At age 44, the live birth rate per in vitro fertilization (IVF) embryo transfer is low, and natural pregnancy is very rare. Here, we report a case of an older infertile patient who gave up on pregnancy after repeated unsuccessful IVF attempts, developed diarrhea, and was administered shinbuto and ninjinto, which are similar to the prescription of bukuryoshigyakuto. She subsequently conceived naturally, resulting in a live birth. The patient was 44 years old and nulligravid. She had undergone IVF eight times, but had never achieved pregnancy. After giving up on pregnancy, she developed diarrhea and other symptoms. With the administration of shinbuto extract granules (7.5 g/day) and ninjinto extract granules (7.5 g/day), her diarrhea completely resolved, and mental symptoms such as irritability and depression also improved. Her menstrual cycle normalized to a 28-day cycle, and natural pregnancy was achieved. The pregnancy progressed smoothly, and at 38 weeks of pregnancy, a cesarean section was performed due to the indication of rigidity of the soft birth canal, resulting in a live birth at age 45. These results suggest that shinbuto and ninjinto, which are similar to the prescription of bukuryoshigyakuto, may be effective in treating the severe fatigue and mental stress experienced after abandoning pregnancy attempts.

Background/Aims: Endoscopic self-expandable metal stent (SEMS) placement is currently the standard technique for treating unresectable malignant distal biliary obstructions (MDBO). Therefore, covered SEMS with longer stent patency and fewer migrations are required. This study aimed to assess the clinical performance of a novel, fully covered SEMS for unresectable MDBO. Methods: This was a multicenter single-arm prospective study. The primary outcome was a non-obstruction rate at 6 months. The secondary outcomes were overall survival (OS), recurrent biliary obstruction (RBO), time to RBO (TRBO), technical and clinical success, and adverse events. Results: A total of 73 patients were enrolled in this study. The non-obstruction rate at 6 months was 61%. The median OS and TRBO were 233 and 216 days, respectively. The technical and clinical success rates were 100% and 97%, respectively. Furthermore, the rate of occurrence of RBO and adverse events was 49% and 21%, respectively. The length of bile duct stenosis (<2.2 cm) was the only significant risk factor for stent migration. Conclusions The non-obstruction rate of a novel fully covered SEMS for MDBO is comparable to that reported earlier but shorter than expected. Short bile duct stenosis is a significant risk factor for stent migration.

Afferent loop syndrome (ALS) is a mechanical obstruction of the afferent limbs after gastrectomy with gastrojejunostomy reconstruction. Patients with cancer recurrence require immediate and less invasive treatment because of their poor condition. Percutaneous transhepatic/transluminal drainage (PTD) and endoscopic enteral stenting offer reasonable palliative treatment for malignant ALS but are not fully satisfactory in terms of patient quality of life (QoL) and stent patency. Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) using a lumen-apposing metal stent may address these shortcomings. Clinical data from 11 reports showed that all patients who had undergone EUS-GE had positive technical and clinical outcomes. The adverse event rate was 11.4%, including only mild or moderate abdominal pain, with no severe adverse events. Indirect comparative studies indicated that patients who had undergone EUS-GE had a significantly superior QoL, a higher clinical success rate, and a lower reintervention rate than those who had undergone PTD or endoscopic enteral stenting. Although the evidence is limited, EUS-GE may be considered as a first-line treatment for malignant ALS because it has better clinical outcomes than other less invasive treatments, such as PTD or endoscopic enteral stenting. Further prospective randomized control trials are necessary to establish EUS-GE as a standard treatment for ALS.

In this study, we assessed a series of our cases in which endoscopic self-expandable metal stents (SEMSs) were used to treat malignant afferent loop obstruction (ALO) that arose after pancreaticoduodenectomy (PD). We retrospectively examined the records of 7 patients who underwent endoscopic SEMS placement for malignant ALO following PD. Clinical success was achieved in all cases. The median procedure time was 30 min (range, 15–50 min). There were no cases of stent occlusion, and no procedure-related adverse events were encountered. All patients died of their primary disease, and the median overall survival period was 155 days (range, 96–374 days). A re-intervention involving endoscopic ultrasound-guided hepaticogastrostomy combined with antegrade stenting was performed for obstructive jaundice and acute cholangitis in 1 case. In conclusion, endoscopic SEMS placement may be an effective and safe treatment for malignant ALO that arises after PD.

To evaluate a comparison for endovascular repair (EVAR) versus open repair (OR) for the treatment of abdominal aortic aneurysm (AAA). Data of all patients with infrarenal AAA treated electively, both with OR (107 cases) and EVAR (24 cases), at our institute between January 1999 and March 2004 were retrospectively reviewed. No difference was found between the 2 groups for sex, age, and AAA size. Cases of chronic obstructive pulmonary disease (20.8% vs 6.5%, p<0.04) and frequencies of laparotomy (25% vs 2.8%, p<0.001) were significantly more in the EVAR group than the OR group. In the initial results, deployment of the stent grafts was successful in all cases and complete thrombosis of the aneurysm was achieved in 21 cases (87.5%). One graft occlusion and a wound infection occurred in the EVAR group. OR was successfully performed in all cases. These were 6 cases of paralytic ileus, 1 of re-operation for hemorrhage, 1 of respiratory failure, and 1 of ischemic colitis in the OR group. One hospital death occurred in each group. Mean blood transfusion (0ml vs 238±345ml) and operation time (131±53min vs 250±76min) were significantly less in the EVAR group than the OR group. In the long term results, the cumulative survival rate was 88.0±6.5% at 1 and 2 years, 80.6±9.2% at 3 years in the EVAR group; 99.0±0.9% at 1 year, 94.1±2.6% at 2 years, 87.7±3.9% at 3 years in the OR group, with no difference between the 2 groups regarding survival rate. Four new endoleak and 3 graft infections were encountered in the EVAR group. Freedom from stent graft-related complications was 81.3±8.5% at 1 year, 61.4±11.9% at 2 years, 47.8±12.6% at 3 years in the EVAR group, but 100% at 1, 2 and 3 years in the OR group. Freedom from procedure-related complications in the EVAR group was significantly lower than that in OR group. In the long term results, EVAR was associated with more procedure-related complications. This finding may justify reappraisal of currently accepted EVAR for AAA management strategies.