Tadalafil for male lower urinary tract symptoms improves endothelial function.

OBJECTIVES: To investigate the effects of tadalafil on vascular endothelial function and cardiovascular risk in patients with prostatic hyperplasia. METHODS: Tadalafil 5 mg was given to 20 patients with prostatic hyperplasia for whom an α1-blocker was ineffective. Voiding symptoms and vascular endothelial function were investigated before and after 4 and 12 weeks of administration, using commercial tests for vascular function and vascular endothelial function. RESULTS: The participants had a median age of 65 years, a mean body mass index of 24.2 and a mean prostate volume of 36.2 mL measured using transabdominal sonography. Voiding symptoms were significantly improved by tadalafil, based on the International Prostate Symptom Score, quality of life index and overactive bladder symptom score (P < 0.05). There were also significant improvements in vascular function (change of brachial-ankle pulse wave velocity from 1701 [before] to 1657 [4 weeks tadalafil] and 1525 [10 weeks tadalafil] cm/s [P < 0.05]) and vascular endothelial function (change of reactive hyperemia index from 1.36 to 1.56 and 1.89 [P < 0.05]). The change in reactive hyperemia index was significantly correlated with International Prostate Symptom Score, quality of life index and brachial-ankle pulse wave velocity. CONCLUSIONS: The improvement in intrapelvic blood flow by tadalafil can result in improved vascular endothelial function, in addition to improvement of voiding symptoms. The change in reactive hyperemia index seems to correlate with the severity of voiding symptoms, with tadalafil being most effective in patients with mild voiding symptoms.

Practical application of color Doppler ultrasonography in patients with ejaculatory dysfunction.

We describe two cases in which dynamic analysis of ejaculation using color Doppler ultrasonography was useful in diagnosis of ejaculatory dysfunction and planning of therapy. The first patient was a 32-year-old man with a diagnosis of retrograde ejaculation. A bladder neck collagen injection was carried out, as the main cause was thought to be the bladder neck remaining open during ejaculation. The patient had antegrade ejaculation 1 week later. The second patient was a 48-year-old man with a diagnosis of anorgasmia accompanied by decreased seminal emission and insufficient function of the rhythmic pelvic striated muscles. The patient was prescribed etilefrine hydrochloride 15 mg/day. The symptom improved 2 weeks after starting this drug. These cases suggest that the use of color Doppler ultrasonography during ejaculation can improve the understanding of ejaculatory dysfunction and therapy for this condition.

Detection of intrahepatic veno-venous shunts by three-dimensional venography using multidetector-row computed tomography during angiography.

PURPOSE: The hepatic vein (HV) can be removed during hepatectomy if there is an effective intrahepatic veno-venous shunt (vv-shunt). We evaluated the efficacy of vv-shunt detection by three-dimensional (3D) venography reconstructed from multidetector-row computed tomography (MDCT) during angiography. METHODS: 3D venography was reconstructed using computer software in 88 patients with intrahepatic tumors. RESULTS: We found that 12 patients had one shunt [4 right hepatic vein (RHV)-middle hepatic vein (MHV) and 12 RHV- inferior right hepatic vein (IRHV)] and 1 patient had 2 shunts (RHV-MHV and -IRHV), confirming a clinically efficient vv-shunt in 14.8% of the patients. In one patient with an RHV-IRHV shunt, the preserved RHV-IRHV shunt worked well and prevented congestion of the postero-caudal subsegment after central bisegmentectomy with partial resection of the RHV ventral trunk for huge hepatocellular carcinoma (HCC). CONCLUSIONS: Although the vv-shunt detection rate by 3D venography is low, a visualized vv-shunt proved to be efficient. Thus, invasive occlusion venography is avoidable if a vv-shunt is seen on 3D venography.

Lysophosphatidylcholine acyltransferase 1 altered phospholipid composition and regulated hepatoma progression.

BACKGROUND & AIMS: Several lipid synthesis pathways play important roles in the development and progression of hepatocellular carcinoma (HCC), although the precise molecular mechanisms remain to be elucidated. Here, we show the relationship between HCC progression and alteration of phospholipid composition regulated by lysophosphatidylcholine acyltransferase (LPCAT). METHODS: Molecular lipidomic screening was performed by imaging mass spectrometry (IMS) in 37 resected HCC specimens. RT-PCR and Western blotting were carried out to examine the mRNA and protein levels of LPCATs, which catalyze the conversion of lysophosphatidylcholine (LPC) into phosphatidylcholine (PC) and have substrate specificity for some kinds of fatty acids. We examined the effect of LPCAT1 overexpression or knockdown on cell proliferation, migration, and invasion in HCC cell lines. RESULTS: IMS revealed the increase of PC species with palmitoleic acid or oleic acid at the sn-2-position and the reduction of LPC with palmitic acid at the sn-1-position in HCC tissues. mRNA and protein of LPCAT1, responsible for LPC to PC conversion, were more abundant in HCCs than in the surrounding parenchyma. In cell line experiments, LPCAT1 overexpression enriched PCs observed in IMS and promoted cell proliferation, migration, and invasion. LPCAT1 knockdown did viceversa. CONCLUSIONS: Enrichment or depletion of some specific PCs, was found in HCC by IMS. Alteration of phospholipid composition in HCC would affect tumor character. LPCAT1 modulates phospholipid composition to create favorable conditions to HCC cells. LPCAT1 is a potent target molecule to inhibit HCC progression.

Detection of hepatocellular carcinomas with near-infrared fluorescence imaging using indocyanine green: its usefulness and limitation.

BACKGROUND: Indocyanine green (ICG), an agent for measuring liver function, becomes fluorescent under near-infrared (NIR) light after binding to serum proteins. Hepatocellular carcinoma (HCC) with a deposit of preoperatively administered ICG becomes clearly detectable under ICG fluorography; however, it remains unclear whether this detection method is always reliable. This case series study was designed to clarify the reliability of this method. METHODS: ICG (0.5 mg/kg) was injected from the 3rd to 28th preoperative day to evaluate hepatic function in 58 patients with HCCs. Preoperative imaging modalities identified 76 HCC foci. The operative fields and resected specimens were observed with an NIR camera system. Preoperatively detected lesions and lesions newly detected by the ICG fluorography were histologically investigated. RESULTS: ICG fluorography identified 73 of 76 preoperatively diagnosed HCC lesions. Intraoperative ICG fluorography visualized 47 lesions in 40 patients. The other 26 lesions showing emission were found in the sectioned specimens under NIR observation. Other than preoperatively diagnosed foci, ICG fluorography visualized 35 new lesions, including 6 HCCs, 2 dysplastic nodules and 27 non-neoplastic lesions, such as bile plugs and cysts. The sensitivity of ICG fluorography for HCCs was 96% and its positive predictive value was 71.5%. CONCLUSIONS: Indocyanine green fluorography is useful to detect HCCs; however, attention should be paid to the fact that HCCs may be occasionally overlooked by this imaging method and that lesions detected by this method are not always neoplastic lesions.

Long-term safety and efficacy of two different antimuscarinics, imidafenacin and solifenacin, for treatment of overactive bladder: a prospective randomized controlled study.

OBJECTIVE: The aim of this study was to assess the efficacy and safety of long-term treatment with two different antimuscarinics, imidafenacin and solifenacin, in patients with overactive bladder (OAB). PATIENTS AND METHODS: Male or female patients 20 years of age or older who had urgency (more than 1 episode in 24 h) were randomized into two groups: group I, imidafenacin (0.1 mg twice daily), and group S, solifenacin (5 mg once daily) for a 12-month treatment regimen. Subjective and objective symptoms were assessed before, and 1, 3, 6 and 12 months after treatment. RESULTS: A total of 109 patients, including 55 (mean age: 72.0 years) in group I and 54 (mean age: 70.4 years) in group S, were treated. Subjective symptoms were significantly improved in group I and S after treatment. Dry mouth significantly worsened in both groups. However, the duration of dry mouth in group I was significantly shorter than that in group S. Three (5.8%) and 7 (13.5%) patients discontinued treatment due to adverse events in group I and group S, respectively. CONCLUSIONS: Imidafenacin and solifenacin were efficacious, safe, and well-tolerated treatments for OAB. As for adverse events, group I had fewer than group S.

Anomalous arterial ramification in the right liver.

PURPOSE: The aim of this study was to investigate whether individual arterial and portal venous division during hepatectomy is always safe by examining the presence of the anomalous arterial ramification in the right liver. METHODS: The ramifications of the right hepatic artery (RHA) were investigated by three-dimensional (3D) reconstruction imaging using a computer software program in 87 patients undergoing computed tomography during angiography as a preoperative assessment of intrahepatic tumors. RESULTS: The anterior view showed that the RHA bifurcated into the anterior and posterior sector arteries at the hilum in 76 patients. Sector-intersecting arteries from the posterior to the anterior sector and vice versa were found in 7 and 4 of those patients, respectively. The RHA in the other 11 patients was divided in a complex manner into more than 2 arteries: e.g., the first branch to the cranial part of the posterior sector, the second to the anterior sector, and the third to the caudal part of the posterior sector. A total of 22 patients showed anomalous ramification of RHA. CONCLUSION: Preoperative observation of the hepatic artery by 3D imaging is very useful to detect anomalous ramification. Arterial dissection during the intrafascial approach should be cautiously performed based on the 3D images.

Unresolved Palliative Care Needs of Elderly Non-Cancer Patients at Home: A Multicenter Prospective Study.

INTRODUCTION/OBJECTIVES: There is growing consensus on the benefits of initiating palliative care early in the disease trajectory; however, palliative care needs for non-cancer patients remain to be elucidated. We investigated the trajectory of unresolved palliative care needs of non-cancer patients at home and explored associated factors. METHODS: We conducted a multicenter prospective cohort study of elderly non-cancer patients at home in Japan between Jan 2020 and Dec 2020. Physicians assessed their palliative care needs using the Integrated Palliative Care Outcome Scale (IPOS). Unresolved palliative care needs were defined as IPOS symptoms above 2 (moderate). RESULTS: In total, 785 patients were enrolled. The most frequent unresolved palliative care needs at enrollment were poor mobility (n = 438, 55.8%), followed by weakness/lack of energy (n = 181, 23.1%) and poor appetite (n = 160, 20.4%). Multivariate logistic regression analysis revealed that female and musculoskeletal disease were significantly positively associated with pain at starting home visits (OR = 1.89, P = .015; OR = 2.69, P = .005). In addition, neurological diseases were significantly positively associated with constipation and poor mobility 3 months after starting home visits (OR = 3.75, P = .047; OR = 3.04, P = .009). CONCLUSIONS: The order of the prevalence of unresolved palliative care needs may remain relatively stable over time, even for those receiving home-based palliative care services. We identified several specific diseases and conditions that were significantly associated with unresolved palliative care needs.

[Impact on opioid precipitation of opioid-starting titration path].

To investigate the effect clinical path of cancer pain treatments for opioid naive patients has on physician practice, a prepost quasi-experimental study was performed. The primary outcome measure was the percentage of patients who received 'recommended pain treatments' during the study periods. We determined the treatment to be the treatment of choice, if the physician 1) ordered a rescue dose, 2) prescribed a laxative, and 3) prescribed antiemetics when starting opioids. The secondary outcome measure was the number of newly consulted patients for our palliative care team. The end-points were measured before and after disseminating the clinical path. The rate of patients receiving recommended pain treatments significantly increased after disseminating the clinical path(p=0.03): 17%(33/18)to 61%(19/31). Patients who received a rescue order, laxative, or antiemetic when starting opioids were: 44% vs. 68%, 77% vs. 90%, and 66% vs. 77%, respectively. The number of patients newly consulting the palliative care team was increased(21 cases to 42 cases/4 month). In conclusion, the clinical path of cancer pain treatments is useful for improving the physician's practice when starting opioids for cancer pain, and might contribute to enhancing palliative care team availability.

Hepatectomy for metastatic liver tumors complicated with right umbilical portion.

We report the case of a 76-year-old man, presenting with a right umbilical portion (RUP), with two liver metastases of rectal cancer, 2cm and 1 cm tumors in the caudate lobe and anterior segment, respectively. The portal first branch ran to the right posterior segment and the remaining formed a left trunk, thereafter forming RUP. The tumor in the caudate was close to the right posterior segment's Glissonean pedicle. On 3-dimensional CT analysis under tubography via an endoscopic naso-biliary tube, the anatomical patterns of the arteries and bile ducts were complicated. On laparotomy, the gallbladder was located to the left of the round ligament. Right posterior segmentectomy plus partial caudate resection and partial hepatectomy of the anterior segment was performed after skeletonization of the biliovascular structures at the hepatic hilum. Precise examination of the biliovascular structures is needed to safely perform hepatectomy in patients complicated with RUP.

Postoperative bile leakage managed by interventional intrabiliary ethanol ablation.

We report a case of postoperative bile leakage that was successfully managed by intrabiliary ethanol ablation. A 68-year-old man with peritoneal and liver metastases from a jejunal gastrointestinal stromal tumor (GIST), which were refractory to molecular-targeted agents, underwent extended left lobectomy and peritoneal tumor resection. Bile leakage from the drainage tube persisted at a constant volume of 100 ml per day. On the 20th postoperative day, fistulography through a drainage tube and endoscopic cholangiography revealed biliary leakage from the bile ducts of segments 5 and 1. Since these bile ducts did not communicate with the proximal hilar bile ducts, two 5F balloon catheters were separately advanced into the leaking bile ducts via the drainage tube on day 30, and 1 ml absolute ethanol was injected into both of these catheters for 10 minutes. After three sessions of ethanol ablation, the bile leakage stopped. Although the bile leakage from segment 1 relapsed five days later, it gradually decreased and then stopped again until day 70. Intrabiliary ethanol ablation using the interventional technique is useful for managing bile leakage after hepatectomy when the leaking distal bile duct is isolated from the proximal biliary tree.

Effects of three types of alpha-1 adrenoceptor blocker on lower urinary tract symptoms and sexual function in males with benign prostatic hyperplasia.

OBJECTIVES: The aim of the present study was to explore the effects of three different types of alpha-1 adrenoceptor blockers (α1-blocker) on lower urinary tract symptoms (LUTS), erectile dysfunction (ED) and ejaculatory dysfunction (EjD) in patients with benign prostatic hyperplasia. METHODS: A total of 136 male LUTS patients aged 50-80 years with International Prostate Symptom Score (IPSS) ≥8 were enrolled. They were divided into three groups. Group S received silodosin at 4 mg twice a day; group T received tamsulosin at 0.2 mg once a day; and group N received naftopidil at 50 mg once a day. Assessment included IPSS, quality of life indexes (QOL), International Index of Erectile Function (IIEF-5), an ejaculation questionnaire, Qmax and post-void residual urine volume (PVR). These parameters were recorded at baseline, and at 1 and 3 months after treatment had ended. RESULTS: Mean IPSS and Qmax significantly improved after treatment in all groups without any significant difference among them. As for the IIEF-5 score, only group N significantly improved at 1 and 3 months. After treatment, 2.6 and 2.4% of patients complained of a de novo reduced volume of ejaculation in both groups T and N, respectively. Ten out of 41 patients (24.4%) complained of a total absence of antegrade ejaculation in group S after treatment. CONCLUSIONS: All three types of α1-blockers provided an objective and subjective improvement of LUTS in the present study population. However, erectile function only improved in patients treated with naftopidil and a higher rate of EjD was observed in those receiving silodosin. Because of their variable effects, we should consider the sexual dimension when prescribing α1-blockers for LUTS.

[A case of hilar bile duct cancer which recurred at abdominal and cervical lymph nodes 8 years after curative resection].

A 40-year-old man underwent right hemihepatectomy with biliary reconstruction for hilar bile duct cancer, and the surgical margin being negative. The tumor, showing atypical intraductal growth, was solid adenocarcinoma with rich mucinous component, although it was negative for MUC1, MUC2 and MUC5AC, suggesting that the tumor was not an intraductal papillary neoplasm of the bile duct (IPN-B). Eight years after operation, abdominal and cervical lymph node metastases were found on computed tomography and (18)F-deoxyglucose positron emission tomography examination. Late remote recurrence after curative resection of the extrahepatic bile duct cancer is relatively rare. The recurrence in the present case maybe explained by the tumor dormancy theory.

[Primary hepatic actinomycosis concomitant with elevation of protein induced by vitamin K absence or antagonist II - report of a case].

We report a case of primary hepatic actinomycosis showing elevation of serum protein induced by vitamin K absence or antagonist II (PIVKA-II). A 68-year-old man visited an affiliated hospital with a complaint of high fever and body weight loss. Hematological examination revealed severe inflammatory reactions and liver dysfunction. Abdominal CT showed a heterogeneous low density area composed of cystic and solid part. We suspected the cystic part with band-like enhancement to be a hepatic abscess and performed percutaneous transhepatic abscess drainage. Although inflammatory reactions decreased after the drainage, the solid part did not shrink and blood chemistry revealed elevation of PIVKA-II. Since we could not rule out the possibility of hepatoma, right hepatectomy was performed. Histological examination revealed actinomycetes. Although primary hepatic actinomycosis is a rare disease, it must be kept in mind in the differential diagnosis of the liver tumor.

Comparison of the prevalence and associated factors of hyperactive delirium in advanced cancer patients between inpatient palliative care and palliative home care.

BACKGROUND: Hyperactive delirium is known to increase family distress and the burden on health care providers. We compared the prevalence and associated factors of agitated delirium in advanced cancer patients between inpatient palliative care and palliative home care on admission and at 3 days before death. METHODS: This was a post hoc exploratory analysis of two multicenter, prospective cohort studies of advanced cancer patients, which were performed at 23 palliative care units (PCUs) between Jan and Dec 2017, and on 45 palliative home care services between July and Dec 2017. RESULTS: In total, 2998 patients were enrolled and 2829 were analyzed in this study: 1883 patients in PCUs and 947 patients in palliative home care. The prevalence of agitated delirium between PCUs and palliative home care was 5.2% (95% CI: 4.2% - 6.3%) vs. 1.4% (0.7% - 2.3%) on admission (p < 0.001) and 7.6% (6.4% - 8.9%) vs. 5.4% (4.0% - 7.0%) 3 days before death (p < 0.001). However, multivariate logistic regression analysis revealed that the place of care was not significantly associated with the prevalence of agitated delirium at 3 days before death after adjusting for prognostic factors, physical risk factors, and symptoms. CONCLUSIONS: There was no significant difference in the prevalence of agitated delirium at 3 days before death between inpatient palliative care and palliative home care after adjusting for the patient background, prognostic factors, symptoms, and treatment.

Pancreatic neuroendocrine cell tumor secreting parathyroid hormone-related protein and gastrin: Report of a case.

This report presents a case of pancreatic neuroendocrine cell carcinoma with multiple liver metastases secreting gastrin and parathyroid hormone-related protein (PTHrP) related to lumbar bone fracture and hypercalcemia. A 58-year-old woman visited an affiliated hospital with a chief complaint of lumbago without any evidence of trauma. She was diagnosed with hepatic dysfunction and hypercalcemia as well as multiple lumbar compression fractures without osteolytic lesions. Abdominal computed tomography (CT) showed a hypervascular mass in the pancreatic tail and multiple liver tumors. Duodenal ulcers were found with gastrointestinal endoscopy. There was a marked increase in the serum gastrin level. She was diagnosed as gastrinoma with multiple liver metastases and was admitted to the hospital. She had an increase in serum PTHrP level without the elevation of intact parathyroid hormone at the time of admission. She underwent an extended right hepatectomy in addition to a distal pancreatectomy with a regional lymphadenectomy and splenectomy. The postoperative course was uneventful, and serum gastrin and PTHrP activities reduced to normal levels. She remained symptom-free, and serum calcium, gastrin, and PTHrP levels remain within the normal ranges 19 months after surgery without adjuvant therapy.

Impact of the preoperative des-gamma-carboxy prothrombin level on prognosis after hepatectomy for hepatocellular carcinoma meeting the Milan criteria.

PURPOSE: Hepatectomy is feasible for patients with hepatocellular carcinoma (HCC) who are eligible for liver transplantation according to the Milan criteria if they have good hepatic function. This retrospective study investigates the prognostic factors of hepatectomy in HCC patients meeting the Milan criteria. METHODS: Between 1991 and 2005, 175 patients underwent hepatectomy for HCC at our institute; 111 met and 64 exceeded the Milan criteria. The prognostic factors for hepatectomy were investigated using a Cox regression model. RESULTS: Operative mortality and morbidity were significantly lower in the patients who met the criteria than in those who exceeded the criteria. After a median follow-up of 51.5 months, the 5-year survival rate was significantly better for the patients who met the criteria than for those who exceeded the criteria (77.8% vs 35.7%; P < 0.0001). The factors predictive of poor prognosis were poor differentiation, microscopic vasculobiliary invasion, and a high serum des-gamma-carboxy prothrombin (DCP) level (>100 mAU/ml) for the patients who met the Milan criteria; and only the presence of a microsatellite lesion for the patients who did not meet the Milan criteria. CONCLUSIONS: Hepatectomy is safe and beneficial for HCC patients who meet the Milan criteria, but a high preoperative serum DCP level may be predictive of a poor prognosis.

Long-term survival after a repetitive surgical approach in a patient with acinar cell carcinoma of the pancreas and recurrent liver metastases: report of a case.

Acinar cell carcinoma is a relatively rare malignant neoplasm, which represents 1%-2% of all pancreatic exocrine tumors. Its prognosis is thought to be poor, especially when it metastasizes to the liver. This report concerns a case of a long-term survivor of metastatic acinar cell carcinoma who was successfully treated with repetitive surgery. A 62-year-old man underwent a distal pancreatectomy for a pancreatic tumor, which was histologically diagnosed as an acinar cell carcinoma. The tumor recurred in the liver three times within 41 months. At the first recurrence, four hepatic lesions appeared 7 months after the initial pancreatectomy and were managed with an extended left hepatic lobectomy and partial liver resection. Thereafter, a solitary nodule in Segment 6 was identified 21 months after the second surgery and was treated with a partial liver resection. A solitary lesion in Segment 8/5 appeared 11 months after the third surgery and was also managed by a partial liver resection. The patient has remained disease-free for 22 months since the last surgery and has survived 65 months since the initial diagnosis. Although no consensus has been reached on surgery for metastatic acinar cell carcinoma, the current case has important implications for establishing an appropriate treatment strategy.

Late postoperative complications in patients with pancreaticobiliary maljunction.

BACKGROUND/AIMS: Reports on the late postoperative complications in patients with pancreaticobiliary maljunction (PBM) are limited. METHODOLOGY: Eighteen PBM patients with biliary dilatation and 12 without biliary dilatation were surgically treated at our institute. These 30 PBM patients were retrospectively reviewed, with particular attention to late postoperative complications. RESULTS: Nineteen patients without biliary malignancies underwent resection of the extrahepatic bile duct (BD) and hepaticojejunostomy. Two patients without biliary dilatation or malignancy underwent cholecystectomy alone. Nine patients with malignancies underwent hepatectomy with extrahepatic BD resection in 7 patients, pancreatoduodenectomy (PD) in 1, and PD + hepatectomy in 1. The median follow-up duration was 110 months. All patients without malignancies are presently alive in good healthy condition and have not developed any malignancy postoperatively. Late postoperative complications were seen in 6 (20%). Four patients with biliary dilatation were surgically or endoscopically treated for intrahepatic lithiasis 3, 12, 42 and 54 months after initial operation. One of them had a pancreatic protein plug 216 months after surgery, and was treated with papilloplasty after open laparotomy. In one patient without biliary dilatation, pancreatic protein plug and intrahepatic lithiasis were found 60 and 72 months after surgery, respectively, and both were treated endoscopically. CONCLUSIONS: Intrahepatic lithiasis and pancreatic protein plug are frequent late postoperative complications. The intrapancreatic residual choledochus or dilated pancreatic duct seems to be related to pancreatic protein plug. However, intrahepatic lithiasis may occur regardless of the pattern of the biliary tract dilatation. Careful, long-term follow-up is important in patients with PBM.

Bile leak test by indocyanine green fluorescence images after hepatectomy.

Bile leak remains a serious complication after hepatectomy. The conventional leak test by intrabiliary injection of normal saline solution is not sensitive. The authors present a new bile leak test using indocyanine green (ICG) fluorescence. After hepatic transection, ICG solution (.05 mg/mL) was intrabiliarily injected through a transcystic tube under distal common bile duct clamping, and fluorescent images were visualized using an infrared camera system. The ICG leak test was performed in 27 patients undergoing hepatectomy without biliary reconstruction. Bile leaks were intraoperatively found in 8 patients and fixed, resulting in no postoperative leaks. There was no adverse reaction to ICG. In contrast, postoperative bile leaks occurred in 2 of 32 patients who received the conventional leak test with normal saline solution between April 2007 and March 2008. The new bile leak test by ICG fluorography is useful to prevent postoperative bile leak.