Background/Aims: Endoscopic activity confirmed by enteroscopy is associated with poor clinical outcome in Crohn’s disease (CD). We investigated which of the existing biomarkers best reflects endoscopic activity in CD patients including the small bowel, and whether their combined use can improve accuracy. Methods: One hundred and four consecutive patients with ileal and ileocolonic type CD who underwent balloon-assisted enteroscopy (BAE) from October 2021 to August 2022 were enrolled, with clinical and laboratory data prospectively collected and analyzed. Results: Hemoglobin, platelet count, C-reactive protein, leucine-rich alpha-2 glycoprotein (LRG), fecal calprotectin, and fecal hemoglobin all showed significant difference in those with ulcers found on BAE. LRG and fecal calprotectin showed the highest areas under the curve (0.841 and 0.853) for detecting ulcers. LRG showed a sensitivity of 78% and specificity of 80% at a cutoff value of 13 μg/mL, whereas fecal calprotectin showed a sensitivity of 91% and specificity of 67% at a cutoff value of 151 μg/g. Dual positivity for LRG and fecal calprotectin, as well as LRG and fecal hemoglobin, both predicted ulcers with an improved specificity of 92% and 100%. A positive LRG or fecal calprotectin/hemoglobin showed an improved sensitivity of 96% and 91%. Positivity for LRG and either of the fecal biomarkers was associated with increased risk of hospitalization, surgery, and relapse. Conclusions The biomarkers LRG, fecal calprotectin, and fecal hemoglobin can serve as noninvasive and accurate tools for assessing activity in CD patients confirmed by BAE, especially when used in combination.

Background/Aims: The efficacy and safety of tofacitinib for the treatment of refractory ulcerative colitis (UC) has been demonstrated in clinical trials. Although, a series of reports with real-world evidence of its short-term efficacy and safety profiles have already been published, reports of long-term real-world data have been limited. We aimed to show our 3-year evidence on the clinical use of tofacitinib for the treatment of UC, focusing on its efficacy and safety profiles. Methods: A retrospective observational study was conducted on patients who started tofacitinib for active refractory UC at our hospital. The primary outcome was the retention rate until 156 weeks after initiating tofacitinib. The secondary outcomes were short-term efficacy at 4, 8, and 12 weeks; long-term efficacy at 52, 104, and 156 weeks; prognostic factors related to the cumulative retention rate; loss of response; and safety profile, including adverse events. Results: Forty-six patients who were able to be monitored for up to 156 weeks after tofacitinib initiation, were enrolled in this study. Continuation of tofacitinib was possible until 156 weeks in 54.3%, with > 50% response rates and > 40% remission rates. Among patients in whom response or remission was achieved and tofacitinib was deescalated after 8 weeks of induction treatment, 54.3% experienced relapse but were successfully rescued by and retained on reinduction treatment, except for 1 patient. No serious AEs were observed in the study. Conclusions Tofacitinib is effective and safe as long-term treatment in a refractory cohort of UC patients in real-world clinical practice.

No abstract available.
Breast ; Female ; Mammaplasty ; Tissue Expansion Devices

No abstract available.
Dermatitis* ; Epinephrine* ; Eyelids*

Large and ptotic breast reconstruction in patients who are not candidates for a transverse rectus abdominalis myocutaneous flap and revision surgery for the contralateral breast remains challenging. We developed a novel breast reconstruction technique using a latissimus dorsi myocutaneous (LD m-c) flap set at the posterior aspect of the reconstructed breast, combined with an anatomical silicone breast implant (SBI), following tissue expander surgery. We performed the proposed technique in four patients, in whom the weight of the resected tissue during mastectomy was >500 g and the depth of the inframammary fold (IMF) was >3 cm. After over-expansion of the lower portion of the skin envelope by a tissue expander, the LD m-c flap was transferred to cover the lower portion of the breast defect and to achieve a ptotic contour, with the skin paddle set at the posterior aspect of the reconstructed breast. An SBI was then placed in the rest of the breast defect after setting the LD m-c flap. No major complications were observed during the follow-up period. The proposed technique resulted in symmetrical and aesthetically satisfactory breasts with deep IMFs, which allowed proper fitting of the brassiere, following large and ptotic breast reconstruction.
Breast Implants ; Breast* ; Female ; Follow-Up Studies ; Humans ; Mammaplasty* ; Mastectomy ; Myocutaneous Flap* ; Reconstructive Surgical Procedures ; Silicon* ; Silicones* ; Skin ; Superficial Back Muscles* ; Surgery, Plastic ; Tissue Expansion Devices* ; Tissue Transplantation

Chronic expanding haematoma (CEH) is a rare type of haematoma that enlarges slowly and continuously without coagulation. It can occur following surgery because of shear stress-induced bleeding in the scar tissue between the subcutaneous fat and fascia. We present three cases of large chronic CEH that were successfully treated with triamcinolone injections. Three female patients developed large chronic CEH at 9 months, 5 years, and 6 years, respectively, after latissimus dorsi flap harvesting for breast reconstruction. Although the condition did not improve after multiple sessions of haematoma aspiration in the first two patients, it resolved following a single 40-mg triamcinolone injection along with appropriate compression dressing for several weeks. In the third patient, triamcinolone was injected immediately after the initial aspiration of the haematoma, and the condition improved considerably. There were no side effects in any of the patients. To the best of our knowledge, this is the first report of successful treatment of large CEH using triamcinolone. Therefore, we suggest that triamcinolone injections be considered for the treatment of CEH.
Bandages ; Cicatrix ; Fascia ; Female ; Free Tissue Flaps ; Hemorrhage ; Humans ; Mammaplasty ; Seroma ; Subcutaneous Fat ; Superficial Back Muscles* ; Triamcinolone*

Objective: Medical information databases provide useful Real World Evidence (RWE) and a comprehensive view of medical activities. However, since each database has limited coverage and cannot be self-sufficient, combining information from multiple databases is a useful research technique. In this study, we examined methods of estimating patient numbers by combining information from multiple databases in order to assess the respective databases and identify the respective characteristics, biases and idiosyncrasies. This process also allowed us to propose improvements in the grand design of medical information databases in Japan.
Design: Retrospective observational cohort study
Methods: We attempted to estimate the numbers of patients treated for certain diseases and the numbers prescribed a drug by three methods: i) We estimated patient numbers for seven diseases using an insurance claims database, adjusting the proportion of elderly patients according to a hospital medical records database; ii) Sales information for drug X was combined with the prescribed volume per person estimated from pharmacy claims databases to estimate the number of patients administered X; this number was divided by the prescription rate obtained from a medical claims database to calculate patient numbers for the associated disease; and iii) We examined two surveys of the National Institute of Infectious Diseases (NIID) for timely estimation of patient numbers for influenza, referring to estimates from an insurance claims database.
Results: In Method i)-iii), we proved that it is possible to estimate patient numbers for many diseases and administered drugs by effectively combining multiple medical information databases. Validation could be claimed when multiple methods lead to similar results.
Conclusion: These databases provided by government agencies and private corporations are separately managed, and there is no grand plan to integrate them into one platform. It is crucial that databases, rather than being designed to stand alone, are standardized according to widely used systems under a solid master data management strategy. This will make it easier to combine information from multiple databases and to maximize their values. Mutual use of these databases by academic researchers for epidemiological and clinical studies and by government policy makers and data scientists of pharmaceutical companies may improve the usefulness of these databases and expand their application in research.

Endoscopic ultrasonography (EUS) combines endoscopy and intraluminal ultrasonography, and allows imaging with a high-frequency transducer over a short distance to generate high-resolution ultrasonographic images. EUS is now a widely accepted modality for diagnosing pancreatobiliary diseases. EUS-guided fine-needle aspiration (EUS-FNA) using a curved linear-array echoendoscope was initially described more than 20 years ago, and since then many researchers have expanded its indications to sample diverse lesions and have also used it for various therapeutic purposes. EUS-guided biliary drainage (EUS-BD) is one of the therapeutic procedures that has been developed using a curved linear-array echoendoscope. Technically, EUS-BD includes rendezvous techniques via transesophageal, transgastric, and transduodenal routes, EUS-guided choledochoduodenostomy (EUS-CDS), and EUS-guided hepaticogastrostomy (EUS-HGS). Published data have demonstrated a high success rate, albeit with a comparatively high rate of nonfatal complications for EUS-CDS and EUS-HGS, and a comparatively low success rate with a low complication rate for the rendezvous technique. At present, these procedures represent an alternative to surgery or percutaneous transhepatic biliary drainage (PTBD) for patients with obstructive jaundice when endoscopic biliary drainage (EBD) has failed. However, these procedures should be performed in centers with extensive experience in linear EUS and therapeutic biliary ERCP. Large prospective studies are needed in the near future to establish standardized EUS-BD procedures as well as to perform controlled comparative trials between EUS-BD and PTBD, between rendezvous techniques and direct-access techniques (EUS-CDS and EUS-HGS), and between EBD and EUS-BD.
Biopsy, Fine-Needle ; Cholangiopancreatography, Endoscopic Retrograde ; Choledochostomy ; Dioxolanes ; Drainage ; Endoscopy ; Endosonography ; Fluorocarbons ; Humans ; Jaundice, Obstructive ; Transducers

BACKGROUNDThe endoscopic surgery for inner-side cancer of the breast is usually performed by periareolar approach, but it often makes deformation or malposition of nipple and areola. The trans-axillary approach is favorable without making any injuries on breast skin. Furthermore, we devised a new approach of retro-mammary route without subcutaneous exfoliation, from axillary skin incision, to preserve skin touch sensation.

METHODSWe have performed video-assisted breast surgery (VABS) on 200 patients since December 2001. The newly devised trans-axillary retromammary-route approach (TARM) was performed on 12 patients of early breast cancer. After endoscopic sentinel lymph node biopsy, we lengthened the axillary skin incision to 2.5 cm, and dissected retromammary tissue from superficial pectoral fascia onto major pectoral muscle below the tumor. The working space was made by lifting traction sutures through the gland. We cut the gland vertically at free margin 2 cm apart from the tumor edge, and dissect skin flap over the tumor. The breast reconstruction was done by filling absorbable fiber cotton.

RESULTSTraction sutures made it easier to cut the mammary gland vertically. We did not experience any skin damages like burn. All surgical margins were negative. The operation time was needed longer but the blood loss was not different. The postoperative esthetic results were good. The sensory disturbance was minimal. All patients were satisfied with this operation.

CONCLUSIONThis newly devised TARM approach need no injury on whole breast, and can become a single standard method for breast conserving surgery wherever the cancer situated.

Adult ; Breast Neoplasms ; surgery ; Endoscopy ; methods ; Female ; Humans ; Mastectomy, Segmental ; methods ; Middle Aged ; Video-Assisted Surgery ; methods