The Success Rate Is Lower but Completion Rate of Laparoscopic Cholecystectomy Is higher in Endoscopic Transpapillary Gallbladder Drainage than Percutaneous Gallbladder Drainage for Acute Cholecystitis.

BACKGROUND: We investigated the success and complication rates of endoscopic transpapillary gallbladder drainage (ETGBD) and percutaneous transhepatic gallbladder drainage (PTGBD) and the outcomes of subsequent cholecystectomy for acute cholecystitis. METHODS: Patients (N=178) who underwent cholecystectomy after ETGBD or PTGBD were retrospectively assessed. RESULTS: ETGBD was successful in 47 (85.5%) of 55 procedures, whereas PTGBD was successful in 123 (100%) of 123 sessions (P<0.001). Complications related to ETGBD and PTGBD occurred in 6 (12.8%) of 47 and 16 (13.0%) of 123 patients, respectively (P=0.97). After propensity matching, 43 patients from each group were selected. Median time from drainage to cholecystectomy was 48 (14 to 560) days with ETGBD and 35 (1 to 90) days with PTGBD (P=0.004). Laparoscopy was selected more often in the ETGBD group (97.7%) than in the PTGBD group (79.1%) (P=0.007), and conversion from laparoscopy to open cholecystectomy was more common with PTGBD (41.2%) than with ETGBD (7.1%) (P<0.001). Mean operation time was significantly shorter with ETGBD (135.8±66.7 min) than with PTGBD (195.8±62.2 min) (P<0.001). The incidence of Clavien-Dindo grade ≥III postoperative complications was 9.3% with ETGBD and 11.6% with PTGBD (P=0.99). CONCLUSIONS: The success rate is lower but completion of laparoscopic cholecystectomy is more in endoscopic gallbladder drainage than percutaneous gallbladder drainage for acute cholecystitis.

[The assessment of chemoradiation therapy with CDDP/S-1 for advanced gastric cancer that was actively bleeding].

In the management of inoperable patients with advanced gastric cancer, it is important to control a tumor bleeding actively and to make sure that the patient can take meals through the stenotic cardia for the purpose of keeping the patients' quality of life well. We treated five gastric cancer patients with chemoradiation therapy consisting of CDDP (6 mg/m2) and S-1 (100 mg/body). In the treatment results, we have never seen an active tumor bleeding and anemic state, which required a blood transfusion after the treatment. In all of the 5 cases, a total quantity of taking meals increased due to a cardia stenosis improvement by tumor. We thought this treatment was useful for patients with cardia stenosis and actively bleeding in advanced gastric cancer.

[Successful treatment of embolization and chemoradiationtherapy with S-1 for the advanced gastric cancer which was actively bleeding].

In the management of inoperable patients who have advanced gastric cancer, it is important to control an active tumor bleeding for the purpose of keeping the patient's quality of life well. We treated two patients: embolization with coil to aneurysm in the gastric tumor in one case, and embolization and chemoradiationtherapy with S-1 in the other. In results, we have never seen an active tumor bleeding and anemic state requiring a blood transfusion after the treatment. Both patients died from other diseases. We think these treatments are useful for patients with active bleeding in advanced gastric cancer.

[A case of advanced rectal cancer responding to radiation therapy and chemotherapy with S-1].

We report a case of a 72-year-old man with advanced rectal cancer who refused an operation for cancer therapy. We underwent radiation therapy (40 Gy) for the purpose of suppressing tumor bleeding. Consequently, we administered S-1 (100 mg/day) orally. As a result, the tumor has disappeared by radiation therapy and chemotherapy with S-1 for 2 years. We have recognized no side effects. This therapy seemed to be an effective treatment for poor-risk elderly patients.

Oral Methotrexate-related Lymphoproliferative Disease Presenting with Severe Osteonecrosis of the Jaw: A Case Report and Literature Review.

Long-term methotrexate (MTX) treatment can cause MTX-related lymphoproliferative disorder (MTX-LPD). We experienced a case of MTX-LPD that was associated with severe osteonecrosis of the jaw mimicking medication-related osteonecrosis of the jaw. The patient was an 81-year-old woman with rheumatoid arthritis (RA) who was treated with MTX and bisphosphonate. After 7 years, she was referred to our department for the assessment of giant ulcer and exposure of the alveolar bone of the left maxilla. Histopathological and immunological analyses confirmed a diagnosis of MTX-LPD. At seven months after the cessation of MTX treatment, the ulcerative and necrotic lesions had markedly decreased in size. A 1-year follow-up examination showed no evidence of recurrence and good RA control.

[A case of intrahepatic cholangiocarcinoma successfully treated by hepatic arterial infusion chemotherapy].

The patient was a 67-year-old man who had been operated for eshophageal cancer 4 years ago. He was diagnosed as intrahepatic cholangiocarcinoma by CT after 2 years of the operation. After admission to our hospital, he was treated by hepatic arterial infusion chemotherapy with CDDP, levofolinate calcium (L-LV) and 5-FU with chronomodulation. After a few more months of the treatment, abdominal CT revealed that the size of hepatic tumor decreased remarkably. There were no side effects without bone marrow suppression (grade 1). It seemed that hepatic arterial infusion chemotherapy with chronomodulation may be an effective strategy against intrahepatic cholangiocarcinoma in high risk case.

[Assessment of efficacy of arterial infusion chemotherapy with gemcitabine for four cases of advanced pancreatic cancer].

We treated 4 cases of advanced pancreatic cancer: 2 cases were nonresectable and the other 2 cases did not choose an operation but arterial infusion chemotherapy with gemcitabine after the transcatheter peripancreatic arterial embolizaiton. One case resulted in a tumor decrease but the other 3 cases observed a tumor progress. Although we confirmed cancer pain suppression in all cases and a disappearance of tumor fever in one case, the survival period was 7 months in spite of the treatment. As for the complication of arterial infusion chemotherapy with gemcitabine, we recognized bone marrow suppression (grade 1) in 3 cases. This therapy seemed to be effective for suppression of pain and tumor fever caused from the advanced pancreatic cancer. However, we need to improve in survival period from this therapy.

[Utility of arterial infusion chemotherapy and radiation therapy for the pelvic local recurrence of rectal cancer].

We treated 3 cases of local pelvic recurrence due to a rectal cancer post operation by arterial infusion chemotherapy with 5-FU and levofolinate calcium and also by radiation therapy. The result of imaging analysis showed that a recurrent tumor was decreased effectively in 2 cases by chemo-radiation therapy. We confirmed the cancer pain and tumor bleeding were gone for all of the 3 cases. As for side effects of arterial infusion chemotherapy and radiation therapy, we confirmed a paralysis of the pelvic nerve in 1 case and dermatopathy in 1 case. This therapy seemed to be an effective treatment for elderly patients with inoperable cases.

[Multi-biomarker approach to acute coronary syndrome].

High-risk acute coronary syndrome is characterized by vulnerable-plaque with subocclusive thrombus and down-stream microemboli spreading minor myocardial damage, resulting in non-ST-elevation myocardial infarction. Advances in the understanding of the pathogenesis and consequences of acute coronary syndrome have stimulated development of novel biomarkers, and expanded their role in the different spectrum of the underlying pathophysiology, namely multi-biomarker strategy; consisted of biomarkers for 1) myocardial necrosis(membrane damage to myofibril necrosis), 2) plaque destabilization, 3) myocardial stress(ischemic stress per se and end-diastolic atrial or ventricular wall stress), 4) myocardial ischemia, and 5) inflammatory process. In this article, we review clinical importance of novel biomarkers referring our previous clinical investigation and other reports, especially troponin T for detection of minor myocardial damage associated with vulnerable plaque with thrombus/embolus, heart-type fatty acid -binding protein for earlier detection of myocardial damage and it's role for the rule-out triage, N-terminal pro-BNP for earlier risk stratification in cardiac emergency, and soluble CD40 ligand for earlier identification of plaque destabilization with platelet activation in non-ST-elevation acute coronary syndrome.

[Utility of convex echo probe in laparoscopic radio frequency ablation therapy for hepatocellular carcinoma].

We have examined the utility of the convex echo probe, which has the fine gutter of a puncture needle in laparoscopic radio frequency ablation therapy. When we use a flexible linear echo probe in RFA treatment, we have to puncture tumor with the hand piece in free hand. But it is difficult to treat in the case of HCC which is located in S1 and the lower area of S5 and S6 because we have a narrow space where colon, duodenum and netz are close for safe and exact puncturing of the tumor. We used a convex echo probe in RFA to the above mentioned area of the liver. We punctured with the hand piece exactly and easily without preliminary puncturing of the tumor. So we can perform RFA treatment successfully and safely by a choice of an appropriate echo probe.

Use of a whole blood rapid panel test for heart-type fatty acid-binding protein in patients with acute chest pain: comparison with rapid troponin T and myoglobin tests.

PURPOSE: We sought to determine the clinical utility of a newly developed qualitative test to measure heart-type fatty acid-binding protein levels in blood for the early identification of myocardial infarction. METHODS: We measured heart-type fatty acid-binding protein levels in 371 consecutive patients with acute chest pain and suspected myocardial infarction, and compared the performance of this test with those of troponin T and myoglobin tests. Levels of heart-type fatty acid-binding protein >or=6.2 ng/mL were considered as positive results. RESULTS: A final diagnosis of acute myocardial infarction was made in 181 patients (49%). Of the 68 patients who presented within 2 hours of the onset of symptoms, 37 (54%) had a final diagnosis of myocardial infarction. The sensitivity of the rapid heart-type fatty acid-binding protein test was 89% (33/37), significantly higher than for troponin T (22% [8/37]; P<0.001) and myoglobin (38% [14/37]; P<0.001). However, the specificity of troponin T (94% [29/31]) was significantly better than for heart-type fatty acid-binding protein (52% [16/31]; P= 0.002) within 2 hours. The area under the receiver operating characteristic curve for heart-type fatty acid-binding protein levels was greater than that for myoglobin (0.72 vs. 0.61, P = 0.01) among patients who presented within 2 hours. CONCLUSION: A novel whole blood rapid heart-type fatty acid-binding protein test can be useful in the early evaluation of patients who present with acute chest pain.

Application of NT-proBNP and BNP measurements in cardiac care: a more discerning marker for the detection and evaluation of heart failure.

BACKGROUND: Measurement of brain natriuretic peptide (BNP) has become a potent diagnostic aid as a means of identifying patients with systolic or diastolic dysfunction. Due to better stability in circulating blood, we reasoned that measurement of N-terminal proBNP (NT-proBNP) may be a more discerning marker for the detection and evaluation of chronic heart failure. METHODS: The relationships between plasma concentrations of NT-proBNP and BNP, and aetiology, New York Heart Association (NYHA) classification, and left ventricular ejection fraction (LVEF) were analyzed in 105 patients with chronic heart failure. Sixty-seven healthy volunteers were studied as the controls. RESULTS: Both NT-proBNP and BNP showed progressive increases (P<0.001) in proportion to the NYHA classification; the increment of NT-proBNP was larger than that of BNP. Elevated NT-proBNP significantly correlated with BNP (r=0.737, P<0.001). Receiver operating characteristics analysis to detect LVEF<40% showed similar values (area under the curve, AUC: NT-proBNP 0.754 vs. BNP 0.770), however, AUC to detect LVEF<50% tended to be greater for NT-proBNP than that for BNP (NT-proBNP 0.820 vs. BNP 0.794). CONCLUSION: NT-proBNP may be a more discerning marker for the detection and evaluation of heart failure than BNP.

N-terminal pro-BNP is a novel biomarker for integrated cardio-renal burden and early risk stratification in patients admitted for cardiac emergency.

BACKGROUND: The expanding role of cardiac markers - cytosolic [heart-type fatty acid-binding protein (H-FABP) and creatine kinase MB (CK-MB)], myofibril [troponin T (TnT)], and cardio-endocrine [N-terminal pro-B-type natriuretic peptide (NT-proBNP)] - has been clarified in patients with acute coronary syndrome and those with heart failure. However, these applications for early risk stratification in the cardiac emergency, and the influence of renal function on these evaluations have not been fully investigated. PATIENTS AND METHODS: We investigated the prognostic value of these representative cardiac markers and influence of renal function on these evaluations in 165 consecutive patients who were admitted for cardiac emergency because of chest pain or dyspnea. RESULTS: There were significant correlations between TnT and CK-MB (r=0.512, p<0.001), and between H-FABP and TnT (r=0.409, p<0.001) and CK-MB (r=0.254, p<0.01); however, NT-proBNP levels did not show significant correlations with other cardiac markers. There were significant correlations between estimated glomerular filtration rate and NT-proBNP (r=-0.466, p<0.001) and H-FABP (r=-0.235, p<0.001) levels, and between left ventricular ejection fraction (LVEF) and NT-proBNP (r=-0.407, p<0.001) and H-FABP (r=-0.253, p<0.01) levels. Kaplan-Meier analysis showed that median of NT-proBNP, H-FABP, and CK-MB significantly discriminated in-hospital cardiovascular death, and multivariate analysis revealed NT-proBNP and LVEF as independent prognostic predictors. CONCLUSION: NT-proBNP is a novel biomarker for integrated cardio-renal burden, and extremely useful for early risk stratification in the situation of cardiac emergency.

Difference in elevation of N-terminal pro-BNP and conventional cardiac markers between patients with ST elevation vs non-ST elevation acute coronary syndrome.

BACKGROUND: N-terminal pro-B-type natriuretic peptide (NT-proBNP) is elevated in patients with acute coronary syndrome (ACS), and is a powerful predictor of long-term mortality. Differences in the clinical utility and pathophysiological implication of NT-proBNP and conventional cardiac markers in patients with ST elevation (STE) vs non-STE (NSTE) ACS were investigated in the present study. METHODS AND RESULTS: Ninety consecutive patients admitted with acute chest pain and a diagnosis of unstable angina or acute myocardial infarction were analyzed. Patients with >or=Killip class II were excluded to focus on the effect of myocardial ischemia on the release of cardiac markers. The markers were measured on admission and analyzed according to the time from onset. Conventional cytosolic marker (creatine kinase-MB) and myofibril marker (troponin T: TnT) were both significantly higher in STE-ACS patients compared with NSTE-ACS patients. Conversely, NT-proBNP was significantly higher in NSTE-ACS patients than STE-ACS especially within 3 h of onset, suggesting a larger ischemic insult despite the smaller extent of myocardial necrosis compared with STE-ACS patients. There was no significant correlation between NT-proBNP level and left ventricular ejection fraction (LVEF) obtained at acute-phase echocardiography in either NSTE-ACS patients (LVEF 57.7+/-11.2%) or STE-ACS patients (LVEF 55.1+/-12.7%). Comparison between NT-proBNP and TnT levels revealed a marked difference of elevations, with significantly augmented elevation of NT-proBNP (p<0.001) in NSTE-ACS patients as compared with prominent elevation of TnT in STE-ACS patients. CONCLUSIONS: NT-proBNP is an early sensitive marker of myocardial ischemia that rises much higher in the earlier phase as compared with conventional markers of myocardial damage, especially in NSTE-ACS patients.

Pacemaker contact dermatitis: The effective use of a polytetrafluoroethylene sheet.

A 52-year-old man with Down's syndrome was implanted with a DDDR pacemaker for advanced atrioventricular block. He was admitted with development of skin eczema and partial exposure of the generator 1 year after reimplantation. There was no evidence of infection on laboratory data. A skin patch test was positive for the metal of the generator (purity 99.9% titanium) after 72 hours. These findings indicated pacemaker contact dermatitis. After the patient was reimplanted with a pacemaker wrapped with a polytetrafluoroethylene sheet, there has been no recurrence of the contact dermatitis during a follow-up period of 3 years.