Studies have shown that postoperative disseminated intravascular coagulopathy (DIC) occurs in some patients with cardiac disease, acute aortic dissection, and ruptured abdominal aortic aneurysm. The specific pathophysiology of DIC in these settings are related to low cardiac function, shock, infection and sepsis as well as activation of coagulation cascade in the aneurysm sac or dissected aorta. A soluble form of recombinant human thrombomodulin (rhsTM) was approved in 2008 for the treatment of DIC. This report describes the safety and efficacy of rhsTM for the treatment of DIC in patients with cardiovascular disease operated in our department. Between October 2010 and March 2012, 35 patients with postoperative DIC were treated with rhsTM. Diagnosis of DIC was based on the diagnostic criteria for DIC of the Japanese Association for Acute Medicine (JAAM). During the first 6 months of the study period, after a diagnosis of DIC was made, the patients were treated with gabexate mesilate and antithrombin III, and if patients showed no improvement with conventional treatment, they received rhsTM for 6 days. During the last 10 months of the study period, patients received rhsTM soon after a diagnosis of DIC was made. Twenty seven patients survived for 28 days after rhsTM treatment, and the mortality rate was 22.9% (8/35). Patients who survived showed improvement in acute phase DIC scores, FDP levels, D-Dimer, fibrinogen and platelet counts during rhsTM treatment, but no improvement was observed in patients who died. No serious adverse events were found up to 28 days after the start of rhsTM administration. In conclusion, this study showed no adverse events of rhsTM, and further studies are needed to confirm that rhsTM administration is an effective therapeutic modality in the management of DIC after cardiovascular surgery.

An isolated quadricuspid aortic valve is an extremely rare congenital anomaly and there have been few surgical case reports published. A 47-year-old man with untreated diabetes mellitus was admitted to our institution because of fever and dyspnea. Transesophageal echocardiography showed severe aortic valve regurgitation and a quadricuspid valve with vegetations. Blood culture revealed Streptococcus agalactiae. Despite administration of antibiotics and treatment of his heart failure, the infection and heart failure were not controlled. Therefore, we performed aortic valve replacement in the presence of active infective endocarditis. The aortic valve had 2 equal-sized larger cusps and 2 equal-sized smaller cusps. There were vegetations on each cusp and an annular abscess was detected. The resection site of the abscess was reinforced with an autologous pericardial patch, and the aortic valve was replaced using a 21-mm SJM valve. His postoperative course was uneventful and he was discharged after recovery.

Endoscopic transpapillary biliary drainage is the current standard of care for unresectable hilar malignant biliary obstruction (MBO) and bilateral metal stent placement is shown to have longer patency. However, technical and clinical failure is possible and percutaneous transhepatic biliary drainage (PTBD) is sometimes necessary. Endoscopic ultrasound-guided biliary drainage (EUS-BD) is increasingly being reported as an alternative rescue procedure to PTBD. EUS-BD has a potential advantage of not traversing the biliary stricture and internal drainage can be completed in a single session. Some approaches to bilateral biliary drainage for hilar MBO under EUS-guidance include a bridging method, hepaticoduodenostomy, and a combination of EUS-BD and transpapillary biliary drainage. The aim of this review is to summarize data on EUS-BD for hilar MBO and to clarify its advantages over the conventional approaches such as endoscopic transpapillary biliary drainage and PTBD.
Constriction, Pathologic ; Drainage ; Endosonography ; Methods ; Standard of Care ; Stents

Although endoscopic retrograde cholangiopancreatography (ERCP) is the first-line treatment for benign biliary diseases, this procedure is technically difficult in some conditions such as a surgically altered anatomy and gastric outlet obstruction. After a failed ERCP, a surgical or a percutaneous approach is selected as a rescue procedure; however, various endoscopic ultrasound (EUS)-guided interventions are increasingly utilized in pancreatobiliary diseases, including EUS-guided rendezvous for failed biliary cannulation, EUS-guided antegrade treatment for stone management, and EUS-guided hepaticogastrostomy for anastomotic strictures in patients with a surgically altered anatomy. There are some technical hurdles in EUS-guided interventions for benign biliary diseases owing to the difficulty in puncturing a relatively small bile duct and in subsequent guidewire manipulation, as well as the lack of dedicated devices. A recent major advancement in this field is the introduction of a 2-step approach, in which EUS-guided drainage is placed in the first session and antegrade treatment is performed in subsequent sessions. This approach allows the use of various techniques such as mechanical lithotripsy and cholangioscopy without a risk of bile leak. In summary, EUS-guided interventions are among the treatment options for benign biliary diseases; however, standardization of the procedure and development of a treatment algorithm are needed.
Bile ; Bile Ducts ; Catheterization ; Cholangiopancreatography, Endoscopic Retrograde ; Constriction, Pathologic ; Drainage ; Gastric Outlet Obstruction ; Humans ; Lithotripsy ; Ultrasonography

Chemotherapy is indispensable for the treatment of advanced biliary tract cancer. Recently, reports regarding first-line chemotherapy have increased, and first-line chemotherapy treatment has become gradually more sophisticated. Gemcitabine and cisplatin combination therapy (or gemcitabine and oxaliplatin combination therapy) have become the standard of care for advanced biliary tract cancer. Oral fluoropyrimidines have also been shown to have good antitumor effects. Gemcitabine, platinum compounds, and oral fluoropyrimidines are now considered key drugs for the treatment of advanced biliary tract cancer. Several clinical trials using molecular targeted agents are also ongoing. Combination therapy using cytotoxic agents and molecular-targeted agents has been evaluated widely. However, reports regarding second-line chemotherapy remain limited, and it has not yet been clarified whether second-line chemotherapy can improve the prognosis of advanced biliary tract cancer. Thus, there is an urgent need to establish second-line standard chemotherapy treatment for advanced biliary tract cancer. Several problems exist when assessing the results of previous reports concerning advanced biliary tract cancer. In the present review, the current status of the treatment of advanced biliary tract cancer is summarized, and several associated problems are indicated. These problems should be solved to achieve more sophisticated treatment of advanced biliary tract cancer.
Antineoplastic Combined Chemotherapy Protocols/adverse effects/*therapeutic use ; Biliary Tract Neoplasms/*drug therapy/mortality/pathology ; Disease Progression ; Disease-Free Survival ; Humans ; Salvage Therapy ; Time Factors ; Treatment Outcome

BACKGROUND/AIMS: Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is useful for the pathological diagnosis of pancreatic masses, but patients are susceptible to severe bleeding and perforation. Because the incidence and severity of these complications have not been fully evaluated. METHODS: We aimed to evaluate severe bleeding and perforation after EUS-FNA for pancreatic masses using large-scale data derived from a Japanese nationwide administrative database. RESULTS: In total, 3,090 consecutive patients from 212 low- to high-volume hospitals were analyzed. Severe bleeding requiring transfusion or endoscopic treatment occurred in seven patients (0.23%), and no perforation was observed. No patient mortality was recorded within 30 days of EUS-FNA. The rate of severe bleeding in low-volume hospitals was significantly higher than that in medium- and high-volume hospitals (0.48% vs 0.10%, p=0.045). CONCLUSIONS: Severe bleeding and perforation following EUS-FNA for pancreatic masses are rare, and the procedure is safe.
Blood Transfusion/statistics & numerical data ; Endoscopic Ultrasound-Guided Fine Needle Aspiration/*adverse effects ; Female ; Fibrinolytic Agents/adverse effects ; Gastrointestinal Hemorrhage/*etiology ; Humans ; Intestinal Perforation/*etiology ; Male ; Middle Aged ; Pancreatic Neoplasms/*pathology

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

Percutaneous transhepatic biliary drainage (PTBD) is an established procedure for biliary obstruction. However, duodenobiliary or jejunobiliary reflux of the intestinal contents through a PTBD catheter sometimes causes recurrent catheter obstruction or cholangitis. A 64-year-old female patient with a history of choledochojejunostomy was referred to our department with acute cholangitis due to choledochojejunal anastomotic obstruction. Emergent PTBD was performed, but frequent obstructions of the catheter due to the reflux of intestinal contents complicated the post-PTBD course. We therefore introduced a catheter with an antireflux mechanism to prevent jejunobiliary reflux. A commercially available catheter was modified; side holes were made at 1 cm and 5 to 10 cm (1 cm apart) from the tip of the catheter, and the catheter was ligated with a nylon thread just proximal to the first side hole. Using this novel "antireflux PTBD technique," jejunobiliary reflux was prevented successfully, resulting in a longer patency of the catheter.
Catheter Obstruction ; Catheters ; Cholangitis ; Choledochostomy ; Dioxolanes ; Drainage ; Female ; Fluorocarbons ; Gastrointestinal Contents ; Humans ; Nylons

  In order to intervene in the management of pain of cancer from an early stage. Our palliative care team (PCT), including pharmacists, makes the ward rounds (screening rounds) of the patients receiving opioids at our hospital. The purpose of this study was to analyze the effects of screening rounds activity by the PCT and its current problems, and to explore how to resolve the problems. We retrospectively studied the records of 196 patients who had receivede interventions by the PCT, with regard to intervention status and prescription proposal (228 subjects) about drug therapy by us. Study groups were as follows: 103 patients to whom interventions were deliveed at the request of medical doctors (intervention request group) and 93 patients who had interventions by the PCT after PCT-screening rounds (screening group). PCT-screening rounds caused to increase the number of interventions by the PCT. After PCT-screening rounds, the cases of intervention started by the request of medical doctors, who had given no heed to PCT intervention, also increased in numher. In this study, some problems with palliative intervention were also brought to light. Even in the screening group where the PCT largely intervened, 33% of prescription proposal by the PCT was ignored. This problem may be, at least in part, due to inadequate communication between PCT and ward staff through an electronic medical recording card, leading to poor relationship between PCT and ward staff. In the future, the PCT needs to work cooperatively with ward staff through direct communication such as medical conference to perform better intervention.

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.