A 61-year-old man with obstructive jaundice caused by distal bile duct cancer recurrence was admitted to our hospital. As treatment, we performed endoscopic ultrasound-guided hepaticogastrostomy and placed a self-expanding metal stent. Computed tomography was performed immediately after the procedure to ensure proper stent placement. Although repeat imaging the next day revealed that the stent on the hepaticogastrostomy route had shortened, the stent on the gastric side maintained sufficient length. However, 11 days after the procedure, the stomach-to-liver distance had increased, and the stent on the gastric side was significantly shortened. Endoscopic imaging revealed that the stent had almost migrated, and we added a fully covered self-expanding metal stent into the previous metallic stent via the hepaticogastrostomy route. The patient was discharged 19 days after the initial procedure without complications. Computed tomography performed 40 days after the hepaticogastrostomy revealed that the initial stent had migrated into the abdominal cavity, but the second stent was in an appropriate position. In conclusion, repeated monitoring by computed tomography after hepaticogastrostomy procedure may be an effective method for preventing stent migration in high-risk cases.

A 61-year-old man with obstructive jaundice caused by distal bile duct cancer recurrence was admitted to our hospital. As treatment, we performed endoscopic ultrasound-guided hepaticogastrostomy and placed a self-expanding metal stent. Computed tomography was performed immediately after the procedure to ensure proper stent placement. Although repeat imaging the next day revealed that the stent on the hepaticogastrostomy route had shortened, the stent on the gastric side maintained sufficient length. However, 11 days after the procedure, the stomach-to-liver distance had increased, and the stent on the gastric side was significantly shortened. Endoscopic imaging revealed that the stent had almost migrated, and we added a fully covered self-expanding metal stent into the previous metallic stent via the hepaticogastrostomy route. The patient was discharged 19 days after the initial procedure without complications. Computed tomography performed 40 days after the hepaticogastrostomy revealed that the initial stent had migrated into the abdominal cavity, but the second stent was in an appropriate position. In conclusion, repeated monitoring by computed tomography after hepaticogastrostomy procedure may be an effective method for preventing stent migration in high-risk cases.

A 61-year-old man with obstructive jaundice caused by distal bile duct cancer recurrence was admitted to our hospital. As treatment, we performed endoscopic ultrasound-guided hepaticogastrostomy and placed a self-expanding metal stent. Computed tomography was performed immediately after the procedure to ensure proper stent placement. Although repeat imaging the next day revealed that the stent on the hepaticogastrostomy route had shortened, the stent on the gastric side maintained sufficient length. However, 11 days after the procedure, the stomach-to-liver distance had increased, and the stent on the gastric side was significantly shortened. Endoscopic imaging revealed that the stent had almost migrated, and we added a fully covered self-expanding metal stent into the previous metallic stent via the hepaticogastrostomy route. The patient was discharged 19 days after the initial procedure without complications. Computed tomography performed 40 days after the hepaticogastrostomy revealed that the initial stent had migrated into the abdominal cavity, but the second stent was in an appropriate position. In conclusion, repeated monitoring by computed tomography after hepaticogastrostomy procedure may be an effective method for preventing stent migration in high-risk cases.

Purpose: Type 4 gastric cancer (GC) has a very poor prognosis even after curative resection, and the survival benefit of splenectomy for splenic hilar lymph node (LN; #10) dissection in type 4 GC remains equivocal. This study aimed to clarify the clinical significance of splenectomy for #10 dissection in patients with type 4 GC. Materials and Methods: The data of a total of 56 patients with type 4 GC who underwent total gastrectomy with splenectomy were retrospectively analyzed. Postoperative morbidity, state of LN metastasis, survival outcomes, and therapeutic value index (TVI) of each LN station were evaluated. TVI was calculated by multiplying the incidence of LN metastasis at each nodal station and the 5-year overall survival (OS) of patients who had metastasis to each node. Results: Overall, the postoperative morbidity rate was 28.6%, and the incidence of #10 metastasis in the patients was 28.6%. The 5-year OS rate for all patients was 29.9%, and most patients developed peritoneal recurrence. Moreover, the 5-year OS rates with and without #10 metastasis were 6.7% and 39.1% (median survival time, 20.4 vs. 46.0 months; P=0.006). The TVI of #10 was as low as 1.92. Conclusions The clinical significance of splenectomy in the dissection of #10 for type 4 GC is limited and splenectomy for splenic hilar dissection alone should be omitted.

A woman in her 60s was being treated for diabetes and hypertension but had impaired activities of daily living (ADL) due to severe obesity (150 kg). She was transported to the emergency department because of disturbance of consciousness in August 201X. Imaging findings showed decreased permeability of the whole right lung field. She was intubated and started on ceftriaxone plus levofloxacin for severe infection with respiratory failure. Erysipelothrix rhusiopathiae was detected in blood cultures, leading to a diagnosis of sepsis due to a large pressure ulcer on the posterior aspect of the thigh. We switched levofloxacin to clindamycin and continued medical treatment, and she was extubated on the 10th day of illness. However, type 2 respiratory failure was prolonged because of alveolar hypoventilation due to obesity and she required noninvasive positive pressure ventilation. Also, she had difficulty getting out of bed due to obesity, disuse syndrome, and pressure ulcer. Cooperation among staff from many professions, including respiratory nursing, intensive care nursing, wound, ostomy and continence nursing, physical therapy, and nutrition management, led to improvement of ADL and weight loss (to 109 kg), allowing her to be transferred out of the intensive care unit.