Successful removal of an accidentally swallowed press-through package sheet using a detachable snare: A case report.

Accidental swallowing of press-through package (PTP) sheets that could cause esophageal perforation is commonly encountered in emergency departments requiring early detection and removal. We report a case in which an accidentally swallowed PTP sheet was removed from the esophagus using a detachable snare after usual endoscopic methods proved ineffective. A Japanese woman in her 60s visited the emergency department with a persistent sore throat. Cervicothoracic computed tomography revealed presence of a PTP sheet in the cervical esophagus, and emergency endoscopy was performed. Pre-endoscopy simulations using a sheet identical to the one swallowed by the patient indicated that the sheet would not have been retrievable using an overtube (its inner diameter was smaller than the sheet's diameter) and grasping forceps (they slipped off the sheet). It was successfully removed using a detachable snare, a device normally employed in colorectal polypectomy, allowing us to ligate the end of the sheet and pull it into the overtube. To the best of our knowledge, this is the first report of endoscopic removal of a PTP sheet from the esophagus using a detachable snare. We suggest that this novel method would facilitate removal of esophageal PTP sheets.

Survival Rate and Shunt Infection Incidence Following Gastrostomy in Adult Patients with an Existing Ventriculoperitoneal Shunt.

Ventriculoperitoneal shunts (VPS) and gastrostomies are frequently provided in daily practice. This study investigated the incidence of VPS infection and the survival rate among adult patients who underwent gastrostomy at least 1 month after VPS placement. This single-center retrospective cohort study was conducted among patients with a VPS, who underwent a gastrostomy. This procedure was performed on a standby basis after a period of at least 1 month had elapsed since VPS placement. Subsequent VPS infection and survival rates were assessed over a period of at least 6 months. We reviewed 31 patients who had a VPS at the time of gastrostomy. Gastrostomy was performed endoscopically in 29 cases and via open surgery in 2 cases. The average interval between VPS insertion and gastrostomy was 1135.5 ± 1717.1 days. A single case of VPS infection (3.2%) was diagnosed during the study. This infection rate was not significantly different than that among 230 patients who underwent their first VPS placement (without gastrostomy) at our institution during the same time period (P = .57); there was also no significant difference in the survival rate, compared to 38 age-matched patients (with cerebrovascular disease, but without a VPS) who underwent gastrostomy (P = .73). Gastrostomy performed after an interval of at least 1 month after VPS placement was extremely safe in adult patients, and their prognosis was excellent. Additional studies are required to develop appropriate nutritional interventions for patients with a VPS.

Procedure-Related Complications and Survival after Gastrostomy: Results from a Japanese Cohort.

INTRODUCTION: In 2010, a large-scale multi-institutional study in Japan showed a good prognosis for percutaneous endoscopic gastrostomy (PEG). However, the function and efficacy of PEG are not fully understood by patients, families, and health-care professionals; thus, the number of PEG treatments in Japan has declined. Therefore, we aimed to investigate the safety of the PEG procedure and subsequent survival after PEG. METHODS: In total, 249 PEGs were performed at Juzenkai Hospital from 2005 to 2017. PEG was originally performed using the pull method and then by a modified introducer method from mid-2011. We examined procedure-related complications and survival rates after PEG. RESULTS: Fifty-one (20.5%) procedure-related complications occurred; emergency surgery was required in 4 cases. Infections accounted for 76.5% (39/51) of complications. More infections occurred with the pull method than with the modified introducer method. The 1-year survival rate was 66.8%; the median survival time was 678 days. Nine patients (3.6%) died within 30 days; no deaths were directly related to PEG. Sex, age, and albumin level before surgery significantly influenced the prognosis. CONCLUSION: Due to changes in the PEG insertion method and other factors, PEG has become a safer treatment method. Additionally, PEG-based nutritional supplementation is associated with adequate survival.

Relationship of α-fetoprotein levels and development of hepatocellular carcinoma in hepatitis C patients with liver cirrhosis.

α-fetoprotein (AFP) is a tumor marker of hepatocellular carcinoma (HCC) and has also been reported to reflect the effectiveness of long-term low-dose interferon (IFN) therapy in hepatitis C virus (HCV)-infected patients with chronic liver disease. The correlation between AFP levels and the incidence of HCC has been discussed over a long period. We investigated whether high levels of AFP at the time of diagnosis were associated with an increased incidence of HCC in patients with HCV. A total of 107 HCV patients with liver cirrhosis without other risks were evaluated for the predictive value of non-invasive risk factors for HCC, including age, gender, alcohol intake, aspartate and alanine aminotransferase levels, bilirubin, albumin, platelet count and AFP levels at study entry, as well as the IFN therapy received. During the follow-up period, HCC developed in 68 (63.6%) patients. Kaplan-Meier estimates were made to assess the cumulative risk of HCC. The 10-year cumulative incidence rate of HCC was 80%. Cox regression analysis was performed on several variables, including age, gender, alcohol consumption, experience of IFN therapy and biochemical parameters. The following factors were identified as exhibiting an increased risk of HCC by univariate analysis: aspartate transaminase (AST) ≥71 IU/l, alanine transaminase (ALT) ≥60 IU/l, AFP ≥6 ng/ml and IFN therapy. Multivariate analysis identified that the AFP level [6-19 ng/ml: hazard ratio (HR), 2.22; P=0.006 and ≥20 ng/ml: HR, 2.09; P=0.003] was an independent and significant risk factor for the development of HCC. A slightly elevated (6-19 ng/ml) AFP level may be a risk factor for HCC in certain cases. By contrast, AFP levels <6 ng/ml indicate a low risk of HCC development in HCV patients with liver cirrhosis.

Implication of cholesterol in cyclosporine pharmacodynamics in minimal change nephrotic syndrome.

BACKGROUND: High blood cholesterol concentrations in patients with minimal change nephrotic syndrome may affect cyclosporine (INN, ciclosporin) pharmacodynamics and its clinical efficacy, but few attempts have been carried out to disclose this problem. METHODS: We evaluated the cellular pharmacodynamics of cyclosporine in 24 patients with minimal change nephrotic syndrome. In vitro cyclosporine concentrations yielding 50% inhibition (IC(50)) of blastogenesis of peripheral blood mononuclear cells (PBMCs) stimulated with concanavalin A were calculated. The relationships between the IC(50) values and laboratory data including serum total cholesterol, low-density lipoprotein (LDL) cholesterol, and high-density lipoprotein (HDL) cholesterol concentrations were examined. Clinical cyclosporine efficacy was assessed by a decreasing rate (percentage) of urinary protein 1 week after cyclosporine therapy. Percentages of LDL receptor-positive or CD3-positive PBMCs were evaluated with flow cytometry in 7 patients and 15 healthy subjects. RESULTS: The cyclosporine IC(50) values negatively correlated with the clinical cyclosporine efficacy assessed by a decreasing rate of urinary protein (r = -0.708, P =.0006). Cyclosporine IC(50) values significantly correlated with either serum total cholesterol (r = 0.681, P =.0003) or LDL cholesterol (r = 0.751, P =.0034) concentrations. Furthermore, serum total or LDL cholesterol levels significantly correlated negatively with clinical cyclosporine efficacy (r = -0.613, P =.0057, and r = -0.773, P =.0399, respectively). In 7 patients, serum total and LDL cholesterol concentrations were significantly higher than those of 15 healthy subjects (P <.005), whereas the percentages of LDL receptor-expressing cells in CD3-enriched PBMCs were not significantly different between these patients and healthy subjects. In addition, the cyclosporine IC(50) values and the percentages of LDL receptor-expressing PBMCs did not negatively correlate in either the patients or the healthy subjects. CONCLUSIONS: The data raised the possibility that hypercholesterolemia in patients with minimal change nephrotic syndrome attenuates cellular and clinical cyclosporine pharmacodynamics. Down-regulation of LDL receptor in T cells was not observed in these patients, and individual deviation of PBMC response to cyclosporine does not appear to be related to the difference of LDL receptor-positive cell numbers.