Novel single-balloon enteroscopy for diagnosis and treatment of the small intestine: preliminary experiences.

BACKGROUND AND AIM: As a tool for examining the small intestine, double-balloon enteroscopy (DBE) has been used routinely. However, there remain a few issues relating to the handling of DBE, such as attaching a balloon to the tip of the scope, and inflating/deflating the two balloon systems. Recently, we developed a novel single-balloon enteroscopy (SBE) system for the examination of the small intestine. The aim of the present study was to evaluate the insertion technique, the safety, and the clinical impact of the SBE system. PATIENTS AND METHODS: Between January 2006 and June 2007, all patients undergoing enteroscopy with the Olympus SBE system (length 200 cm, outer diameter 9.2 mm) were studied. Instead of a balloon attached to the distal scope end, the distal scope end was hook-shaped, and manipulating the up-angle or down-angle of the scope end enabled exploration of the small intestine. RESULTS: A total of 78 procedures were performed in 41 patients (24 men, 17 women; mean age 48.9 years, range 23 - 85 years). The indications for the examination were suspected mid-gastrointestinal bleeding (n = 12), Crohn's disease (n = 17), abdominal pain (n = 8), and abdominal tumor (n = 4). The mean procedure time was 62.8 +/- 20.2 minutes and 70.4 +/- 19.3 minutes for the oral and anal routes, respectively. Among 24 patients in whom total enteroscopy was attempted, the entire small intestine was explored in 6. CONCLUSION: SBE is not only easy to perform, due to the single balloon, but it can also safely examine the deep small intestine. Therefore, SBE may be a useful diagnostic and therapeutic tool in addition to DBE for investigating suspected small bowel disease.

[The characteristics of the optically calculated axial length and the predicted refraction when using the intraoperative refraction].

PURPOSE: To understand the effect of the error in corneal refractive power on the optically calculated axial length (AXO) and the postoperative predicted refraction (Q'gl) calculated from the aphakic refraction (Qaph). METHOD: We used the Gullstrand's schematic eye, in which the intraocular lens (+20 D) was inserted at a depth of 5 mm, and calculated Qaph and postoperative refraction (Qgl) geometrically when the corneal radius of the anterior surface (Rfc) changed from 7 mm to 9 mm. AXO was calculated using the calculation formula from a previous report, and then Q'gl was calculated from the AXO and the true axial length (AXT) using the theoretical calculation formula (regarding the fictitious corneal refractive index as 1.3315). RESULTS: When the measured corneal radius of the anterior surface (K) was equal to Rfc, the error of the AXO was largest (AXO/AXT = 101.512) when K was 9 mm. The error in power prediction (Qgl-Q'gl) of the AXT was 7.7 times larger than that of AXO. CONCLUSION: If K is exact, AXO is useful to predict the intraocular lens depth because the error of AXO is small. The error in power prediction of AXO is smaller than that of AXT.

An analysis of risk factors for upper urinary tract deterioration in patients with myelodysplasia.

OBJECTIVE: To identify the risk factors for upper urinary tract deterioration in a retrospective study of patients with myelodysplasia. PATIENTS AND METHODS: The medical history, radiographic studies and urodynamic results from 39 children with myelodysplasia who were treated at our hospital were reviewed retrospectively to obtain more accurate data in the prognosis of such patients. The upper urinary tracts were assessed by cysto-urethrography and excretory urography to determine the incidence of vesico-ureteric reflux (VUR) and hydronephrosis. The relationships between the urodynamic variables, including vesical compliance, detrusor hyper-reflexia, detrusor-sphincter dyssynergia (DSD) and the maximum urethral closing pressure (MUCP) to such upper tract deterioration were evaluated using both univariate and multiple logistic regression analysis. RESULTS: The univariate analysis showed low vesical compliance, a high level of MUCP and the presence of DSD to be significant factors for the incidence of VUR. Low vesical compliance and a high level of MUCP also correlated with the incidence of hydronephrosis. The multivariate analysis showed a significant relationship between urodynamic values and upper urinary tract deterioration. The incidence of VUR was strongly correlated with a high MUCP and the presence of DSD. A high MUCP was also a significant factor in the incidence of hydronephrosis. CONCLUSION: Urodynamic results associated directly with the abnormal function of urethral control are significantly correlated with the cause of upper tract deterioration in patients with myelodysplasia.

[Prediction of postoperative refraction using intraoperative retinoscopy].

PURPOSE: Postoperative refraction was calculated using aphakic refraction measured with intraoperative retinoscopy, and its clinical usefulness was investigated statistically. OBJECTS AND METHODS: We studied 115 eyes of 89 patients, 28 males and 61 females aged 35 to 90 years, who had received intracapsular insertion of an intraocular lens. To decrease the error in measuring, retinoscopy was performed after the attachment of a hard contact lens of +15 D to the patient's cornea, with the exclusion of high myopia. We modified the Haigis calculation and used it to predict the postoperative refraction. RESULTS: The refraction could be measured in 112 eyes. The mean error between the actual and the predicted (actual minus predicted) in 112 eyes was 0.40 +/- 1.05 (mean +/- standard deviation) D. The mean error calculated using the SRK-II method, the Binkhorst method, and the Holladay method was -0.09 +/- 1.13 D, -0.58 +/- 1.00 D, and -0.44 +/- 1.00 D, respectively. The mean error of the average of these three formulas and our method was 0.15 +/- 0.82 D, -0.09 +/- 0.83 D, and -0.02 +/- 0.82 D, respectively. CONCLUSION: Our method seemed to have the same accuracy as other calculation formulas. By using our method together with other formulas, the postoperative refraction could be predicted more accurately.

[Long-term follow-up of a bladder exstrophy case after successful repair].

We present a female case of bladder exstrophy where the patient was followed up for 15 years. In 1982 primary closure of the bladder and urethra with bilateral iliotomy by the posterior approach was performed at the age of 4 months. However, realignment was necessary, since the wound split open postoperatively. We used a corset specially prepared for this patient to prevent wound dehiscence during the subsequent postoperative course. Four years later, VUR was surgically eradicated. At the age of 9 years old, her bladder function was satisfactory, demonstrating a normal CM pattern with synergia and Pmax 128 cm H2O on UPP. She had no urge or stress incontinence. The most recent IVP and DMSA renal scan revealed almost normal findings. VCUG showed no VUR and renal function tests (PSP, Ccr 24) also confirmed no interval deterioration. We believe that the approximation of the intersymphyseal band at the time of bladder neck closure is the single most important factor for ensuring urinary continence.

Congenital megalourethra: a case report.

We describe a case of a male infant with a scaphoid megalourethra. A physical examination showed a large, flabby phallus with bilateral undescended testes. The corpus spongiosum was absent with normal corpora cavernosa. Urethrography showed a crescent-shaped dilatation of the anterior urethra. Further examination revealed an association with concomitant urogenital anomalies, right renal hypoplasia-dysplasia, bilateral vesicoureteral reflux and the prune-belly syndrome. A urethroplasty with resection of the excess urethral tissue and reconstruction of the urethra was performed. There was a satisfactory surgical result and the patient now voids without difficulty.

Elevated interleukin-8 levels in the urine of children with renal scarring and/or vesicoureteral reflux.

PURPOSE: Elevation of urinary levels of interleukin-6 and 8 has been observed in patients with acute urinary tract infections. However, to our knowledge there have been no studies concerning the secretion of interleukin-6 and 8 into the urine after acute inflammation has resolved and renal scarring has occurred. On the other hand, it is well known that cytokines are variously related to glomerular diseases and, thus, it is possible that the progression of reflux nephropathy depends on interleukin-6 or 8. Therefore, we assessed urinary levels of interleukin-6 and 8 in children with vesicoureteral reflux and/or renal scarring. MATERIALS AND METHODS: We evaluated interleukin-6 and interleukin-8 levels in the urine of 32 children without a urinary tract infection who presented or were admitted to our hospital because of vesicoureteral reflux between April and December 1994. Interleukin-6 and 8 were determined using a commercially available human enzyme-linked immunosorbent assay kit and the 2-step sandwich method. RESULTS: Urinary interleukin-6 levels were below the lower detection limit (less than 10 pg./ml.) in all samples. There were statistically significant differences between urinary interleukin-8 levels in children with and without renal scarring (p = 0.001), and with and without vesicoureteral reflux (p = 0.0246). CONCLUSIONS: Urinary interleukin-8 is an effective marker for renal scarring and vesicoureteral reflux.

[Management of the impalpable testis; the value of laparoscopy for subsequent treatment].

During a 5-year period between April 1984 and March 1989, we were unable to palpate 62 testes (56 child patients) at the time of diagnosis. An average of 10 months later, 51 testes (48 patients) still remained impalpable preoperatively. Of the two imaging techniques, computed tomography and ultrasonography, the former is rather superior to the latter for verifying the existence of the impalpable testis. However, careful palpation under anaesthesia results in the accurate location of the testis more often than either of those two imaging techniques. On the other hand, as an aid in management of the impalpable testis, laparoscopy offers the most useful information for use in later surgery. This is because we are able to see the spermatic vessel and the vas deferens intraabdominally, in addition to the abdominal testis. Thirty-six patients (39 testes), whose testes remained impalpable even under anaesthesia, underwent laparoscopy. In two cases, we were unable to perform laparoscopy successfully due to failed pneumoperitoneum. However, in all the other cases, the information which could be obtained was fully utilized during subsequent management. Of a total of 37 instances, 8 testes which were abdominal or just canalicular (pendulous) could be recognized. In addition, 4 more were found to have no spermatic vessel in the visual field and a further 4 had a vessel disappearing before reaching the internal ring. In the remaining 21, we were able to detect the spermatic vessel and the vas deferens. At 59 instances of exploratory surgery, a mere 11 testes, among 27 testes, could be fixed to the bottom of the scrotum, resulting in scrotal dimples lasting for several months in 2 cases. Another 14 testes were placed in the upper scrotal region, while 2 were left in the groin region subcutaneously for lack of any alternative site.

A WGA-HRP study of the fiber arrangement in the cat optic radiation: a demonstration via three-dimensional reconstruction.

The fiber arrangement of the optic radiation was investigated in fourteen adult cats. The retinotopies of the lateral geniculate nucleus (LGN) were first identified electrophysiologically, and thereafter, wheat germ agglutinin conjugated to horseradish peroxidase (WGA-HRP) was iontophoretically injected into defined positions of the LGN. These corresponded to the central (medial LGN), horizontal peripheral (lateral LGN), dorsal (rostral LGN), and ventral (caudal LGN) retina. Geniculocortical fibers from the each position of the LGN and corticogeniculate fibers projecting to these positions were always labeled reciprocally. Labeled terminals were found massively in layer IV with some extending to the lower part of layer III, but layers VI and I also contained substantial numbers. Although most of the labeled neurons were localized in layer VI, some neurons were labeled in layer V and transsynaptically in layer IV. Labeled fibers were superimposed in three-dimensionally reconstructed maps of the white matter for the easy understanding of the pathways connecting the LGN and the visual cortex. They were localized in certain zones in the white matter without wide dispersion; however, we did not obtain any findings which suggested clearly different populations of geniculocortical and corticogeniculate fibers. In agreement with previous studies, fibers from the rostral LGN and the caudal LGN projected to the striate cortex in a regular order, rostrocaudally, and fibers from the medial LGN and the lateral LGN projected to the striate cortex inversely (i.e. lateromedially). This inverse projection resulted because fibers from the lateral LGN traversed fibers from the medial LGN in a lateromedial direction; however, there was only partial crossing of these two pathways. The distribution of geniculocortical fibers together with corticogeniculate fibers formed topographic zones arrayed mediolaterally in the white matter. Thus, fibers of the medial LGN were positioned in the intermediate zone, and fibers of the rostral LGN and the lateral LGN were positioned in the rostral and caudal parts of the lateral zone, respectively. Fibers of the caudal LGN were found in the medial zone. This fiber arrangement displayed a rough centroperipheral retinotopy in that fibers representing the central area were placed between fibers representing the peripheral retina. Finally, this fiber arrangement was compared with that of the optic nerve and optic tract.

[Usefulness of ultrasonography in follow-up of postoperative pelviureteric dilatation in children].

To determine the availability of ultrasonography in follow-up of postoperative pelviureteric dilatation, 35 children, who had previously been operated on in some part of the urinary tract, were examined by both excretory urography and ultrasonography. Of 59 kidneys shown to be with a dilated collecting system on excretory urography, 58 were correctly detected by ultrasonography, with a sensitivity of 98.3%. The grade of dilatation of the collecting system diagnosed by ultrasonography was corresponded to that by excretory urography in 99 of 123 kidneys [80.5%). At the level of the lower calyx, 40 of 43 ureters which measured 5 mm or greater in diameter on excretory urogram, were detected by ultrasonography. Thirty of 36 ureters posterior to the bladder with a diameter of over 5 mm were also detected by ultrasonography. The diameters of the ureters measured by ultrasonography were well correlated with those on excretory urogram. These results suggest that the availability of ultrasonography is so high that it could substitute for excretory urography in follow-up of postoperative hydronephroureter in children.

Angiomatous lesions of glans penis.

Two patients with an angiomatous lesion of the glans penis are presented. These lesions are rare and difficult to distinguish from the spongiosum tissue. There is much controversy concerning their true nature, i.e., whether they represent a true neoplasm, herniation of the corpus spongiosum, or vascularization of a hematoma or thrombus. The present lesions were not true neoplasms, but are best described as malformative lesions.

Followup study after conservative and surgical treatment of vesicoureteral reflux.

Our series of 94 cases (145 ureters) of vesicoureteral reflux is reviewed. The occasional disappearance of reflux during conservative treatment should not be mistaken for cure because of its variable nature. To avoid such a mistake voiding cystography under fluoroscopic monitoring is repeated indefinitely. Those patients who were treated surgically were followed for at least 2 to 3 years before cure was established. Transient ureteral dilatation after reimplantation was eradicated within 3 months. Postoperative urinary infection was observed at various intervals, ranging from 1 week to 5 months, and the erythrocyte sedimentation rate was likely to be influenced by infection. Postoperative chemotherapy was continued until the erythrocyte sedimentation rate was normal and there was no infection and/or dilatation of the upper tract.

Non-obstructive vesicoureteral reflux in adults: value of conservative treatment.

Chronic or recurrent non-obstructive urinary tract infection was investigated in 158 adult patients, 39 of whom had vesicoureteral reflux. Conservative, long-term chemotherapy did not eradicate the reflux in these patients. The characteristics of reflux in adults were studied with cystograms, excretory urograms, cystoscopic findings of the ureteral orifices or trigones and the clinical histories of the patients. These data were evaluated and compared to data obtained from adults with chronic or recurrent uncomplicated urinary tract infection and from children with vesicoureteral reflux who were referred to us during the same period. Non-obstructive vesicoureteral reflux in adults may be considered to be congenital in most cases, since the proportion of trigonal anomalies in adults with reflux is equal to that in children and the frequency of abnormalities at the ureteral orifice and trigonal region is significantly more than the frequency noted in control patients with uncomplicated pyelonephritis. Characteristically, excretory urography revealed caliceal scarring in adults with reflux in contrast to children, in whom a normal or dilated pattern of the upper tract was prominent. Recurring renal infection, for which this congenital defect of the ureterovesical valve must be responsible, produces progressive renal damage. Prolonged conservative treatment is of little use and is often destructive in adults with reflux.