Pancreatic cancer is the fifth leading cause of cancer-related death in Japan. Surgical treatment is the effective way to achieve a long survival. Because of the development of surgical procedure and perioperative management, pancreatic surgery becomes safer. However, it still includes a certain number of morbidities and mortalities. It is important to perform safe operation for long survival. We herein introduce our operative procedure for pancreatic surgery including pancreaticoduodenectomy (PD) and distal pancreatectomy. In patients undergoing PD, leakage from the pancreatic anastomosis remains an important cause of morbidity and contributes to prolonged hospitalization and mortality. Recently, a new end-to-end pancreatojejunostomy technique without the use of any stitches through the pancreatic texture or pancreatic duct has been developed. In this novel anastomosis technique, the pancreatic stump is first sunk into deeply and tightened with a purse string in the bowel serosa. We modified this method in an end-to-side manner to complete the insertion of the pancreatic stump into the jejunum, independent of the size of the pancreas or the jejunum. Since April 2013, we have performed this new anastomosis technique in 36 patients. The breakdown of preoperative diagnosis of 36 patients were 13 pancreatic cancers, 8 extrahepatic bile duct cancers, 7 intraductal papillary mucinous neoplasms and so on. Of 36 PD, 32 were subtotal stomach preserving PD (SSPPD), and the rest were SSPPD combined with left hemihepatectomy or distal pancreatectomy, and middle pancreatectomy. The concentration of amylase in discharged fluid through an abdominal drain decreased day by day. According to the ISGPF definition, pancreatic fistula (PF) was observed in 4 patients (11%). Of 4, only 1 case had grade C PF. This case had a hemorrhage from pancreatic cut end. This occurred probably because the pancreatic cut end was not compressed by the intestinal wall with this technique. This case had reoperation and the hemostasis of pancreatic cut end was secured. The other severe complications were not observed. This new method can be performed safely and is expected to reduce the occurrence of leakage from PD. The development of PF following distal pancreatectomy is an unsolved problem. We introduce a simple technique, the parallel suturing technique, which prevents severe PF by hand-sewn closure of the pancreatic stump. After standard distal pancreatectomy in the described cases, the main pancreatic duct was secured. The stump of the pancreatic remnant was closed with three nonabsorbable monofilament sutures. The three sutures were positioned about 3 mm proximal to the cut end of the pancreas and tied parallel to the pancreatic stump. Ascites fluid was collected through a drain tube, and its concentration of amylase was measured on days 1, 2, 3, and 4 postoperatively. PF was diagnosed according to the ISGPF classification. On postoperative day 4, three patients were categorized as having grade A PF, six were diagnosed with no PF, and the drain tubes of the remaining three were removed on day 3. This simple technique may effectively lighten the severity of PF following distal pancreatectomy. It may have a particular advantage in patients with a wide pancreatic stump.

Neoadjuvant chemotherapyeoadjuvant chemoradiotherapy (NAC/NACRT) can be performed in patients with pancreatic cancer to improve survival. We aimed to clarify the clinical outcomes of biliary drainage with a metal stent (MS) or a plastic stent (PS) during NAC/NACRT. Between October 2013 and April 2016, 96 patients with pancreatic cancer were registered for NAC/NACRT. Of these, 29 patients who underwent biliary drainage with MS or PS before NAC/NACRT and a subsequent pancreatoduodenectomy were retrospectively analyzed with regard to patient characteristics, preoperative recurrent biliary obstruction rate, NAC/NACRT delay or discontinuation rate, and operative characteristics. The median age of the patients was 67 years. NAC and NACRT were performed in 14 and 15 patients, respectively, and MS and PS were used in 17 and 12 patients, respectively. Recurrent biliary obstruction occurred in 6% and 83% of the patients in the MS and PS groups, respectively (p<0.001). NAC/NACRT delay was observed in 35% and 50% of the patients in the MS and PS groups, respectively (p=0.680). NAC/NACRT discontinuation was observed in 12% and 17% of the patients in the MS and PS groups, respectively (p=1.000). The operative time in the MS group tended to be longer than that in the PS group (625 minutes vs 497 minutes, p=0.051), and the operative blood loss volumes and postoperative adverse event rates were not different between the two groups. MS was better than PS from the viewpoint of preventing recurrent biliary obstruction, although MS was similar to PS with regards to perioperative outcomes.

Objective: Risk factors for hypermagnesemia due to magnesium oxide (MgO) include advanced age, decreased renal function, and long-term administration; however, no study has evaluated patients that present all of these factors. This study was aimed to evaluate the safety of long-term MgO administration in elderly patients with impaired renal function.Methods: We investigated changes in serum Mg in patients aged 65 years or older, who had been taking oral MgO and presenting a glomerular filtration rate (eGFR) ＜60 mL/min/1.73 m2 for 6 months or longer.Results: Thirty patients were surveyed. Their median age was 81 years (range, 68-92). No significant change in patient background was observed before and after initiating MgO administration, with no change in serum Mg detected. Furthermore, the oral dose of MgO was divided into groups taking ＜1,000 mg and ≥ 1,000 mg; no change in serum Mg was observed in either group. Based on renal function, the analysis was divided into a mildly decreased group (60＞ eGFR ≥ 45) and a moderately to severely decreased group (45＞ eGFR ≥ 15), and no change in serum Mg was observed in either group.Conclusions: We targeted elderly patients with renal dysfunction who were taking long-term MgO, a known risk factor for hypermagnesemia, indicating that MgO can be safely continued.

We evaluated the role of pharmacists in an interdisciplinary pain center using text mining analysis. We investigated 28 patients who visited an interdisciplinary pain center from May 2014 to July 2015. All patients were interviewed by a pharmacist. Further, we performed morphological analysis of medical records; classification of appearing words into “medicines/side effects,” “diagnosis/disease name,” “pain site,” “pain characteristics/concomitant symptoms,” “life/environment,” and “mental”; and correspondence analysis. The frequently appearing words “pain characteristics/concomitant symptoms” and “medicines/side effects” were used by 47.2% doctors and 35.3% pharmacists, respectively. In the correspondence analysis, doctors frequently referred to “pain characteristics/concomitant symptoms,” pharmacists frequently referred to “medicines/side effects,” and nurses frequently referred to “life/environment” and “pain site.” The fact that the three occupations used distinguishing phrases suggests that each is specialized in a distinct area. At an interdisciplinary pain center, we interviewed a nurse, a pharmacist, and a doctor, and shared information from various angles. The pharmacist focused on listening to the “medicines/side effects,” which is information related to his profession. Pharmacists contribute to medical care by recording information in medical records and sharing the information with other occupations. It is necessary to continue to provide information related to our specialized profession, respect each other, and provide high-quality medical care.

Distigmine has reversible and persistent cholinesterase (ChE) antagonism, and is used for the dysuria due to low activity bladders such as the neurogenic bladder dysfunction widely postoperatively, but fatal cases were reported by cholinergic syndrome. Therefore a dose was limited to 5mg only for adaptation of “the dysuria due to hypotonic bladder such as after surgery and the neurogenic bladder dysfunction” in March, 2010. In the current study, we examined a ministerial policy in the package insert revision using Japanese Adverse Drug Event Report database (JADER). Using a side effect report registered with JADER from January, 2004 to June, 2016, we calculated Reporting Odds Ratio (ROR) which was the index of the safe signal of the medical supplies adverse event and we compared number of reports and ROR of the cholinergic syndrome by the distigmine in approximately the measure in March, 2010 and evaluated it. The number of reports of the cholinergic syndrome by the distigmine was 138 cases before March 2010 and 65 cases after March 2010. After a measure, the number of reports decreased. The possibility that the package insert revision of the distigmine contributed to a decrease in cholinergic syndrome onset was suggested. Whereas monitoring careful sequentially needs the onset of the cholinergic syndrome in constant frequency to be found.