We report a very rare case of a coronary artery fistula with communication between the right coronary artery and the left atrium. The patient was a 45 year-old woman admitted for evaluation of heart murmur. Selective coronary angiography demonstrated right coronary artery-left atrial fistula. The operation was indicated due to volume overload of the left ventricle. At operation, the proximal portion of the coronary fistula was successfully ligated from the epicardial side and the entrance of the fistula into the left atrium was directly closed from the inside of the left atrium under the cardiopulmonary bypass. The post-operative course was uneventful. Post-operative coronary angiography showed disappearance of the fistula. Angiography 6 months later, demonstrated that the orifice of the right coronary artery remained dilated, while the diameter of the distal site was normalized.

Purpose: We report two patients receiving high doses of systemic opioids in whom gradual switching of the opioid administration route from systemic to intrathecal provided satisfactory pain relief without excessive sedation or withdrawal symptoms. Case reports: In one of the patients, who was already receiving 500mg morphine intravenously but still suffered from right upper quadrant pain, it was difficult to increase the opioid dosage according to the WHO guidelines because of intolerable side effects. The other patient, in spite of taking a combination of systemic opioids equivalent to 760mg oral morphine, had inadequate pain relief and could not continue receiving home medical care. In both cases we could successfully change from systemic to intrathecal opioid administration in a step-wise manner without deterioration of pain control, adverse effects due to over dosage, or withdrawal symptoms. Intrathecal opioid administration also reduced drowsiness and improved daily activity. Conclusion: Currently, there are no guidelines for change of route of opioid administration from systemic to intrathecal administration and few published reports have concretely documented opioid route switching in Japan. A carefully planned, step-wise switching of opioid administration route from systemic to intrathecal should be considered in patients who are already taking high doses of systemic opioids. Palliat Care Res 2009; 4(1): 317-320

Background/Aims: ManoScan and Sandhill high-resolution manometry (HRM) systems are used worldwide; however, the diagnosis of achalasia on the Starlet HRM system is not fully characterized. Furthermore, the impact of calcium channel blockers and nitrites in treating achalasia has not been investigated using HRM. Management of recurrent cases is a priority issue, although few studies have examined patient characteristics. Methods: We conducted a multicenter, large-scale database analysis. First, the diagnosis of treatment-naive achalasia in each HRM system was investigated. Next, patient characteristics were compared between type I-III achalasia, and the impact of patient characteristics, including calcium channel blocker and nitrite use for integrated relaxation pressure (IRP) values, were analyzed. Finally, patient characteristics with recurrent achalasia were elucidated. Results: The frequency of type I achalasia with Starlet was significantly higher than that with ManoScan and Sandhill HRM systems. In achalasia, multivariate analysis identified male sex, advanced age, long disease duration, obesity, type I achalasia, and sigmoid type as risk factors related to normal IRP values (< 26 mmHg). Calcium channel blockers and nitrites use had no significant impact on the IRP values, although achalasia symptoms were indicated to be alleviated. In recurrent cases, the IRP value was significantly lower, and advanced age, long disease duration, and sigmoid type were more common than in treatment-naive patients. Conclusions We should cautiously interpret the type of achalasia and IRP values in the Starlet HRM system. Symptoms of recurrent cases are related to disease progression rather than IRP values, which should be considered in decision making.

Background/Aims: Patients with achalasia-related esophageal motility disorders (AEMDs) frequently present with dilated and sigmoid esophagus, anddevelop esophageal diverticulum (ED), although the prevalence and patients characteristics require further elucidation. Methods: We conducted a multicenter cohort study of 3707 patients with AEMDs from 14 facilities in Japan. Esophagography on 3682 patients were analyzed. Results: Straight (n = 2798), sigmoid (n = 684), and advanced sigmoid esophagus (n = 200) were diagnosed. Multivariate analysis revealed that long disease duration, advanced age, obesity, and type I achalasia correlate positively, whereas severe symptoms and integrated relaxation pressure correlate negatively with development of sigmoid esophagus. In contrast, Grade II dilation (3.5-6.0 cm) was the most common (52.9%), while grade III dilation (≥ 6 cm) was rare (5.0%). We found early onset, male, obesity, and type I achalasia correlated positively, while advanced age correlated negatively with esophageal dilation. Dilated and sigmoid esophagus were found mostly in types I and II achalasia, but typically not found in spastic disorders. The prevalence of ED was low (n = 63, 1.7%), and non-dilated esophagus and advanced age correlated with ED development. Patients with right-sided ED (n = 35) had a long disease duration (P = 0.005) with low integrated relaxation pressure values (P = 0.008) compared with patients with left-sided ED (n = 22). Patients with multiple EDs (n = 6) had lower symptom severity than patients with a single ED (P = 0.022). Conclusions The etiologies of dilated esophagus, sigmoid esophagus, and ED are considered multifactorial and different. Early diagnosis and optimal treatment of AEMDs are necessary to prevent these conditions.