A 64-year-old man had been followed up under the diagnosis of chronic idiopathic thrombocytopenic purpura (ITP), and infrarenal abdominal aortic aneurysm with a maximum diameter of 85mm since August in 1998. He suffered from sudden abdominal pain in August 1999, and as impending ruptured abdominal aortic aneurysm was diagnosed based on the CT findings showing left retroperitoneal hematoma and leakage of contrast medium from the aneurysm. We decided to perform elective surgery. Since he was not in shock and had a low platelet count (2.5×10⁴/mm³), medical treatment was indicated for hypertension and thrombocytopenia prior to surgery. High-dose immunogloblin infusion and platelet transfusion was begun two days before the operation and increased the platelet count to 6.1×10⁴/mm³, resulting in a successful elective operation.

Chronic disseminated intravascular coagulation (DIC) complicates 5.7% of thoracic aortic aneurysm. DIC with thoracic aortic aneurysm is characterized by hyperfibrinolysis, but usually shows a stable condition in a state of compensated non-overt DIC with limited hemorrhagic symptoms. However, in some cases, hemorrhage caused by external factors may induce uncompensated overt DIC and lead to serious hemorrhagic tendencies. In the present study, we report a patient with a thoracic aortic aneurysm complicated by DIC who exhibited marked hemorrhagic tendencies. DIC remarkably improved following administration of recombinant human soluble thrombomodulin.

A 71-year-old woman underwent VVI pacemaker implantation for complete atrioventricular block 38 years ago at the cardiovascular department of another hospital. In the course of observation, she developed atrial fibrillation. One year ago, she was admitted to hospital for aggravated congestive heart failure and was subsequently treated by a cardiovascular practitioner. She had persistent shortness of breath and lower leg edema, which were treated with increasing doses of oral diuretics. Due to poor treatment outcomes, she was referred to our hospital. Her echocardiography results suggested severe tricuspid regurgitation (TR) and moderate mitral regurgitation. She was also found to have impaired renal function and liver cirrhosis (Stage A of the Child classification), and was admitted. In addition, she had undernutrition with suspected cardiac cachexia. She was first treated by inotrope infusion and central venous hyperalimentation before tricuspid annuloplasty and mitral valvuloplasty were performed. Even though her postoperative management was complicated, she was discharged from our hospital. The conservative treatment with the increased dose of the diuretic for TR-associated right heart failure was prolonged in this patient, leading to severe right heart failure and aggravation of impaired renal function or congestive liver-associated hepatic disorders. Eventually, the patient required operative intervention; however, postoperative management is usually complex, and the operation result may be poor in such patients. We suggest that, from the time when right heart failure can be managed with relatively small doses of diuretics, surgeons should be involved in the care of patients with severe TR who do not require left heart valvular surgery, and should discuss the necessity of surgery earlier than the relevant guidelines suggest, depending on the patient's condition.

BACKGROUND/AIMS: This study examined the accuracy of endoscopic evaluation for determining the Helicobacter pylori infection status in patients with mild atrophy who might not exhibit characteristic endoscopic findings. METHODS: Forty endoscopists determined the H. pylori infection status of 50 randomly presented H. pylori-positive and H. pylori-negative cases on the basis of a list of established findings. RESULTS: The median clinical endoscopy experience was 7 years (range, 1–35 years), including 22 board-certified endoscopists (55%) of the Japan Gastroenterological Endoscopy Society. The mean accuracy rate of endoscopic diagnosis was 67% and was unrelated to experience status (experienced vs. trainee: 69% vs. 65%, p=0.089) and total years of experience (R 2 =0.022). The most frequently selected endoscopic findings were regular arrangement of collecting venules (59%), atrophy (45%), and red streak (22%), which had fair accuracy rates of 67%, 65%, and 73%, respectively. By contrast, the accuracy rates of nodularity (89%) and mucosal swelling (77%) were highest. The 20 endoscopists who more frequently identified these findings diagnosed H. pylori infection significantly more accurately than did the other endoscopists (71% vs. 64%, p=0.008). CONCLUSIONS: Careful attention to nodularity and mucosal swelling in patients with mild atrophy may enhance diagnosis, enable prompt treatment, and avoid possible long-term carcinogenesis.
Atrophy ; Carcinogenesis ; Diagnosis* ; Endoscopy ; Gastritis, Atrophic* ; Helicobacter pylori* ; Helicobacter* ; Humans ; Japan ; Venules

Afferent loop syndrome is often difficult to resolve. Among patients with afferent loop syndrome whose data were extracted from databases, 5 patients in whom metal stent placement was attempted were included and evaluated in this study. The procedure was technically successful without any adverse events in all patients. Metal stent(s) was placed with an endoscope in the through-the-scope manner in 4 patients and via a percutaneous route in 1 patient. Obvious clinical efficacy was observed in all patients. Adverse events related to the procedure and stent occlusion during the follow-up period were not observed. Metal stent placement for malignant obstruction of the afferent loop was found to be safe and feasible.
Afferent Loop Syndrome ; Endoscopes ; Follow-Up Studies ; Humans ; Intestinal Obstruction ; Palliative Care ; Self Expandable Metallic Stents ; Stents* ; Treatment Outcome

STUDY DESIGN: Animal study. PURPOSE: To review the present warning point criteria of the compound muscle action potential (CMAP) and investigate new criteria for spinal surgery safety using an animal model. OVERVIEW OF LITERATURE: Little is known about correlation palesis and amplitude of spinal cord monitoring. METHODS: After laminectomy of the tenth thoracic spinal lamina, 2-140 g force was delivered to the spinal cord with a tension gage to create a bilateral contusion injury. The study morphology change of the CMAP wave and locomotor scale were evaluated for one month. RESULTS: Four different types of wave morphology changes were observed: no change, amplitude decrease only, morphology change only, and amplitude and morphology change. Amplitude and morphology changed simultaneously and significantly as the injury force increased (p<0.05) Locomotor scale in the amplitude and morphology group worsened more than the other groups. CONCLUSIONS: Amplitude and morphology change of the CMAP wave exists and could be the key of the alarm point in CMAP.
Action Potentials* ; Animals* ; Contusions ; Gravitation ; Laminectomy ; Models, Animal* ; Spinal Cord

1) Osaka City University Medical School provides basic life support courses in the Skills Simulation Center. Most instructors are members of the Life Support Club, a medical students' extracurricular activity.2) We investigated the numbers and opinions of participants(December 2006 through July 2008). The numbers of trainee and instructors were 1071 and 1223, respectively. The student instructors considered their activities worthwhile.3) The trainees highly appreciated the student instructors and showed that the effectiveness of training was excellent. Our results show that basic life support courses taught by medical students are beneficial for both trainees and student instructors.

Background/Aims: The anastomotic site after distal gastrectomy is the area most affected by duodenogastric reflux. Different reconstruction methods may affect the lesion characteristics and treatment outcomes of remnant gastric cancers at the anastomotic site. We retrospectively investigated the clinicopathologic and endoscopic submucosal dissection outcomes of remnant gastric cancers at the anastomotic site. Methods: We recruited 34 consecutive patients who underwent endoscopic submucosal dissection for remnant gastric cancer at the anastomotic site after distal gastrectomy. Clinicopathology and treatment outcomes were compared between the Billroth II and non-Billroth II groups. Results: The tumor size in the Billroth II group was significantly larger than that in the non-Billroth II group (22 vs. 19 mm; p=0.048). More severe gastritis was detected endoscopically in the Billroth II group (2 vs. 1.33; p=0.0075). Moreover, operation time was longer (238 vs. 121 min; p=0.004) and the frequency of bleeding episodes was higher (7.5 vs. 3.1; p=0.014) in the Billroth II group. Conclusions Compared to remnant gastric cancers in non-Billroth II patients, those in the Billroth II group had larger lesions with a background of severe remnant gastritis. Endoscopic submucosal dissection for remnant gastric cancers in Billroth II patients involved longer operative times and more frequent bleeding episodes than that in patients without Billroth II.

Background/Aims: The aim of this study was to evaluate the safety of sedation with propofol as an alternative to benzodiazepine drugs in outpatient endoscopy. Methods: In this prospective study, examinees who underwent outpatient endoscopy under propofol sedation and submitted a nextday questionnaire with providing informed consent were evaluated. Periprocedural acute responses, late adverse events within 24 hours, and examinee satisfaction were evaluated. Results: Among the 4,122 patients who received propofol in the 17,978 outpatient-based endoscopic examinations performed between November 2016 and March 2018, 2,305 eligible examinees (esophagogastroduodenoscopy for 1,340, endoscopic ultrasonography for 945, and total colonoscopy for 20) were enrolled, and their responses to a questionnaire were analyzed. The mean propofol dose was 69.6±24.4 mg (range, 20–200 mg). Diazepam, midazolam, and/or pentazocine in combination with propofol was administered to 146 examinees. Mild oxygen desaturation was observed in 59 examinees (2.6%); and mild bradycardia, in 2 (0.09%). Other severe reactions or late events did not occur. After eliminating 181 invalid responses, 97.7% (2,065/2,124) of the patients desired propofol sedation in future examinations. Conclusions Propofol sedation was found to be safe—without severe adverse events or accidents—for outpatient endoscopy on the basis of the patients’ next-day self-evaluation. Given the high satisfaction level, propofol sedation might be an ideal tool for painless endoscopic screening.

Background/Aims: The aim of this study was to evaluate the safety of sedation with propofol as an alternative to benzodiazepine drugs in outpatient endoscopy. Methods: In this prospective study, examinees who underwent outpatient endoscopy under propofol sedation and submitted a nextday questionnaire with providing informed consent were evaluated. Periprocedural acute responses, late adverse events within 24 hours, and examinee satisfaction were evaluated. Results: Among the 4,122 patients who received propofol in the 17,978 outpatient-based endoscopic examinations performed between November 2016 and March 2018, 2,305 eligible examinees (esophagogastroduodenoscopy for 1,340, endoscopic ultrasonography for 945, and total colonoscopy for 20) were enrolled, and their responses to a questionnaire were analyzed. The mean propofol dose was 69.6±24.4 mg (range, 20–200 mg). Diazepam, midazolam, and/or pentazocine in combination with propofol was administered to 146 examinees. Mild oxygen desaturation was observed in 59 examinees (2.6%); and mild bradycardia, in 2 (0.09%). Other severe reactions or late events did not occur. After eliminating 181 invalid responses, 97.7% (2,065/2,124) of the patients desired propofol sedation in future examinations. Conclusions Propofol sedation was found to be safe—without severe adverse events or accidents—for outpatient endoscopy on the basis of the patients’ next-day self-evaluation. Given the high satisfaction level, propofol sedation might be an ideal tool for painless endoscopic screening.