Clinical practice guideline for post-ERCP pancreatitis.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERPC) is used for the diagnosis and treatment of pancreatic and biliary diseases. Post-ERCP pancreatitis (PEP) is a complication which needs special care and clinical practice guideline for this morbidity is also needed. METHODS: The key clinical issues of diagnosis and treatment of PEP were listed and checked, and then the clinical questions were formulated. PubMed (MEDLINE) and Ichushi-web (Japanese medical literature) were used as databases. For the study of diagnostic test accuracy, items similar to QUADAS-2, i.e., random selection from a population to which the diagnostic test is applied, blinding of index tests and reference tests, completeness of reference standard, completeness of test implementations, the same timing of tests, and missing data were assessed as well as the indirectness of the study subjects, index tests, reference standard, and outcomes. Grading of recommendations was determined as strong or weak. In clinical practice, the judgment of attending doctors should be more important than recommendations described in clinical practice guidelines. Gastroenterologists are the target users of this clinical practice guideline. General practitioners or general citizens are not supposed to use this guideline. The guideline committee has decided to include wide clinical issues such as etiological information, techniques of ERCP, the diagnosis, treatments, and monitoring of PEP in this guideline. RESULTS: In this concise report, we described ten clinical questions, recommendations, and explanations pertaining to risk factors, diagnosis, prognostic factors, treatments, and preventive interventions in the medical practice for PEP. CONCLUSIONS: We reported here the essence of the clinical practice guideline for PEP.

Improve morbidity and mortality in coronary artery bypass graft surgery for severe atherosclerosis.

OBJECTIVES: Atherosclerosis has been identified as a risk factor for both morbidity and mortality in patients undergoing coronary artery bypass grafting (CABG). To investigate outcomes following CABG for severe atherosclerosis, and to determine whether different surgical techniques can reduce the risk of neurologic events in these patients. METHODS: We studied 225 consecutive patients who underwent elective isolated CABG. Routine preoperative and intraoperative examinations identified patients with severe atherosclerosis. We compared the outcomes between patients with (group A; 42 ceses) and those without (group N; 183 cases) severe atherosclerosis. RESULTS: 36 patients (85.7%) in group A and 176 (96.2%) in group N underwent off-pump coronary artery bypass (OPCAB); 6 (14.3%) in group A and 7 (3.8%) in group N underwent on-pump beating CABG. Three patients in group A suffered deep sternal infection (7.1%), and one suffered stroke (2.4%) compared with none in group N. No cerebral infarction or neurologic events occurred in patients who underwent OPCAB (n = 212, 94.2%). CONCLUSIONS: Prevalence of complications was significantly greater among patients with severe atherosclerotic disease who underwent OPCAB than in those without atherosclerotic disease. Careful selection of surgical strategies can prevent perioperative stroke and reduce mortality.

Aortic valve destruction and pseudoaneurysm of the sinus of Valsalva associated with infective endocarditis.

We report the successful surgical treatment of a case of aortic valve destruction and pseudoaneurysm of the sinus of Valsalva associated with infective endocarditis (IE) in an 80-year-old woman. Multidetector-row computed tomography revealed an abnormal cavity in the left posterior aortic root. We had made the diagnosis of the aortic valve destruction and saccular pseudoaneurysm of the sinus of Valsalva associated with IE. Aortic valve replacement and patch plasty of the left sinus of Valsalva was performed successfully. A histopathologic examination of the resected aortic valve leaflet revealed inflammatory changes consistent with IE. We describe the surgical technique used in this rare case of pseudoaneurysm of the sinus of Valsalva resulting from IE.

A ball-shaped thrombus of the tricuspid valve after VSD closure.

We report successful surgical management of a 26-year-old man with a ball-shaped thrombus of the tricuspid valve. He had been treated with prednisolone for IgA nephropathy and undergone surgical closure of an isolated ventricular septal defect (VSD). No symptoms, coagulative disorders, or pulmonary embolisms were found. Preoperative echocardiography showed a ball-shaped mass that had originated from the anterior leaflet of the tricuspid valve; it also revealed a small residual VSD. A histological examination revealed the mass to be an organized thrombus with no tumor components. This was a rare case of excision of an organized thrombus of the tricuspid valve. The findings suggest that the thrombus formation may have been associated with the small shunt and/or prednisolone.

Chronic expanding hematoma in sternum resected 5 years after median sternotomy.

Chronic expanding hematomas occur at various locations in the body; however, their occurrence in the sternum has not been reported yet. We report a patient with chronic expanding hematoma in the sternum 5 years after undergoing a median sternotomy for cardiac surgery. Although preoperative biopsy specimens did not lead to a definitive diagnosis, we could not rule out the possibility of a malignant tumor because of the expanding and infiltrative behavior of the hematoma. We performed a sternectomy and reconstructed the chest wall using artificial materials.

Treatment of pancreatic stones with extracorporeal shock wave lithotripsy: results of a multicenter survey.

OBJECTIVES: A retrospective multicenter survey was performed to evaluate the efficacy of extracorporeal shock wave lithotripsy (ESWL) as a treatment of pancreatic stones. METHODS: A survey was sent to 11 institutions belonging to the Japanese Association of Extracorporeal Shock Wave Lithotripsy in Digestive Diseases, and data were collected on 555 patients who underwent ESWL for pancreatic stones between January 1990 and September 2002. The male:female ratio was 5.2:1, and the mean age was 52.5 years. The etiology was alcohol related in 425 patients (76.6%) and idiopathic in 111 patients (20.0%); 204 patients (36.8%) had a single stone and 470 patients (84.7%) were symptomatic. RESULTS: Mean frequency of the procedure was 5.0 times (range, 1-29). Fragmentation of stones was achieved in 513 patients (92.4%), and the complete stone clearance rate after ESWL alone or in combination with interventional endoscopy was 72.6%. Symptom relief was achieved in 428 (91.1%) of 470 patients. Thirty-five patients (6.3%) developed complications, including 30 patients (5.4%) who developed acute pancreatitis. Five hundred four (90.8%) patients were followed for a mean of 44.3 months, during which 122 (22.0%) suffered stone recurrence (mean time to recurrence, 25.1 months). Twenty-two (4.1%) of the 504 patients who were followed required surgery. Pancreatic exocrine function improved in 65 patients (38.0%), was unchanged in 49 patients (28.7%), and progressed in 57 patients (33.3%). Pancreatic endocrine function improved in 44 patients (24.3%), was unchanged in 85 patients (47.0%), and progressed in 52 patients (28.7%). CONCLUSION: ESWL is the treatment of choice for clearing pancreatic stones.

Skeletonized gastroepiploic artery for off-pump coronary artery bypass grafting.

BACKGROUND: Skeletonized arterial grafting may reduce the risk of graft spasm and may improve graft patency. Previously we reported a pilot study of skeletonized gastroepiploic artery (GEA) grafting with favorable results. Skeletonized GEA harvesting with an ultrasonic scalpel has now become our routine procedure. In this report, we compare the early clinical outcomes of skeletonized versus pedicled GEA grafting to assess the safety and benefit of use of skeletonized GEA in coronary artery bypass grafting. METHODS: Between July 2002 and October 2003, the GEA was used as a conduit for isolated off-pump coronary artery bypass grafting in 105 patients. Of these, 21 patients (group P) received pedicled GEA and 59 patients (group S) received skeletonized GEA grafts (excluding 25 patients whose results were reported in the pilot study). The perioperative and early follow-up data were prospectively collected and compared. RESULTS: No graft injury was found in either group. The preoperative characteristics were similar in the two groups except that group S had a smaller body surface area (1.64 +/- 0.16 m 2 in group S versus 1.73 +/- 0.16 m 2 in group P, P <.05) and a significant number of patients with diabetes (36/59, 61.0% versus 7/21, 33.3%, P <.05). The number of distal anastomoses was 4.3 < 1.0 versus 3.9 +/- 0.9 ( P = not significant [NS]). An in situ GEA composite graft was constructed in 8 (13.6%) of the patients in group S and none of the patients in group P ( P = NS). There was one hospital death due to infection in group S. Otherwise, there were no cases of low output syndrome or postoperative myocardial infarction in either group. During early postoperative follow-up, no angina recurrence or myocardial infarction was found. CONCLUSION: The GEA can be skeletonized safely with an ultrasonic scalpel. Skeletonization enables a wider variety of choices in the use of GEA grafting.

Metal allergy to stainless steel wire after coronary artery bypass grafting.

To our knowledge, this is the first reported case of a manganese metal allergy to stainless steel wire. A 51-year-old man suffered from a refractory pruritic erythematous wheal after the insertion of a stainless steel wire. The patch test showed strong reactions to manganese, one of the constituents of stainless steel wire. After the removal of all stainless steel wires, the symptoms were much improved, except for mild pruritus on his face.

Venous coronary artery bypass grafting: late results of a 15-year actuarial follow-up in 486 patients.

PURPOSE: The aim of this study was to clarify the long-term results of venous coronary artery bypass grafting in Japanese patients. METHODS: The study population included 492 patients who underwent venous coronary artery bypass procedures at the Department of Cardiothoracic Surgery of Juntendo University from January 1984 to December 1989. The great majority of patients, 420 of 492 (85.4%), were males, and the mean patient age was 61.1 years (range: 32-82 years). The disease conditions included single-vessel disease in 32 patients (6.5%), double-vessel disease in 111 patients (22.6%), triple-vessel disease in 251 patients (51.2%), and 50% or more stenosis of the left main coronary artery in 98 patients (19.9%). A mean of 2.4 grafts was used per patient. RESULTS: The 15-year survival rate was 57.7%. The 15-year actuarial cardiac survival and cardiac event-free survival were 81.3% and 51.3%, respectively. The 15-year actuarial freedom from reoperation and myocardial infarction were 87.5% and 92.1%, respectively. Of 192 patients who died during the follow-up period, 62 deaths were due to cardiac causes (32.3%), 43 were due to malignant neoplasms (22.4%), and 25 were due to cerebral vascular accidents (13.0%). CONCLUSION: The prognosis of Japanese patients undergoing coronary artery bypass grafting may therefore be more favorable than that of Western patients. In addition, diabetes mellitus was an independent risk factor for both cardiac death and cardiac events.