Exposed Blood Vessels Research Articles

Two cases of strangulated bowel obstruction due to exposed vessel and nerve after laparoscopic and robot-assisted lateral lymph node dissection (LLND) for rectal cancer

BackgroundThe majority of small bowel obstructions (SBO) are caused by adhesion due to abdominal surgery. Internal hernias, a very rare cause of SBO, can arise from exposed blood vessels and nerves during pelvic lymphadenectomy (PL). In this report, we present two cases of SBO following laparoscopic and robot-assisted lateral lymph node dissection (LLND) for rectal cancer, one case each, of which obstructions were attributed to the exposure of blood vessels and nerves during the procedures.Case presentationCase 1: A 68-year-old man underwent laparoscopic perineal rectal amputation and LLND for rectal cancer. Four years and three months after surgery, he visited to the emergency room with a chief complaint of left groin pain. Computed tomography (CT) revealed a closed-loop in the left pelvic cavity. We performed an open surgery to find that the small intestine was fitted into the gap between the left obturator nerve and the left pelvic wall, which was exposed by LLND. The intestine was not resected because coloration and peristalsis of the intestine improved after the hernia was released. The obturator nerve was preserved. Case 2: A 57-year-old man underwent a robot-assisted rectal amputation with LLND for rectal cancer. Eight months after surgery, he presented to the emergency room with a complaint of abdominal pain. CT revealed a closed-loop in the right pelvic cavity, and he underwent a laparoscopic surgery with a diagnosis of strangulated SBO. The small intestine was strangulated by an internal hernia caused by the right umbilical arterial cord, which was exposed by LLND. The incarcerated small intestine was released from the gap between the umbilical arterial cord and the pelvic wall. No bowel resection was performed. The umbilical arterial cord causing the internal hernia was resected.ConclusionAlthough strangulated SBO due to an exposed intestinal cord after PL has been a rare condition to date, it is crucial for surgeons to keep this condition in mind.

Case report: atypical presentation of mpox with massive hematochezia and prolonged viral shedding despite tecovirimat treatment

BackgroundThe outbreak of mpox that occurred between 2022 and 2023 is primarily being transmitted through sexual contact. As of now, there is no consensus on the recommended duration of isolation to prevent sexual transmission of the virus. Moreover, this particular mpox outbreak has presented with distinct complications in comparison to previous occurrences. In this report, we present a case involving severe rectal bleeding from an ulcer in a mpox patient with a history of engaging in receptive sexual contact.Case presentationA 30-year-old Korean man presented at the hospital with complaints of fever, multiple skin lesions, and anal pain. Monkeypox virus polymerase chain reaction (PCR) results were positive for skin lesions on the penis and wrist. The patient received a 12-day course of tecovirimat due to anal symptoms and perianal skin lesions. Following isolation for 12 days and after all skin scabs had naturally fallen off, with no new skin lesions emerging for a consecutive 48 hours—conforming to the criteria of the Korean Disease Control and Prevention Agency—the patient was discharged. However, 1 day after discharge, the patient returned to the hospital due to hematochezia. His hemoglobin level had significantly dropped from 14.0 g/dL to 8.2 g/dL. Sigmoidoscopy unveiled a sizable rectal ulceration with exposed blood vessels, prompting the application of hemostasis through metal clipping. Subsequent monkeypox virus real-time PCR conducted on rectal tissue and swabs yielded positive results (with cycle threshold values of 28.48 and 31.23, respectively). An abdominal CT scan exposed a perirectal abscess, for which ampicillin-sulbactam was administered.ConclusionThis case underscores the importance of monitoring for bleeding complications and confirming the resolution of rectal lesions before discharging patients from isolation, particularly in cases where patients have a history of engaging in receptive sexual contact with men or are presenting with anal symptoms.

Successful laparoscopic cholecystectomy for gallbladder hemorrhage from a Dieulafoy lesion in a patient on hemodialysis: a case report

BackgroundPatients on long-term dialysis are prone to hemorrhagic complications, particularly uremic bleeding, but gallbladder hemorrhage is rare, even in patients on dialysis. There have been occasional reports of a Dieulafoy lesion being a cause of gastrointestinal hemorrhage, but its occurrence within the gallbladder is quite rare. This report describes a case of gallbladder hemorrhage from a Dieulafoy lesion in a patient on hemodialysis that was diagnosed early and successfully treated by laparoscopic cholecystectomy.Case presentationThe patient was a 68-year-old woman on long-term hemodialysis with end-stage renal failure who presented with epigastralgia and back pain. There was no history of trauma or oral administration of antiplatelet or anticoagulant agents. There were no signs of an inflammatory reaction or hyperbilirubinemia. Contrast-enhanced computed tomography revealed a slightly hyperdense area in the distended gallbladder and extravasation within the gallbladder lumen but no gallstones. A severe atherosclerotic lesion was also found. She was diagnosed to have gallbladder hemorrhage and emergency laparoscopic cholecystectomy was performed. Although the postoperative course was complicated by drug fever, she was discharged on postoperative day 10 in a satisfactory condition. Histology revealed hemorrhagic ulceration with an exposed blood vessel accompanied by abnormal arteries in the submucosa. Arteriosclerosis with eccentric intimal hyperplasia in a small-sized artery was also seen. The diagnosis was gallbladder hemorrhage from a Dieulafoy lesion.ConclusionsA Dieulafoy lesion should be kept in mind as a cause of gallbladder hemorrhage in a patient with severe arteriosclerosis and a bleeding diathesis, particularly if on dialysis, and treated as early as possible.

Liver metastases 2 years after resection of a very-low-risk duodenal gastrointestinal stromal tumor: a case report

BackgroundGastrointestinal stromal tumors (GISTs) are rare mesenchymal tumors, but are the most common mesenchymal tumors of the gastrointestinal tract. The risk classification of GISTs is based on the tumor size, mitotic index, tumor site, and presence of tumor rupture. Recurrence in the very-low-risk group is extremely rare. We herein report a case of liver metastases 2 years after resection of a very-low-risk duodenal GIST.Case presentationA 57-year-old woman presented to the hospital for evaluation of melena. Esophagogastroduodenoscopy showed bleeding from the exposed blood vessels at the top of a submucosal tumor approximately 20 mm in size located in the second (descending) part of the duodenum, and the bleeding was controlled with electrocoagulation. A GIST was suspected, and the patient underwent wedge resection of the duodenum. The resected specimen contained a 16- × 12-mm (< 20-mm) white submucosal tumor composed of spindle cells with a mitotic count of 4 per 50 high-power fields, and a histologically negative margin was achieved. Immunochemical analysis revealed positive tumor staining for c-kit protein and alpha-smooth muscle actin and negative staining for CD34, desmin, and S-100 protein. Therefore, the tumor was diagnosed as a very-low-risk duodenal GIST based on the Fletcher classification and modified Fletcher classification (Joensuu classification). The postoperative course was uneventful, and the patient was discharged on postoperative day 11. At the follow-up visit 2 years postoperatively, contrast-enhanced computed tomography revealed liver tumors in S8 and S6 measuring 26 × 24 and 10 × 10 mm, respectively. Both lesions showed peripheral dominant hyperenhancement with hypoenhancement inside, indicating tissue degeneration within the tumors. These imaging findings closely resembled those of the duodenal GIST. Hence, the patient was diagnosed with liver metastases of GIST 2 years postoperatively. She was subsequently started on treatment with 400 mg of imatinib. At the time of this writing (2 months after diagnosis), the patient was clinically well and asymptomatic and was continuing imatinib therapy.ConclusionsRecurrence of very-low-risk GISTs is extremely rare. Even a small GIST with low mitotic activity can never be considered completely benign, and long-term follow-up is necessary.

Bleeding Risk Factors after Endoscopic Submucosal Dissection in Early Gastric Cancer and the Necessity of "Second-Look" Endoscopic Examination on the following Day.

Background and Aim: Hemorrhage is often encountered after endoscopic submucosal dissection (ESD). In addition to active bleeding after resection, exposed blood vessels and blood clots without active bleeding on the post-dissection ulcer floor have been recognized within our department. We consider exposed and/or observable vessel findings and clots on the ulcer floor after re-section as important risk factors for hemorrhage. Here, we compared and examined the active bleeding frequency and “post-resection ulcer at risk of bleeding” on the day following ESD, in relation to their risk factors. Method: We retrospectively examined 447 patients who underwent second-look endoscopy in our department between August 2008 and March 2018. Logistic regression analyses were performed to determine the hazard ratio and 95% confidence interval. We compared the association of each factor mentioned above with active bleeding on the day after ESD and the presence of ulcers at risk of bleeding after resection. Results: Our retrospective analysis revealed that the risk factors were larger ulcer sizes and the administration of antithrombotic drugs. Additionally, the risk was low for upper body lesions but high for antral lesions. Conclusion: Our results may help determine whether second-look endoscopy should be performed to minimize active bleeding after ESD, reduce postoperative complications, and improve medical safety.

Low-vacuum negative pressure wound therapy protocol for complex wounds with exposed vessels.

Treating high-risk surgical patients with complex wounds over exposed blood vessels is a challenge. Guided wound healing may be the only treatment possible. Negative pressure wound therapy (NPWT) is not recommended in these cases. The authors challenged these current recommendations and share their preliminary experience. The authors adapted a NPWT protocol that uses low-vacuum continuous pressure (-80mmHg) with a silicone sheath and gauze/foam dressing between the wound bed and the device. They monitored the clinical features of patients' wounds to detect bleeding/ischaemia early on. Dressings were changed every 72-96 hours. This protocol was followed in five male patients (aged 23-68 years) with complex wounds over exposed vessels. Two cases were foot crush injuries, one midfoot amputation, one hand self-subamputation and one vascular bypass infection. Comorbidities included monoarterial limbs/stump, severe arteriopathy and psychiatric disorder. The exposed vessels were femoral, radial and ulnar, anterior and posterior tibial arteries and veins. Mean treatment lasted 37 days (range 20-61 days). No episodes of severe bleeding/ischaemia of the extremities were observed. Treatment was discontinued once debridement was complete and granulation tissue allowed spontaneous closure/grafting. All wounds appeared stable at 1-year follow-up. The low-vacuum NPWT protocol was successful in solving five difficult cases. This regimen reduces risks associated with NPWT use on wounds with exposed vessels. The authors believe further validation is required to strengthen the evidence. However, preliminary data are encouraging and might help to change future NPWT recommendations by extending the indications for its use to exposed vessels.

Factors for unsuccessful endoscopic hemostasis in patients with severe peptic ulcer bleeding

Objectives Although the first approach for peptic ulcer bleeding is endoscopic hemostasis, quick determination of a hemostatic strategy is important in patients with vitals indicating shock. However, the unsuccessful factors for endoscopic treatment have yet to be sufficiently examined. We aimed to investigate the factors for unsuccessful endoscopic hemostasis in severe peptic ulcer bleeding. Materials and methods Unsuccessful factors were retrospectively investigated in 150 eligible patients who underwent endoscopic hemostasis for shock-presenting peptic ulcer bleeding at our critical care center between April 2007 and March 2021. Results There were 123 and 27 cases of successful and unsuccessful endoscopic hemostasis, respectively. Causative diseases included gastric ulcer bleeding in 124 patients (82.7%) and duodenal ulcer bleeding in 26 patients (17.3%). Shock index (SI) (1.46 vs. 1.60) (p = .013), exposed blood vessel diameter (1.4 mm vs. 3.1 mm) (p < .001) identified on contrast-enhanced computed tomography (CE-CT), duodenal ulcer bleeding (p = .012), and Forrest classification Ia (p = .004) were extracted as independent factors for unsuccessful endoscopic hemostasis. In receiving operating curve analysis, when the cut-off value for the SI was set at 1.53, the sensitivity and specificity were 70.4% and 63.4%, respectively. When the cut-off value for the exposed blood vessel diameter was set at 1.9 mm, these were 88.9% and 83.7%, respectively. Conclusions When these factors (SI ≥ 1.53, exposed blood vessel diameter ≥1.9 mm identified on CE-CT, duodenal ulcer bleeding, and Forrest Ia) are present in patients with severe peptic ulcer bleeding, non-endoscopic hemostasis, such as interventional radiology (IVR) and surgery, should be considered.

A Case of Strangulated Bowel Obstruction Due to Exposed Blood Vessels after Laparoscopic Super-Low Anterior Resection with Lateral Lymph Node Dissection for Rectal Cancer

症例は68歳の男性で，下部直腸癌に対して腹腔鏡下超低位前方切除，両側側方リンパ節郭清術を施行された．最終病理組織診断はpT2N0M0，pStage Iであった．術後に麻痺性イレウスを認めたが，保存的加療により軽快退院となった．術後3か月目に，右鼠径部痛を自覚し当院を救急受診した．腹部造影CTにて，骨盤内右側で小腸がclosed loopを形成し，絞扼性腸閉塞の診断で緊急手術を施行した．術中所見では側方リンパ節郭清によって露出された右上膀胱動脈と内腸骨動脈の間隙に小腸が迷入し陥頓／壊死していたが，容易に陥頓解除できた．左上膀胱，右下膀胱動脈が温存されていることを確認し，再発予防目的に右上膀胱動脈を結紮切離し，壊死腸管を含めた小腸部分切除を行い吻合再建した．病理組織診断では腸管壁全層が壊死していた．直腸癌に対し側方リンパ節郭清後の露出血管が原因となった絞扼性腸閉塞の1例を経験したので報告する．

Negative-Pressure Wound Therapy for a Replanted Finger with Complicated Wound

Negative-pressure wound therapy (NPWT) is widely used for open wounds in various anatomical sites. Extensive research has been carried out on the application of NPWT; exposed blood vessels in the periwound area are a known contraindication to NPWT. In this study, we report a case where a replanted finger with not only exposed vessels but also uncontrolled infection was treated with NPWT. A 60-year-old man visited our emergency department with incomplete amputation of his left index and middle fingers. After replantation of his two fingers, necrosis of the middle finger with severe methicillin-resistant &lt;i&gt;Staphylococcus aureus&lt;/i&gt; infection complicated managing the wound. After 3 weeks of maintaining conventional wound dressings, we performed NPWT for successful granulation tissue formation and infection control. After the treatment, the wound was completely covered by a split-thickness skin graft. We thus suggest that NPWT can be an effective reconstructive method, including for intractable wounds with exposed pedicle and severe infection after replantation.

Red dichromatic imaging helps in detecting exposed blood vessels in gastric ulcer induced by endoscopic submucosal dissection.

Delayed bleeding is one of the postoperative complications of gastric endoscopic submucosal dissection (ESD) [1]. The clipping of exposed blood vessels after ESD completion is effective in preventing delayed bleeding [2] [3]. However, the exposed blood vessels are sometimes difficult to detect. Herein we report the effectiveness of a novel image-enhanced endoscopic technology called red dichromatic imaging (or dual red imaging) for detecting exposed blood vessels and preventing delayed bleeding after gastric ESD.

A rare maternal gastrointestinal stromal tumor found in the second trimester of pregnancy: A case report

Gastrointestinal stromal tumors are rare, and in pregnancy they are extremely rare. We present a case of a maternal gastrointestinal stromal tumor found in the second trimester of pregnancy. A 29-year-old woman, gravida 1 para 0, complained of bloody vomiting at 14 weeks of gestation. She had no significant medical history. We performed plain computed tomography and upper gastrointestinal endoscopy. Precise examination revealed a large mass in the stomach and an exposed blood vessel on the surface. An exposed blood vessel can be harmful for mother and fetus as it might rupture during the pregnancy. We performed a distal gastrectomy at 16 weeks of gestation. Histology confirmed a localized gastrointestinal stromal tumor with a high risk of recurrence, and adjuvant imatinib was recommended. The patient elected to delay adjuvant imatinib until after delivery. The postoperative and antenatal course was favorable, and the patient was followed up by ultrasound every 2 months after the operation. After she gave birth at 40 weeks of gestation, she started adjuvant imatinib 400 mg/day. There was no evidence of recurrence 1 year after surgery. There are no guidelines for the management of gastrointestinal stromal tumors in pregnancy. Given the treatment challenges, we believe that pregnant patients should be managed by a multidisciplinary team with expertise in gastrointestinal tumors and fetal-maternal medicine.

Gastroduodenal artery pseudoaneurysm hemorrhage 1 year after laparoscopic distal gastrectomy: a case report

BackgroundPostoperative bleeding originating from pseudoaneurysms after radical gastrectomy is not common, but it can be fatal. In particular, delayed bleeding that occurs after the seventh postoperative day is rare.Case presentationA 54-year-old man underwent laparoscopic distal gastrectomy, D2 lymph node dissection, and Roux en-Y reconstruction for duodenal neuroendocrine tumors. Drainage was performed for a postoperative pancreatic fistula and abdominal abscess. On the 28th postoperative day, he passed a large amount of bloody stool; therefore, emergency esophagogastroduodenoscopy (EGD) and angiography were performed. However, neither examination demonstrated any bleeding foci or pseudoaneurysm. He was conservatively observed and discharged on the 50th postoperative day. Approximately 1 year after the surgery, he passed a bloody stool and experienced hemorrhagic shock. An EGD revealed exposed blood vessels at the duodenal blind end. His condition was diagnosed as a pseudoaneurysm arising from gastroduodenal artery, which ruptured into the duodenum, based on abdominal contrast-enhanced computed tomography findings. Emergency angiography was performed, and the pseudoaneurysm and artery were successfully embolized.ConclusionsThis case illustrates that there is a possibility of delayed bleeding even 1 year after gastrectomy. Such cases may be serious and require immediate and careful management.

182 A Comparison of the Mucosal Defects and Healing by Hot Snare Polypectomy (HSP) vs. Cold Snare Polypectomy (CSP) for Endoscopic Removal of Colorectal Polyps

INTRODUCTION: Screening colonoscopy with polypectomy of small polyp substantially reduces colorectal cancer incidence and mortality. CSP and HSP are two major methods for polypectomy. The basic difference of CSP and HSP is the use of a high frequency generator of HSP. HSP may damage deeper vessels with increased risk of delayed healing, thereby post-polypectomy bleeding and even perforation. For this reason, CSP is usually considered safer, in recent years, CSP has increasingly been used for the removal of colorectal polyps. On the other hand, CSP is concerned associate with a rate of incomplete resection. So far few studies have confirmed endoscopically the early condition after treatment. In this study, through a randomized controlled study, we evaluated to compare mucosal defects and healing one week after treatment, from polypectomy using CSP vs. HSP. METHODS: The 52 patients has tumor size under 10 mm were randomly divided into two groups using opaque envelopes: CP (n = 27) and HP (n = 25). We compared the mean tumor size, ulcer diameter one week after endoscopic treatment, exposed blood vessels, residual recurrence and contingencies for CSP and HSP. Pathological diagnosis of complete resection was defined as no evidence of adenomatous tissue in the biopsied specimens, among all pathologically confirmed adenomatous polyps. RESULTS: The overall the mean tumor size did not differ between the two groups (CSP vs. HSP: 5.44 mm vs. 5.32 mm). Ulcer base diameter one week after treatment is CSP group had a smaller compared to the HSP group (2.7 mm vs. 4.84 mm; P &lt; 0.001). And the CSP group had a lower exposed blood vessels compared to the HSP group (7.4% vs. 36.0%; P &lt; 0.05). Delayed perforation or bleeding was not recognized in any patient during the one weeks after treatment. One case of residual recurrence was admitted to CSP group. CONCLUSION: Our study findings show that although there is no difference tumor diameter between the two techniques, the size of ulcer diameter one weeks after treatment, resection time and the rate of post-polypectomy bleeding is lower with CSP. However remnant recurrence was observed only in CSP. In clinically, CSP can be safely used as one of the effectively techniques for the resection colorectal polyps, but It is important to make an accurate endoscopic diagnosis and exclude cancer before treatment.

Estimation on Formation Time of Thrombus.

To observe the changes of the formation time of venous thrombus in rats, and to provide new ideas and methods for the estimation on thrombus formation time of the forensic cases died from thrombosis. Totally 80 rats were randomly divided into 10 groups （0 h, 3 h, 6 h, 12 h, 1 d, 3 d, 1 week, 2 weeks, 3 weeks and 4 weeks after operation）. A vein thrombosis model was established by the "narrow" method. The processes of thrombosis, organization, recanalization and the features of change on hemosiderin and calcium salt were observed by HE stain, Perls stain and Von Kossa stain. The expression changes of CD61, α-SMA and CD34 were observed by immunohistochemical staining technique. Platelets adhered to the exposed blood vessel intima 3 h after operation, and platelet trabeculae were formed by the repeated accumulation of platelets 1 d after operation. The thrombus organization formed through the fibroblasts from vessel wall that grew into the interior of the thrombus 3 d after operation. Endothelial cells covered the surface of thrombus and then the new blood vessels were reformed, and the vessels were reconstructed. The expression of CD61 upregulated at the stages of the thrombus formation （3 h） and thrombus reformation （4 weeks）, and reached the peak 1 d after thrombus formation. The release of hemosiderin and the initial expression of α-SMA were detected 3 d later. Calcium deposit and expression of CD34 were observed 1 week later. The hemosiderin, calcium salt, CD61, α-SMA and CD34 show time-dependent changing characteristics, which is expected to provide a reference for the estimation on thrombus formation time of the forensic cases died from thrombosis.

A multispectral microscope for in vivo oximetry of rat dorsal spinal cord vasculature

Quantification of blood oxygen saturation (SO2) in vivo is essential for understanding the pathogenesis of diseases in which hypoxia is thought to play a role, including inflammatory disorders such as multiple sclerosis (MS) and rheumatoid arthritis (RA). We describe a low-cost multispectral microscope and oximetry technique for calibration-free absolute oximetry of surgically exposed blood vessels in vivo. We imaged the vasculature of the dorsal spinal cord in healthy rats, and varied inspired oxygen (FiO2) in order to evaluate the sensitivity of the imaging system to changes in SO2. The venous SO2 was calculated as 67.8 ± 10.4% (average ± standard deviation), increasing to 83.1 ± 11.6% under hyperoxic conditions (100% FiO2) and returning to 67.4 ± 10.9% for a second normoxic period; the venous SO2 was 50.9 ± 15.5% and 29.2 ± 24.6% during subsequent hypoxic states (18% and 15% FiO2 respectively). We discuss the design and performance of our multispectral imaging system, and the future scope for extending this oximetry technique to quantification of hypoxia in inflamed tissue.

Red blood cells mediate the onset of thrombosis in the ferric chloride murine model

AbstractApplication of ferric chloride (FeCl3) to exposed blood vessels is widely used to initiate thrombosis in laboratory mice. Because the mechanisms by which FeCl3 induces endothelial injury and subsequent thrombus formation are little understood, we used scanning electron and brightfield intravital microscopy to visualize endothelial damage and thrombus formation occurring in situ. Contrary to generally accepted belief, FeCl3 does not result in appreciable subendothelial exposure within the time frame of thrombosis. Furthermore, the first cells to adhere to FeCl3-treated endothelial surfaces are red blood cells (RBCs) rather than platelets. Energy dispersive x-ray spectroscopy demonstrated that ferric ions predominantly localize to endothelial-associated RBCs and RBC-derived structures rather than to the endothelium. With continuing time points, RBC-derived structures rapidly recruit platelets, resulting in large complexes that subsequently enlarge and coalesce, quickly covering the endothelial surface. Further studies demonstrated that neither von Willebrand factor nor platelet glycoprotein Ib-α receptor (GPIb-α) is required for RBCs to adhere to the endothelium, and that deficiency of GPIb-α greatly abrogated the recruitment of platelets to the endothelial-associated RBC material. These findings illuminate the mechanisms of FeCl3-mediated thrombosis and reveal a previously unrecognized ability of RBCs to participate in thrombosis by mediating platelet adhesion to the intact endothelial surface.

Effect of DADLE on expressions of Bax and Bcl-2 proteins in rats with acute cerebral ischemia repeffusion

Objective To observe the expressions of Bax and Bcl-2 proteins in the brain tissue of the rats with acute cerebral ischemia reperfusion, and to explore the effect of DADLE, a delta opioid receptor ago- nist, on brain apoptotic pathways of acute cerebral ischemia reperfusion and the role of DADLE in the protection of brain. Methods 50 healthy female SD rats（ 180-220 g） were randomly divided into 5 groups： sham operation group （Sham, n = 10）： only exposed blood vessels without clipping; ischemia reperfusion group （I/R, n = 10）： modified two-vessel occlusion with hypotension to establish a model of cerebral ischemia, and reperfused 15 min after ischemia; DADLE treatment group was subdivided into group of 2 mg/kg（A, n = 10）, group of 3mg/kg （B, n= 10）, and group of 5 mg/kg （C, n-- 10）： on the basis of I/R group with reperfusion via external jugular vein injection of DADLE. Expressions of Bax and Bcl-2 proteins were detected by immunohistochemistry assay after the operation. Results The number of cells with Bax or Bcl-2 expression （20.38 ＋ 2.84 and 9.62 ＋ 2.10, P 〈 0.05 ）was significantly smaller in Sham group than in the other groups; In I/R group, the number of cells with Bax or Bcl-2 expression was 52.73 ＋ 6.08 and 19.49 ＋ 2.35 ; In DADLE treatment groups, the number of cells with Bax experssion was 43.71 -＋ 3.85 for group A, 37.92 ＋ 4.08 for group B, and 36.20 -＋ 3.94 for group C; the number of cells with Bel-2 expression was 28.74 _＋ 2.41,33.58 ＋ 2.16,and 34.96 ＋ 1.98, respectively. The ratio of Bel-2/Bax was significantly higher in Sham group than in I/R group （49.3% ＋ 3.4% vs. 35.8% ＋ 3.2%, P〈 0.05 ） ; and it was 66.4% ~ 6.8% in group A, 85.7% ：t 7.3% in group B, and 92.6% ＋ 6.9% in group C.Conelusions In rats with acute cerebral ischemia reperfusion injury, expressions of Bax and Bcl-2 proteins are obviously upregulated. DADLE can play a role in protection of brain by affecting the expression degree of Bax and Bcl-2 and thus lowering apoptosis. Bcl-2Bax ratio shows that the role and the dose is in a S-shape curve of dose-effect. Key words: DADLE ; Whole brain ischemia reperfusion; Bax; Bcl-2

A case of surgically-treated hemorrhaging Meckel’s diverticulum diagnosed by contrast-enhanced computed tomography and intraoperative endoscopy

A 74-year-old man was admitted to our hospital complaining of bloody stools and anemia. Computed tomography with enhanced contrast showed leakage of contrast media to a diverticulum of the ileum. We suspected hemorrhage from a Meckel’s diverticulum. Bloody stools persisted, precluding small intestinal endoscopy, so emergency surgery was performed. A diverticulum of about 4 cm length was found in the ileum approximately 100 cm from the ileocecal valve. Observation via intraoperative endoscopy identified an ulcer with an exposed blood vessel in the diverticulum. Hemorrhage from a Meckel’s diverticulum was diagnosed, and wedge resection of the diverticulum at the base was performed. Pathological findings confirmed a true diverticulum, and heterotopic pyloric glands were observed in the circumference of the ulcer. When small intestinal endoscopy cannot be performed immediately, computed tomography with enhanced contrast and intraoperative endoscopy are useful techniques to employ in order to diagnose hemorrhage from Meckel’s diverticula.

A Primary Arterio Enteric Fistula with Takayasu Arteritis

Arterio enteric fistulas (AEFs) are rare. We herein report a case of a primary arterio enteric fistula of the rectum associated with Takayasu arteritis. A 77-year-old woman presented with acute massive hematochezia and was taken to our hospital. Colonoscopy revealed pulsatile extrinsic rectal wall compression with an exposed blood vessel. Transvaginal ultrasonography and Doppler ultrasound revealed a localized vascular growth laying on the dorsal surface of the uterus that showed an arterial blood-flow signal. We diagnosed the patient to have a pelvic aneurism that had formed a fistula within the rectal wall. We eliminated the aneurysm by ligating the drainage and feeder arteries. Following surgery, the patient did not experience any relapses of hematochezia.

Aortic valve papillary fibroelastoma associated with acute cerebral infarction: a case report.

An 80-year-old woman with a history of congestive heart failure, atrial fibrillation, and hypertension was transferred to our institution with hematemesis. Her drug regimen included 2 mg warfarin potassium/day to prevent thromboembolic events. Transthoracic echocardiography (TTE) performed at 78 years of age revealed a mass attached to the noncoronary cusp and a cardiac tumor was suspected. The patient declined surgery and was meticulously followed up with periodic TTE. Upper gastroendoscopy revealed a gastric ulcer with an exposed blood vessel; anticoagulant therapy was ceased. On day 15 of admission, acute cerebral infarction occurred. Heparin sodium and warfarin potassium were administered rapidly, and her symptoms improved. TTE revealed no alteration of the mobile, string-like mass attached to the noncoronary cusp. Cardiac tumor was considered the cause of cerebral infarction, and the patient consented to surgical therapy. Pathological examination of the resected tumor suggested papillary fibroelastoma (PFE). Although no guidelines exist for PFE management, a mobile, cardiac tumor necessitates surgical resection to prevent thromboembolic events, even when small in size.