We present the case of a 76-year-old man who underwent preoperative endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) for obstructive jaundice caused by pancreatic head cancer. The patient had obstructive jaundice and cholangitis during neoadjuvant chemotherapy. Transpapillary biliary drainage using endoscopic retrograde cholangiopancreatography was attempted; however, it was unsuccessful because of duodenal tumor invasion. Therefore, EUS-HGS was performed. Jaundice and cholangitis improved promptly after EUS-HGS, and stent obstruction and migration were not observed before surgery. The stent was safely removed during surgery, and no postoperative complications occurred. Most studies of EUS-HGS for preoperative biliary drainage have been small and retrospective, and few have examined the safety of intraoperative stent removal. The fistula in our patient was promptly identified and the stent was safely removed despite the relatively limited field of view during robot-assisted laparoscopy.The promising findings of our case report can be used to inform EUS-based surgical strategies for biliary drainage with obstructive jaundice.

We present the case of a 76-year-old man who underwent preoperative endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) for obstructive jaundice caused by pancreatic head cancer. The patient had obstructive jaundice and cholangitis during neoadjuvant chemotherapy. Transpapillary biliary drainage using endoscopic retrograde cholangiopancreatography was attempted; however, it was unsuccessful because of duodenal tumor invasion. Therefore, EUS-HGS was performed. Jaundice and cholangitis improved promptly after EUS-HGS, and stent obstruction and migration were not observed before surgery. The stent was safely removed during surgery, and no postoperative complications occurred. Most studies of EUS-HGS for preoperative biliary drainage have been small and retrospective, and few have examined the safety of intraoperative stent removal. The fistula in our patient was promptly identified and the stent was safely removed despite the relatively limited field of view during robot-assisted laparoscopy.The promising findings of our case report can be used to inform EUS-based surgical strategies for biliary drainage with obstructive jaundice.

We present the case of a 76-year-old man who underwent preoperative endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) for obstructive jaundice caused by pancreatic head cancer. The patient had obstructive jaundice and cholangitis during neoadjuvant chemotherapy. Transpapillary biliary drainage using endoscopic retrograde cholangiopancreatography was attempted; however, it was unsuccessful because of duodenal tumor invasion. Therefore, EUS-HGS was performed. Jaundice and cholangitis improved promptly after EUS-HGS, and stent obstruction and migration were not observed before surgery. The stent was safely removed during surgery, and no postoperative complications occurred. Most studies of EUS-HGS for preoperative biliary drainage have been small and retrospective, and few have examined the safety of intraoperative stent removal. The fistula in our patient was promptly identified and the stent was safely removed despite the relatively limited field of view during robot-assisted laparoscopy.The promising findings of our case report can be used to inform EUS-based surgical strategies for biliary drainage with obstructive jaundice.

[Objective] The purpose of this study was to investigate the effects of acupuncture on exercise-induced prolongation of information processing and decrease in attentional resource allocation, excluding the placebo effect.[Design] Crossover, double-blind randomized controlled trial[Settings] Tokyo Ariake University[Subjects] Fifteen healthy men aged 21.1 ± 0.9 years[Methods] We used a handgrip exercise for exercise loading. The handgrip was maintained for six seconds at an intensity of 40% of the maximal voluntary contraction (MVC), followed by rest for four seconds. This was alternately repeated and continued until the subject was incapable of exerting a grip strength of 40% of the MVC. To induce P300, an auditory oddball paradigm was used, and P300 was measured before and after the handgrip exercise. In the same subjects, thumbtack needle (TN) intervention (TN group) and placebo thumbtack needle (PTN) intervention (PTN group) were performed in random order. TN or PTN was applied to ST36, HT7, and GV14 before the handgrip exercise. After the experiment, we asked the subjects and practitioner about the intervention (TN or PTN). The allocation was conducted by a third party who did not participate in the experiment, and the subjects, practitioner, and measurer completed a series of all the experiment procedures and were blinded to the results.[Outcomes] The indicators for measuring the main outcomes were P300 latency and amplitude. reaction time, and masking were indicators for secondary outcomes. [Results and Conclusion] In the PTN group, P300 latency was increased significantly and P300 amplitude was decreased significantly after the handgrip exercise. In the TN group, no significant changes were observed in P300 latency and amplitude after the handgrip exercise. In both groups, reaction time was considerably slower after the handgrip exercise. The k value indicating the degree of agreement between the actual (genuine or placebo) and guessed intervention assignment was k = -0.06 for the practitioner and k = 0.66 for the subjects. No adverse events were found in this study.[Conclusions] The index changes in the TN and PTN in this study were the same as in our previous studies, and acceptable reproducibility was observed. However, the k values indicated that subject masking was inadequate. In the future, the reliability and validity of PTN must be investigated further.

Purpose: Postoperative pancreatic fistula (POPF) is the most important factor affecting morbidity and mortality after pancreaticoduodenectomy (PD). Patients with a high controlling nutritional status (CONUT) score, which is used to assess nutritional status, are expected to have high morbidity rates. This study aimed to determine the usefulness of the CONUT score. Methods: Data from 97 consecutive cases of PD performed in the Department of Surgery of Iwakuni Clinical Center, from April 2008 to May 2018, were included. Preoperative patient data, including sex, age, and hypertension, and postoperative complication data were collected to analyze pancreatic fistula occurrence. Results: Of the 97 patients, 2 9 patients (29.8%) were diagnosed with POPF ≥ B, with 26 cases (26.8%) classified as grade B and 3 (3.1%) as grade C. The mortality rate was 2.1% (2 of 97). In the univariate analysis, a significant association was observed between POPF and the following factors: body mass index (BMI) ≥ 22 kg/m2, high CONUT score, nonpancreatic carcinoma, and CT attenuation values. In multivariate analysis, BMI ≥ 22 kg/m2 (odds ratio [OR], 6.16; P < 0.001), high CONUT score (OR, 3.77; P = 0.009), nonpancreatic carcinoma (OR, 5.72; P = 0.009), and CT attenuation values (late/early ratio) in the pancreas (OR, 9.07; P = 0.006) were independent risk factors for POPF. Conclusion Patients with a high CONUT score are at high risk of POPF. Further study correlating preoperative nutritional intervention with risk of POPF is necessary.

Introduction: Paroxysmal atrial fibrillation (Paf) occurred in an inpatient who has been prescribed methadone for cancer pain in our palliative care unit, but oral administration of aprindine (antiarrhythmic agent) succeeded in defibrillation and methadone administration could be continued. Case: A 75-year-old man had developed multiple bone metastases after resection of thyroid cancer. Due to refractory cancer pain, switching from oxycodone to methadone was performed. Pain relief was achieved with methadone 40 mg/day and without QT interval prolongation. After methadone administration about 9 months, there suddenly became loss of appetite in the morning of one day. ECG examination revealed Paf onset. Aprindine 20 mg was orally administered for the purpose of defibrillation. After about 2 hours sinus rhythm was gained and later without recurrence. Conclusion: This case was considered to have the coincidental complication of paroxysmal atrial fibrillation in the course of methadone administration. If administration of antiarrhythmic agents is performed in a patient whom has been prescribed methadone, it is feared to lead to result in QT interval prolongation due to drug interactions. It is important to carefully select an agent that rarely leads to QT prolongation.

Purpose：Methadone is an opioid used in Japan for the treatment of cancer pain. A thorough consideration of complex pharmacokinetics with individual differences and of serious adverse effects is necessary before switching to methadone; therefore, methadone is not yet widely used. We examined the analgesic and adverse effects of methadone through clinical cases and considered the clinical significance of methadone as an opioid analgesic for the treatment of cancer pain. Methods：The clinical course of 44 patients with cancer pain who were switched to methadone from other opioids was analyzed. Results：Out of the 44 cases investigated, 37 cases （84.1％） were successful. In the successful cases, pain intensity before and after methadone administration was reduced from an average of 7.5 to 2.8, respectively, on the numerical rating scale. Strong drowsiness （six cases） and nausea （three cases） were observed as adverse effects. However, no serious effects, such as QT prolongation and respiratory depression, were recognized. Conclusion：For patients with refractory cancer pain who require a high opioid dose, methadone is considered to be one of the alternatives in pain therapeutics.

Background: Methadone can only be administered orally in Japan. However, it is unclear how to treat pain when patients become unable to take methadone orally because of the progression of the disease. Aims: To assess retrospectively end-of-life pain control management after patients become unable to take methadone orally. Methods: Twenty-eight patients with cancer pain undergoing treatment with oral methadone died at a palliative care unit between April 2013 and September 2014. All patients died of cancer and were unable to swallow before death. We assessed pain control approaches after the patients became unable to take methadone orally. Results: Twenty-one patients survived 1 day or longer after becoming unable to swallow. Methadone was switched to another opioid because of pain. Of these 21 patients, 10 patients survived for 1 week or longer after being switched to another opioid. At this point, methadone would be mostly eliminated from the blood circulation. Among these 10 patients, seven patients were treated with subcutaneous morphine, and three patients were excluded because their pain could not be evaluated. The conversion ratio from final oral methadone dosage to oral morphine equivalent dose of opioids used on the seventh day was 6.1. Conclusion: Even when patients become unable to ingest methadone, switching to other opioids may not always be necessary because of the long half-life of methadone when pain is absent at the end of life. If necessary, pain could be managed by switching to other opioids with a conversion ratio of 6.1.