[A Case of Retroperitoneal Metastasis of Breast Cancer with Effective Insertion of Plural Stents].

A 61-year-old woman was referred to our hospital because of epigastric pain during chemotherapy for breast cancer recurrence. She was diagnosed with left breast cancer and underwent mastectomy with axillary lymph node dissection 13 years previously. The postoperative pathological examination result was luminal invasive lobular carcinoma. Hydronephrosis appeared after 1 month, which we diagnosed as ureter stenosis caused by radiation therapy for the lumbar metastasis and thus inserted an ureteralstent. After 1 month, computed tomography demonstrated expansion of the tumor into the stomach and duodenum. Upper gastrointestinalendoscopy demonstrated stenosis of the duodenum with intact mucosa. We diagnosed the duodenalstenosis due to the retroperitonealmetastasis of breast cancer and inserted duodenal, biliary, and pancreatic duct stents. The plural stent insertion was effective, and chemotherapy was administered with enforcement possibility for 7 months afterward.

Clinical utility of 0.025-inch guidewire VisiGlide2TM in the endoscopic retrograde cholangiopancreatography-related procedures.

AIM: To examine the result of the use of 0.025-inch guidewire (GW) VisiGlide2TM as the first choice in the endoscopic retrograde cholangiopancreatography (ERCP)-related procedures without selecting the patient in a multicenter prospective study. METHODS: ERCP using 0.025-inch GW VisiGlide2TM as the first choice was conducted in patients who have needed ERCP, and its accomplishment rate of procedure, procedural time, incidence of accidental symptoms were compared with those of ERCP using 0.025-inch GW VisiGlideTM. RESULTS: The accomplishment rate of procedure was 97.5% (197/202), and procedural time was 23.930 ± 16.207 min. The accomplishment rate of procedure using 0.025-inch GW VisiGlideTM was 92.3% (183/195), and procedural time was 31.285 ± 19.122 min, thus the accomplishment rate of procedure was significantly improved and procedural time was significantly shortened (P < 0.05). Accidental symptoms by ERCP-related procedures were observed in 3.0% (6/202), and all were conservatively alleviated. CONCLUSION: When 0.025-inch GW VisiGlide2TM was used for ERCP-related procedure as the first choice, it showed high accomplishment rate of procedure and low incidence of accidental symptoms, suggesting it can be used as the universal GW. Clinical Trial Registry (UMIN0000016042).

A Novel Guide-Wire Technique for Repositioning a Nasobiliary Catheter from Mouth to Nostril without Using a Nelaton Tube.

OBJECTIVE: We aimed to assess the usefulness of a novel guide-wire technique for repositioning without the use of a Nelaton tube and to compare this to the conventional technique. SUBJECTS AND METHODS: A total of 50 patients who underwent endoscopic nasobiliary drainage (ENBD) at the Yachiyo Medical Center, Chiba, Japan, were enrolled into the study. The patients were randomly divided into 2 groups according to the use of a novel guide-wire technique (n = 28) or the conventional technique (n = 22). The ENBD catheters were repositioned from the mouth to the nose. The primary end point was the procedural time from the insertion of the Nelaton tube or guide wire into the nostril until the ENBD catheter had been repositioned in the nose. The secondary end point was the success rate of the procedure. RESULTS: The mean procedure time of our technique (120.8 s) was shorter than the traditional technique (131.9 s), but this difference was not statistically significant (p = 0.56). Our technique did not involve the use of the Nelaton tube, and so could save the cost of USD 1.17 per patient. The novel technique did not require the removal of the mouthpiece with a laryngoscope or the use of a Nelaton tube, and no postural change was necessary. A single operator performed the novel procedure unassisted. No adverse events were observed relating to either the novel or the traditional technique. CONCLUSIONS: The novel guide-wire technique for repositioning ENBD catheters was effective and is recommended for use.

Metachronous early gastric cancer over a period of 13 years after eradication of Helicobacter pylori.

Stomach cancer can occur during chronic inflammation from Helicobacter pylori (HP) infection, and its occurrence can be suppressed by eradication of HP. However, the effects of suppressing stomach cancer by HP eradication are limited, and the cancer is known to recur even after eradication of this infection. Here, we report the case of a 56-year-old male patient with gastric cancer who, although undergoing HP eradication after treatment of early gastric cancer with endoscopy, experienced five metachronous cancer recurrences over a period of 13 years. Whether observation of patients who undergo eradication of HP due to peptic ulcers or chronic gastritis and patients who undergo eradication after endoscopic treatment for early gastric cancer should be performed at the same interval is an issue that must be addressed in the future. The appropriate observation period for each patient must be established while considering the burdens to the patient and from the medical economic perspective.

Clinical evaluation of the Tokyo Guidelines 2013 for severity assessment of acute cholangitis.

BACKGROUND: We evaluated the severity assessment criteria for acute cholangitis (AC) of the Tokyo Guidelines 2013 (TG13) and developed a scoring system for predicting the need for urgent/early biliary drainage. METHODS: We retrospectively reviewed 66 AC cases prospectively managed based on the TG07 and divided into an urgent/early biliary drainage group (n = 30) and elective biliary drainage group (n = 36). RESULTS: There were 26 mild, 27 moderate, and 13 severe cases based on the TG13. The TG13 assessment in 12 of the 17 cases requiring early biliary drainage based on the TG07 was moderate, but underestimated the other five cases as mild AC. When five predictors (blood urea nitrogen >20 mg/dL, SIRS presence, platelet count <120 000/µL, serum albumin level <3.0 g/dL, age ≥75 years old) were used to devise a scoring system, the receiver-operator characteristic curve of the scores showed good test performance for predicting the need for urgent/early biliary drainage. The area under the curve (AUC) was 0.95 and higher than the TG13 AUC (0.80). CONCLUSIONS: The TG13 is practical, but some AC cases requiring urgent/early biliary drainage were underestimated as mild AC. The scoring system allows identification of high-risk AC patients and will improve the TG13.

Proposed new simple scoring system to identify indications for urgent ERCP in acute cholangitis based on the Tokyo Guidelines.

BACKGROUND/PURPOSE: The Tokyo Guidelines (TG) have enabled more accurate diagnosis of acute cholangitis (AC). This study was undertaken to develop a new prognostic scoring system to predict the need for urgent endoscopic retrograde cholangiopancreatography (ERCP) based on the clinical findings on admission. METHODS: We prospectively reviewed 40 consecutive cases of AC and divided them into an urgent-ERCP group and an elective-ERCP group. RESULTS: Univariate analysis identified four factors that predicted the need for urgent ERCP: serum albumin level below 3.0 g/dl, blood urea nitrogen level above 20 mg/dl, platelet count below 120,000/µl, and the presence of systemic inflammatory response syndrome. These four predictors plus four predictors of organ dysfunction in the TG: shock, consciousness disturbance, respiratory failure, and prothrombin time/international normalized ratio >1.5, were used to devise a scoring system in which 1 point was assigned for the first four predictors and 2 points were assigned for the latter four predictors (maximum score possible: 12 points). The receiver-operator characteristic curve of the scores showed good test performance for predicting the need for urgent ERCP and for predicting a positive blood culture, and the areas under the concentration curves (AUCs) were 0.96 and 0.97, respectively. The optimal cut-off value for urgent ERCP was 2 points. CONCLUSIONS: This new simple scoring system allows identification of high-risk AC patients soon after admission to hospital.

[Case report of rheumatoid arthritis associated with type A gastritis and Hashimoto thyroiditis].

A 59-year-old woman was initially thought to have either type A gastritis, or autoimmune gastritis by upper-gastrointestinal-tract endoscopy and a serological examination. Furthermore, the patient was also suspected to have Hashimoto disease based on a positive antithyroid-antibody test. Rheumatoid arthritis was diagnosed 1 year later. Pernicious anemia, gastric-carcinoid and stomach cancer are the primary complications of A type gastritis. However, we hypothesized that the development of other autoimmune diseases, such as autoimmune thyroid disease, was the primary complication experienced in this case. Therefore, we report the findings of this case while taking into consideration the findings of several other previously published studies.

Mechanistic studies on alpha-trifluoromethylation of ketones via silyl enol ethers and its application to other carbonyl compounds.

Synthesis of alpha-CF(3) carbonyl compounds has been recognized to be difficult up to now because the polarization of CF(3)(delta-)-I(delta+) is opposite to that of CH(3)(delta+)-I(delta-), and this makes it difficult to introduce CF(3)(+) unit to enolates. We recently reported an effective alpha-trifluoromethylation of ketones by using Et(2)Zn with Rh catalyst, but the mechanism has not fully been cleared. Now, we carried out the detailed mechanistic studies and found the involvement of a highly reactive alkylrhodium complex which derived from Et(2)Zn and RhCl(PPh(3))(3) in this alpha-trifluoromethylation. Furthermore, this alpha-trifluoromethylation was applied to other types of carbonyl compounds in good yields.