Subdural hematoma or effusion is a common complication in ventriculoperitoneal shunts. However, the incidence of subdural hematoma in shunted patients requiring a surgical procedure has been decreasing recently, since it can be treated with a newly developed pressure-programmable valve system. We treated two shunted patients with subdural hematomas caused by simple falls during gait training. The management was complicated, involving multiple surgical procedures. Case 1 : A 65-year-old woman, who had undergone ventriculoperitoneal shunting for normal pressure hydrocephalus after removal of a meningioma, suffered mild head trauma due to a fall during gait training and developed consciousness disturbance after 2 hours. Computed tomography revealed an acute subdural hematoma with marked midline shift. Emergency craniotomy and hematoma evacuation were performed. Case 2 : A 61-year-old man, who had previously undergone ventriculoperitoneal shunting for normal pressure hydrocephalus after subarachnoid hemorrhage, fell to the floor during gait training. Computed tomography demonstrated a thin subdural hematoma, thus the pressure-programmable valve was adjusted to a higher pressure. However, the hematoma continued to enlarge and his level of consciousness deteriorated. Consequently, shunt ligation and irrigation of the chronic subdural hematoma were performed 6 days after the head trauma. Brain atrophy and a lowering of the intracranial pressure, which are both shunt-related complications, may have contributed to these patient's subdural hematomas forming after such relatively minor head traumas. In conclusion, rehabilitation physicians treating shunted patients must be aware of the possibility of a catastrophic intracranial hemorrhage following minor head trauma and of the various treatment-related difficulties arising in such a scenario including exacerbation of hydrocephalus, meningitis, and rebleeding.

Background/Aims: Covered self-expandable metallic stents (cSEMS) have become popular for endoscopic ultrasound-guided hepaticogastrostomy with transmural stenting (EUS-HGS). We compared the time to recurrent biliary obstruction (TRBO), complications, and reintervention rates between EUS-HGS using plastic stent (PS) and cSEMS in patients with unresectable malignancies at multicenter institutions in Japan. Methods: Patients with unresectable malignant biliary obstruction who underwent EUS-HGS between April 2015 and July 2020 at any of the six participating facilities were enrolled. Primary endpoint: TRBO; secondary endpoints: rate of complications other than recurrent biliary obstruction and technical success rate of reintervention were evaluated. Results: PS and cSEMS were used for EUS-HGS in 109 and 43 patients, respectively. The TRBO was significantly longer in the cSEMS group than in the PS group (646 vs. 202 days). Multivariate analysis identified two independent factors associated with a favorable TRBO: combined EUS-guided antegrade stenting with EUS-HGS and the use of cSEMS. No significant difference was observed in the rate of complications other than recurrent biliary obstruction between the two groups. The technical success rate of reintervention was 85.7% for PS and 100% for cSEMS (p=0.309). Conclusions cSEMS might be a better option for EUS-HGS in patients with unresectable malignancies, given the longer TRBO.

Objective: Direct oral anticoagulants (DOACs) are increasingly being used for the treatment of cancer-associated venous thromboembolism (CAT). However, there is limited evidence of the efficacy of DOACs for the treatment of gynecological CAT. Thus, this study aimed to investigate the efficacy and safety of edoxaban for the treatment of gynecological CAT using Japanese real-world data. Methods: We reviewed the medical records of patients with 371 gynecological cancer who received edoxaban or vitamin K antagonist (VKA) between January 2011 and December 2018. Results: Altogether, 211 and 160 patients were treated with edoxaban and VKA, respectively. Fourteen patients (6.8%) in the edoxaban group and 22 (13.8%) in the VKA group showed recurrence of venous thromboembolism (VTE). Cumulative VTE recurrence was not significantly different between the 2 groups (p=0.340). Adverse events occurred in 15 (7.1%) and 11 (6.9%) patients in the edoxaban and VKA groups, respectively (p=0.697). Subgroup analysis of the edoxaban and VKA groups according to different tumor types, including ovarian, endometrial, and cervical cancer, showed equivalent outcomes in terms of VTE recurrence and adverse events. Patients without pulmonary embolism (PE) were mostly omitted from initial unfractionated heparin (UFH) therapy prior to administration of edoxaban. However, this did not increase the recurrence of VTE. Conclusion This study confirmed that edoxaban is effective and safe for the treatment of gynecological CAT. This finding was consistent for different types of gynecological cancer. Additionally, initial UFH therapy prior to the administration of edoxaban may be unnecessary for patients without PE.