Percutaneous management of bile duct injuries after cholecystectomy

Intraoperative biliary tract injuries are relatively uncommon, but are a cause of significant morbidity and mortality. We have repaired open biliary tract injuries found postoperatively in three patients without reoperation by percutaneous intervention. In two cases, biliary stents were placed percutaneously across the injured portion of the bile duct. For this procedure, a unique coaxial guidewire technique was used. The bile leaks resolved soon after insertion of the biliary stents. In one patient, an expandable metallic biliary endoprosthesis was inserted, and the temporary stent was removed. This patient had no signs or symptoms of cholangitis or biliary obstruction at the 6-year follow-up. The other patient died of heart failure soon after reconstruction. In the last patient, a biliary drain was inserted through the injured duct via the biliocutaneous fistula. In this case, biliary drainage alone resulted in resolution of the bile leak, because the injury was partial without a stricture. This patient was well at the 3-year follow-up. Percutaneous management of bile duct injuries is an alternative in selected patients.     

Hemangioma located just above the left main coronary artery, in a subject who had cardiac arrest due to ventricular fibrillation, led to a diagnosis of Brugada syndrome

We report the case of a 38-year-old Asian man with a pericardial hemangioma on the left main coronary artery. The patient presented initially at our hospital after cardiopulmonary resuscitation following an episode of ventricular fibrillation (VF). Because of spontaneous coved-type ST segment elevation on the higher intercostal space V1 to V2 in a 12-lead electrocardiogram, documented VF in the absence of structural heart disease, and a family history of sudden death, he was diagnosed with Brugada syndrome. Transesophageal echocardiography showed a smooth-surfaced mass with well-demarcated borders, directly above the left main coronary artery. Computed tomography confirmed the presence of the mass, which showed no enhancement at early phase, but did demonstrate homogenous enhancement at delay phase by contrast material. There were no findings from either the nuclear medicine or the tumor marker investigations which indicated that the mass located just above the main coronary arteries was malignant. Therefore, taken together, these findings suggested that the tumor might be a pericardial hemangioma. The relationship between the location of the hemangioma just above the left main coronary artery and the occurrence of VF was not clear, i.e. whether the presence of the hemangioma caused the stimulation of the left main coronary artery and as a result, led to the spasm of the left main coronary artery and the occurrence of VF. Furthermore, as the tumor did not extend into any of the adjacent structures, such as the coronary arteries or the right ventricular outflow tract, surgical resection was not performed; instead, the patient received a dual chamber implantable cardioverter-defibrillator.     

HLA analysis of immune checkpoint inhibitor-induced and idiopathic isolated ACTH deficiency

Pituitary - Isolated adrenocorticotropic hormone deficiency is a rare disease; however, since immune check point inhibitors (ICIs) have become widely used, many more cases have been reported. In...     

Factors affecting emotional instability in female rheumatoid arthritis outpatients with limited functional disorder

We attempted to identify which background factors were the most important indicators of such psychological problems as emotional instability, a feeling of hopelessness, and suicidal tendencies in female rheumatoid arthritis (RA) outpatients with limited functional disorder. Among female RA patients aged 20 years and older who visited the outpatient clinic, 101 class I and II patients were selected as subjects for the present study. An original questionnaire and a psychological test (CMI) were given to those subjects who had given their written consent to such testing, and an analysis was carried out on 85 patients who returned all the written forms. Their emotional instability was related to factors such as "not being able to understand the nature of RA disease and its treatment," "sense of value had changed after developing RA," "nonuse of drugs," and "duration of disease." A feeling of hopelessness was related to "smoking," and a suicidal tendency was related to "smoking" and "class I." We identified a characteristic correlation between emotional instability and background factors in this study. Paying close attention to these factors may thus be useful in preventing the appearance of psychological problems as well as in developing effective early treatment strategies. Received: April 5, 2000 / Accepted: July 19, 2000     

Correlation between haemoglobin level and type of erythropoiesis-stimulating agent at initiation of haemodialysis

International Journal of Clinical Pharmacy - Background Renal anaemia worsens because of the uraemic status immediately before the initiation of haemodialysis. The haemoglobin level in patients...     

Initial report of bridge to recovery in a patient with DuraHeart LVAD

Continuous-flow left ventricular assist devices (LVADs) provide acceptable clinical results, but the long waiting period for heart transplantation leads to diverse complications. LVAD support can cause reverse left ventricular (LV) remodeling that results in the improvement of LV function and allows LVAD removal. We present a case of successful removal of a DuraHeart LVAD because of sufficient recovery of LV function. Before LVAD removal, we conducted an “LVAD weaning test” by decreasing pump speed and performing an additional normal saline infusion test. We consider that the LVAD weaning test can be used in place of the “pulsatile LVAD off test.”     

Insulin and heparin challenge tests are useful for choosing an optimal insulin regimen in a case of subcutaneous insulin resistance

A 38‐year‐old woman with type 1 diabetes, whose fasting plasma glucose levels were >500 mg/dL under 176 U/day of subcutaneous insulin injection, was admitted to Nippon Medical School Hospital, Tokyo, Japan. When insulin was administered intravenously, she was able to maintain favorable glycemic control even under 24 U/day of regular insulin, showing that she was accompanied by subcutaneous insulin resistance. To choose an optimal insulin regimen, we carried out subcutaneous insulin challenge tests without or with heparin mixture, and found a cocktail of insulin lispro and heparin could reduce blood glucose levels markedly. As a consequence, she achieved favorable blood glucose control by continuous subcutaneous insulin infusion of the cocktail. In summary, the insulin and heparin challenge tests are useful for choosing an optimal insulin regimen in cases of subcutaneous insulin resistance.