Adrenal tumors: 10-year experience at Kaohsiung Medical University Hospital and literature review

We report our 10-year experience of managing adrenal tumors at Kaohsiung Medical University Hospital (KMUH) between January 1992 and January 2002. In total, 53 patients with adrenal tumors were analyzed, including 19 men (mean age +/- standard deviation, SD, 41.8 +/- 12.9 yr; range, 24-66 yr) and 34 women (mean age +/- SD, 42.3 +/- 12.4 yr; range, 19-74 yr), with an overall mean age +/- SD of 42.6 +/- 12.5 years. All 53 adrenal tumors were confirmed by surgery and pathology. In our series, 41 (77.4%) tumors were functional, of which 39 (95%) were benign; 12 (22.6%) tumors were nonfunctional, of which two (16.7%) were malignant. Overall, women were more common than men in our series, especially in Cushing's syndrome and primary aldosteronism (female:male ratio, 4 and 1.9, respectively). Of the 41 functional adrenal tumors, 20 were primary aldosteronism, 10 were Cushing's syndrome, 10 were pheochromocytoma, and one was an androgen-producing tumor. Of the 12 nonfunctional adrenal tumors, all of which presented as adrenal incidentalomas, four were cortical adenoma, three were myelolipoma, two were ganglioneuroma, one was an adrenal cyst, one was an adrenocortical carcinoma, and one was a metastatic carcinoma. Overall, 48 patients underwent adrenalectomy, three underwent partial adrenalectomy for small and well-circumscribed tumors, and two were explored. The diagnosis and management of adrenal tumors is discussed and the literature reviewed.     

Education and management of diabetes at The University of Tokyo Hospital

Along with reduced physical activity, increased fat intake, and intensified psychological stresses associated with work and social life, the number of diabetic patients and diabetes-related complications has increased significantly in Japan. Our aim at The University of Tokyo Hospital is to provide comprehensive diabetes treatment, including the use a diabetes handbook with guidelines for the diagnosis and treatment of diabetes consistent with evidence-based medicine. Diabetes specialists and certified diabetes educators work together to provide the best possible treatment. In addition, we have established a diabetic foot care service for outpatients, with the objective of preventing diabetes-related foot disease. The inpatients wards offer the most ideal diabetes treatments, including diet therapy, exercise therapy, guided self-monitoring of blood glucose, daily body weight measurement, and diabetes seminars. All these services provide guidelines that encourage patient self-management even after discharge from hospital. Management dietitians use food samples and a Food Exchange Table to brief patients about nutrition guidelines. Exercise therapy programs are developed according to the specific needs of each individual patient. We have also established a diabetes seminar series for the patients, to which physicians, nurses, dietitians, pharmacists, clinical laboratory technicians, and other professionals are invited to give talks on their respective areas of expertise. The aim of our ongoing efforts to implement diet and exercise therapies and improve the living habits of the patients is to achieve an ideal standard for diabetes education and management.     

Radiofrequency ablation for management of malignant biliary obstruction: a single-center experience and review of the literature

Background: Radiofrequency ablation (RFA) causes coagulative necrosis of tissue and may be beneficial prior to biliary stenting. We report our experience using RFA for malignant biliary obstruction and review the literature.

Methods: Retrospective analysis of all patients undergoing RFA for malignant biliary obstruction over the last two years. Success, complications and re-intervention following RFA were assessed. Controls were age, sex and disease matched who had stenting alone.

Results: 31 patients were included and 15 patients underwent biliary RFA prior to stenting (median age 78 years, 8 females). 14 patients had pancreatic cancer, 13 cholangiocarcinoma (6 hilar lesions) and 4 malignant disease invading the bile duct. Adverse events included acute pancreatitis (n = 2) and bacteremia in (n = 1). Median duration of intervention free survival was 220 days in the RFA group compared to 106.5 days in controls (hazard ratio 2.4, 95% CI 1.1 – 5.3, p = 0.025). Multivariable Cox proportional hazard analysis showed survival was associated with RFA (hazard ratio 2.55, 95% CI 1.09–5.96, p = 0.026) but not age, site or type of malignancy.

Conclusion: Biliary RFA is a technically feasible with a low adverse event rate and is associated with increased survival. Multi-centre randomized controlled trials are required.     

Living-donor liver transplantation in adults: Tokyo University experience

The objective of this study was to analyze the experience of a single center with living-donor liver transplantation (LDLT) for adult patients. Ninety consecutive LDLT procedures were analyzed. Preoperative status, morbidity, hospital stay duration, and postoperative graft function and survival rates were examined. Donors showed only minimal morbidity and were discharged 15 ± 6 days after LDLT. Morbidity in the patients included acute rejection (32%), vascular complications (8%), and biliary complications (20%). The mortality rate was 6% and three additional patients experienced late death. The 2-year cumulative survival rate was 92%. The present results suggest that LDLT can be performed with an acceptable outcome in adult patients.     

Magnetic compression anastomosis for rectal atresia following necrotizing enterocolitis: A case report

Rationale:Rectal atresia caused by necrotizing enterocolitis (NEC) is a serious and rare complication in children. Magnetic compression anastomosis (MCA) has been effectively applied in children with congenital oesophageal atresia and biliary atresia. Herein, we reported a case of successfully application of MCA in an infant with rectal atresia following NEC.Patient concerns:A 30⁺⁶ weeks premature birth female fetal infant was transferred to our neonatal intensive care unit due to premature delivery, low birth weight, and neonatal respiratory distress. On postpartum day 11, the infant developed abdominal distension and mucosanguineous feces. This infant was then clinically diagnosed as NEC. She underwent anesthesia and intestinal fistula operation on postpartum day 11 because of NEC.Diagnosis:After 3 months, radiographic examination revealed rectal atresia and stricture.Interventions:This infant was successfully treated with MCA following a cecum-rectal anastomosis and ileocecal valve was reserved.Outcomes:On postoperative day 9, she passed the 2 magnets per rectum. In addition, there were no difficult defecation or fecal incontinence or other short-term complications. After the 7-month follow-up, the patient had an excellent clinical outcome.Lessons:MCA is a feasible and effective method for treating rectal atresia in infants.     

Intussusception: Jordan University Hospital experience

BACKGROUND/AIMS: The aim of this study was to retrospectively review all children who presented with intussusception over a 24-year period. METHODOLOGY: The medical records of children who presented with intussusception from July 1979 through July 2003 at Jordan University Hospital were reviewed. RESULTS: One hundred and nine children (74 male, 35 female) presented with intussusception. Their mean age was 16.3 months (range 2 months-14 years). The presenting symptoms were: vomiting (92%), abdominal colic/pain (80%) rectal bleeding (78%), and abdominal mass (65%). Ninety-six cases were ileocolic intussusception (idiopathic type). Eleven patients had small bowel intussusception. Laparotomy was required in 86 cases, manual reduction being successful in 59 (56%); 20 (18%) had bowel resection; 2 had resection of Meckel's diverticulum; and 5 patients underwent Ladd procedure for associated malrotation. CONCLUSIONS: Idiopathic intussusception commonly presenting as an ileocolic type constituted the majority of the cases in the present study, occurring in 96 patients (89.7%). The clinical features were classical, vomiting being the most common. The average interval between the onset of symptoms and presentation to the hospital was 46 hours and barium enema reduction was successful in 20 out of 48 cases in which it was attempted. Surgical intervention was required in 86 cases (81%); of which manual reduction was successful in 59 cases, resection was required in 22 cases and 5 patients required an additional Ladd procedure for associated malrotation.     

Endoscopic ultrasound-guided vs ERCP-guided biliary drainage for malignant biliary obstruction: A up-to-date meta-analysis and systematic review

Endoscopic ultrasound-guided biliary drainage (EUS-BD) is being used increasingly as an alternative treatment for malignant biliary obstruction (MBO). However, few studies have compared EUS-BD and endoscopic retrograde cholangiopancreatography biliary drainage (ERCP-BD). We searched the PubMed, Embase, Web of Science, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov databases until 1 November 2020 for studies comparing EUS-BD versus ERCP-BD. The primary outcomes of interest in this study were technical and clinical success. Nine studies involving 634 patients were included in this meta-analysis. Regarding technical and clinical success, there were no significant differences between EUS-BD and ERCP-BD (odds ratio [OR], 0.76; 95% CI: 0.30–1.91; OR, 1.45, 95% confidence interval [CI], 0.66–3.16, respectively). EUS-BD was associated with significantly less reintervention vs ERCP-BD (OR, 0.36, 95% CI, 0.15–0.86). Regarding adverse events, the rates were similar for EUS-BD and ERCP-BD (OR: 0.75, 95% CI, 0.45–1.24). There were no significant differences in the types of adverse events (stent occlusion, stent migration, stent dysfunction, and duration of stent patency) between the two techniques. EUS-BD was associated with lower reintervention rates compared with ERCP-BD, with comparable safety and efficacy outcomes. However, more high-quality randomized trials are required.     

Endoscopic stenting for inoperable malignant biliary obstruction: A systematic review and meta-analysis

AIM: To analyze through meta-analyses the benefits of two types of stents in the inoperable malignant biliary obstruction.METHODS: A systematic review of randomized clinical trials(RCT) was conducted, with the last update on March 2015, using EMBASE, CINAHL(EBSCO), MEDLINE, LILACS/CENTRAL(BVS), SCOPUS, CAPES(Brazil), and gray literature. Information of the selected studies was extracted in sight of six outcomes: primarily regarding dysfunction, complication and reintervention rates; and secondarily costs, survival, and patency time. The data about characteristics of trial participants, inclusion and exclusion criteria and types of stents were also extracted. The bias was mainly assessed through the JADAD scale. This meta-analysis was registered in the PROSPERO database by the number CRD42014015078. The analysis of the absolute risk of the outcomes was performed using the software Rev Man, by computing risk differences(RD) of dichotomous variables and mean differences(MD) of continuous variables. Data on RD and MD for each primary outcome were calculated using the MantelHaenszel test and inconsistency was qualified and reported in χ2 and the Higgins method(I2). Sensitivity analysis was performed when heterogeneity was higher than 50%, a subsequent assay was done and other findings were compiled. Student's t-test was used for the comparison of weighted arithmetic means regarding secondary outcomes.RESULTS: Initial searching identified 3660 studies; 3539 were excluded through title, repetition, and/or abstract, while 121 studies were fully assessed and were excluded mainly because they did not compare self-expanding metal stents(SEMS) and plastic stents(PS), leading to thirteen RCT selected, with 13 articles and 1133 subjects meta-analyzed. The mean age was 69.5 years old, that were affected mostly by bile duct(proximal) and pancreatic tumors(distal). The preferred SEMS diameter used was the 10 mm(30 Fr) and the preferred PS diameter used was 10 Fr. In the metaanalysis, SEMS had lower overall stent dysfunction compared to PS(21.6% vs 46.8%, P 0.00001) and fewer re-interventions(21.6% vs 56.6%, P 0.00001), with no difference in complications(13.7% vs 15.9%, P = 0.16). In the secondary analysis, the mean survival rate was higher in the SEMS group(182 d vs 150 d, P 0.0001), with a higher patency period(250 d vs 124 d, P 0.0001) and a lower cost per patient(4193.98 vs 4728.65 Euros, P 0.0985).CONCLUSION: SEMS are associated with lower stent dysfunction, lower re-intervention rates, better survival, and higher patency time. Complications and costs showed no difference.     

Magnetic resonance evaluations of biliary malignancy and condition at high-risk for biliary malignancy:Current status

Tumors of the biliary tree are relatively rare; but their incidence is rising worldwide. There are several known risk factors for bile duct cancers, and these are seem to be associated with chronic inflammation of the biliary epithelium. Herein, 2 risk factors have been discussed, primary sclerosing cholangitis and reflux of pancreatic juice into the bile duct, as seen in such as an abnor- mal union of the pancreatic-biliary junction because magnetic resonance imaging(MRI) is used widely and effectively in the diagnosis of these diseases. When biliary disease is suspected, MRI can often help dif- ferentiate between benignity and malignancy, stage tumors, select surgical candidates and guide surgical planning. MRI has many advantages over other modali- ties. Therefore, MRI is a reliable noninvasive imaging tool for diagnosis and pre-surgical evaluation of bile duct tumors. Nowadays remarkable technical advances in magnetic resonance technology have expanded the clinical applications of MRI in case of biliary diseases. In this article, it is also discussed how recent develop- ments in MRI contributes to the diagnosis of the bile duct cancer and the evaluation of patients with risk fac- tors affecting bile duct cancer.     

肝门部恶性胆道梗阻单、双侧引流的荟萃分析

目的 评价肝门部恶性胆道梗阻单、双侧引流的有效性与安全性. 方法 联合检索PubMed、Embase、Cochrane Library数据库,检索年限均从1975年至2013年8月,纳入单、双侧引流的随机对照和非随机对照试验.用RevMan5.0软件进行荟萃分析,用相对危险度(RR)值及95％可信区间(CI)对单、双侧引流进行比较.在荟萃分析中用RR及其95％CI比较两组差异.混合性的数据资料采用固定效应模型和随机效应模型,当研究间出现显著异质性时,荟萃分析采用随机效应模型.研究之间的异质性检验采用卡方检验(P＜ 0.10为异质性有统计学意义)和I2分析(I2＞ 50％为异质性有统计学意义).对于异质性的来源采用亚组分析和敏感性分析,潜在的发表偏倚采用漏斗图分析. 结果 经过筛选共纳入3个随机对照试验和7个观察性研究,合计894例患者.荟萃分析结果显示主要观察重点:单、双侧引流的支架通畅率优于单侧(RR=2.03,95％CI:1.16 ～ 3.56,P=0.01);而引流的有效性(RR=1.07,95％CI:0.97～1.18,P=0.20)和患者的生存率(RR=-0.16,95％CI:-0.40 ～ 0.08,P=0.20)差异无统计学意义.次要观察重点:单双侧引流的技术成功率(RR=1.05,95％CI:0.98 ～ 1.17,P=0.34)、早期并发症(RR=1.15,95％CI:0.75 ～ 1.76,P=0.52)、晚期并发症(RR=1.09,95％CI:0.75 ～ 1.60,P=0.65)、30 d病死率(RR=0.68,95％CI:0.38 ～ 1.23,P=0.20)同样差异没有统计学意义. 结论 虽然双侧引流支架通畅率较单侧好,现存循证医学证据还不足够支持双侧引流,期待更多严格设计前瞻性随机对照研究出现来验证.     

Clinical features and therapeutic outcomes of 65 patients with acromegaly at Tokyo Women's Medical University.

OBJECTIVE: The purpose of this study was to survey the clinical characteristics, complications, and therapeutic outcome in patients with acromegaly. PATIENTS AND METHODS: The clinical features of 65 patients with acromegaly (31 males, 34 females; mean age: 50+/-2 yr.) who were admitted to Tokyo Women's Medical University between 1990 and 1999 were analyzed retrospectively from medical records. RESULTS: The retrospective analysis revealed that the diagnosis of acromegaly was preceded by approximately 8.1+/-1.1 years of signs and symptoms of the disease. Forty-six of the 65 patients (71%) had macroadenomas, 16 (25%) had microadenomas, and the remaining three had empty sella. The rate of biochemical cure or remission was 81% for microadenoma (13/16), 64% for macroadenoma without extrasellar extension (9/14), and 13% for macroadenoma with cavernous sinus extension (2/15). Eighteen (28%) patients had impaired glucose tolerance (IGT) and 32 (49%) had diabetes mellitus (DM). After treatment for acromegaly, glucose metabolism was analyzed again in 38 patients, and it improved in 26 patients with IGT or DM. Twenty-five of 65 patients (38%) had hypertension. Of 26 patients who underwent barium enema or colonoscopy, 10 had colonic polyps and 4 had colon cancer. CONCLUSION: This study suggests that long-term excessive growth hormone (GH) secretion causes many complications. Therefore, awareness of the early symptoms and signs of acromegaly and long-term careful management of complications, along with therapy to reduce serum GH/insulin-like growth factor (IGF)-I levels, are important for patients with acromegaly.     

Techniques of biliary drainage for acute cholecystitis: Tokyo Guidelines

The principal management of acute cholecystitis is early cholecystectomy. However, percutaneous transhepatic gallbladder drainage (PTGBD) may be preferable for patients with moderate (grade II) or severe (grade III) acute cholecystitis. For patients with moderate (grade II) disease, PTGBD should be applied only when they do not respond to conservative treatment. For patients with severe (grade III) disease, PTGBD is recommended with intensive care. Percutaneous transhepatic gallbladder aspiration (PTGBA) is a simple alternative drainage method with fewer complications; however, its clinical usefulness has been shown only by case-series studies. To clarify the clinical value of these drainage methods, proper randomized trials should be done. This article describes techniques of drainage for acute cholecystitis.     

Techniques of biliary drainage for acute cholangitis: Tokyo Guidelines

Biliary decompression and drainage done in a timely manner is the cornerstone of acute cholangitis treatment. The mortality rate of acute cholangitis was extremely high when no interventional procedures, other than open drainage, were available. At present, endoscopic drainage is the procedure of first choice, in view of its safety and effectiveness. In patients with severe (grade III) disease, defined according to the severity assessment criteria in the Guidelines, biliary drainage should be done promptly with respiration management, while patients with moderate (grade II) disease also need to undergo drainage promptly with close monitoring of their responses to the primary care. For endoscopic drainage, endoscopic nasobiliary drainage (ENBD) or stent placement procedures are performed. Randomized controlled trials (RCTs) have reported no difference in the drainage effect of these two procedures, but case-series studies have indicated the frequent occurrence of hemorrhage associated with endoscopic sphincterotomy (EST), and complications such as pancreatitis. Although the usefulness of percutaneous transhepatic drainage is supported by the case-series studies, its lower success rate and higher complication rates makes it a second-option procedure.     

Macrolide resistance and detection in Mycoplasma pneumoniae at Kansai Medical University Hirakata Hospital

Mycoplasma pneumoniae causes bronchitis and pneumonia predominantly in subjects 5 to 20 years old. M. pneumoniae is detected by measuring specific antibodies and/or isolating the microorganism, but the frequency of false-positive/negative results, and the culture time required until isolation pose problems. We detected M. pneumoniae using real-time PCR with clinical specimens. We also determined the drug sensitivity of isolated M. pneumoniae and searched for the gene mutation responsible for macrolide resistance. In 275 cases of suspected M. pneumoniae infection, positive cases in real-time PCR numbered 40 (14.5%). Of these, 16 showed positive culture (5.8%). Of these 16, A2063G point mutation that causes macrolide resistance was found in 12. Drug sensitivity testing showed resistance to clarithromycin (MIC> or =64 microg/ml) in 11 and susceptibility in 4 (MIC 0.0039 microg/ml). The clarithromycin resistance ratio was 75%. Growth was insufficient for testing in 1 case. M. pneumoniae was susceptible to minocycline and all quinolone drugs. M. pneumoniae detection using real-time PCR proved much more sensitive than conventional culture. Macrolide resistance results correlated well with genomic mutation. Our study's macrolide resistance ratio was high at 75% possibly due to a restricted subject population that had been administered macrolide drugs elsewhere but with an unsatisfactory outcome. The increasing number of reports on macrolide resistance requires that we monitor drug resistance trends, particularly among macrolide derivatives.