Background/Aims: Intralesional steroid injections have been administered as prophylaxis for stenosis after esophageal endoscopic submucosal dissection. However, this method carries a risk of potential complications such as perforation because a fine needle is used to directly puncture the postoperative ulcer. We devised a new method of steroid intralesional infusion using a spray tube and evaluated its efficacy and safety. Methods: Intralesional steroid infusion using a spray tube was performed on 27 patients who underwent endoscopic submucosal dissection for superficial esophageal cancer with three-quarters or more of the lumen circumference resected. The presence or absence of stenosis, complications, and the number of endoscopic balloon dilations (EBDs) performed were evaluated after treatment. Results: Although stenosis was not observed in 22 of the 27 patients, five patients had stenosis and dysphagia requiring EBD. The stenosis in these five patients was relieved after four EBDs. No complications related to intralesional steroid infusion using the spray tube were observed. Conclusions Intralesional steroid infusion using a spray tube is a simple and safe technique that is adequately effective in preventing stenosis Clinical trial number (UMIN000037567).

Laparoscopy is useful for minimally invasive detailed examination of patients with suspected gastrointestinal perforation. Here we report a case of gastrointestinal perforation of unknown cause that was diagnosed laparoscopically as perforation of the sigmoid colon by a toothpick. The patient was a 41-year-old woman. She presented with a chief complaint of left lower abdominal pain and CT showed a small amount of free air in the peritoneal cavity, so emergency surgery was performed. Laparoscopy revealed a foreign body penetrating the sigmoid colon. After mobilization of the sigmoid colon, the surgical technique was switched to minilaparotomy and partial sigmoid colectomy was performed. The foreign body that had penetrated the intestine was identified as a toothpick. We later learned that the patient had become intoxicated while eating at a yakiniku barbecue restaurant 7 days prior to the operation, and she guessed that she had accidentally consumed a toothpick stuck in an onion. Gastrointestinal perforation by a toothpick is rare and is difficult to diagnose preoperatively because toothpicks appear transparent on X-ray imaging. In this case, laparoscopy was useful for identifying the site and cause of perforation as well as the extent of leakage into the peritoneal cavity.

Objective: Schwannomas are the most common type of neoplasm of the peripheral nerves. Enucleation is a standard surgical procedure; however, it occasionally results in iatrogenic nerve injury, even with atraumatic procedures. Herein, we present the clinical characteristics of schwannoma arising in the extremities and discuss the clinical outcomes of extra- and intra-capsular enucleation.Patients and Methods: We reviewed 122 schwannomas treated at our institute. Schwannomas arising from the minor nerve (n=30) or intramuscularly (n=15) were operated using the extra-capsular technique. Of the 77 major nerve schwannomas, 62 schwannomas were treated using the intra-capsular technique and 15 schwannomas using the extra-capsular technique.Results: Neurological deficits following enucleation were significantly lower using the intra-capsular technique than with the extra-capsular technique. The patient age, duration of symptoms, maximum tumor diameter, and site of occurrence were not associated with subsequent neurological deficits. With both techniques, no tumor recurrence was observed at the final follow-up.Conclusion: These results support the use of intra-capsular micro-enucleation as a safe and reliable treatment for every type of schwannoma. To minimize the risk of nerve injury, en bloc resection should not be used because the main purpose of schwannoma surgery is the relief of symptoms, not tumor resection.

Bovine abortion, diarrhea, and respiratory disease complexes, caused by infectious agents, result in high and significant economic losses for the cattle industry. These pathogens are likely transmitted by various vectors and reservoirs including insects, birds, and rodents. However, experimental data supporting this possibility are scarce. We collected 117 samples and screened them for 44 bovine abortive, diarrheal, and respiratory disease complex pathogens by using Dembo polymerase chain reaction (PCR), which is based on TaqMan real-time PCR. Fifty-seven samples were positive for at least one pathogen, including bovine viral diarrhea virus, bovine enterovirus, Salmonella enterica ser. Dublin, Salmonella enterica ser. Typhimurium, and Neospora caninum; some samples were positive for multiple pathogens. Bovine viral diarrhea virus and bovine enterovirus were the most frequently detected pathogens, especially in flies, suggesting an important role of flies in the transmission of these viruses. Additionally, we detected the N. caninum genome from a cockroach sample for the first time. Our data suggest that insects (particularly flies), birds, and rodents are potential vectors and reservoirs of abortion, diarrhea, and respiratory infectious agents, and that they may transmit more than one pathogen at the same time.
Animals ; Birds ; Cattle ; Cockroaches ; Diarrhea Viruses, Bovine Viral ; Diarrhea ; Diptera ; Disease Reservoirs ; Disease Vectors ; Enterovirus ; Enterovirus, Bovine ; Genome ; Insects ; Neospora ; Polymerase Chain Reaction ; Real-Time Polymerase Chain Reaction ; Rodentia ; Salmonella enterica ; Virulence Factors

A 64-year-old man was found to have a nodule in his right lung. He also complained of nausea and abdominal pain during the clinical course. Esophagogastroduodenoscopy revealed a duodenal ulcer associated with severe stenosis and a suspicion of malignancy. However, three subsequent biopsies revealed no evidence of malignancy. The fourth biopsy showed scattered large eosinophilic cells with an eccentric nucleus, leading to a diagnosis of Russell body duodenitis (RBD). RBD is an extremely rare disease, and little is known about its etiology and clinical course. The pathogenesis of RBD is discussed based on our experience with this case.
Abdominal Pain ; Biopsy ; Constriction, Pathologic ; Diagnosis ; Duodenal Ulcer ; Duodenitis* ; Endoscopy, Digestive System ; Eosinophils ; Humans ; Lung ; Middle Aged ; Nausea ; Rare Diseases

Objective: The aim of this study was to establish the proper definitions of venous thromboembolism (VTE) and bleeding events for a healthcare database in Japan.
Study Design: Validation study.
Methods: The study comprised patients with VTE or who had undergone orthopedic surgery of the lower extremities and whose outpatient or inpatient medical information from April 1, 2008 to September 30, 2013 was available.  The source population of the database was derived from 100 acute-care hospitals.  The endpoints were VTE events (deep venous thrombosis [DVT], pulmonary thromboembolism [PE]) and bleeding events (bleeding requiring blood transfusion, intracranial hemorrhage, intraocular hemorrhage, upper gastrointestinal [GI] bleeding, and lower GI bleeding).  The frequent events with laboratory data were randomly extracted and evaluated, while all the infrequent events with laboratory data were extracted and evaluated.  Positive predictive value (PPV) was defined as the proportion of events judged to be clinical by medical experts of all the extracted events.  First, we conducted a test with a small number of cases and then revised the definitions of events.  Second, we extracted and evaluated data in 50 patients for VTE and bleeding events patients, based on which we defined the target PPV level between 60 and 70%.
Results: Of the 5,044,743 patients in the database, 36,947 patients underwent orthopedic surgeries of the lower extremities and 3,578 patients experienced a VTE event.  The PPV at the first evaluation was 80.0% (8/10) for DVT, 57.1% (4/7) for PE, and 27.3% (6/22) for bleeding events.  At the second evaluation using the revised definitions, the PPV were 75.0% (42/56) for VTE and 73.3% (33/45) for bleeding events.  Overall, the PPVs for VTE and bleeding events were over 70%.  The PPV of the VTE events were 76.9% (30/39) for DVT and 70.6% (12/17) for PE.  The PPVs of each type of bleeding event were over 70% except for intracranial hemorrhage (44.4%, 4/9).
Conclusion: The PPV was high for VTE events (75.0%) and bleeding events (73.3%).  The definitions used in this study are rational for the identification of VTE, DVT, PE, and bleeding events in the healthcare database in Japan.  The definition for each type of bleeding event should be investigated in further studies.

Alpha-fetoprotein-Producing gastric cancer is associated with poor prognosis because of frequent liver and lymph node metastasis. We present a case with synchronous liver metastasis who survived for 5 years. A 69-year-old man with upper abdominal pain was referred to our hospital. Gastrointestinal endoscopy revealed a Borrmann II-like tumor in the lower part of the stomach. Computed tomography revealed a tumor in the left lobe of the liver. Serum alpha-fetoprotein levels were markedly increased. We performed distal gastrectomy after administering oral tegafur/gimeracil/oteracil potassium and administered hepatic intra-arterial cisplatin injection. Liver metastasis showed partial response on computed tomography. Despite left hepatic lobectomy, further metastases to the liver and mediastinal lymph nodes became difficult to control. After sorafenib tosylate administration, stabilization of the disease was observed for 4 months. We conclude that hepatic intra-arterial chemotherapy and oral administration of sorafenib tosylate may potentially improve the prognosis in such cases.
Abdominal Pain ; Administration, Oral ; alpha-Fetoproteins ; Cisplatin ; Endoscopy, Gastrointestinal ; Gastrectomy ; Liver ; Lymph Nodes ; Neoplasm Metastasis ; Niacinamide ; Phenylurea Compounds ; Potassium ; Prognosis ; Stomach ; Stomach Neoplasms

We report a patient who was successfully treated with a herbal formulation of goreisan (Wu-ling-san) for recurrent vomiting associated with pyloric stenosis, with significant simultaneous improvement of congestive heart failure.
A 78-year-old woman was in a bedridden state after cerebral infarction and was being fed through a nasal tube. She often experience repeated vomiting and aspiration pneumonia. Cicatricial stenosis was found in the pyloric region and we performed an expansion operation with balloon endoscopy. However, symptoms did not improve and her heart failure worsened. Therefore, we administered goreisan. Urinary output volume increased, edematous changes gradually disappeared, and pleural effusion decreased. The stenosis-related lesion did not change, but the vomiting ceased, even after nasal tube feeding was resumed.
Goreisan is an herbal formula used to promote diuresis that is considered to correct water absorption in digestive organs. In this case, goreisan was effective for the improvement of many symptoms.

We report a case of chronic heart failure with hypotension, successfully treated with goreisan (Wu lin san).In this case, goreisan improved both the heart failure symptoms and water regulation. This 91-old woman had been receiving treatment for congestive heart failure, mitral regurgitation, aortic regurgitation and atrial fibril lation, and had undergone pacemaker implantation due to sick sinus syndrome. She underwent repeated hospi talization due to aggravation of her chronic heart failure. She was re-admitted because of systemic edema as well as exacerbation of heart failure symptoms which included pleural effusions. Blood pressure remained constant at about 80/50 mmHg. She was prescribed furosemide 40 mg. Thereafter, cerebral infarction compli cations arose. Therefore, it became difficult to increase the quantity of diuretics. We administered goreisan without change to the other oral medications. Many of her symptoms improved and the pleural effusion resolved without affecting blood pressure.
Goreisan is one representative herbal formula for promoting diuresis. In this case, it is thought that goreisan showed actions that influenced water regulation.

The aim of this study was to clarify the comorbidities of patients with Leriche syndrome and ischemic heart disease. We enrolled 26 patients with Leriche syndrome and who had undergone preoperative coronary angiography were enrolled. The comorbidities of diabetes, hypertension, and coronary artery disease developed in more than half of Leriche patients with Leriche syndrome. Marked coronary artery disease was diagnosed in 14 patients, 7 of whom underwent coronary artery bypass surgery. The Revascularization procedures performed in patients with Leriche syndrome were anatomical aortofemoral bypass in 15 and an extra-anatomical axillofemoral bypass in 9. In 2 cases of extra-anatomical bypass, occlusion developed in the long-term.