Lung-to-heart ratio analysis using virtual planar images obtained from myocardial perfusion SPECT data: A phantom and clinical studies.

BACKGROUNDS: The lung-to-heart ratio (L/H ratio) in myocardial perfusion scintigraphy (MPS) is a useful marker that complements the sensitivity of ischemia detection. However, it requires planar imaging acquired following a separate protocol in addition to single-photon emission computed tomography (SPECT). We developed a novel method for constructing virtual planar image (VPI) from SPECT data. METHODS: Myocardial phantoms using Tl-201 were built with different amounts of radioactivity in the lungs. SPECT data and conventional planar images of these phantoms were collected with an Anger-type gamma camera. VPIs were constructed by adding all coronal images reconstructed from SPECT data. The clinical utility of VPIs obtained from 52 patients who underwent MPS with Tc-99m sestamibi was evaluated. RESULTS: The radioactivity linearity of VPIs was satisfactory, with a correlation coefficient of r ≥ .99 between the measured amounts of radioactivity and image counts. The L/H ratios obtained from VPI analysis were strongly correlated with those of conventional planar images with a correlation coefficient of r ≥ .99 in the phantom study and r = .929 in clinical application. CONCLUSION: The accuracy of VPI-based L/H ratio analysis was comparable to that of conventional planar image-based analysis. VPIs could be used as an alternative method of obtaining planar images in clinical settings.

Risk factors for postoperative bleeding and early death in percutaneous endoscopic gastrostomy: A multicenter retrospective study.

BACKGROUND AND AIM: Comprehensive reports on the risk factors for bleeding and early death after percutaneous endoscopic gastrostomy (PEG) are limited. In this multicenter study, we retrospectively investigated the risk factors for bleeding and early death after PEG. METHODS: Patients (n = 1234) who underwent PEG between 2015 and 2020 at Osaka Medical and Pharmaceutical University and its affiliated hospitals (11 institutions in total) were evaluated for postoperative bleeding and early death (within 60 days) after PEG according to patient characteristics, construction method, medical history, medications, preoperative hematological findings, and perioperative adverse events. Multivariate logistic regression was performed to identify independent predictors of bleeding and early death after PEG. RESULTS: The risk factors for bleeding after PEG were PEG tube insertion using the modified introducer method (odds ratio [OR], 4.37; P = 0.0003), low platelet count (OR, 0.99; P = 0.014), antiplatelet therapy (OR, 2.11; P = 0.036), and heparinization (OR, 4.50; P = 0.007). Risk factors for early death were low body mass index (BMI) (OR, 0.89; P = 0.015), low serum albumin levels (OR, 0.50; P = 0.035), and comorbidity of active cancer (OR, 4.03; P < 0.0001). There was no significant association between bleeding and early death after PEG. CONCLUSIONS: We identified several risk factors for bleeding and early death after PEG. Risk factors for bleeding were PEG tube insertion using the modified introducer method, low platelet count, antiplatelet therapy, and heparinization. Risk factors for early death were low BMI, low serum albumin levels, and comorbidity of active cancer.

Effect of echoendoscope angle on success of guidewire manipulation during endoscopic ultrasound-guided hepaticogastrostomy.

BACKGROUND: With endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS), guidewire manipulation might be a critically limiting step for nonexperts. However, the causes of difficult guidewire manipulation remain unclear. The aim of this study was to evaluate factors associated with successful guidewire manipulation. METHODS: This retrospective cohort study included consecutive patients who underwent EUS-HGS between October 2018 and October 2019. We measured scope angle between the long and needle axes of the echoendoscope using still fluoroscopic imaging immediately after puncturing the intrahepatic bile duct. Factors associated with successful guidewire insertion were assessed by multivariable analysis using logistic regression. RESULT: The influence of the angle between the fine-needle aspiration (FNA) needle and echoendoscope on failed guidewire insertion was assessed using receiver operating characteristic (ROC) curves. Area under the ROC curve was 0.86 (95 % confidence interval [CI] 0.00 - 0.76), and an angle of 135° offered 88.0 % sensitivity and 82.9 % specificity for predicting successful guidewire insertion. According to multivariable analysis, only angle between the FNA needle and echoendoscope > 135° was independently associated with successful guidewire insertion (odd ratio 0.03, 95 %CI 0.01 - 0.14; P < 0.05), whereas sex, puncture site, and diameter of puncture site were not significant factors. After multivariable analysis, all variables were adjusted using age ≥ 70 or < 70 years, yielding the same results. CONCLUSION: The angle between the FNA needle and echoendoscope might be associated with successful guidewire manipulation during EUS-HGS. Adjusting this angle to 135° before puncturing the intrahepatic bile duct might be helpful in achieving successful guidewire manipulation during EUS-HGS.

The Management of Recurrence within Six Months after Hepatic Resection for Colorectal Liver Metastasis.

BACKGROUND: Hepatectomy is currently recommended as the most reliable treatment for colorectal liver metastases. However, the association between the choice of treatment for recurrence and the timing of recurrence remains controversial. METHODS: Two-hundred ninety-five patients who underwent hepatectomy were retrospectively analyzed for the risk factors and the outcomes for early recurrence within 6 months. The remnant liver volumes (RLVs) and laboratory data were measured postoperatively using multidetector computed tomography on days 7 and months 1, 2, and 5 after the operation. RESULTS: Early recurrence developed in 88/295 patients (29.8%). Colorectal cancer lymph node metastasis, synchronous liver metastasis, and multiple liver metastases were independent risk factors for the occurrence of early recurrence (p < 0.001, 0.032, and 0.019, respectively). Patients with early recurrence had a poorer prognosis than did patients who developed later recurrence (p < 0.001). Patients who underwent surgery or other local treatment had better outcomes. The changes in RLV and laboratory data after postoperative month 2 were not significantly different between the 2 groups. CONCLUSION: Patients with early recurrence within 6 months had a poorer prognosis than did patients who developed later recurrence. However, patients who underwent repeat hepatectomy for recurrence had a better prognosis than did those who underwent other treatments, with good prospects for long-term survival.

A randomized phase II study of nutritional and exercise treatment for elderly patients with advanced non-small cell lung or pancreatic cancer: the NEXTAC-TWO study protocol.

BACKGROUND: Most advanced elderly cancer patients experience fatigue, anorexia, and declining physical function due to cancer cachexia, for which effective interventions have not been established. We performed a phase I study of a new nonpharmacological multimodal intervention called the nutritional and exercise treatment for advanced cancer (NEXTAC) program and reported the excellent feasibility of and compliance with this program in elderly patients with advanced cancer who were at risk for cancer cachexia. We report here the background, hypothesis, and design of the next-step multicenter, randomized phase II study to evaluate the efficacy of the program, the NEXTAC-TWO study. METHODS: Patients with chemo-naïve advanced non-small cell lung cancer or pancreatic cancer, age ≥ 70 years, performance status ≤2, with adequate organ function and without disability according to the modified Katz index will be eligible. In total, 130 participants will be recruited from 15 Japanese institutions and will be randomized into either the intervention group or a control group. Computer-generated random numbers are allocated to each participant. Stratification factors include performance status (0 to 1 vs. 2), site of primary cancer (lung vs. pancreas), stage (III vs. IV), and type of chemotherapy (cytotoxic vs. others). Interventions and assessment will be performed 4 times every 4 ± 2 weeks from the date of randomization. Interventions will consist of nutritional counseling, nutritional supplements (rich in branched-chain amino acids), and a home-based exercise program. The exercise program will include low-intensity daily muscle training and lifestyle education to promote physical activity. The primary endpoint is disability-free survival. It is defined as the period from the date of randomization to the date of developing disability or death due to any cause. This trial also plans to evaluate the improvements in nutritional status, physical condition, quality of life, activities of daily living, overall survival, and safety as secondary endpoints. Enrollment began in August 2017. The study results will demonstrate the efficacy of multimodal interventions for elderly cancer patients and their application for the maintenance of physical and nutritional conditions in patients with cancer cachexia. This work is supported by a grant-in-aid from the Japan Agency for Medical Research and Development. DISCUSSION: This is the first randomized trial to evaluate the efficacy and safety of a multimodal intervention specific for elderly patients with advanced cancer. TRIAL REGISTRATION: Registered at August 23, 2017. Registry number: UMIN000028801 .

Can Iodixanol Prevent Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis? A Prospective, Randomized, Controlled Trial.

BACKGROUND: It is yet not clear whether differences in the contrast medium may affect post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). AIM: The aim of this study was to evaluate the rate of PEP between high osmolality contrast medium (HOCM) and iso osmolar medium (IOCM) in a prospective, randomized, controlled trial. METHODS: Patients who were scheduled to undergo a diagnostic or therapeutic procedure under ERCP guidance were included. Patients were excluded from this study if they (1) were < 20 years old; (2) had acute or active pancreatitis; (3) had previously undergone ERCP; (4) had surgical altered upper gastrointestinal tract anatomy; or (5) refused to be involved in this study. RESULTS: Seventy-five patients were randomly assigned to the IOCM group, and 71 patients were assigned to the HOCM group. PEP occurred in 27 patients (18.5%). Although there were no significant differences, the severe grade of PEP was more frequent in the HOCM group than in the IOCM group (p = 0.08). The results of the multivariate analyses for PEP were not identified as independent risk factors. Also, independent risk factors of hyperamylasemia were performing pre-cut. In subgroup analyses, HOCM was an independent risk factor for hyperamylasemia. CONCLUSIONS: In conclusion, HOCM may play a role in the development of PEP and in PEP severity grade.

Comparison of the clinical impact of endoscopic ultrasound-guided choledochoduodenostomy and hepaticogastrostomy for bile duct obstruction with duodenal obstruction.

BACKGROUND AND STUDY AIM: To date, only a few reports with small numbers of patients have described double stenting (biliary and duodenal), in particular endoscopic ultrasound (EUS)-guided biliary drainage, for patients with obstructive jaundice. In addition, no reports have sought to determine which EUS-guided biliary drainage route has better outcomes. The aim of the current study was to investigate adverse events and stent patency in patients who underwent EUS-guided biliary drainage and duodenal stenting. PATIENTS AND METHODS: Patients who were admitted to the Osaka Medical College with obstructive jaundice caused by lower biliary obstruction and duodenal obstruction due to malignant tumor between June 2012 and April 2014 were retrospectively enrolled in the study. RESULTS: A total of 39 patients were enrolled in the study; 13 underwent EUS-guided choledochoduodenostomy (EUS-CDS), and 26 underwent EUS-guided hepaticogastrostomy (EUS-HGS). Adjusted analyses for covariates using propensity scores showed that the EUS-HGS group had significantly longer stent patency than the EUS-CDS group (duodenal stent patency: median 113 vs. 34 days; hazard ratio [HR] 0.415, 95 % confidence interval [CI] 0.175 - 0.984; P = 0.046; biliary stent patency: median 133 vs. 37 days; HR 0.391, 95 %CI 0.156 - 0.981; P = 0.045). On logistic regression analysis, only EUS-CDS was associated with adverse events, in particular reflux cholangitis (OR 10.285, 95 %CI 1.686 - 62.733; P = 0.012). CONCLUSION: In cases of obstructive jaundice with duodenal obstruction, EUS-HGS may be better than EUS-CDS, with longer stent patency and fewer adverse events.

Yield of endoscopic ultrasound-guided fine needle aspiration and endoscopic retrograde cholangiopancreatography for solid pancreatic neoplasms.

OBJECTIVE: Both endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) and endoscopic retrograde cholangiopancreatography (ERCP) cytology may provide tissue diagnoses in solid pancreatic neoplasms. However, there are scant data comparing these two methods. This study aims at retrospectively comparing EUS-FNA and ERCP tissue sampling and ability of cytopathological diagnosis in solid pancreatic neoplasms and to determine usefulness and adverse events of combining both procedures. MATERIAL AND METHODS: Two hundred and thirty four patients suspected to have solid pancreatic mass on abdominal ultrasound and/or computed tomography (CT) were enrolled. EUS-FNA (group A), ERCP cytology (group B) and combined procedures (Group C) performed in 105, 91 and 38 cases, respectively. RESULTS: Sensitivity, specificity and accuracy were 98.9%, 93.3% and 98.1% for group A, and 72.1%, 60% and 71.4% for group B. Those for group C were all 100%. Sensitivity for malignancy in the pancreas head was 100% for group A and 82.4% for group B, and in the pancreas body and tail, 97.6% for group A and 57.1% for group B. EUS-FNA was more sensitive than ERCP cytology in diagnosing malignant pancreatic neoplasms 21-30 mm in size (p = 0.0068), 31-40 mm (p = 0.028) and ≥ 41 mm (p < 0.0001). Sensitivity for pancreatic malignancy with group C was 100% regardless of mass location or size. Adverse events were 1.9%, 6.6% and 2.6% following EUS-FNA, ERCP and combined procedures, respectively. CONCLUSIONS: EUS-FNA is superior to ERCP cytology for diagnosis of solid pancreatic neoplasms. Although combination of both procedures provide efficient tissue diagnosis and with a minimal adverse events rate, a prospective study including larger number of patients is required.

Endoscopic ultrasound-guided biliary drainage for right hepatic bile duct obstruction: novel technical tips.

Endoscopic ultrasound (EUS)-guided biliary drainage (EUS-BD) is not normally indicated for an obstructed right intrahepatic bile duct (IHBD). The technical feasibility and clinical efficacy of a novel technique of EUS-BD for right IHBD obstruction were evaluated. A total of 11 patients underwent drainage using either a left or a right biliary access route. The causes of obstructive jaundice were cholangiocarcinoma (n = 6), pancreatic cancer (n = 3), gastric cancer (n = 1), and colon cancer (n = 1). After placement of an uncovered metal stent to bridge the obstruction, a hepaticogastrostomy was completed using a covered stent. Mean procedure time was 33.9 ±â€Š10.0 minutes. Technical and functional success were achieved in all patients, and no adverse events occurred. This novel method appears to be safe and effective for right IHBD obstruction.

Stent length is impact factor associated with stent patency in endoscopic ultrasound-guided hepaticogastrostomy.

BACKGROUND AND STUDY AIM: Despite high technical and functional success rates with endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS), rates of adverse events have also been high. No reports have focused on EUS-HGS alone with a large sample size about predictors of stent patency. The present study examined predictors of stent patency in patients who underwent EUS-HGS. PATIENTS AND METHODS: The consecutive 51 patients who underwent EUS-HGS using one metallic stent were retrospectively enrolled in this study. Baseline characteristics, stent length from the hepatic portion and in the luminal portion, kinds of stent dysfunction, and stent patency were reviewed. RESULTS: Median duration of stent patency was significantly shorter with stent length in the luminal portion <3 cm (52 days) than with ≥3 cm (195 days; P < 0.01). On the other hand, median duration of stent patency did not differ significantly between ≥4 cm (194 days) and <4 cm (127 days; P = 0.1726). Length of stent in the luminal portion ≥3 cm (Hazard ration [HR], 9.242; 95% confidence interval [CI], 3.255-26.244, P < 0.05) and performance of chemotherapy (HR, 3.022; 95% CI, 1.448-6.304, P < 0.05) were also associated with long stent patency on the Cox proportional hazards model. CONCLUSION: In conclusion, to obtain long-term stent patency, our data suggest that a stent length ≥3 cm in the luminal portion may be suitable for EUS-HGS.

EUS-guided hepaticogastrostomy combined with fine-gauge antegrade stenting: a pilot study.

BACKGROUND AND STUDY AIM: To minimize bile leakage and avoid possible death because of stent migration in endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS), we have recently combined EUS-HGS with EUS-guided antegrade stenting (EUS-AS) of the biliary obstruction using a novel uncovered metallic stent with a fine-gauge delivery system. In this pilot study, we evaluated the feasibility and adverse events associated with this combination therapy using the novel stent. PATIENTS AND METHODS: We performed EUS-guided antegrade stenting and hepaticogastrostomy in 12 consecutive patients. RESULTS: The novel EUS-AS stent was placed across the ampulla of Vater in 8 patients and above the ampulla in 4. Technical and functional success rates were 100 %. In addition, the insertion of the first stent was achieved in all patients without dilation of the fistula between stomach and intrahepatic bile duct. Although 1 patient experienced mild pancreatitis, adverse events such as bile peritonitis or stent dysfunction did not occur during follow-up (mean 122 days, range 62 - 210 days). CONCLUSION: This method appears to safely and effectively avoid adverse events associated with EUS-HGS.

Novel method of endoscopic ultrasound-guided hepaticogastrostomy to prevent stent dysfunction.

BACKGROUND AND STUDY AIM: The present study assesses the feasibility as well as the technical and functional success rates of a novel endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) technique called the locking stent method that uses end-bare covered metallic stents (EBCMS). METHODS: Twenty consecutive patients who were histologically diagnosed with unresectable cancer complicated with obstructive jaundice underwent EUS-HGS due to failed endoscopic biliary drainage or inaccessible papilla. We retrospectively collected clinical data for these patients including technical and functional success rates and complications. RESULTS: Seven were treated by EUS-HGS (EUS-HGS group), and 13 were treated using the locking stent EUS-HGS method (LS group). Technical and functional success rates were 100% in both groups. Procedural duration did not significantly differ between the EUS-HGS and LS groups (26.9 ± 9.0 versus 32.3 ± 11.1 min, P = 0.30). Two patients developed complications related to stent migration in the EUS-HGS group. In contrast, although mild post-procedural bile peritonitis required conservative treatment for a few days, none of the stents malfunctioned in the LS group. CONCLUSION: Our method can safely and effectively prevent stent dysfunction, but validation in a prospective clinical trial is required.

Can endoscopic ultrasound-guided fine needle aspiration offer clinical benefit for thick-walled gallbladders?

BACKGROUND: No previous studies have compared cytology obtained under endoscopic transpapillary gallbladder drainage (ETGD) and EUS-guided fine needle aspiration (EUS-FNA) for thick-walled gallbladders. AIM: The present study investigated the diagnostic yield of bile cytology under ETGD and EUS-FNA for gallbladder tumors. METHODS: A total of 69 patients were diagnosed as having gallbladder wall thickening. Among these patients, 28 patients were diagnosed by clinical follow-up, solely by imaging such as computed tomography or by histological examination of surgical specimens. The remaining 41 patients underwent ETGD and/or EUS-FNA. In these 41 patients, the clinical data collected included gender, age, diameter of gallbladder wall, site of gallbladder wall thickening, final diagnosis, adverse events, and diagnostic yield of ETGD and EUS-FNA. RESULTS: Cyto-histological diagnosis with EUS-FNA was higher than that with ETGD, with a sensitivity of 100 versus 71%, specificity of 100 versus 94%, and accuracy of 100 versus 88%, respectively, in the two groups. In addition, the sampling adequacy of EUS-FNA was 100%. Adverse events were seen in five patients in the ETGD group (mild pancreatitis), although no adverse events were seen in the EUS-FNA group (P = 0.08). CONCLUSION: Our results suggest that EUS-FNA can be safely performed for the diagnosis of gallbladder lesions. Further, this procedure may be the diagnostic method of choice over cytology of bile juice obtained via ETGD to obtain histological evidence of gallbladder cancer.

Potential predictors of disease progression for main-duct intraductal papillary mucinous neoplasms of the pancreas.

BACKGROUND AND AIM: The evidence for main pancreatic duct intraductal papillary mucinous neoplasms (MPD-IPMN) malignancy is based predominantly on investigation of resected cases, and the natural history is still unclear. The aim of the present study is to investigate the natural history of MPD-IPMN and examine potential predictors of disease progression in MPD-IPMN patients who conformed to "high-risk stigmata" criteria. METHODS: This study included consecutive 20 follow-up patients and 19 surgical patients with "high-risk stigmata" MPD-IPMN, in whom the diameter of the MPD was > 10 mm, branch duct was < 5 mm, and who underwent clinical follow up for ≥ 2 years. RESULTS: Among surgical patients, mural nodules and MPD diameter of invasive patients were significantly different compared with non-invasive patients. On the other hand, among follow-up patients, univariate analysis revealed the following potential predictors for disease progression: diameter of MPD ≥ 15 mm (hazard ratio [HR], 20.9; 95% confidence interval [CI], 2.59-173.4; P < 0.01); and diffuse lesions of MPD-IPMN (HR, 4.46; 95% CI, 1.10-18.0; P = 0.04). On the other hand, multivariate analysis identified only diameter of MPD ≥ 15 mm (HR, 19.2; 95% CI, 1.87-198.5; P = 0.01) as a potential predictor of disease progression. CONCLUSION: If MPD-IPMN patients have other severe complications or reasons for not undergoing surgical treatment, MPD diameter < 15 mm, negative cytology, and no mural nodules, conservative clinical follow up for several years may be an option.

[A case of xanthogranulomatous cholecystitis diagnosed by EUS-FNA in which changes were observed on FDG-PET].

An elderly man in his 70s presented with pain in the right hypochondrium. Computed tomography revealed thickening of the gall bladder wall and liver invasion. In addition, fluorine-18-fluorodeoxyglucose positron emission tomography (FDG-PET) revealed an abnormal accumulation in the gall bladder, leading to a suspicion of gall bladder carcinoma. To confirm the diagnosis, endoscopic ultrasound-guided fine-needle aspiration was performed, which revealed a diagnosis of xanthogranulomatous cholecystitis (XGC). FDG-PET revealed decreased wall thickness and standardized uptake value a month later. Cholecystectomy was performed on the basis of a histological and clinical diagnosis of XGC. Histological examination revealed inflammatory and foamy cells and exuberant granulation of the gall bladder wall, confirming XGC.

Neural invasion induces cachexia via astrocytic activation of neural route in pancreatic cancer.

Pancreatic cancer is characterized by a high frequency of cachexia, pain and neural invasion (N-inv). Neural damage is occurred by N-inv and modulates pain and muscle atrophy via the activation of astrocyte in the connected spine. The activated astrocyte by N-inv, thus, may affect cachexia in pancreatic cancer. Clinical studies in patients and autopsy cases with pancreatic cancer have revealed that N-inv is related to cachexia and astrocytic activation. We established a novel murine model of cancer cachexia using N-inv of human pancreatic cancer cells. Mice with N-inv showed a loss of body weight, skeletal muscle and fat mass without appetite loss, which are compatible with an animal model of cancer cachexia. Activation of astrocytes in the spinal cord connected with N-inv was observed in our model. Experimental cachexia was suppressed by disrupting neural routes or inhibiting the activation of astrocytes. These data provide the first evidence that N-inv induces cachexia via astrocytic activation of neural route in pancreatic cancer.

The Effects of Allogeneic Blood Transfusion in Hepatic Resection.

BACKGROUND: Hepatectomy has a high risk of perioperative bleeding due to the underlying disease. Here, we investigated the postoperative impact of allogeneic blood transfusion during hepatectomy. METHODS: The surgical outcomes in 385 patients who underwent hepatic resection for hepatocellular carcinoma were retrospectively reviewed. The association of allogeneic blood transfusion with surgical outcomes and remnant liver regeneration data was analyzed. RESULTS: Eighty-six patients (24.0%) received an allogeneic blood transfusion and 272 patients (76.0%) did not. After propensity score matching, the incidence rates of postoperative complication (Clavien-Dindo grade >IIIA), posthepatectomy liver failure, and massive ascites were significantly higher for the group that received a blood transfusion than for the group that did not receive blood transfusion (P < .001, P = .001, and <.001, respectively). Postoperative measures of total bilirubin, albumin, platelet count, prothrombin time, aspartate aminotransferase, and alanine aminotransferase were significantly more favorable in patients without blood transfusion until day 7 after surgery. There were no correlations in the remnant liver regeneration at 7 days, and 1, 2, 5, and 12 months postoperatively between the 2 groups (P = .585, .383, .507, .261, and .430, respectively). Regarding prognosis, there was no significant difference in overall and recurrence-free survival between the 2 groups (P = .065 and .166, respectively). CONCLUSION: Allogeneic transfusion during hepatectomy strongly affected remnant liver function in the early postoperative period; however, this was not related to the remnant liver regeneration volume. Despite that the allogeneic transfusion resulted in poorer postoperative laboratory test results and increased postoperative complication and mortality rates, it had no effect on the long-term prognosis.