Biomedical subjects
Publications and source records attributed to P Sakai.
After a long symptom period of 19 years a submucosal tumor was suspected on endoscopy to account for the patient's intermittent nausea and abdominal pain. Duodenal waterfilling during endoscopic ultrasound led to the endosonographic diagnosis of an intraluminal duodenal diverticulum which was removed surgically. The patient became completely asymptomatic.
Partial gastrectomy is a risk factor for subsequent gastric cancer. The genetic alterations associated with malignant transformation, however, are poorly understood. Ninety-eight biopsies from 22 patients with benign gastric mucosa (BGM) at least 15 years after gastrectomy and resected specimens from 13 patients with postgastrectomy stump cancer (GC), were evaluated for immunohistochemical expression of bcl-2 oncogenic protein and correlated with the presence of dysplasia and subtypes of intestinal metaplasia (IM), categorized using high-iron diamine-alcian blue and alcian blue-periodic acid-Schiff stains. In BGM patients, 91% had chronic gastritis with atrophy, 18% showed complete (Type I) IM, 36% showed incomplete (Type II) IM, and 45% Type III IM. Twelve biopsy specimens from nine BGM patients showed mild-to-moderate dysplasia. Increased bcl-2 expression was present in 27% of BGM patients, with a significant association with increasing grade of IM: 20% in specimens with Type I IM, 30% with Type II, and 40% with Type III (P = .01). bcl-2 overexpression was more often present in the area of the anastomosis than in the body or fundus (P = .06). Of GC patients, 15% had Type II IM and 85% Type III IM. Moderate-to-severe dysplasia was present in adjacent benign mucosa in 46%. bcl-2 was present in 54% of GCs, and increased expression was detected in the adjacent benign mucosa in 60%. bcl-2 expression did not correlate with the presence or degree of dysplasia in either BGM or GC patients. bcl-2 protein is frequently expressed in GC. Increased expression is observed in mucosa adjacent to tumor and, to a lesser extent, in biopsy specimens of BGM, often associated with Type III IM. These findings suggest a possible role for the bcl-2 proto-oncogene in malignant progression.
BACKGROUND AND STUDY AIMS: The endoscopic treatment of symptomatic pharyngoesophageal diverticula (PED) with rigid instruments involves the incision of the septum between the diverticulum and the esophageal lumen, within which the cricopharyngeal muscle is present. The aim of this study is to report on the feasibility and efficacy of our method using flexible endoscopy and an electro-surgery system with minimal trauma to the patients. PATIENTS AND METHODS: Forty-two patients (13 female, 29 male) with symptomatic pharyngoesophageal diverticula underwent endoscopic treatment. The average age of the patients was 68.4 years (range 46 to 102 years) and 26 of them (61%) had concomitant cardiopulmonary diseases. The procedure consisted of endoscopic incision of the septum with a needle knife, using cutting/coagulation current. It was performed under preparation for routine endoscopic examination. All patients were clinically and endoscopically evaluated at two and four weeks, and afterwards followed clinically at 12, 24, and 60 months after the procedure. RESULTS: The endoscopic incision was performed in one to live sessions (mean of 1.8 session per patient). Two complications (one cervical emphysema, and one hemorrhage) were managed clinically. Dysphagia disappeared in all patients soon after the treatment, although the post-operative radiological and endoscopic controls revealed the presence of a remaining diverticulum. Manometric findings disclosed a significant reduction in upper esophageal sphincter pressures in all five patients after endoscopic incision. Mean follow-up was 38 months. There was recurrence of dysphagia in three patients (7.1%) at 12, 22, and 60 months after the procedure. They experienced relief of dysphagia after a repeated endoscopic incision. CONCLUSIONS: Endoscopic incision of PED using flexible equipment proved to be a highly efficient and safe method of treating symptomatic disease. It should be considered as an alternative therapy for Zenker's diverticula, especially for patients at a high surgical risk.
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Ninety-seven patients with bleeding esophageal varices due to mansonic schistosomiasis were treated with endoscopic sclerotherapy. Seventy-five patients (Group I) had previously undergone surgery for portal hypertension and presented with bleeding recurrence. Twenty-two patients (Group II) had not undergone surgical treatment. The sclerotherapy technique employed was intravascular (IV) injections of ethanolamine in 40 patients and paravascular (PV) in 57 patients. Of a total of 38 (39%) patients who had bleeding recurrence, 27 (36%) were from Group I and 11 (50%) from Group II (p less than 0.005). Over a follow-up period of 48 to 132 months, 367 sessions of sclerotherapy were carried out in the 72 remaining patients from Group I (4.93 +/- 2.05). The remaining 16 patients from Group II needed 121 (7.56 +/- 2.70) sessions of sclerotherapy (p less than 0.001). Thus, sclerotherapy was effective in the control of rebleeding in 73 (97.3%) patients from Group I and 16 (72.7%) from Group II (p less than 0.05). We conclude that previous surgical treatment for portal hypertension in patients with mansonic schistosomiasis, greatly benefits treatment of rebleeding esophageal varices by endoscopic sclerotherapy. This is probably due to the lower portal pressure after splenectomy.
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The endoscopic Congo red test (ECRT) was performed in 43 patients who underwent proximal gastric vagotomy (PGV) for duodenal ulcer (DU). The aim of the study was to develop a standard and reliable way to interpret the results obtained in this test. Thus, the results of ECRT were related to post-operative clinical evaluation and to pre- and post-operative basal and pentagastrin-stimulated gastric acidity. Whenever ECRT was considered positive, we called it in "large extension" if a red-to-black colour change occurred in three or more of the areas studied. Positive ECRT was observed in 39 patients (90.7%). There was a statistically significant (P less than 0.01) correlation between poor clinical results and positive ECRT in "large extension". We concluded that: (1) a positive ECRT result has no clinical or prognostic significance in DU patients after PGV; (2) ECRT, analysed according to the extension of the areas turning black, is a practical and reliable method to establish clinical results and prognosis in these patients.
Endoscopic sclerotherapy for bleeding esophageal varices was carried out in 78 patients with schistosomiasis (Group I) and 71 cirrhotic patients (Group II). All Group I patients had uniformly good liver function. According to Child's classification 25 patients (35%) of Group II were Child A, 16 (23%) Child B and 30 (42%) Child C. The sclerotherapy was performed by intravascular injections of 3% ethanolamine. Throughout a follow-up period of at least 24 months, hemorrhage recurred in 13% of the Group I patients, with one death (1%). The Child A category had a 24% recurrence with a 4% death rate, Child B a 38% recurrence with a 50% death rate, and Child C group a 73% recurrence with no survivals. A comparison of patients with schistosomiasis and cirrhosis type A revealed no differences with respect to rebleeding or survival (p greater than 0.05). Differences were significant for bleeding recurrence and survival in Child B patients as compared with schistosomiasis patients (p less than 0.025). This difference was highly remarkable when patients with schistosomiasis were compared with Child C cases, both for recurrence and survival (p less than 0.001). On the basis of these observations it is concluded that results of sclerotherapy depend fundamentally on liver function, and thus this procedure is justified in the early phases of liver cirrhosis.
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To avoid gastroesophageal reflux which is reported to occur in about 4-25 per cent after Heller esophago-cardiomyotomy, a modified gastro-fundoplication was designed using a transabdominal approach. Forty patients with idiopathic esophageal achalasia were subjected to this surgery. There were no serious complications and suppression of dysphagia and gastroesophageal reflux manifestations were excellent.
Recurrent peptic ulcer following surgery has been extensively studied, but its causes are not always clear. Difficulties in the differential diagnosis of the various possible factors can be very puzzling, since most of the methods described fail to provide a reliable definitive diagnosis. In the present study the authors report on the results obtained with the use of fiberoptic endoscopy complemented by biopsy of the mucosa of the duodenal stump for the diagnosis of retained gastric antrum in recurrent ulcer following B-II type gastrectomy. Considering the good results obtained with this method in 20 out of 23 patients, with a high degree of accuracy in association with biopsy and without any complications, it is strongly recommended whenever there is a possibility that retained antrum is the cause of recurrent peptic ulcer.
Three cases of a phytobezoar in B-II-gastrectomy are considered in relation to their development around a suture thread acting as precipitating factor; the bezoar was responsible for the presenting obstructive syndrome. Endoscopic diagnosis and definitive treatment by removal of the bezoar together with the thread after cutting the fixed end is stressed. Various kinds of treatment proposed by other authors for the common types of bezoar are discussed.
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The treatment of megaesophagus through the forced dilatation of the cardia has been used in Brazilian medical centers for the treatment of megaesophagus in the initial stage. In patients with advanced megaesophagus without surgical conditions due to the involvement of various systems or those who present severe degrees of malnutrition it is necessary to perform the dilatation of the cardia even with an temporary effect for the improvement of the general condition. The dilatation balloon usually employed does not permit the device to be used safely due to the deviation of the axis of the distal third of the esophagus. A hydrostatic balloon attached to the fiberesophagoscope was adapted to allow the dilating apparatus to be introduced under direct vision for greater safety. Twenty-one patients were treated under the above mentioned conditions and the results justified the indication.
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