In the past 11 years, we treated 41 patients with Stanford type B aortic dissection. Principally, medical therapy was carried out and surgery was performed only when complications related to the dissection occurred. Twenty two patients (53.7%) had complications, including 5 (12%) with peripheral limb ischemia, 3 (7%) with rupture, 13 (32%) with dilatation of the aorta, 4 (10%) with extension of dissection (type A dissection). Seventeen patients received surgery including palliative operation. Among 41 patients, 3 died due to aortic rupture and 2 died at surgery for type A dissection, while 4 of them had developed proximal extension of the dissection. The 5-year survival rate for all patients was 86.7±6.6%. Long term survival will improve in patients with Stanford type B aortic dissection when the operative mortality for type A dissection is reduced and sound management policies are developed.

We experienced two rare cases of acute aortic dissection with leg ischemia after Y graft repair of the abdominal aortic aneurysma. Case 1 was a 63-year-old woman who had received Y graft repair at age 55, and case 2 was a 28-year-old man with Marfan's syndrome who received a Y graft repair at age 21. Both patients sustained DeBakey type I dissections terminating at the suture line of the Y graft and had symptoms of acute arterial occlusion of bilateral lower extremities. Emergency operation was performed 8 hours after onset in case 1 and 6 hours after in case 2. Case 1 could not be weaned from cardiopulmonary bypass because of intraoperative rupture and acute heart failure, but case 2 underwent successfully aortic root replacement and total arch replacement under selective cerebral perfusion.

We evaluated the interview skills of 46 sixth year medical students (32 men, 14 women) in our outpatient clinic. Six items were evaluated, including the manner in which students responded to patients, the number of times students interrupted patients' statements with closed-ended questions, and the extent to which students maintained eye contact with patients. We found that students interrupted patients every 46.2 seconds on average, and often did not make eye contact with tha patients. It became clear that, although we teach medical interview skills to students, students do not learn these skills very well. We suggest that in order to properly educate medical students, close cooperation between departments is needed.

We evaluated basic surgical skills in students using the Objective Structured Clinical Examination (OSCE). The study was conducted on 101 sixth-grade medical students (67 males, 34 females) at Kawasaki Medical School in 1993. Theme A (tying of a silk suture) was given to 44 students, and theme B (tying of nylon suture using surgical instruments) was given to 57 students. The following items were evaluated (1) handling of surgical instruments, (2) suturing, (3) knot tying, and (4) suture removal. The average score for theme B was slightly lower than that for theme A. The average score for knot tying was lower than scores for the other items. Thus, it was revealed that all students were not good at tying knots. These scores for minor surgery correlated with the scores for other skills as evaluated by the OSCE. In conclusion, the OSCE appears to be an appropriate method for evaluating basic surgical skills.

Objectives: Infective endocarditis (IE) has an extremely poor prognosis unless appropriate treatment is received. Hemodialysis patients with IE show higher rates of morbidity and mortality in comparison with non-dialysis patients with IE. We focused on hemodialysis patients, as well as patients in other stages of chronic kidney disease. We sought to assess the relationship between renal function and mortality in patients with IE.
Methods: We carried out a retrospective cohort study on 45 consecutive patients with IE in an urban teaching hospital between November 2003 and August 2008. We collected demographic and clinical data as well as pre- and post-discharge outcomes. Patients were subdivided into four groups according to their eGFR level at admission: A: eGFR≧60 ml/min/1.73 m² (n=23); B: eGFR 30-59 ml/min/1.73 m² (n=15); C: eGFR<30 ml/min/1.73 m² (n=3); and, D: dialysis patients (n=3). It was not possible to determine the outcome status of one patient. The Trend Test was used to evaluate the association between renal function and mortality.
Results: There were 29 male and 16 female patients with IE and the mean age was 67.9+-17.6 (SD). There were 10 diabetic patients (22%). Thirty-nine patients (84%) were either discharged or transferred to another hospital. Seven patients (16%) died: two (9%) Group A patients; three (20%) Group B patients; no Group C patients; and, two (67%) Group D patients. Patients with lower eGFR had higher mortality rates (Trend Test, P=0.046).
Conclusion: We presume a trend towards a higher mortality rate in conjunction with advancing CKD stage.

PURPOSE: Recently, the clinical application of the forced oscillation technique (FOT) has progressed with the spread of commercially available FOT devices, including the impulse oscillation system and MostGraph. We investigated the usefulness of color 3D imaging of respiratory impedance in asthma using MostGraph. METHODS: Whole-breath and within-breath respiratory system resistance (Rrs) and reactance (Xrs) were measured in 78 patients with asthma. Color 3D images were classified into three patterns: the chronic obstructive pulmonary disease (COPD)-like pattern (high values of Rrs and Xrs with a marked respiratory cycle and frequency dependence), the asthma pattern (moderately high Rrs over the entire frequency and a respiratory cycle with slight Xrs changes), and a normal-like pattern (low Rrs and Xrs with few within-breath changes). The classification was performed by three researchers, who were unaware of the clinical information, and the clinical characteristics were compared among the three groups. RESULTS: Color 3D imaging provided a COPD-like pattern in 25 patients, an asthma pattern in 39 patients, and a normal-like pattern in 14 patients. Patients with the COPD-like pattern were predominantly female with a higher body mass index, lower forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC), and higher Rrs and Xrs values (whole-breath and within-breath variation). Those with the normal pattern had higher FEV1 and FVC, and a lower single-breath nitrogen washout slope. There were no differences in asthma control or exhaled nitric oxide levels among the three groups. CONCLUSIONS: These results suggest that color 3D imaging of respiratory impedance may show asthma phenotypes.
Asthma ; Body Mass Index ; Electric Impedance ; Female ; Forced Expiratory Volume ; Humans ; Nitric Oxide ; Nitrogen ; Phenotype ; Pulmonary Disease, Chronic Obstructive ; Respiratory System ; Vital Capacity

Background/Aims: Digital single-operator cholangioscopy (DSOC)-guided mapping biopsy (DMB) and tube-assisted mapping biopsy (TMB) are two techniques used for preoperative evaluation of biliary tract cancer (BTC). However, data regarding the diagnostic performance of these techniques are limited. Methods: We retrospectively examined consecutive patients with BTC who underwent either technique at our institution between 2018 and 2020. We evaluated the technical success rate, adequate tissue acquisition rate, and diagnostic performance of these techniques for the evaluation of lateral spread of BTC. Results: A total of 54 patients were included in the study. The technical success rate of reaching the target sites was 95% for DMB and 100% for TMB. The adequate tissue acquisition rate was 61% for DMB and 69% for TMB. The adequate tissue acquisition rate was low, especially for target sites beyond the secondary biliary radicles. The sensitivity of DMB alone was 39%, which improved to 65% when combined with visual impression. Experts demonstrated a higher negative predictive value and diagnostic accuracy with respect to both DSOC visual impression and DMB for the evaluation of lateral spread of BTC compared to trainees. Conclusions Adequate tissue acquisition rates were similar between the two techniques. Since DMB requires expertise, TMB may be an acceptable option when DSOC is unavailable or when DSOC expertise is limited.

Background/Aims: Selective bile duct or pancreatic duct cannulation remains a significant initial hurdle in endoscopic retrograde cholangiopancreatography (ERCP) despite advances in endoscopy and accessories. This study evaluated our experience with a rotatable sphincterotome in cases of difficult cannulation. Methods: We retrospectively reviewed ERCP cases using TRUEtome, a rotatable sphincterotome, as a rescue device for cannulation at a cancer institute in Japan from October 2014 to December 2021. Results: TRUEtome was used in 88 patients. Duodenoscopes were used for 51 patients, while single-balloon enteroscopes (SBE) were used for 37 patients. TRUEtome was used for biliary and pancreatic duct cannulation (84.1%), intrahepatic bile duct selection (12.5%), and strictures of the afferent limb (3.4%). Cannulation success rates were similar in the duodenoscope and SBE groups (86.3% vs. 75.7%, p=0.213). TRUEtome was more commonly used in cases with steep cannulation angles in the duodenoscope group and in cases requiring cannulation in different directions in the SBE group. There were no significant differences in adverse events between the two groups. Conclusions The cannulation sphincterotome was useful for difficult cannulations in both unaltered and surgically altered anatomies. It may be an option to consider before high-risk procedures such as precut and endoscopic ultrasound-guided rendezvous techniques.

Background/Aims: Hepaticojejunostomy anastomotic stricture (HJAS) is a feared adverse event associated with hepatopancreatobiliary surgery. Although balloon dilation for benign HJAS during endoscopic retrograde cholangiopancreatography with balloon-assisted enteroscopy has been reported to be useful, the treatment strategy remains controversial. Therefore, we evaluated the outcomes and risk factors of recurrent stenosis after balloon dilation alone for benign HJAS. Methods: We retrospectively analyzed consecutive patients who underwent balloon-assisted enteroscopy–endoscopic retrograde cholangiopancreatography for benign HJAS at our institution between July 2014 and December 2020. Results: Forty-six patients were included, 16 of whom had recurrent HJAS after balloon dilation. The patency rates at 1 and 2 years after balloon dilation were 76.8% and 64.2%, respectively. Presence of a residual balloon notch during balloon dilation was an independent predictor of recurrence (hazard ratio, 2.80; 95% confidence interval, 1.01–7.78; p=0.048), whereas HJAS within postoperative 1 year tended to be associated with recurrence (hazard ratio, 2.43; 95% confidence interval, 0.85–6.89; p=0.096). The patency rates in patients without a residual balloon notch were 82.1% and 73.1% after 1 and 2 years, respectively. Conclusions Balloon dilation alone may be a viable option for patients with benign HJAS without residual balloon notches on fluoroscopy.