A Case of Brugada Syndrome Treated With Percutaneous Epicardial Catheter Ablation / 日本農村医学会雑誌

This case report describes our first experience performing percutaneous epicardial catheter ablation for Burugada syndrome in our hospital. We describe the good results achieved in this case. The patient was a man in his 30s with no remarkable medical history. However, his family history was notable for the sudden death of his grandfather at age 37 years and his father at age 27 years. While asleep, the patient experienced convulsions and lost consciousness. During emergency transportation, defibrillation was performed 7 times by the ambulance crew. When the patient arrived at our hospital, sinus rhythm was observed on ECG. During resuscitation, Burugada syndrome was diagnosed based on ECG findings. On hospital day 6, an internal cardioverter defibrillator was implanted. After discharge, the defibrillator operated 10 times, so we opted for ablation treatment. Fractionated potential of over 150 ms was confirmed in the right ventricular outflow tract. A low voltage zone of <1 mV could be mapped, and the same site was cauterized a total of 46 times. As a result, ST segment amplitude decreased significantly in lead V1 on ECG. Percutaneous epicardial catheter ablation performed with reference to Nademanee’s report achieved good results in this case of Burugada syndrome.

Diagnostic Ability of Convex-Arrayed Endoscopic Ultrasonography for Major Vascular Invasion in Pancreatic Cancer

BACKGROUND/AIMS: This study aimed to examine the diagnostic ability of endoscopic ultrasonography (EUS) for major vascular invasion in pancreatic cancer and to evaluate the relationship between EUS findings and pathological distance. METHODS: In total, 57 consecutive patients who underwent EUS for pancreatic cancer before surgery were retrospectively reviewed. EUS image findings were divided into four types according to the relationship between the tumor and major vessel (types 1 and 2: invasion, types 3 and 4: non-invasion). We also compared the EUS findings and pathologically measured distances between the tumors and evaluated vessels. RESULTS: The sensitivity, specificity, and accuracy of EUS diagnosis for vascular invasion were 89%, 92%, and 91%, respectively, in the veins and 83%, 94%, and 93%, respectively, in the arteries. The pathologically evaluated distances of cases with type 2 EUS findings were significantly shorter than those of cases with type 3 EUS findings in both the major veins (median [interquartile range], 96 [0–742] µm vs. 2,833 [1,076–5,694] µm, p=0.012) and arteries (623 [0–854] µm vs. 3,097 [1,396–6,000] µm, p=0.0061). All cases with a distance of ≥1,000 µm between the tumors and main vessels were correctly diagnosed. CONCLUSIONS: Tumors at a distance ≥1,000 µm from the main vessels were correctly diagnosed by EUS.

Endoscopic Ultrasonography-Guided Gallbladder Drainage as a Treatment Option for Acute Cholecystitis after Metal Stent Placement in Malignant Biliary Strictures

BACKGROUND/AIMS: It is often difficult to manage acute cholecystitis after metal stent (MS) placement in unresectable malignant biliary strictures. The aim of this study was to evaluate the feasibility of endoscopic ultrasonography-guided gallbladder drainage (EUS-GBD) for acute cholecystitis. METHODS: The clinical outcomes of 10 patients who underwent EUS-GBD for acute cholecystitis after MS placement between January 2011 and August 2018 were retrospectively evaluated. The procedural outcomes of percutaneous transhepatic gallbladder drainage (PTGBD) with tube placement (n=11 cases) and aspiration (PTGBA) (n=27 cases) during the study period were evaluated as a reference. RESULTS: The technical success and clinical effectiveness rates of EUS-GBD were 90% (9/10) and 89% (8/9), respectively. Severe bile leakage that required surgical treatment occurred in one case. Acute cholecystitis recurred after stent dislocation in 38% (3/8) of the cases. Both PTGBD and PTGBA were technically successful in all cases without severe adverse events and clinically effective in 91% and 63% of the cases, respectively. CONCLUSIONS: EUS-GBD after MS placement was a feasible option for treating acute cholecystitis. However, it was a rescue technique following the established percutaneous intervention in the current setting because of the immature technical methodology, including dedicated devices, which need further development.

Predictive Factors for Inaccurate Diagnosis of Swollen Lymph Nodes in Endoscopic Ultrasound-Guided Fine Needle Aspiration

BACKGROUND/AIMS: This study aimed to identify the predictive factors for inaccurate endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) diagnosis of swollen lymph nodes without rapid on-site cytopathological evaluation. METHODS: Eighty-three consecutive patients who underwent EUS-FNA for abdominal or mediastinal lymph nodes from January 2008 to June 2017 were included from a prospectively maintained EUS-FNA database and retrospectively reviewed. The sensitivity, specificity, and accuracy of EUS-FNA for the detection of neoplastic diseases were calculated. Candidate factors for inaccurate diagnosis (lymph node size and location, needle type, puncture route, number of passes, and causative disease) were evaluated by comparison between accurately diagnosed cases and others. RESULTS: The final diagnosis of the punctured lymph node was classified as neoplastic (65 cases: a metastatic lymph node, malignant lymphoma, or Crow-Fukase syndrome) or non-neoplastic (18 cases: a reactive node or amyloidosis). The sensitivity, specificity, and accuracy were 83%, 94%, and 86%, respectively. On multivariate analyses, small size of the lymph node was the sole predictive factor for inaccurate EUS-FNA diagnosis with a significant difference (odds ratios, 19.8; 95% confidence intervals, 3.15–124; p=0.0015). CONCLUSIONS: The lymph node size of <16 mm was the only independent factor associated with inaccurate EUS-FNA diagnosis of swollen lymph nodes.

Predictive Value of Localized Stenosis of the Main Pancreatic Duct for Early Detection of Pancreatic Cancer

BACKGROUND/AIMS: In this study, we aimed to evaluate the predictive value of localized stenosis of the main pancreatic duct (MPD) for early detection of pancreatic cancer.METHODS: Among 689 patients who underwent endoscopic retrograde pancreatography from January 2008 to September 2018, 19 patients with MPD findings were enrolled. These patients showed findings for indicating suspicious pancreatic cancer at an early stage (FiCE); FiCE was defined as a single, localized stenosis in the MPD without a detectable mass (using any other imaging methods) and without other pancreatic diseases, such as definite chronic pancreatitis, intraductal papillary mucinous neoplasm, and autoimmune pancreatitis. Final diagnoses were established by examining resected specimens or through follow-up examinations after an interval of >5 years.RESULTS: Among 19 patients with FiCE, 11 underwent surgical resection and 8 were evaluated after a >5-year observation period. The final diagnosis of the MPD stenosis was judged to be pancreatic cancer in 9 patients (47%), including 3 with intraepithelial cancer, and to be a non-neoplastic change in 10. The sensitivity, specificity, and accuracy of preoperative pancreatic juice cytology were 75%, 100%, and 88%, respectively.CONCLUSIONS: The predictive value of FiCE for pancreatic cancer prevalence was 47%. Histological confirmation with pancreatic juice cytology is necessary before surgical resection.

Capability of Radial- and Convex-Arrayed Echoendoscopes for Visualization of the Pancreatobiliary Junction

BACKGROUND/AIMS: Although both radial- and convex-arrayed endoscopic ultrasonography (EUS) scopes are widely used for observational EUS examinations, there have been few comparative studies on their power of visualization. The aim of this study was to evaluate the capability of these EUS scopes for observation of the pancreatobiliary junction. METHODS: The rate of successful visualization of the pancreatobiliary junction was retrospectively compared between a radial-arrayed and a convex-arrayed echoendoscope, from a prospectively maintained database. Study periods were defined as January 2010 to December 2012 for the radial group, and February 2015 to October 2016 for the convex group because the respective scope was mainly used during those periods. RESULTS: During the study period, 1,660 cases with radial EUS and 1,984 cases with convex EUS were recruited. The success rates of observation of the pancreatobiliary junction were 80.0% and 89.5%, respectively (p < 0.0001). CONCLUSIONS: The capability of visualization of the pancreatobiliary junction in observational EUS was found to be better with a convex-arrayed than with a radial-arrayed echoendoscope.

Hyperbaric Oxygen Treatment of Carbon Monoxide Poisoning in the Past 5 Years / 日本農村医学会雑誌

　　Hyperbaric oxygen (HBO) therapy for acute carbon monoxide (CO) poisoning is performed after oxygen therapy and breathing therapy. The usefulness of HBO therapy in emergency treatment has been reported. In this study, we examined the effectiveness of HBO for CO poisoning that was performed at our hospital over the past 5 years. Subjects were 23 patients who had HBO therapy for CO poisoning in the period January 2008-November 2013. The male to female ratio of the cases was 14:9 and the mean age was 54.6±20.8 years. The cause was suicide in 39.1% of cases and accident in 60.9%. The mean number of treatments was 5.4±6.8. The atmosphere absolute was 2ATA:2.8ATA=12:11. The ratio of direct conveyance of the patient to our hospital to indirect conveyance of the patient from another hospital was 15:8. The effectiveness of HBO therapy at the time of discharge was 73.9%. However, delayed neuropsychiatric sequelae (DNS) was detected in 3 of the 23 cases of CO poisoning. No correlations were found between elapsed time after CO inhalation and various blood parameters. However, time to start of therapy is important for DNS, and our results suggest that early treatment at a hospital with a hyperbaric chamber is necessary.

A case in which sodium valproate through a percutaneous endoscopic gastrostomy tube was effective for delirium in a terminal cancer patient

<b>Purpose</b>: We report a case in which oral sodium valproate through a percutaneous endoscopic gastrostomy (PEG) tube for palliative decompression drainage in inoperable ileus achieved an effective drug concentration and ameliorated delirium and extrapyramidal side effects. <b>Case Report</b>: The patient was a male in his seventies who suffered from bladder cancer. He underwent PEG because of paralytic ileus with cancerous peritonitis. He had been receiving continuous intravenous infusion of haloperidol for the management of delirium, but needed to discontinue treatment with this agent due to tremor, an extrapyramidal side effect of haloperidol. Oral sodium valproate was therefore administered through the PEG tube for palliative decompression drainage. Plasma valproate concentrations showed effective levels, and his irritability was relieved. A good combination of sodium valproate and quetiapine fumarate allowed successful reduction of and eventual withdrawal from haloperidol, and tremor then improved. <b>Conclusion</b>: We often encounter difficulty with symptom control for patients who cannot use oral medications. When medication by other routes is difficult, this case suggests that sodium valproate through a PEG tube for palliative decompression drainage may be useful as a last resort for improving delirium.