or diffused staining of such lesions, represented neoplastic changes or inflammation.

Hoffman A, Kiesslich R, Bittinger F, Galle PR, Neurath MF.

Medical Clinic I, Johannes Gutenberg University of Mainz, Germany.

Transluminal closure for NOTES: an ex vivo study comparing leak pressures of various gastrotomy and colotomy closure modalities.

BACKGROUND AND STUDY AIMS: Transluminal closure is fundamental to the safe introduction of natural orifice transluminal endoscopic surgery (NOTES) into humans. Suture, staples, and clips have been used. We aimed to evaluate the acute strength of various gastrotomy and colotomy closure techniques in an ex vivo porcine model by assessing air leak pressures. PATIENTS AND METHODS: The following closure modalities were assessed with at least five samples per arm: conventional open/laparoscopic suturing techniques including full-thickness interrupted sutures, double-layer sutures, and purse-string sutures, as well as endoscopic clips and endoscopic staples. Historical values for transgastric closures with hand-sewn interrupted sutures, endoscopic clips, and a prototype endoscopic suture device were used from our laboratory\’s prior study. RESULTS: Using Kruskal-Wallis analysis, the overall comparisons were significant ( P = 0.0038 for gastrotomy closure; P = 0.0018 for colotomy closure). Post hoc paired comparisons revealed that the difference between all closure arms versus negative control were significant. Significance could not be established among the various closure arms. However, trends suggested hand-sewn double-layer sutures, endoscopic staples, and both hand-sewn and endoscopically-placed purse-string sutures produced the strongest closures. Furthermore, endoscopic clips appeared sufficient for colotomy closure when ideally placed. CONCLUSIONS: Suture (both hand-sewn and endoscopically deployed) appears to produce the strongest closures in both stomach and colon, with the important caveats that (1) a continuous through-thickness suture track be avoided, such as in the full-thickness closure, or (2) suture holes be buried, such as in the purse-string configuration. When suture tracks are full-thickness, they can serve as leak sites. Staples and clips can produce comparable closures, but only under ideal conditions.

Ryou M, Fong DG, Pai RD, Rattner DW, Thompson CC.

Division of Gastroenterology, Brigham and Women’s Hospital, Harvard Medical School, Boston, USA.

Antiatherogenic Effects of Cilostazol and Probucol Alone, and in Combination in Low Density Lipoprotein Receptor-deficient Mice Fed with a High Fat Diet.

Cilostazol, an antiplatelet drug, and probucol, a cholesterol-lowering drug, are reported to ameliorate atherosclerosis in animal models. However, their combined effect on atherosclerosis is unclear. We therefore evaluated their combined effect on atherosclerotic lesions in LDL receptor-deficient mice. Male LDL receptor-deficient mice were fed a high fat diet with or without cilostazol alone, probucol alone, or with cilostazol and probucol in combination, for 8 weeks. Body weight and plasma lipid levels were measured before and during treatment. At the end of treatment, the size distribution of plasma lipoproteins was analyzed by HPLC and then plasma HDL cholesterol levels and en face aortic atherosclerotic lesion areas were measured. Probucol alone significantly decreased both total cholesterol and HDL cholesterol, while cilostazol alone did not decrease total cholesterol, but significantly increased HDL cholesterol. Both cilostazol alone and probucol alone significantly decreased atherosclerotic lesion areas, and their combined administration showed more significant decreases than when each drug was administered singly. The combination of cilostazol and probucol was more effective in preventing atherosclerotic lesion formation than the administration of each drug alone; this may provide us with a new strategy for treating atherosclerosis.

Yoshikawa T, Mitani K, Kotosai K, Nozako M, Miyakoda G, Yabuuchi Y.

1Free Radical Research Institute, Ostuka Pharmaceutical Co., Ltd., Tokushima, Japan.

Ghrelin as an Acute-phase Reactant during Postoperative Stress Response.

Ghrelin is a growth hormone-releasing peptide, discovered in 1999 by Kojima et al. Its potential role in inflammation and stress response is not yet clear. The purpose of this study was to characterize perioperative levels of circulating ghrelin in relation to different surgical procedures. The authors compared plasma ghrelin changes with cortisol, cytokines, and acute-phase proteins. The prospective study was performed on 22 patients with resection for colon cancer (group 1). Group 2, functioning as a comparative group, consisted of 22 patients with elective laparotomic cholecystectomy. Plasma concentrations of ghrelin, cortisol, tumor necrosis factor-alpha (TNF-alpha), interleukin-1beta, IL-6, IL-8, soluble IL-2 receptor, C reactive protein, and alpha1-antitrypsin were estimated repeatedly during a 72-hour postoperative period. Data revealed significant elevation of plasma ghrelin 24 hours after resection of coli (median 508.0 ng/l, interquartile range 398.2-633.7 ng/l) in relation to both preoperative levels (317.6 ng/l, 253.4-355.1 ng/l, p<0.01) and group 2 maximal postoperative levels (386.2 ng/l, 324-432 ng/l, p<0.05). Ghrelin levels returned to initial status 36-48 hours after surgery with subsequent decline to subnormal levels. The regression coefficient was the highest for ghrelin and TNF-alpha 24 hours after laparotomy (r=0.64, p<0.05) and for ghrelin and IL-6 24 hours after surgery (r=0.56, p<0.05). Maximal postoperative levels of all tested parameters except for cortisol and IL-1beta differed significantly between both patient groups at p<0.05. After large abdominal surgery, ghrelin shows itself as an acute-phase reactant. The significant correlation between ghrelin and inflammatory cytokines supposes their regulatory role in this period. Our comparison of more- and less-invasive surgical procedures with similar nutritional restrictions argues for a dominant role of inflammatory factors in postoperative ghrelin elevation.

Maruna P, Gürlich R, Rosická M.

1Institute of Pathological Physiology, First Faculty of Medicine, Charles University, Prague, Czech Republic.

Plant polyphenols against UV-C-induced Cellular Death.

The glycosylated phenylpropanoid verbascoside isolated from cultured cells of the medicinal plant SYRINGA VULGARIS (Oleaceae) has previously been characterized as an effective scavenger of biologically active free radicals such as hydroxyl, superoxide, and nitric oxide, as a chelator of redox active transition metal ions (Fe (2+), Fe (3+), Cu (2+), and Ni (2+)), and an inhibitor of lipid peroxidation. In the present work, we have compared the cytoprotective effects of the biotechnologically produced verbascoside with two commercially available polyphenols (the glycosylated flavonoid rutin and its aglycone quercetin) against free radical-mediated UVC-induced cellular death in cultures of human keratinocytes (HaCaT) and breast cancer cells (MCF 7). We have shown that all the polyphenols studied afforded effective protection against UVC-induced necrosis and did not prevent UVC-induced apoptosis in both normal and tumor cell lines. The cytoprotection did not correlate either with UVC absorbance by polyphenols or with their superoxide radical scavenging properties. However, UVC protection strongly depended on the lipid peroxidation inhibiting and Fe (2+) chelating properties of polyphenols. We suggest that these plant polyphenols could be feasible for a photoprotection of human skin. AO:acridine orange DMEM:Dulbecco\’s modified Eagle\’s medium EB:ethidium bromide EDTA:ethylenediaminetetraacetic acid FCS:fetal calf serum GST:glutathione S-transferase LDH:lactate dehydrogenase MTT:3-(4,5-dimethylthiazol-2-yl)-2,5-diphe- nyltetrazolium bromide TBARS:thiobarbituric acid reactive substances UV-C:ultraviolet C VB:verbascoside.

Kostyuk V, Potapovich A, Suhan T, De Luca C, Pressi G, Dal Toso R, Korkina L.

Dermatology Research Hospital (Istituto Dermopatico dell\’Immacolata, IDI IRCCS), Rome, Italy.

Protective Effects of Amburoside A, a Phenol Glucoside from Amburana cearensis, against CCl4-Induced Hepatotoxicity in Rats.

The aim of this study was to investigate the possible beneficial effects of amburoside A, AMB [4-(O-beta- D-glycopyranosyl)benzyl protocatechoate], against carbon tetrachloride (CCl (4)) toxicity in rats. AMB is a phenol glucoside from the Brazilian medicinal plant AMBURANA CEARENSIS, popularly used for the treatment of respiratory tract affections. Acute AMB (25 and 50 mg/kg, I. P. or P. O.) treatments of CCl (4)-intoxicated rats significantly inhibited the increase in serum aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels, as compared to the group treated with CCl (4) only. Histological studies showed less centrolobular necrosis and inflammatory cell infiltrates in the liver of animals treated with AMB plus CCl (4), when compared to the group treated with CCl (4) alone. In hepatic tissues, AMB at both doses inhibited CCl (4)-induced thiobarbituric acid-reactive substances (TBARS) formation, indicating a blockade of CCl (4)-induced lipid peroxidation. AMB also reversed the decrement in glutathione contents of hepatic tissues in CCl (4)-intoxicated rats. Furthermore, it restored catalase activity to normal values, which was significantly increased after CCl (4) treatment. Our results indicate that CCl (4)-induced oxidative damage in hepatic tissues is reversed by AMB treatment. The protective effect of AMB is probably due to the phenolic nature of this glucoside.

Leal LK, Fonseca FN, Pereira FA, Canuto KM, Felipe CF, Fontenele JB, Pitombeira MV, Silveira ER, Viana GS.

Departmento de Farmácia, Universidade Federal do Ceará, Fortaleza, Brasil.

A Time Course Analysis of Systemic Administration of Aqueous Licorice Extract on Spatial Memory Retention in Rats.

In the present study, the time course of the effects of GLYCYRRHIZA GLABRA L. (Leguminosae) aqueous extract (GE), administered systemically to rats, on the spatial memory retention in the Morris water maze was investigated. The dose of glycyrrhizin (GL), i. e., 0.5, 2.5 and 5 mg/mL in daily water intake of GE was administered to three groups of rats. The first, second and third groups received GE for 1, 2 and 4 weeks, respectively (each group included 3 subgroups). Three additional control groups of animals received only tap water during the same periods of time. After terminating the treatments, all animals were trained for four days; each day included one block and each block contained four trials. Test trials were conducted 48 h after the completion of the training period. Nicotine (1 mug/side) was infused into the CA1 region of the hippocampus as a positive drug control. GE treatment decreased both escape latency and traveled distance, but not swimming speed, compared with control, suggesting significant spatial memory retention enhancement by GE. Statistical analysis did not show any significant difference between GE-treated animals and the nicotine group in escape latency and traveled distance. At the end of the testing trials plasma samples were collected and the concentrations of glycyrrhetinic acid (GA) as a major metabolite of GL were measured in the different groups of treated rats. The maximum concentration was observed after four weeks of GE administration at 5 mg/mL of GL. These results showed that the enhancement effect of GE on spatial memory retention does not correlate with GA blood levels. Ach:acetylcholine ChAT:choline acetyltransferase COX:cyclooxygenase CREB:cAMP response element binding protein GE: GLYCYRRHIZA GLABRA aqueous extract GA:glycyrrhetinic acid GL:glycyrrhizin NSAIDs:non-steroidal anti-inflammatory drugs PKA:protein kinase A.

Sharifzadeh M, Shamsa F, Shiran S, Karimfar MH, Miri AH, Jalalizadeh H, Gholizadeh S, Salar F, Tabrizian K.

Department of Toxicology-Pharmacology and Center of Excellence of Toxicology, Pharmaceutical Sciences and Medicinal Plants Research Centers, Faculty of Pharmacy, Tehran University of Medicinal Sciences, Tehran, Iran.

[Minimalinvasive Operationen an der Lendenwirbelsäule. Teil 1.]

Röllinghoff M, Sobottke R, Koy T, Delank KS, Eysel P.

Universitätsklinikum zu Köln, Orthopädische Klinik.

[The \”Well-Leg\” Syndrome: Calf Compartment after Lothoiomy Position.]

AIM: The lower leg compartment syndrome is in most cases a post-traumatic soft tissue complication. Nevertheless, it can also occur in a primarily not injured calf, due to external muscle compression during lithotomy positioning. This complication is seen rarely after gynaecological, urological or abdominal operations performed in the Lloyd-Davis position. METHOD: We present a case of calf compartment after prolonged lithotomy position of the uninjured leg during the nailing of a femur shaft fracture. RESULTS: Postoperatively a diffuse turgor of the healthy calf was seen. The compartment pressures were elevated and the enzyme creatine kinase was elevated up to 3000 U/l. After dermatofasciotomy the enzyme level normalised, but in the further course we had to resect the necrotic peroneal muscle compartment. CONCLUSION: During operative procedures at the coxal femur, it is necessary to deposit the other leg in the lithotomy postion. By this means, the compartment pressures can increase in the calf muscles to critical values. Together with operation times longer than 4 hours and a high ponderosity a bedding compartment can develop. As it is in the assumed \”healthy\” leg, this syndrome can be overseen, especially in sedated patients. It has to be considered with high creatine kinase levels and the typical risk factors. If a compartment syndrome is suspected, we recommend early dermatofasciotomy, as this is a low-risk and low-complication operation, in comparison to a later performed compartment decompression. By extending both legs, especially in risky patients, the surgeon can avoid this dangerous complication.

Weber O, Kabir K, Goost H, Wirtz DC, Burger C.

Klinik für Orthopädie und Unfallchirurgie, Universitätsklinik Bonn.

[Embolisation of aneurysmal bone cysts as a minimally invasive treatment option - presentation of two cases.]

AIM: The aim of this study was to evaluate embolisation as a therapy option for aneurysmal bone cysts of the trunk. METHOD: Case reports about two males with intermittent pseudo-radicular lumboischialgia and coxalgia are discussed. RESULTS: The diagnostic work-up and biopsies verified an aneurysmal bone cyst in both males. In one patient the tumour-like lesion was localised in the fifth lumbar vertebral body, in the other in the left ischium and pubis. Arterial embolisation was performed in both cases. Follow-up at 6 and 24 months after embolisation showed a significant increase of sclerosis and a reduced volume of the cysts. CONCLUSION: In accord with literature data, arterial embolisation seems to be a sufficient and minimally invasive therapy option in aneurysmal bone cysts of the spine and the pubis.

Kocak T, Huch K, Ulmar B, Aschoff A, Reichel H.

Orthopädische Universitätsklinik Ulm am RKU (Arztlicher Direktor: Prof. Dr. med. H. Reichel).