Pyloric Research Articles

Bedside ultrasound-guided nasointestinal feeding tube placement in critically ill elderly patients

Objective To investigate the feasibility of inserting and detaining nasointestinal feeding tube in small bowl guided by bedside ultrasound(US)in critically ill elderly patients. Methods This was a retrospective study.Sixty-four aged patients(≥60 years)in general ICU, the Second Affiliated Hospital of Jiaxing College, received the US-guided nasointestinal feeding tubes inserting and detaining.Feeding tubes passed through nasal and went into the stomach by manual blind method.Under US-guiding condition, the tube passed through the pyloric sphincter and further into the duodenum or jejunum.Finally the correct position of the tube head was assessed by bedside X-ray examination. Results The US-guided nasointestinal feeding tube-detaining technique was successfully operated in 57 patients(89.1%). The feeding tube heads were in the duodenum in thirty-four cases(53.1%), and in proximal jejunum in twenty-three cases(35.9%). The untoward reaction included the bleeding of nasal cavity in 1 case, and hypotension in another case. Conclusions Bedside US-guided nasointestinal feeding-tube placement is safe and feasible in aged critical patients. Key words: Ultrasonography; Enteral nutrition

Not Cancer … but Pyloric Stenosis in a 69-year-old?

Idiopathic hypertrophic pyloric stenosis (IHPS) is most commonly reported in infants with rates ranging from 0.25% to 0.8% of all live births. Adult IHPS is rare and only 200 cases have been reported in the literature. We present a patient in her late-sixties with cachexia and severe malnutrition with a gastric mass visualized on CT that initially was concerning for malignancy and was subsequently diagnosed with IHPS. A 69-year-old woman, with limited healthcare exposure, was admitted to the hospital with weight loss, anorexia, fatigue, severe malnutrition (BMI 13.7), severe anemia, elevated inflammatory markers (CRP >200, ESR 76), and hypotension leading to a traumatic fall. She was an active smoker with a 51 pack-year history and consumed 2 alcoholic drinks daily. She denied history of acid reflux and had no known history of H. pylori. Rheumatologic workup was negative. Given lack of medical history and severe cachexia, CT chest and abdomen were obtained as there was concern for malignancy. A right ovarian cyst and cystic lesion in the head of pancreas was initially reported and were subsequently determined to be benign. Due to her continued inability to tolerate oral intake, EGD was performed which revealed gastric stenosis with pinhole opening at the pylorus and no visible ulcerations. Biopsy revealed reactive gastropathy and foveolar hyperplasia without inflammation. Review of CT did show evidence of hypertrophy around the pyloric sphincter. She was endoscopically dilated and was able to advance her diet with careful monitoring for refeeding syndrome. At her three-month follow-up visit, she was tolerating general diet, was slowly gaining weight, and her anemia had resolved. This case demonstrates an uncommon case of adult-onset IHPS causing severe malnutrition and cachexia. Most cases of hypertrophic pyloric stenosis are diagnosed in early infanthood. Initial management often includes nasogastric tube placement to remove gastric contents. Gastrectomy, pyloromyotomy, and pyloroplasty have been recommended for surgical management with laparoscopic pyloroplasty as the preferred intervention due to its favorable safety profile. Dilation is another acceptable treatment option; however has a high recurrence rate of stenosis.Figure: Computed tomography, coronal view of pyloric stenosis in a 69-year-old female.

Gastrogastric Intussusception Caused by Gastric Mass

A 65-year-old woman with a past medical history of peptic ulcer disease and migraine headaches presented to our GI clinic complaining of dull left upper quadrant abdominal pain without radiation for the past 3 years. In addition she complained of unintentional weight loss and intermittent melena. She denied use of NSAIDs or a family history of gastric cancer. On exam, a palpable left upper quadrant mass was appreciated. A CT scan of the abdomen and pelvis with oral and intravenous contrast showed a gastrogastric intussusception without a clear lead point. Upper endoscopy revealed a 4.5 cm subepithelial mass with an overlying ulceration arising from the anterior wall of the body of the stomach. Mucosal biopsies of the mass were non-diagnostic however given the clinical presentation and concern for GIST, surgery was recommended. Patient underwent a laparoscopic partial gastrectomy with pathology showing GIST.Figure: (A) portable Chest x-ray (CXR) revealing left hemi-thorax findings were suspicious for left diaphragmatic hernia containing bowel loops. (B, C,D) Axial and Coronal contrast-enhanced CT scan of the Abdomen with 3D reconstruction showing left hemi-diaphragm defect with a large portion of the stomach herniating through it. (L:liver; St:stomach; K:kidney; Sp:spleen).Figure: EGD findings: (A) ulcerative esophagitis. (B and C) Endoscopic exam of the stomach fundus showed hyperemic gastric mucosa, with two outlet channels, one of which was blind and other one was going into the pylorus with significant looping through this area. (D) pylorus. (E) Pyloric sphincter (F) Duodenum.Most documented cases of intussusception occur in children (90%) rather than adults (10%). 95% of children have primary intussusception, whereby the etiology is benign and idiopathic without defined causes. In contrast, almost 90% of the cases of intussusception in adults are secondary to a pathologic condition that serves as a lead point, such as carcinomas, polyps, Meckel's diverticulum, colonic diverticulum, strictures or benign neoplasms. Secondary intussusception is believed to initiate from any pathologic lesion of the bowel wall or irritant within the lumen that alters normal peristaltic activity and serves as a lead point, which is able to initiate an invagination of one segment (intussusceptum) of the bowel into the other (intussuscipien). Classic triad of cramping abdominal pain, bloody diarrhea and a palpable mass is rare in adults. Symptoms could range from nausea, vomiting, and gastrointestinal bleeding to a change in bowel habits, constipation or abdominal distension. CT scan is the most sensitive radiologic modality to confirm intussusception with a characteristic “target” sign when the intussusception is perpendicular to the long axis or a “sausage” sign when it is parallel to the long axis. Intussusception in adult needs surgical resection or investigation given the high risks of secondary causes such as neoplasm.Figure: Sausage-shaped mass indicates gastrogastric intussusceptions.Figure. 4: 5 cm smooth with central ulceration mass arising from body of the stomach.Gastrogastric intussusception is rare. Fortunately for our patient the intussusception was transient allowing time for work up and elective surgery.

A159 - Prevalence of Dumping Syndrome After Laparoscopic Sleeve Gastrectomy and Comparison with Laparoscopic Roux-En-Y Gastric Bypass

The aim of this study was to assess the incidence and prevalence of symptoms of Dumping Syndrome (DS) after Laparoscopic Sleeve Gastrectomy (LSG). Although DS is a well-known side effect of Laparoscopic Roux-En-Y Gastric Bypass (LRYGB), it is widely believed that DS does not occur after LSG; often attributed to the preservation of the pyloric sphincter. However, patients undergoing LSG at our center have consistently reported symptoms suggestive of DS. It is important when choosing a bariatric procedure to present accurate information to patients regarding the potential risk of developing DS after LSG.

Gastrectomy for Giant Stomach Due to Hypertonic Pylorus in a Patient With Simpson-Golabi-Behmel Syndrome: First Known Case Reported

SImpson-Golabi-Behmel Syndrome (SGBS)is inherited in an X-linked fashion. If there is only one affected individual in a family, which is the case of our patient,he may have inherited the mutation from his mother or may have a de novo mutation. Reviewing all published cases of SGBS indicates that the frequency of de novo mutations is about 20-30%. Clinical findings in the abdominal region of the reported cases include visceromegaly (nephromegaly, splenomegaly and hepatomegaly), which were common conditions. Congenital diaphragmatic hernia (CDH) was described in less than 10% of children. Neonatal liver disease and choledochal cyst were both reported once in distinct cases. A 15 year old male presented at our urgent care department complaining of a 20 days abdominal pain with occasional episodes of vomiting. On clinical exam he presented distended abdomen, and mild abdominal tenderness. He underwent X-Ray investigation, which showed a significant large gastric distention and therefore we placed a nasogastric tube to relieve the gastric distention that did not bring any improvement of the condition. Abdominal computed tomography (CT) photo 1, was performed and detected dilated stomach without bowel dilation. Afterwards an endoscopy, photo 2, was executed to investigate hypertrophic pyloric and found open pyloric without stenosis. We have found in intra op field a dilatated stomach and 20 cm long tear involving antrun and boby without perfuration leeding us to decide to do a partial gastrectomy,photo 3,, no complications were found in the early post operative period. Our case of pyloric ring leading to gastric outlet obstruction in the SGB Syndrome appears not to have been reported previously. Hypertrophy of the pyloric sphincter in the adult is not a common condition, even less common associated with SGBS, so that the knowledge of the surgeon plays a important role in making this condition diagnosable. Awareness of the disease may lead to an more accurate intervention, which is advantageous for both patient and medical staff.Figure: Ct showing a dilatated stomach and pectus excavatum.Figure: A) Endoscpy showing an open non-functional pylorus B) the intraop view - dilatated stomach and the tear.Figure: Hipertrophic pylorus.

Endoscopic Ultrasonography-Guided Intrapyloric Sphincter Injection of Botulinum Toxin into Muscularis Propria to Treat Refractory Diabetic Gastroparesis

A 46 year-old African American woman with past medical history of diabetes mellitus type 1 for 22 years and gastroparesis for 12 years status post gastric pacemaker placement 2 years ago presented with abdominal pain, nausea, and recurrent vomiting for 2 days. The severity of her symptoms on the day of admission, as measured by the gastrointestinal symptom rating scale (GSRS), was 16. Due to the refractory nature of her symptoms, EUS-guided intrapyloric injection of botulinum toxin was performed. 100 units of botulinum toxin was diluted with normal saline to 25 U/ml and injected into 4 quadrants of muscularis propria of pyloric sphincter, with a 25-gauge FNA needle (Figure 1). On post procedure day one the patient demonstrated significant improvement in her symptoms and scored 11 on the GSRS. She was discharged from the hospital soon after. During follow up 3 weeks post procedure, she reported one episode of vomiting since being discharged and scored 8 on the GSRS. She was again seen on post procedure week 4 and reported only intermittent nausea with no further episodes of vomiting. Her GSRS score at 4 and 12 weeks post procedure were 5 and 4, respectively. Diabetic gastroparesis is a relatively common and often difficult to manage chronic motility disorder where there is delayed gastric emptying in the absence of mechanical obstruction. It is thought to arise from a complex interplay of factors including disturbances in fundic accommodation, gastric arrhythmia, impaired corpus-antral contractility, vagal neuropathy and pyloric dysfunction (in the form of pylorospasm). Symptoms include nausea, vomiting, early satiety and epigastric pain. The currently available modalities of treatment for this condition, including prokinetic medications and placement of gastric pacemaker, are often sub-optimally efficacious. Based on the theory that gastric emptying improves with decreased pyloric resting pressure, intrapyloric sphincter botulinum toxin injection was introduced in 1998. Since that time, its use has been reported to have variable clinical response in the medical literature. We postulate that inconsistencies in clinical response from botulinum toxin injection may be due, in part, to variability in injection sites, and propose that its efficacy may be improved by precise injection (via EUS guidance) into the muscularis propria of pyloric sphincter, as was demonstrated in our case. Further clinical studies in patients with are required to confirm our hypothesis.Figure: Linear array endoscopic ultrasonography-guided botulinum toxin injection by a 25-gauge needle (large arrow) into the muscularis propria (small arrow) of pylorus in a patient with refractory diabetic gastroparesis.

Functional Characterization of Paralogous Gonadotropin-Releasing Hormone-Type and Corazonin-Type Neuropeptides in an Echinoderm.

Homologs of the vertebrate neuropeptide gonadotropin-releasing hormone (GnRH) have been identified in invertebrates, including the insect neuropeptide corazonin (CRZ). Recently, we reported the discovery of GnRH-type and CRZ-type signaling systems in an echinoderm, the starfish Asterias rubens, demonstrating that the evolutionary origin of paralogous GnRH-type and CRZ-type neuropeptides can be traced back to the common ancestor of protostomes and deuterostomes. Here, we have investigated the physiological roles of the GnRH-type (ArGnRH) and the CRZ-type (ArCRZ) neuropeptides in A. rubens, using mRNA in situ hybridization, immunohistochemistry and in vitro pharmacology. ArGnRH precursor (ArGnRHP)-expressing cells and ArGnRH-immunoreactive cells and/or processes are present in the radial nerve cords, circumoral nerve ring, digestive system (e.g., cardiac stomach and pyloric stomach), body wall-associated muscle (apical muscle), and appendages (tube feet, terminal tentacle). The general distribution of ArCRZ precursor (ArCRZP)-expressing cells is similar to that of ArGnRHP, but with specific local differences. For example, cells expressing ArGnRHP are present in both the ectoneural and hyponeural regions of the radial nerve cords and circumoral nerve ring, whereas cells expressing ArCRZP were only observed in the ectoneural region. In vitro pharmacological experiments revealed that both ArGnRH and ArCRZ cause contraction of cardiac stomach, apical muscle, and tube foot preparations. However, ArGnRH was more potent/effective than ArCRZ as a contractant of the cardiac stomach, whereas ArCRZ was more potent/effective than ArGnRH as a contractant of the apical muscle. These findings demonstrate that both ArGnRH and ArCRZ are myoexcitatory neuropeptides in starfish, but differences in their expression patterns and pharmacological activities are indicative of distinct physiological roles. This is the first study to investigate the physiological roles of both GnRH-type and CRZ-type neuropeptides in a deuterostome, providing new insights into the evolution and comparative physiology of these paralogous neuropeptide signaling systems in the Bilateria.

Discussion on standardized implementation of laparoscopic radical lymphadenectomy for distal gastric cancer

Laparoscopic radical gastrectomy for gastric cancer has been widely applied in clinical practice, and its indications have been extended from early gastric cancer to advanced gastric cancer. It is acknowledged that laparoscopic radical gastrectomy is technically challenging because of the complexity of anatomy, rich blood supply, and extensive lymph node dissection. This paper primarily intends to share the experience of laparoscopic radical D2 gastrectomy for distal gastric cancer with details of choosing the location of Trocar, surgical approaches and the sequence of lymph node dissection. All the surgeries were performed at Department of General Surgery and Gastrointestinal Surgery, Guangdong General Hospital. The finding suggests that a correct laparoscopic Trocar placement is the foundation of adequate surgical field visualization. Under most circumstances, the observation hole should be around 2 cm below the umbilicus and the operating hole should be close to the bilateral clavicle midline. Furthermore, proper surgical approach and sequence of lymph node dissection are the prerequisites for successful laparoscopic radical D2 gastrectomy, as well as the reassurance of dissecting lymph node safely and comprehensively. The position of surgical team adopted in our center is that the surgeon stands to the left of the patient, with laparoscope operator stands in between patient's legs while the first assistant positions himself opposite the surgeon on the right side of the patient. This position correlates to the rules of sequential lymph node dissection, which is "from left to right", "from proximal to distal" and "from inferior to superior". Therefore, it is conductive to inferior and superior pylorus region dissection and it can effectively prevent subsidiary-injury. In our center, the procedure of lymph node dissection has been standardized: the initial step is to undergo station 4sb dissection and greater gastric curvature clearance; then change the patient's position to clean the sub-pyloric lymph node region and cut off the duodenum by linear stapler; followed by the clearance of inferior region of the pylorus and the upper margin of the pancreas; in the final step, the first and the third groups of lymph node dissection is performed. Although varied surgical approaches and sequences of lymph node dissection are applied in different hospitals, the techniques required for laparoscopic D2 radical gastrectomy for gastric cancer are sophisticated and advanced in general. Radical lymph node dissection is complicated, urging surgeons to familiarize themselves with the anatomy of gastric peripheral vascular system and characteristics of lymph node drainage. By designing and implementing effective strategies, such as formulating a regular team, positioning surgical team reasonably, changing a patient's posture during operation, choosing an appropriate surgical approach and following a logically sequence of lymph node dissection, surgeons can standardize the complete surgical procedure, which ultimately reduces bleeding during surgery and shortens the operative time.

Anesthetic management of congenital hypertrophic pyloric stenosis combined with congenital laryngeal cartilage dysplasia in children

Objective To investigate anesthetic management of congenital hypertrophic pyloric obstruction (CHPS) combined with congenital laryngeal cartilage dysplasia in children, in order to provide reference for the anesthetic management of children with respiratory tract collapse. Methods On 15 March 2016, one child suffering from CHPS combined with congenital laryngeal cartilage dysplasia who was treated in Pediatric Surgery Department of West China Hospital of Sichuan University was selected as the subject. Under general anesthesia with laryngeal mask airway (LMA) combined with sacral block anesthesia guided by ultrasound, the treatment strategy for this child laparoscopic pyloromyotomy should be performed. Considering the risk of reflux aspiration would be increased by pneumoperitoneum pressure of laparoscopy, open pyloromyotomy for CHPS combined with congenital laryngeal cartilage dysplasia was performed finally. The clinical features and anesthetic management of this child were analyzed retrospectively. Results The anesthetic effect of this child was satisfactory and the open pyloromyotomy for CHPS combined with congenital laryngeal cartilage dysplasia was successful. About 10 min after surgery, this child was conscious and catheter of LMA was removed without any adverse events. During the treatment period of this child in intensive care unit (ICU) after surgery, there was no respiratory problems occurred. And this child discharged from hospital on the 7th day after surgery. One year after surgery, father of this child confirmed that laryngeal symptoms of this child disappeared gradually at 6 month old, and this child had good growth and development by telephone follow-up. Conclusions The method of LMA general anesthesia with caudal block could match the requirement of open pyloromyotomy of this child suffering from CHPS combined with congenital laryngeal cartilage dysplasia, and reduce the incidence of respiratory adverse events. Key words: Pyloric stenosis, hypertrophic; Congenital laryngeal cartilage dysplasia; Anesthetic management

Clinical application of radial endoscopic ultrasonography on preoperative T and N staging for advanced gastric cancer

Objective To assess the value of endoscopic ultrasonography (EUS) and abdominal CT scan on preoperative T and N staging of advanced gastric cancer. Methods A total of 188 patients with advanced gastric cancer received EUS and CT scan to evaluate the T and N staging and lymphatic metastasis before surgical operation. The postoperative pathologic results acted as gold standard for comparison of the two methods. The results consistent with pathologic results were considered as correct otherwise were incorrect. The accuracy of EUS and CT and the each consistency of two methods with pathology were analyzed. Results For T staging, the accuracy of EUS and CT was 87.2%(164/188), 76.6%(144/188), respectively, and Kappa value of EUS and CT was 0.726 and 0.509, respectively. There was a statistical difference between the two methods(χ2=7.181, P=0.007). For lymph node metastasis, the accuracy of EUS and CT was 72.9%(137/188) and 79.8%(150/188), respectively, and Kappa value of EUS and CT was 0.397 and 0.487, respectively. No statistical difference was found between them(χ2=0.963, P=0.326). The consistency test between the two methods for T and N staging and lymph node metastasis revealed that the Kappa value was 0.507 and 0.649, respectively. The accuracy of EUS on T staging was 93.0%, 93.3%, 96.8% and 91.5% in cardiac cancer, gastric fundus cancer, gastric corpus cancer, and gastric antrum cancer, respectively. Corresponding Kappa value in the 4 different positions were 0.843, 0.881, 0.940 and 0.710, respectively according to consistency tests. The accuracy of gastric antrum cancer with pylorus invasion was 63.2% and the consistency test Kappa value was 0.340. Conclusion EUS is an accurate method for T staging and lymphatic metastasis of advanced gastric cancer, but there is a lower accuracy for T staging of gastric antrum cancer with pylorus invasion. Key words: Endoscopic ultrasonography; Advanced gastric cancer; Neoplasm staging

Why sleeve gastrectomy is a better strategy than Roux-en-Y gastric bypass for type-2 diabetes mellitus

Type-2 diabetes mellitus is a chronic disease that affects now 417 millions worldwide. Surgery is now the only efficacious treatment, when compared to best medical treatment. Sleeve gastrectomy, the most frequent bariatric/metabolic surgery performed in the world, is associated with significant improvement in glycemic status in long-term. There are no real significant differences between the sleeve gastrectomy and gastric bypass at 5 years, nor in weight loss, nor in resolution of type-2 diabetes mellitus as measured by fasting blood glucose. The author strongly advocates sleeve gastrectomy as a first intention. If the patients fail to have substantial effect on their diabetes or if recidivism is seen, then the second stage intestinal procedures can be added, which include single anastomosis duodeno-ileostomy, duodenal switch, ileal inter-position, duodeno-jejunal bypass, amongst others, all preserving the sleeve and pylorus. Conversion from sleeve to Roux-en-Y gastric bypass may be problematic, increasing risks of peptic ulcers, dumping syndromes, bowel obstructions, micro-nutrients deficiencies and it may not be strong enough to reverse diabetes. Because of the loss of pylorus, the risk of glycemic deregulations with severe hypoglycemia or delayed hyperglycemia syndromes would possibly appear. Key words: Diabetes mellitus, type 2; Sleeve gastrectomy; Gastric bypass

Diagnosis and interventional treatment value of digital subtraction angiography for post pancreatectomy hemorrhage

Objective To investigate the diagnosis and treatment value of digital subtraction angiography (DSA) and transcatheter arterial embolization (TAE) for post pancreatectomy hemorrhage (PPH), and influencing factors of severity of PPH. Methods The retrospective case-control study was conducted. The clinicopathological data of 20 patients with PPH who were admitted to the Zhongshan Hospital of Fudan University from August 2009 to November 2016 were collected. Patients with PPH in the early stage underwent reoperations for hemostasis; patients with PPH in the later stage received conservative treatment, and then DSA and TAE were considered when patients had the stable vital signs. Observation indicators: (1) DSA situations: overall times, positive rate and bleeding sites; (2) TAE situations: successful rate of hemostasis, operating time and postoperative complications; (3) follow-up situations; (4) influencing factors analysis of severity of PPH. Follow-up using outpatient examination and telephone interview was performed to detect occurrence of complications after discharging from hospital up to April 2017. Measurement data with skewed distribution were described as M (range). Count data were evaluated by the ratio and proportion. The univariate analysis was done using the Fisher exact probability. Results (1) DSA situations: all the 20 patients underwent DSA, with overall times of 27. The direct sign was 18 times extravasation of the contrast medium, with a positive rate of 66.7% (18/27). Of 18 times positive DSA, clear bleeding sites were located in 5 times gastroduodenal artery (3 times with pseudoaneurysm of gastroduodenal artery stump), in 4 times common hepatic artery (3 times with pseudoaneurysm of common hepatic artery), in 3 times superior mesenteric artery, in 2 times splenic artery, in 1 time left gastric artery, in 1 time right gastric artery, in 1 time left hepatic artery (pseudoaneurysm of left hepatic artery) and in 1 time inferior mesenteric artery. (2) TAE situations: of patients with 18 times positive DSA, patients with 15 times positive DSA received TAE, with a successful rate of hemostasis of 13/15, and patients with 5 times positive DSA received successful hemostasis by reoperation. A median operating time of TAE for patients with 15 times positive DSA was 30 minutes. There was no occurrence of adverse reaction, including fever, abdominal pain, melena, elevated aminotransferase and liver abscess. One patient complicated with splenic abscess after transcatheter splenic arterial embolization underwent puncture drainage and then had a good recovery. Of patients with 9 times negative DSA, patients with 8 times negative DSA were cured by conservative treatment and patient with 1 time negative DSA received successful hemostasis by operation. All the 20 patients were cured and then discharged from hospital. (3) Follow-up situations: 20 patients were followed up for 4-92 months, with a median time of 24 months. During the follow-up, 20 patients recovered well, without long-term complications. (4) Influencing factors analysis of severity of PPH: the results of univariate analysis showed that gender, age, preoperative blood sugar, preoperative combined jaundice, preoperative albumin (Alb), preoperative prothrombin time (PT) extended, preserving pylorus, pancreatic duct stent placement, pancreatic operation time, volume of intraoperative blood loss, intraoperative blood transfusion, property of tumor, postoperative pancreatic fistula and time of PPH were not factors affecting the severity of PPH (P>0.05). Conclusion DSA is minimal-invasive in the diagnosis for PPH, and TAE is safe and effective for patients with positive DSA. Key words: Post pancreatectomy hemorrhage; Digital subtraction angiography; Transcatheter arterial embolization; Outcomes

Histomorphological and mucin histochemical study of the alimentary canal of pangas catfish, Pangasius pangasius (Hamilton 1822)

The present study describes the histological and mucin histochemical properties of the alimentary canal (AC) of the pangas catfish, Pangasius pangasius . The results revealed that the mucosa of the oesophagus was lined by a stratified epithelium containing chloride cells and taste buds which suggested mechanic, gustatory and physiologic roles of the oesophagus in this species. The stomach mucosa was lined by a simple columnar epithelium. The lamina propria-submucosa in cardiac and fundic stomach contained gastric glands. The pyloric stomach had the thickest muscularis layer among all the parts of the AC. The villi showed the maximum height and width in the middle intestine. The tunica muscularis and serosa showed the thinnest thickness among all parts of AC. The mucin histochemistry showed that the goblet cells of oesophagus and intestine contained both neutral and acidic with carboxylated and sulfated mucins and there was not acidic mucins in epithelial cells of the stomach.

Parasitic infections in the East Asian finless porpoise Neophocaena asiaeorientalis sunameri living off the Chinese Yellow/Bohai Sea coast.

Parasitic disease is among the major causes of health problems in marine mammals. However, little information on parasitic species composition and infection levels in finless porpoises (Neophocaena spp.) is available. In this study, we report the first systematic survey on parasitic infections in the East Asian finless porpoise N. asiaeorientalis sunameri (EAFP) living off the Chinese Yellow/Bohai Sea coast. Using both morphological and molecular methods, 5 parasitic helminths were identified: Campula oblonga in the liver and pancreas; Synthesium seymouri in the pyloric stomach and duodenum ampulla; Anisakis pegreffii in the forestomach, main stomach, and esophagus; Halocercus sp. in the lungs; and Crassicauda magna in the mammary glands and muscle. Among these helminths, C. oblonga (80.7%), S. seymouri (80.7%), A. pegreffii (80.7%), and Halocercus sp. (77.4%) were the most prevalent, whereas C. magna (6.5%) were only observed in 2 EAFP individuals. All juvenile and adult EAFPs were parasitized by at least 3 parasites species (C. oblonga, S. seymouri, and A. pegreffii), whereas in neonates, only Halocercus sp. were detected. We observed no significant difference in parasite prevalence between males and females. In addition, A. pegreffii and C. magna represented new infection records in Neophocaena. A pathological examination associated with parasitic lesions in EAFPs showed damage or destruction of cells or tissues to some extent. This study represents the first systematic survey on parasitic infections in EAFPs, providing important and valuable parasitological information for the research and conservation of this coastal marine mammal.

Effect of premedication with butorphanol or methadone on ease of endoscopic duodenal intubation in dogs

ObjectiveThe effect of premedication with butorphanol or methadone on ease of endoscopic duodenal intubation. Study designProspective, randomized, blinded clinical trial. AnimalsA group of 20 client-owned dogs. MethodsDogs were assigned randomly to be administered intravenous (IV) premedication with either butorphanol (0.4 mg kg−1) or methadone (0.3 mg kg−1). General anaesthesia was induced with propofol to effect and maintained with isoflurane in 100% oxygen. Sedation score 20 minutes after premedication administration and induction dose of propofol were recorded. Heart rate, mean arterial pressure, haemoglobin oxygen saturation, respiratory rate and end-tidal isoflurane concentration were recorded every 5 minutes. Spontaneous lower oesophageal and pyloric sphincter opening, presence of gastro-oesophageal and duodeno-gastric reflux, antral peristaltic contractions and response to endoscopy were recorded as yes or no. Ease of duodenal intubation (EDI) was graded on a scale ranging from 1 (immediate entry with minimal manoeuvring required) to 4 (no entry after 2 minutes). Time (seconds) from the start of pyloric intubation to successfully entering the duodenum was recorded. ResultsMedian EDI score [3 ± 1 (butorphanol), 4 ± 1 (methadone), p = 0.035], time [65 ± 36 seconds (butorphanol), 120 ± 38 seconds (methadone), p = 0.028] and number of dogs with spontaneous pyloric sphincter opening [7/10 (butorphanol), 2/10 (methadone), p = 0.035] differed between groups. No other significant differences were found. Conclusions and clinical relevanceIn these clinical cases, duodenal intubation was performed with greater ease, shorter time and more frequent spontaneous opening of the pyloric sphincter after premedication with butorphanol in comparison to methadone. The use of butorphanol facilitated the passage of the endoscope and is therefore recommended for premedication prior to upper gastrointestinal tract endoscopy.

Rodent stomach sample preparation for nitrogen NIRS analysis

Near infrared reflectance spectroscopy is a highly promising method for estimating food quality in small mammals. The method used to prepare rodent stomach content samples, however, may influence nitrogenous substance results. In this study, we focus on comparing methods of preparation of samples and finding the optimal preparation method, which means saving time and costs as well as maintenance of reliability and precision of estimation. We examined 1497 stomachs of the following species: Apodemus flavicollis, A. sylvaticus, Clethrionomys glareolus and Microtus arvalis. We used two preparation methods (grinding and abrasion). Where possible, cardiac and pyloric stomach sections were also examined separately. We found no significant difference between these data, hence only financial, time and equipment factors need determine the processing method in future studies.

Class side effects: decreased pressure in the lower oesophageal and the pyloric sphincters after the administration of dopamine antagonists, neuroleptics, anti-emetics, L-NAME, pentadecapeptide BPC 157 and L-arginine.

The ulcerogenic potential of dopamine antagonists and L-NAME in rats provides unresolved issues of anti-emetic neuroleptic application in both patients and experimental studies. Therefore, in a 1-week study, we examined the pressures within the lower oesophageal and the pyloric sphincters in rats [assessed manometrically (cm H2O)] after dopamine neuroleptics/prokinetics, L-NAME, L-arginine and stable gastric pentadecapeptide BPC 157 were administered alone and/or in combination. Medication (/kg) was given once daily intraperitoneally throughout the 7days, with the last dose at 24h before pressure assessment. Given as individual agents to healthy rats, all dopamine antagonists (central [haloperidol (6.25mg, 16mg, 25mg), fluphenazine (5mg), levomepromazine (50mg), chlorpromazine (10mg), quetiapine (10mg), olanzapine (5mg), clozapine (100mg), sulpiride (160mg), metoclopramide (25mg)) and peripheral(domperidone (10mg)], L-NAME (5mg) and L-arginine (100mg) decreased the pressure within both sphincters. As a common effect, this decreased pressure was rescued, dose-dependently, by BPC 157 (10µg, 10ng) (also note that L-arginine and L-NAME given together antagonized each other's responses). With haloperidol, L-NAME worsened both the lower oesophageal and the pyloric sphincter pressure, while L-arginine ameliorated lower oesophageal sphincter but not pyloric sphincter pressure, and antagonized L-NAME effect. With domperidone, L-arginine originally had no effect, while L-NAME worsened pyloric sphincter pressure. This effect was opposed by L-arginine. All these effects were further reversed towards a stronger beneficial effect, close to normal pressure values, by the addition of BPC 157. In addition, NO level was determined in plasma, sphincters and brain tissue. Thiobarbituric acid reactive substances (TBARS) were also assessed. Haloperidol increased NO levels (in both sphincters, the plasma and brain), consistently producing increased TBARS levels in the plasma, sphincters and brain tissues. These effects were all counteracted by BPC 157 administration. In conclusion, we revealed that BPC 157 counteracts the anti-emetic neuroleptic class side effect of decreased pressure in sphincters and the dopamine/NO-system/BPC 157 relationship.

Infantile hypertrophic pyloric stenosis as a concealed dilemma; A retrospective population-based study

Infantile hypertrophic pyloric stenosis as a concealed dilemma; A retrospective population-based study

Cis-diammin-odichloroplatinum and pseudomonas aeruginosa-mannose sensitive haemagglutination combined with continuous cycle hyperthermie intraperitoneal perfusion chemotherapy in the treatment of gastric cancer with pyloric obstruction in rabbit model

Objective To establish rabbit models of VX-2 carcinoma with pyloric obstruction and explore the curative effects and safety of Cis-diammin-odichloroplatinum (DDP) and pseudomonas aeruginosa-mannose sensitive haemagglutination (PA-MSHA) combined with continuous cycle hyperthermie intraperitoneal perfusion chemotherapy (CCHIPC) on gastric cancer with pyloric obstruction in a rabbit model. Methods VX-2 tumor cell suspension was injected to establish the rabbit model of gastric cancer with obstruction. Forty-two rabbits were randomly divided into the control group and the treatment group. All rabbit models treatment blood routine, liver and kidney function, electrolytes detection forward, the control group rabbits were 21, give direct resection of gastric cancer; treatment group rabbits were 21, given preoperative combined with enteral and parenteral nutrition after reoperation. Records of chemotherapy combined with enteral and parenteral nutrition in the treatment of rabbit model of survival, all the rabbits died the day be abdominal and thoracic, determine the primary tumor size in the gastric antrum, pyloric obstruction degree, respectively in treatment before laparotomy, died that day to take primary lesions and metastasis lesions were, he staining, under optical microscope observed. After the death of rabbits, gastric cancer was taken in situ and metastatic tumor. The expression levels of vascular endothelial growth factor (VEGF) and proliferating cell nuclear antigen (PCNA) were detected by immunohistochemistry. Results Experimental group and control group of gastric cancer radical resection rate was 85. 5% (18/21) and 66. 7% (14/21), the experimental group was significantly higher than the control group, the difference was statistically significant (P=0.025). In the experimental group and control group, the amount of bleeding, operation time, and postoperative anastomotic leakage or duodenal fistula, bleeding, stress ulcer bleeding and intestinal obstruction were not statistically significant (P=0.253). In the treatment group, the incidence of postoperative abdominal infection, pulmonary infection and gastric paralysis was significantly lower than that of the control group (P=0.019). Compared with the control group, the degree of metastasis of abdominal cavity in the experimental group was less than that in the control group, and there was less liver metastasis and less metastatic nodules. Control group experimental peritoneal carcinomatosis index (ePCI) score was 18.00±1.55, the experimental group ePCI score was 12.00±1.79, the difference between the two groups was statistically significant (P=0.013). The abdominal adhesion score of control group was 3.67±0.52, the abdominal adhesion score of the experimental group was 1.17±0.75, and there was a significant difference between the two groups (P=0.016). The gray value of VEGF expression in the control group was 77.33±6.77, the gray value of the experimental group VEGF was 200.17±4.26, the gray value of the control group PCNA was 83.33±3.49, the gray value of the experimental group PCNA was 184.83±3.76. The difference between the two groups was statistically significant (P=0.006, 0.011). Conclusion Preoperative adjuvant DDP and PA-MSHA combined with enteral and parenteral nutrition support treatment to control the progression of gastric carcinoma and relieve pyloric obstruction has a better effect and higher safety. Key words: Cis-diammin-odichloroplatinum; Ppseudomonas aeruginosa-mannose sensitive haemagglutination; Continuous cycle hyperthermie intraperitoneal perfusion chemotherapy; Gastric cancer; Pyloric obstruction

Clinical efficacy and prognostic factors analysis of radical hepatectomy of hepatocellular carcinoma in 760 patients

Objective To investigate the clinical efficacy and prognostic factors of radical hepatectomy of hepatocellular carcinoma (HCC). Methods The retrospective case-control study was conducted. The clinico-pathological data of 760 HCC patients who were admitted to the First Affiliated Hospital of Nanjing Medical University from August 2003 to June 2015 were collected. Surgical procedures were determined according to the location, number and size of tumors and anatomical relations among vessels. Observation indicators included: (1) intra- and post-operative situations: surgical procedures, operation time, volume of intraoperative blood loss, cases of intraoperative blood transfusion, postoperative complications, duration of postoperative hospital stay and pathological examination; (2) follow-up: 1-, 3-, 5-year overall and tumor-free survival situations; (3) prognostic factors analysis of HCC patients. Follow-up using outpatient examination and telephone interview was performed to detect patients′ survival up to January 2016. Measurement data with normal distribution were represented as ±s. The survival curve and survival rate were respectively drawn and calculated by the Kaplan-Meier method. The univariate analysis and multivariate analysis were done using the COX regression model. Results (1) Intra- and post-operative situations: all the 760 patients underwent successful operations, including 419 undergoing anatomical hepatectomy and 341 undergoing non-anatomical hepatectomy. R0 and R1 resections were respectively applied to 742 and 18 patients. Two patients were combined with portal vein resection and reconstruction and 1 was combined with resection and reconstruction of inferior vena cava. Operation time, volume of intraoperative blood loss and cases of intraoperative blood transfusion were (226±115)minutes, (714±706)mL and 88, respectively. Fifty-five patients had postoperative complications, including 20 with abdominal effusion or abscess, 16 with pleural effusion, 9 with recurrent fever, 8 with incisional infection, 7 with intra-abdominal hemorrhage, 6 with liver failure, 3 with pyloric or intestinal obstruction and 2 with renal failure (some patients with multiple complications). Of the 55 patients with postoperative complications, 7 with hemorrhage underwent reoperation or interventional therapy and other patients underwent conventional symptomatic treatment. Of 55 patients, 5 patients died and other 50 patients were improved. Duration of postoperative hospital stay was (14±6)days. There were 457 patients with minimum margin of tumors ≤1.0 cm and 303 with minimum margin of tumors >1.0 cm. (2) Follow-up: all the 760 patients were followed up for 1-139 months, with a median time of 25 months. The overall and tumor-free median survival times were 59 months and 31 months, respectively. The 1-, 3-, 5-year overall and tumor-free survival rates were 81.7%, 63.4%, 47.9% and 68.7%, 44.9%, 29.6%, respectively. (3) Prognostic factors analysis of HCC patients: results of univariate analysis showed that clinical symptoms, alpha-fetoprotein (AFP), Barcelona clinic liver cancer staging, surgical procedures, intraoperative blood transfusion, minimum margin of tumors, number and diameter of tumors, tumor capsule, tumor differentiation, vascular cancer embolus, macrovascular invasion and tumor staging of American Joint Committee on Cancer (AJCC) were related factors affecting prognosis of HCC patients after radical hepatectomy [HR=1.39, 1.50, 1.92, 0.65, 1.45, 1.68, 1.96, 1.66, 2.26, 1.50, 2.68, 3.37, 2.00, 95% confidence interval (CI): 1.08-1.79, 1.16-1.94, 1.68-2.20, 0.50-0.84, 1.04-2.02, 1.28-2.20, 1.54-2.49, 1.42-1.94, 1.69-3.02, 1.22-1.85, 1.99-3.60, 2.61-4.36, 1.77-2.27, P<0.05]. Results of multivariate analysis showed that AFP, number and diameter of tumors, tumor differentiation and tumor staging of AJCC were independent factors affecting prognosis of HCC patients after radical hepatectomy (HR=1.61, 1.62, 1.31, 1.40, 1.78, 95%CI: 1.14-2.26, 1.22-2.14, 1.06-1.63, 1.10-1.79, 1.27-2.51, P<0.05). Conclusions The anatomical and non-anatomical hepatectomies are safe and feasible for optional HCC patients, with a good long-term outcome. AFP, number and diameter of tumors, tumor differentiation and tumor staging of AJCC are independent factors affecting prognosis of HCC patients after radical hepatectomy. Key words: Carcinoma, hepatocellular; Hepatectomy, anatomy; Prognosis