Objective : In Europe, carbon dioxide therapy has been used for treating cardiac disease and skin problems for a long time. Previously, we demonstrated that transcutaneous carbon dioxide (CO₂) application facilitated dioxygen (O₂) dissociation from hemoglobin (Hb) in the human body. Additionally, we proved that transcutaneous CO₂ application to the lower limbs of rats increased the expression of peroxisome proliferator-activated receptor (PPAR) gamma coactivator-1α (PGC-1α), vascular endothelial growth factor (VEGF) and silent mating type information regulation 2 homologs 1 (SIRT1). It also increased the number of mitochondria, and changed IIB fiber to IIA fiber in similar manner to the change that occurs after exercise. The transcutaneous CO₂ application caused a similar effect to that of exercise training in skeletal muscle and indicated the possibility of improved endurance strength. However, the effect of transcutaneous CO₂ application on endurance exercise and the recovery of muscle fatigue has not been studied. Methods : In this study, we investigated the performance of endurance exercise in rats with/without transcutaneous CO₂ application and analyzed the muscle fiber changes, capillary density and mitochondrial DNA number of the skeletal muscles after training, using activity wheels. Results： Training with CO₂ application resulted in a higher percentage of TA muscle transformed to IIA and/or IID than training alone, suggesting that transcutaneous CO₂ application may increase the production of ATP, mitochondria number, and capillary density. Therefore, transcutaneous CO₂ application might lead to muscle damage recovery. Conclusion : We suggest that transcutaneous CO₂ application has a therapeutic potential for recovery of damaged muscle after excessive exercise and rehabilitation.

Infectious abdominal aortic aneurysm is a relatively rare disease, and there is no consensus regarding its surgical treatment. Medical infectious control should be concerned comparison with surgical treatment if there is sepsis, however we sometimes have no other choice but emergency operation for uncontrollable cases. In many reports, cryopreserved homografts were used as in-situ alternative grafts for infectious aortic aneurysms because they had some merits such as anti-infectious effects, suitability and so on. However the number of in-situ cryopreserved homograft replacement cases are few, and the long term result is unclear. We encountered a ruptured cropreserved homograft case 7 months after urgent in-situ cryopreserved homograft replacement. We report the case and refer to the relevans literature.

A 39-year-old woman was referred for assessment of abnormality of on a CT scan with a vascular anomaly of the aortic arch. This patient was completely asymptomatic with no concomitant pathologies and no reported prior trauma. Laboratory data for syphilitic or other microbial infections were negative. The diagnosis was confirmed by angiographic computed tomographic scan with 3-dimensional reconstruction. This technique documented the presence of the aneurysm and the left subclavian artery arising from the unique form of aneurysm. Early surgery was preferred because of the young age of the patient and the morphology and the size of the aneurysm (50 mm). Surgery was performed by a left postero-lateral thoracotomy through the forth intercostal space. Femoro-femoral partial cardiopulmonary bypass was used for distal perfusion. An aortic clamp was placed just distal to the left carotid artery, and a second clamp was placed in the descending thoracic aorta. The aortic isthmus was replaced with a 20-mm Dacron graft, and the left subclavian artery was reimplanted to the prosthesis with an 8-mm Dacron graft interposition. This aneurysm was the result of abnormal organogenesis of a primitive aortic arch and the remnant of the dorsal aorta, in other words, Kommerell's diverticulum. Microscopic examination demonstrated severe medial layer atrophy. In the light of the high risk of rupture, which was proved to be present by the very thin aneurysm wall at the time of surgery, we suggest early surgical treatment of idiopathic isthmus aneurysms in young patients regardless of aneurysm diameter.

We encountered three cases of infra-renal infected abdominal aortic aneurysm in 2007 and 2008. Preoperative blood culture was positive in two of the three patients. All of the patients presented with fever of unknown origin. We replaced the affected segment of the abdominal aorta with a synthetic graft in 1 patient, and with a cryopreserved arterial homograft in the remaining 2 patients. An infected abdominal aortic aneurysm is a life-threatening condition. Diagnosis is often difficult, and emergency surgery may be necessitated by rupture of the aneurysm. Our experience suggests that computed tomography is effective for the diagnosis of infected aneurysms. The most effective surgical technique consists of complete resection of the aneurysm, in-situ replacement of the affected aortic segment with a synthetic graft or homograft, and omental coverage.

BACKGROUND/AIMS: It is often difficult to manage acute cholecystitis after metal stent (MS) placement in unresectable malignant biliary strictures. The aim of this study was to evaluate the feasibility of endoscopic ultrasonography-guided gallbladder drainage (EUS-GBD) for acute cholecystitis. METHODS: The clinical outcomes of 10 patients who underwent EUS-GBD for acute cholecystitis after MS placement between January 2011 and August 2018 were retrospectively evaluated. The procedural outcomes of percutaneous transhepatic gallbladder drainage (PTGBD) with tube placement (n=11 cases) and aspiration (PTGBA) (n=27 cases) during the study period were evaluated as a reference. RESULTS: The technical success and clinical effectiveness rates of EUS-GBD were 90% (9/10) and 89% (8/9), respectively. Severe bile leakage that required surgical treatment occurred in one case. Acute cholecystitis recurred after stent dislocation in 38% (3/8) of the cases. Both PTGBD and PTGBA were technically successful in all cases without severe adverse events and clinically effective in 91% and 63% of the cases, respectively. CONCLUSIONS: EUS-GBD after MS placement was a feasible option for treating acute cholecystitis. However, it was a rescue technique following the established percutaneous intervention in the current setting because of the immature technical methodology, including dedicated devices, which need further development.
Bile ; Cholecystitis, Acute ; Constriction, Pathologic ; Dislocations ; Drainage ; Gallbladder ; Humans ; Retrospective Studies ; Stents ; Treatment Outcome

Background/Aims: We aimed to investigate (1) promising clinical findings for the recognition of focal type autoimmune pancreatitis (FAIP) and (2) the impact of endoscopic ultrasound (EUS)-guided tissue acquisition (EUS-TA) on the diagnosis of FAIP. Methods: Twenty-three patients with FAIP were involved in this study, and 44 patients with resected pancreatic ductal adenocarcinoma (PDAC) were included in the control group. Results: (1) Multivariate analysis revealed that homogeneous delayed enhancement on contrast-enhanced computed tomography was a significant factor indicative of FAIP compared to PDAC (90% vs. 7%, p=0.015). (2) For 13 of 17 FAIP patients (76.5%) who underwent EUS-TA, EUS-TA aided the diagnostic confirmation of AIPs, and only one patient (5.9%) was found to have AIP after surgery. On the other hand, of the six patients who did not undergo EUS-TA, three (50.0%) underwent surgery for pancreatic lesions. Conclusions Homogeneous delayed enhancement on contrast-enhanced computed tomography was the most useful clinical factor for discriminating FAIPs from PDACs. EUS-TA is mandatory for diagnostic confirmation of FAIP lesions and can contribute to a reduction in the rate of unnecessary surgery for patients with FAIP.

Background/Aims: This study aimed to clarify the efficacy and safety of pancreatic duct lavage cytology combined with a cell-block method (PLC-CB) for possible pancreatic ductal adenocarcinomas (PDACs). Methods: This study included 41 patients with suspected PDACs who underwent PLC-CB mainly because they were unfit for undergoing endoscopic ultrasonography-guided fine needle aspiration. A 6-Fr double lumen catheter was mainly used to perform PLC-CB. Final diagnoses were obtained from the findings of resected specimens or clinical outcomes during surveillance after PLC-CB. Results: Histocytological evaluations using PLC-CB were performed in 87.8% (36/41) of the patients. For 31 of the 36 patients, final diagnoses (invasive PDAC, 12; pancreatic carcinoma in situ, 5; benignancy, 14) were made, and the remaining five patients were excluded due to lack of surveillance periods after PLC-CB. For 31 patients, the sensitivity, specificity, and accuracy of PLC-CB for detecting malignancy were 94.1%, 100%, and 96.8%, respectively. In addition, they were 87.5%, 100%, and 94.1%, respectively, in 17 patients without pancreatic masses detectable using endoscopic ultrasonography. Four patients developed postprocedural pancreatitis, which improved with conservative therapy. Conclusions PLC-CB has an excellent ability to detect malignancies in patients with possible PDACs, including pancreatic carcinoma in situ.

Background/Aims: The aim of this study was to evaluate outcomes of inside plastic stents (iPSs) versus those of metal stents (MSs) for treating unresectable perihilar malignant obstructions. Methods: For all patients who underwent endoscopic suprapapillary placement of iPS(s) or MS(s) as the first permanent biliary drainage for unresectable malignant perihilar obstructions between January 2014 and August 2019, clinical outcomes using iPSs (n=20) and MSs (n=85), including clinical efficacy, adverse events, and time to recurrence of biliary obstruction (RBO), were retrospectively evaluated. Results: There were no differences in clinical effectiveness (95% for the iPS group vs. 92% for the MS group, p=1.00). Procedure-related adverse events, including pancreatitis, acute cholangitis, acute cholecystitis, and death, were observed for 8% of the MS group, although no patient in the iPS group developed such adverse events. The median time to RBO was 561 days (95% confidence interval, 0–1,186 days) for iPSs and 209 days (127–291 days) for MSs, showing a significant difference (p=0.008). Conclusions Time to RBO after iPS placement was significantly longer than that after MS placement. IPSs, which are removable, unlike MSs, were an acceptable option.

Background/Aims: The factors affecting the detection rate of lymphoplasmacytic sclerosing pancreatitis (LPSP) using endoscopic ultrasound-guided tissue acquisition (EUS-TA) in patients with type 1 autoimmune pancreatitis (AIP) have not been thoroughly studied. Therefore, we conducted a retrospective study to identify the predictive factors for histologically detecting level 1 or 2 LPSP using EUS-TA. Methods: Fifty patients with AIP were included in this study, and the primary outcome measures were the predictive factors for histologically detecting level 1 or 2 LPSP using EUS-TA. Results: Multivariate analysis identified the use of fine needle biopsy (FNB) needles as a significant predictive factor for LPSP detection (odds ratio, 15.1; 95% confidence interval, 1.62–141; ¬¬p=0.017). The rate of good-quality specimens (specimen adequacy score ≥4) was significantly higher for the FNB needle group than for the fine needle aspiration (FNA) needle group (97% vs. 56%; p<0.01), and the FNB needle group required significantly fewer needle passes than the FNA needle group (median, 2 vs. 3; p<0.01). Conclusions The use of FNB needles was the most important factor for the histological confirmation of LPSP using EUS-TA in patients with type 1 AIP.