Safety measures for gastrointestinal endoscopy in patients receiving antithrombotic therapy

Aim: Owing to carelessness of endoscopists, invasive procedures, such as biopsy, are sometimes carried out inadvertently in patients receiving antithrombotic therapy. The aim of the present study was to retrospectively evaluate the actual status of such careless mistakes and the efficacy of new safety measures. Methods: A questionnaire survey was conducted in 34 endoscopists at Toranomon Hospital about experiences of careless mistakes and experiences of anxiety before and after the procedure. ‘Anxiety before procedure’ was defined as the experience of discontinuing a given procedure because endoscopists remembered that the patient was receiving antithrombotic therapy, and ‘anxiety after procedure’ was defined as the experience of feeling anxious about the status of medication after the invasive procedure. A new measure was introduced at Health Management Center in August 2009. In this measure, endoscopists directly interview each patient about the status of medication just before examination, and attach forceps valves of one of two colors depending on the status of medication. A blue forceps valve is attached for patients undergoing antithrombotic therapy, and a conventional black forceps valve is attached for patients not undergoing antithrombotic therapy. Six months after introduction, a questionnaire survey was conducted in 10 endoscopists in this center. Results: Approximately half of endoscopists (18/34) experienced such careless mistakes. ‘Anxiety’ had been experienced by approximately 80%. After introduction, there was no report of careless mistakes and frequency of ‘anxiety’ evaluated by visual analog scale score decreased significantly. Conclusion: This new safety measure is expected to facilitate safer gastrointestinal endoscopy in patients receiving antithrombotic therapy.     

ENDOSCOPIC SUBMUCOSAL DISSECTION FOR SUBMUCOSAL INVASIVE GASTRIC CANCER AND CURABILITY CRITERIA

Aims: The aims of the present study were to evaluate the feasibility of endoscopic submucosal dissection (ESD) as curative treatment for node‐negative submucosal invasive early gastric cancer (EGC) and to consider further expansion of the curability criteria for submucosal invasive EGC. Methods: A total of 977 EGC in 855 patients treated by ESD were enrolled. They were divided into intramucosal cancer (M); minimally submucosal invasive cancer (<500 µm from the muscularis mucosa) (SM1); and deeper submucosal invasive cancer (>500 µm from the muscularis mucosa) (SM2). The technical feasibility of ESD for SM1 and M were compared, and the clinical prognosis of SM1 was evaluated. Furthermore, the volume of carcinoma invading to the submucosal layer, which we called the SM volume index, was calculated virtually to analyze its correlation with lymphatic‐vascular invasion. Results: There were no statistical differences in technical outcomes and complications between M and SM1. Curative resection rates were significantly better in M than in SM1 (M, 92.6%; SM1, 63.8%). No local recurrences and distant metastases were found in 48 SM1 patients declared to have undergone curative resections. Most cases (72.0%) with successful ESD but non‐curative resection exceeded 30 mm in maximum size, and no local recurrences and metastases were found in these patients. The SM volume index of these cases was comparatively small. Conclusion: The technical and theoretical validity of ESD for SM1 was validated. The possibility of further expansion of the curability criteria for submucosal invasive cancers was suggested by the evaluation of the SM volume index.     

Blue laser imaging identifies endoscopic findings corresponding to metachronous esophageal squamous cell carcinoma

Esophagus - This study aimed to evaluate endoscopic findings using non-magnifying blue laser imaging (BLI) to determine the risk factors for metachronous esophageal squamous cell carcinoma (ESCC)....     

A new strategy for management of retroperitoneal tumors with supradiaphragmatic vena caval thrombi

A new surgical technique to treat retroperitoneal tumors with supradiaphragmatic vena caval invasion is described. In this technique, hepatic warm ischemia can be avoided with reversed hepatic outflow through the portal vein and neither hypothermic circulatory arrest nor cardiopulmonary bypass is necessary using centrifugal blood pump-driven bypass.     

Nephrologist care for 12 months or more increases hemodialysis initiation with permanent vascular access

Background  

The objective of this study was to evaluate the effect of early referral (ER) to nephrologists on the type of vascular access (VA) available for use at the time of initiation of maintenance hemodialysis (HD). In patients who have been followed by nephrologists for less than 3 months, management before the initiation of HD is often insufficient and urgent initiation of HD is often necessary; therefore, patients in this study were limited to those who had been followed for at least 3 months by nephrologists.     

Impact of obesity on the surgical outcome following repeat hepatic resection in Japanese patients with recurrent hepatocellular carcinoma

AIM： To evaluate the impact of obesity on the postoperative outcome after hepatic resection in patients with hepatocellular carcinoma （HCC）. METHODS： Data from 328 consecutive patients with primary HCC and 60 patients with recurrent HCC were studied. We compared the surgical outcomes between the non-obese group （body mass index： BMI 〈 25 kg/m2） and the obese group （BMI ≥ 25 kg/m2）. RESULTS： Following curative hepatectomy in patients with primary HCC, the incidence of postoperative complications and the long-term prognosis in the nonobese group （n = 240） were comparable to those in the obese group （n = 88）. Among patients with recurrent HCC, the incidence of postoperative complications after repeat hepatectomy was not significantly different between the non-obese group （n = 44） and the obese group （n = 16）. However, patients in the obese group showed a significantly poorer long-term prognosis than those in the non-obese group （P 〈 0.05, five-yearsurvival rate; 51.9% and 92.0%, respectively）. CONCLUSION： Obesity alone may not have an adverse effect on the surgical outcomes of patients with primary HCC. However, greater caution seems to be required when planning a repeat hepatectomy for obese patients with recurrent HCC.     

Regional distribution of lead, zinc, iron and copper in suckling and adult rat brains

The flameless atomic absorption method was applied to reveal regional differences in heavy metals between suckling and adult rat brains. The lead concentration in the suckling brains were considerably different from those in the adult rats. The levels of lead concentration in the cerebrum and cerebellum of the normal suckling rats were 3–4 times higher than those of adult rats. Iron concentrations in the cerebrum of the suckling brains were approximately half those in the adult brains. Zinc and copper concentrations in medulla from the suckling rats were higher than those in the same region from the adult rats.     

Magnetic resonance imaging of acute cerebellar ataxia: Report of a case with gadolinium enhancement and review of the literature

Abstract A 10-year-old girl exhibited severe cerebellar ataxia following acute enterocolitis, and was diagnosed as having acute cerebellar ataxia (ACA). MR1 of the brain in the acute stage revealed moderate swelling of the cerebellum and abnormal signal intensity enhanced with gadolinium in the cerebellar hemisphere. This is the first report of an ACA case with positive gadolinium enhancement. Cases of ACA with MRI abnormalities are reviewed and the clinical entity of ACA is discussed in association with autoimmune encephalitis,     

Myxoma of the mitral valve prolapsing into the left atrium and ventricle: Report of a case

A rare case of myxoma originating from the mitral valve is reported. A 25-year-old woman was found to have a mobile mass around the mitral valve that prolapsed into the left atrium and the left ventricular outflow tract. The mitral valve was approached via the left atrium and aorta, and was excised completely along with the tumor; it was thus replaced with a mechanical prosthesis. The patient recovered and demonstrated no signs of recurrence 16 months postoperatively.     

Secondary c-kit Mutation in a Recurrent Gastrointestinal Stromal Tumor Under Long-Term Treatment with Imatinib Mesylate: Report of a Case

Gastrointestinal stromal tumors (GISTs) commonly harbor oncogenic mutations of the c-kit receptor gene, which are targets for imatinib mesylate. However, imatinib resistance is an increasing clinical problem. We herein present such a case with a recurrent GIST, in association with the development of a secondary mutation in the c-kit gene. A 67-year-old man, who had a GIST of the stomach with multiple liver metastases, underwent a partial gastrectomy, distal pancreatectomy, and partial hepatectomy. After surgery, he was treated with imatinib. However, during the approximately 4-year treatment period, a recurrence of the GIST in the liver was detected, for which a partial hepatectomy was again performed. The primary GIST constitutively had a deletion mutation in exon 11. In addition, the recurrent hepatic tumor developed a secondary point mutation (Val654Ala) in exon 13, which may be responsible for the imatinib resistance.