The case was a man in his 80s, who had been in home care with primary hepatocellular carcinoma before hospitalization. He suffered nausea and appetite loss. However, hypercalcemia in laboratory data, brain metastasis on head CT and MRI, and intestinal obstruction or dilatation on abdominal CT, were not revealed. Upper gastrointestinal endoscopy detected no mechanical abnormality after admission to hospital and medical treatment with 3.75mg/day of mirtazapine was started. The dietary intake increased on the following day of the administration and nausea and appetite loss were improved, so the patient was discharged. In conclusion, low-dose mirtazapine was considered to be one of the effective therapeutic agents for nausea from unknown causes in cancer patients.

The purpose of this study was to examine the relationship between isometric cervical extension strength and the cross-sectional area (CSA) of neck extensor muscles in order to obtain fundamental data for conducting neck muscle training to prevent neck injuries. Subjects were 8 males belonging to the judo or American football club in N University. Isometric cervical extension strength was measured at eight positions (0°, 18°, 36°, 54°, 72°, 90°, 108°, maximum flexion) using a cervical extension machine (Medx Inc., USA) . A transaxial magnetic resonance imaging (MRI) image of neck muscles was obtained at the intervertebral disk between C4 and C5 (using an MRI machine made by Hitachi medical Corp., JAPAN) . The findings were as follows.
1. The correlation between isometric cervical extension strength at 36°, 54°and 72°in a neutral position (60.8±1.4°) and the CSA of neck extensor muscles were higher than at other degrees (0°, 18°, 90°, 108°, maximum flexion) . In particular, there was a significant linear relationship at 54° (slightly extended position) .
2. A significant linear relationship was observed between the neck girth and CSA of neck extensor muscles.
In conclusion, there was a closer relationship between isometric cervical extension strengths at certain angles in a neutral position and the CSA of neck extensor muscles. Therefore, it was shown that isometric cervical extension strengths at certain angles in a neutral position mainly represented the CSA of neck extensor muscles.

Endoscopic ultrasound-guided biliary drainage (EUS-BD), EUS-guided choledochoduodenostomy (EUS-CDS), and EUS-guided hepaticogastrostomy (EUS-HGS) can effectively palliate obstructive jaundice, but have not been well established yet. The incidence of complications is about 30% in EUSBD and higher for EUS-HGS. Several complications have been reported such as bleeding, perforation and peritonitis. Bleeding occurs due to puncture of portal vein, hepatic vein and artery, and we should use color Doppler. When a cautery dilator is used for fistula dilation, burn effects may cause delayed bleeding. Endoscopic hemostasis is only effective for anastomotic bleeding and embolization with interventional radiology technique is required for pseudo aneurysm. There are some types of perforation: failed stent placement after puncture or fistula dilation, double puncture during CDS procedure, and stent migration. Peritonitis with perforation requires surgery and can be fatal. Stent migration before mature fistula formation causes severe peritonitis because EUS-BD makes fistula between two unattached organs. Stents with flaps or long covered self-expandable metallic stents (cSEMSs) are effective to prevent migration. Recent development of lumen apposing stents may reduce early migration in EUS-CDS. Peritonitis without migration can be due to 1) leakage of bile juice or gastric/duodenal contents during EUS-BD or 2) leakage along the placed stent. We should make procedure time as short as possible, and cSEMSs reduce bile leak along the stent by occluding the dilated fistula. In summary, we should understand the mechanism of complications and the technique to prevent and manage complications. Development of dedicated devices to increase the success rate and reduce complications is required.
Aneurysm ; Arteries ; Bile ; Burns ; Cautery ; Choledochostomy ; Drainage* ; Fistula ; Hemorrhage ; Hemostasis, Endoscopic ; Hepatic Veins ; Incidence ; Jaundice, Obstructive ; Peritonitis ; Portal Vein ; Punctures ; Radiology, Interventional ; Stents

Background/Aims: The aim of this study was to evaluate the safety and efficacy of partially covered self-expandable metallic stents (PCSEMS) in patients undergoing neoadjuvant chemo (radio) therapy (NAC) for pancreatic cancer (PC). Methods: This was a prospective multicenter study to evaluate the safety and efficacy of PCSEMS in patients receiving NAC for resectable and borderline resectable PC. The primary endpoint was the rate of recurrent biliary obstruction (RBO). Results: Twenty-six patients with PC (three with resectable PC and 23 with borderline resectable PC) who underwent NAC at seven Japanese centers were included in the analysis. Both the technical and functional success rates of PCSEMS placement were 100%. Early stent-related complications were observed in three patients (11.5%): mild pancreatitis (n=2) and mild liver abscess (n=1). The median time to surgery or palliation was 4.0 months. Surgical resection was eventually performed in 73.1% of patients, and stent removal during surgery was successful in all patients. RBO was observed in nine patients (34.6%): seven with stent occlusion, one with kinking and one with migration. The RBO rates in resected cases and nonresected cases were 36.8% and 28.6%, respectively. Conclusions Biliary drainage by PCSEMS was safe and feasible in patients undergoing NAC for resectable and borderline resectable PC.

BACKGROUND/AIMS: Endoscopic placement of self-expandable metal stents (SEMSs) has emerged as a palliative treatment for malignant gastric outlet obstruction (GOO). Although covered SEMSs can prevent tumor ingrowth, frequent migration of covered SEMSs may offset their advantages in preventing tumor ingrowth. METHODS: We conducted this multicenter, single-arm, retrospective study at six tertiary referral centers to evaluate the safety and efficacy of a partially covered SEMS with an uncovered large-bore flare at the proximal end as an antimigration system in 41 patients with symptomatic malignant GOO. The primary outcome was clinical success, and the secondary outcomes were technical success, stent dysfunction, adverse events, and survival after stent placement. RESULTS: The technical and clinical success rates were 100% and 95%, respectively. Stent dysfunctions occurred in 17 patients (41%), including stent migration in nine (23%), tumor ingrowth in one (2%), and tumor overgrowth in four (10%). Two patients (5%) developed adverse events: one pancreatitis and one perforation. No procedure-related death was observed. CONCLUSIONS: A novel partially covered SEMS with a large-bore flare proximal end was safe and effective for malignant GOO but failed to prevent stent migration. Further research is warranted to develop a covered SEMS with an optimal antimigration system.
Gastric Outlet Obstruction* ; Humans ; Palliative Care ; Pancreatitis ; Retrospective Studies ; Self Expandable Metallic Stents ; Stents* ; Tertiary Care Centers

BACKGROUND/AIMS: Groove pancreatitis (GP) is an uncommon disease involving the pancreaticoduodenal area. Possible pathogenesis includes obstructive pancreatitis in the duct of Santorini and impaired communication with the duct of Wirsung, minor papilla stenosis, and leakage causing inflammation. Limited data regarding endoscopic treatment have been published. METHODS: Seven patients with GP receiving endoscopic treatment were reviewed. The morphology of the pancreatic duct was evaluated by a pancreatogram. Endoscopic dilation of the minor papilla and drainage of the duct of Santorini were performed. RESULTS: There were two pancreatic divisum cases, one ansa pancreatica case and four impaired connections between the duct of Santorini and the main pancreatic duct. Three to 31 sessions of endoscopy, with 2 to 24 sessions of transpapillary stenting and dilation, were performed. Interventions through the minor papilla were successfully performed in six of seven cases. The pancreatic stenting duration ranged from 2 to 87 months. Five patients with evidence of chronic pancreatitis (CP) tended to receive more endoscopic interventions than did the two patients without CP (2–24 vs 2, respectively) for GP and other complications associated with CP. CONCLUSIONS: Disconnection or impairment of communication between the ducts of Santorini and Wirsung was observed in all cases of GP. No surgery was required, and endoscopic minor papilla dilation and drainage of the duct of Santorini were feasible for the treatment of GP.
Constriction, Pathologic ; Drainage ; Endoscopy ; Humans ; Inflammation ; Pancreatic Ducts* ; Pancreatitis* ; Pancreatitis, Chronic ; Stents

BACKGROUND/AIMS: Stent migration occurs frequently, but the prevention of complications resulting from covered self-expandable metal stents (C-SEMSs) remains unresolved. We prospectively assessed a newly developed C-SEMS, a modified covered Zeo stent (m-CZS), in terms of its antimigration effect. METHODS: Between February 2010 and January 2011, an m-CZS was inserted into 42 patients (31 initial drainage cases and 11 reintervention cases) at a tertiary referral center and three affiliated hospitals. The laser-cut stent was flared for 1.5 cm at both ends, with a 1 cm raised bank located 1 cm in from each flared end. The main outcome of this study was the rate of stent migration, and secondary outcomes were the rate of recurrent biliary obstruction (RBO), the time to RBO, the frequencies of complications, and overall survival. RESULTS: Of the 31 patients with initial drainage, stent migration occurred in four (12.9%, 95% confidence interval, 5.1% to 29.0%), with a mean time of 131 days. RBO occurred in 18 (58%), with a median time to RBO of 107 days. Following previous C-SEMS migration, seven of 10 patients (70%) did not experience m-CZS migration until death. CONCLUSIONS: m-CZSs with antimigration properties effectively, although not completely, prevented stent migration after stent insertion.
Aged ; Aged, 80 and over ; Alloys ; Carcinoma/*complications ; Cholestasis/etiology/*therapy ; Digestive System Neoplasms/*complications ; Drainage ; Equipment Design ; Feasibility Studies ; Female ; Humans ; Kaplan-Meier Estimate ; Lymphatic Metastasis ; Male ; Middle Aged ; *Prosthesis Failure ; Recurrence ; Reoperation ; *Stents/adverse effects ; Time Factors

BACKGROUND/AIMS: In distal malignant biliary obstruction, an antireflux metal stent (ARMS) with a funnel-shaped valve is effective as a reintervention for metal stent occlusion caused by reflux. This study sought to evaluate the feasibility of this ARMS as a first-line metal stent. METHODS: Patients with nonresectable distal malignant biliary obstruction were identified between April and December 2014 at three Japanese tertiary centers. We retrospectively evaluated recurrent biliary obstruction and adverse events after ARMS placement. RESULTS: In total, 20 consecutive patients were included. The most common cause of biliary obstruction was pancreatic cancer (75%). Overall, recurrent biliary obstruction was observed in seven patients (35%), with a median time to recurrent biliary obstruction of 246 days (range, 11 to 246 days). Stent occlusion occurred in five patients (25%), the causes of which were sludge and food impaction in three and two patients, respectively. Stent migration occurred in two patients (10%). The rate of adverse events associated with ARMS was 25%: pancreatitis occurred in three patients, cholecystitis in one and liver abscess in one. No patients experienced non-occlusion cholangitis. CONCLUSIONS: The ARMS as a first-line biliary drainage procedure was feasible. Because the ARMS did not fully prevent stent dysfunction due to reflux, further investigation is warranted.
Arm ; Asian Continental Ancestry Group ; Cholangiopancreatography, Endoscopic Retrograde ; Cholangitis ; Cholecystitis ; Drainage ; Humans ; Liver Abscess ; Pancreatic Neoplasms ; Pancreatitis ; Pilot Projects* ; Retrospective Studies ; Sewage ; Stents*

Background: The “work style reform of physicians” is due to come into effect in April 2024. Cardiovascular surgery involves many life-saving surgeries after hours, and it is expected to be difficult to achieve the upper limit (level A) of 960 h per year and less than 100 h per month for overtime work. In 2021, there were five full-time cardiovascular surgeons, four of whom were responsible for performing emergency surgery for acute aortic dissection in our facility. The ability to provide emergency surgical care with any two-person combination increases the flexibility of staffing for routine surgery or after-hours on-call. The working environment and surgical outcomes of acute aortic dissection under this system are reported, and changes in work style in cardiovascular surgery are discussed. Methods: The surgical outcomes of 39 cases of acute aortic dissection requiring emergency open heart surgery at this hospital during the one-year period from January to December 2021 were investigated. The number of cases (and first assistants) performed by five full-time surgeons were 7(13), 9(6), 12(3), 11(7) and 0(10), respectively. In addition, there were 8 cases of acute aortic dissection requiring urgent stent graft treatment during the same period. The emergency response rate for emergency patients (including those other than acute aortic dissection) was 100% during the same period. Results: The age was 69 years (median), 48.7% were female, 92.3% were Stanford type A, of which 22.2% were DeBakey type II. Shock vital 20.5%, malperfusion 30.8%. The surgical procedures included TAR in 19 cases, PAR in 8 cases, HAR in 12 cases (including 2 Bentall). Concomitant operations were AVR in 5 cases, CABG in 2 cases, TEVAR in 1 case, lower limb arterioplasty in 2 cases and right hemispherectomy in 1 case. Operating time 400 min (median), extracorporeal circulation time 194 min (median), cardiac arrest 108 min (median), selective cerebral perfusion time 125 min (median), lower body circulation arrest 46 min (median). Hospital mortality 7.7%, stroke 12.8%, delayed paraparesis 2.6%. Ventilation time was 1 day (median), hospital stay 23 days (median), 64.1% were discharged at home. Working Environments: 12-13 on-calls per month. Maximum yearly overtime work is 480.5 h with full overtime pay. Exemptions from working after night shift were also possible. Conclusions: The surgical outcomes of acute aortic dissection at our hospital were acceptable. Not having a fixed surgeon enabled a flexible emergency response, and increased the flexibility of staffing for routine surgery and on-call, and was considered to enable both a change in working style and surgical safety while meeting the needs of the community.