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Background: Surgical resection is standard treatment for invasive intraductal papillary mucinous carcinoma (IPMC); however, impact of multidisciplinary treatment on survival including postoperative adjuvant therapy (AT), neoadjuvant therapy (NAT), and treatment for recurrent lesions is unclear. We investigated the effectiveness of multidisciplinary treatment in prolonging survival of patients with invasive IPMC. Methods: This retrospective multi‐institutional study included 1183 patients with invasive IPMC undergoing surgery at 40 academic institutions. We analyzed the effects of AT, NAT, and treatment for recurrence on survival of patients with invasive IPMC. Results: Completion of the planned postoperative AT for 6 months improved the overall survival (OS), disease‐specific survival (DSS), and recurrence‐free survival (RFS) of patients with stage IIB and stage III resected invasive IPMC, elevated preoperative carbohydrate antigen 19–9 level, lymphovascular invasion, perineural invasion, serosal invasion, and lymph node metastasis on un‐matched and matched analyses. Of the patients with borderline resectable (BR) invasive IPMC, the OS (p = 0.001), DSS (p = 0.001), and RFS (p = 0.001) of patients undergoing NAT was longer than that of those without on the matched analysis. Of the 484 invasive IPMC patients (40.9%) who developed recurrence after surgery, the OS of 365 patients who received any treatment for recurrence was longer than that of those without treatment (40.6 vs. 22.4 months, p < 0.001). Conclusion: Postoperative AT might benefit selected patients with invasive IPMC, especially those at high risk of poor survival. NAT might improve the survivability of BR invasive IPMC. Any treatment for recurrence after surgery for invasive IPMC might improve survival. [ABSTRACT FROM AUTHOR]

Aim: For women, being underweight increases their susceptibility to osteoporosis, anemia, and other conditions and affects the weight of their infants and the well‐being of future generations. This study examined the association between low pre‐pregnancy body mass index (BMI) and low birthweight using health insurance claims data and health checkup data, including weight measurements. Methods: We used health insurance claims data and health checkup data (JMDC, Tokyo, Japan) of women and their newborns in Japan between 2006 and 2020. We used checkup data, which included more accurate weight measurements and blood test‐based diagnoses of anemia and hyperlipidemia compared to self‐reported data. Maternal pre‐pregnancy BMI was compared across three groups: underweight (BMI <18.5 kg/m2), normal weight (BMI 18.5–24.9 kg/m2), and overweight (BMI ≥25.0 kg/m2). The primary outcome was low birthweight (<2500 g), and secondary outcome was preterm childbirth. Logistic regression analyses were conducted to compare outcomes in the three groups by BMI. The underweight BMI group was considered as the reference group. A subgroup analysis was performed by maternal age. Results: In total, 16 363 mothers (underweight, 3418 [21%], normal weight, 11 493 [70%], and overweight, 1452 [8.9%]) were included. The risk of primary outcome (low birthweight) was significantly lower in the normal weight group than in the underweight group (4.6% vs. 5.7%; adjusted odds ratio 0.78 [95% confidence interval: 0.65–0.96]). In the subgroup analyses, no significant differences were noted in the incidences of low birthweight and preterm childbirth between maternal age groups. Conclusions: Pre‐pregnancy BMI was associated with an increased risk of delivering low‐birthweight infant. Awareness about the importance of women's pre‐pregnancy health and appropriate BMI may reduce the incidence of low birthweight. [ABSTRACT FROM AUTHOR]

Background and Purpose: Bardoxolone methyl (2‐cyano‐3,12‐dioxooleana‐1,9(11)‐dien‐28‐oic acid methyl ester, CDDO‐Me) is a potent activator of nuclear factor erythroid 2‐related factor 2 (Nrf2), which induces the expression of antioxidative‐associated genes. CDDO‐Me exerts protective effects against chronic inflammatory diseases in the kidneys and lungs. However, its pharmacological effects on metabolic dysfunction‐associated steatohepatitis (MASH) caused by fat accumulation remain unknown. In this study, we examined the hepatoprotective effects of CDDO‐Me in a diet‐induced MASH mouse model and elucidated its pharmacological mechanisms using RNA‐seq analysis. Experimental Approach: CDDO‐Me was orally administered to mice fed a choline‐deficient, L‐amino acid‐defined, high‐fat diet (CDAHFD), and histological, biochemical, and transcriptomic analyses were performed on livers of mice that developed MASH. Key results: CDDO‐Me administration induced the expression of antioxidant genes and cholesterol transporters downstream of Nrf2 and significantly prevented the symptoms of MASH. Whole‐transcriptome analysis revealed that CDDO‐Me inhibited the inflammatory pathway that led to phagocyte recruitment, in addition to activating the Nrf2‐dependent pathway. Among inflammatory pathways, CC chemokine ligands (CCL)3 and CCL4, which are downstream of NF‐κB and are associated with the recruitment of macrophages expressing CC chemokine receptors (CCR)1 and CCR5, were released into the blood in MASH mice. However, CDDO‐Me directly inhibited the expression of CCL3‐CCR1 and CCL4‐CCR5 in macrophages. Conclusions and Implications: Overall, we revealed the potent hepatoprotective effect of CDDO‐Me in a MASH mouse model and demonstrated that its pharmacological effects were closely associated with a reduction of macrophage infiltration, through CCL3‐CCR1 and CCL4‐CCR5 inhibition, in addition to Nrf2‐mediated hepatoprotective effects. [ABSTRACT FROM AUTHOR]

The consensus‐based TOKYO criteria were proposed as a standardized reporting system for endoscopic transpapillary biliary drainage. The primary objective was to address issues arising from the inconsistent reporting of stent outcomes across studies, which has complicated the comparability and interpretation of study results. However, the original TOKYO criteria were not readily applicable to recent modalities of endoscopic biliary drainage such as biliary drainage based on endoscopic ultrasound or device‐assisted endoscopy. There are increasing opportunities for managing hilar biliary obstruction and benign biliary strictures through endoscopic drainage. Biliary ablation has been introduced to manage benign and malignant biliary strictures. In addition, the prolonged survival times of cancer patients have increased the importance of evaluating overall outcomes during the period requiring endoscopic biliary drainage rather than solely focusing on the patency of the initial stent. Recognizing these unmet needs, a committee has been established within the Japan Gastroenterological Endoscopy Society to revise the TOKYO criteria for current clinical practice. The revised criteria propose not only common reporting items for endoscopic biliary drainage overall, but also items specific to various conditions and interventions. The term “stent‐demanding time” has been defined to encompass the entire duration of endoscopic biliary drainage, during which the overall stent‐related outcomes are evaluated. The revised TOKYO criteria 2024 are expected to facilitate the design and reporting of clinical studies, providing a goal‐oriented approach to the evaluation of endoscopic biliary drainage. [ABSTRACT FROM AUTHOR]

The progress of endoscopic diagnosis and treatment for inflammatory diseases of the biliary tract and pancreas have been remarkable. Endoscopic ultrasonography (EUS) and EUS‐elastography are used for the diagnosis of early chronic pancreatitis and evaluation of endocrine and exocrine function in chronic pancreatitis. Notably, extracorporeal shock wave lithotripsy and electrohydraulic shock wave lithotripsy have improved the endoscopic stone removal rate in patients for whom pancreatic stone removal is difficult. Studies have reported the use of self‐expanding metal stents for stent placement for pancreatic duct stenosis and EUS‐guided pancreatic drainage for refractory pancreatic duct strictures. Furthermore, EUS‐guided drainage using a double‐pigtailed plastic stent has been performed for the management of symptomatic pancreatic fluid collection after acute pancreatitis. Recently, lumen‐apposing metal stents have led to advances in the treatment of walled‐off necrosis after acute pancreatitis. EUS‐guided biliary drainage is an alternative to refractory endoscopic biliary drainage and percutaneous transhepatic biliary drainage for the treatment of acute cholangitis. The placement of an inside stent followed by switching to uncovered self‐expanding metal stents in difficult‐to‐treat cases has been proposed for acute cholangitis by malignant biliary obstruction. Endoscopic transpapillary gallbladder drainage is an alternative to percutaneous transhepatic gallbladder drainage for severe and some cases of moderate acute cholecystitis. EUS‐guided gallbladder drainage has been reported as an alternative to percutaneous transhepatic gallbladder drainage and endoscopic transpapillary gallbladder drainage. However, it is important to understand the advantages and disadvantages of each drainage method and select the optimal drainage method for each case. [ABSTRACT FROM AUTHOR]

Background and Aim: Some patients with functional gastrointestinal disorders exhibit pancreatic dysfunctions and pancreatic enzyme abnormalities. Thus, we aimed to clarify whether significant differences in clinical characteristics, prevalence of pancreatic enzyme abnormalities, duodenal inflammation, and protease‐activated receptor 2 (PAR2) expression levels related to hypersensitivity exist between functional dyspepsia (FD) alone and FD‐irritable bowel syndrome (IBS) overlap group. Methods: Ninety‐three patients based on the Rome IV criteria, FD alone (n = 44) and FD overlapped with IBS (n = 49) group were enrolled. The patients scored their own clinical symptoms after consuming high‐fat meals. Serum trypsin, PLA2, lipase, p‐amylase, and elastase‐1 levels were measured. PAR2, eotaxin‐3, and TRPV4 mRNA levels in duodenum were determined using real‐time polymerase chain reaction methods. PRG2‐ and PAR2 in the duodenum were evaluated using immunostaining. Results: FD score and global GSRS in patients with FD‐IBS overlap were significantly higher than FD alone. Although the prevalence of pancreatic enzyme abnormalities in patients with FD alone was significantly (P < 0.01) higher than that in FD‐IBS overlap, the ratio of aggravation of clinical symptoms following high‐fat intake in patients with FD‐IBS overlap was significantly higher (P = 0.007) than that in patients with FD alone. PAR2‐ and PRG2‐double positive cells were localized in the degranulated eosinophils in the duodenum of patients with FD‐IBS overlap. The number of PAR2‐ and PRG2‐double positive cells in FD‐IBS overlap was significantly (P < 0.01) higher than FD alone. Conclusions: Pancreatic enzyme abnormalities and PAR2 expression on degranulated eosinophils infiltrations in the duodenum may be associated with the pathophysiology of patients with FD‐IBS overlap in Asian populations. [ABSTRACT FROM AUTHOR]

Suppression of atrial fibrillation (AF) arising within the superior vena cava (SVC) requires SVC electric isolation (SVCI) without sinus node (SN) injury. If an ectopic rhythm and AF trigger coexist within the SVC, the intra‐SVC ectopic rhythm complicates the pre‐SVCI search for the SN. This coexistence is without precedent; however, it is important to carefully locate the SN to prevent injury during SVCI. This case shows a paroxysmal AF with both phenomena coexisting in the SVC. Moreover, outpatient electrocardiographic assessment for tall P‐waves in inferior leads before catheter ablation could predict these phenomena and enable safer SVCI. [ABSTRACT FROM AUTHOR]

Pancreatic fluid collections (PFCs) typically develop as local complications of acute pancreatitis and complicate the clinical course of patients with acute pancreatitis and potentially fatal clinical outcomes. Interventions are required in cases of symptomatic walled‐off necrosis (WON) (matured PFCs with necrosis) and pancreatic pseudocysts (matured PFCs without necrosis). In the management of necrotizing pancreatitis and WON, endoscopic ultrasound‐guided transluminal drainage combined with on‐demand endoscopic necrosectomy (i.e. the step‐up approach) is increasingly used as a less invasive treatment modality compared with a surgical or percutaneous approach. Through the substantial research efforts and development of specific devices and stents (e.g. lumen‐apposing metal stents), endoscopic techniques of PFC management have been standardized to some extent. However, there has been no consensus about timing of carrying out each treatment step; for instance, it is uncertain when direct endoscopic necrosectomy should be initiated and finished and when a plastic or metal stent should be removed following clinical treatment success. Despite emerging evidence for the effectiveness of noninterventional supportive treatment (e.g. antibiotics, nutritional support, irrigation of the cavity), there has been only limited data on the timing of starting and stopping the treatment. Large studies are required to optimize the timing of those treatment options and improve clinical outcomes of patients with PFCs. In this review, we summarize the current available evidence on the indications and timing of interventional and supportive treatment modalities for this patient population and discussed clinical unmet needs that should be addressed in future research. [ABSTRACT FROM AUTHOR]

Background: We attempted to determine the indications and limitations of steroid therapy as the first‐line therapy in patients with autoimmune pancreatitis (AIP) with cyst formation (ACF). Methods: This Japanese multicenter survey was conducted to examine the merits/demerits of steroid treatment as the initial therapy for ACF. Results: Data of a total of 115 patients with ACF were analyzed. Complete remission was achieved in 86% (86/100) of patients who had received steroid treatment, but only 33.3% (5/15) of patients who had not received steroids. Relapse after the remission (n = 86) occurred in 7.6% (6/86) of patients who had received steroid therapy, but 40% (2/5) of patients who had not received steroid therapy. Multivariate analysis identified adoption of the wait and watch approach without steroid treatment (odds ratio = 0.126, P <.001) as a significant and independent negative predictor of remission of ACF. As for predictors of relapse, the presence of varix (odds ratio = 5.83, P =.036) was identified as an independent risk factor. Conclusion: Steroid therapy plays an important role as first‐line therapy in AIP patients with pancreatic cyst formation, however, varix formation, besides the diameter of the cyst(s), is a risk factor for refractoriness to steroid therapy. [ABSTRACT FROM AUTHOR]

Aim: We evaluated the predictive ability of prolonged requirements for mechanical ventilation or tube feeding support for 18‐month composite outcomes in infants with hypoxic‐ischaemic encephalopathy treated with hypothermia. Methods: This retrospective, nationwide, observational study focused on newborn infants registered in Japan's Baby Cooling Registry between 1 January 2012 and 31 December 2016. The adverse outcomes were defined as death or survival with cerebral palsy, visual or auditory impairment or the requirement for mechanical ventilation or tube feeding at 18 months of age. Results: Adverse outcomes occurred in 165 (28%) of the 591 children in the final cohort. These were predicted by prolonged dependence on mechanical ventilation or tube feeding for more than seven and more than 14 days. The respective values were positive predictive value 0.34 (95% CI 0.33–0.34) and 0.60 (95% CI 0.56–0.62), negative predictive value 0.97 (95% CI 0.91–0.99) and 0.93 (95% CI 0.90–0.95) and area under the curve 0.59 (95% CI 0.54–0.64) and 0.81 (95% CI 0.77–0.85). Conclusion: Prolonged dependence on mechanical ventilation or tube feeding for more than 14 days may be useful in predicting 18‐month outcomes in newborn infants who have received therapeutic hypothermia. [ABSTRACT FROM AUTHOR]

Background: There have been few reports of covered self-expandable metallic stent (SEMS) placement for malignant hilar-biliary obstruction (MHBO) because of risk of biliary branch obstruction. We studied feasibility and efficacy of 6-mm- diameter, slim, fully covered SEMS (SFCSEMS) in a relatively large cohort. Methods: We retrospectively evaluated SFCSEMS in unresectable MHBO from December 2016 to September 2021 in Juntendo University Hospital. Results: We enrolled consecutive 54 unresectable MHBO (18 bile duct, 11 gallbladder, eight pancreatic, two hepatocellular, and 15 metastatic cancer cases) including Bismuth-type II (n = 11), III (n = 17), and IV (n = 26), and placed two (n = 35) or three (n = 19) SFCSEMS. The technical and clinical success rate was 100% and 92.5%, respectively, with 76.3 min of mean procedure time. Recurrent biliary obstruction (RBO) was observed in 35.2% and the median cumulative time to RBO (TRBO) was 181 days. Other adverse events were 11.1% (four mildpancreatitis, one segmental-cholangitis, and one cholecystitis). There were no failed cases of stent exchange and second SFCSEMS (n = 6) showed significantly lower RBO (16.7% vs. 81.8%, P = .0364) and longer TRBO (undefined vs 86 days; P = .0617) than plastic stent (n = 11). Conclusions: Endoscopic placement of SFCSEMS for unresectable MHBO was effective and feasible with low incidence of segmental cholangitis, and exchange strategy of SFCSEMS was promising. [ABSTRACT FROM AUTHOR]

Objectives: Interventional endoscopic ultrasonography is performed for various situations that require drainage, after which stent migration is the most severe adverse event. Several lumen‐apposing metal stents (LAMS) and covered self‐expandable metal stents (CSEMS) provide antimigration systems; however, their anchoring ability has not been studied well. Therefore, we measured and compared the anchoring force (ACF) of commercially available LAMS and CSEMS. Methods: Anchoring force was measured for five types of LAMS (NAGI, SPAXUS, Plumber, and AXIOS 8 and 10 mm) and seven types of CSEMS (BCL, SHCL, BCG, BPD [four types of HANAROSTENT], HILZO, Niti‐S [Spring Stopper], and Wallflex). We created a phantom model for inducing stent migration. It has a rotatable part as a curved fixture, and we measured ACF at angles between 0° and 40°. Results: The mean ACF at 0° and 20° were NAGI 1.50, 1.84 N, SPAXUS 1.73, 1.72 N, Plumber 2.64, 2.03 N, and AXIOS 3.96, 3.61 N, respectively; and BCL 0.48, 0.53 N, Wallflex 0.53, 0.48 N, SHCL 0.64, 0.73 N, HILZO 1.09, 1.09 N, BCG 1.22, 1.20 N, BPD 1.78, 1.67 N, and Spring Stopper 2.29, 2.51 N. Conclusion: We measured ACF in LAMS and CSEMS with a new phantom model. The highest value among the LAMS was for the AXIOS and among the CSEMS was for the Spring Stopper. Some of the ACF values varied with the direction of pull. These findings may have a significant impact on stent selection for interventional endoscopic ultrasonography, and this model can be used to evaluate newly developed stents. [ABSTRACT FROM AUTHOR]

The article focuses on the use of gabapentin to treat apnea in infants with trisomy 13 and 18. The study presents a case series demonstrating the effectiveness of gabapentin in managing breath-holding spells associated with apnea in these infants, highlighting its potential as a therapeutic option. Topics discussed include the characteristics of apnea treated with gabapentin, the dosage recommendations, and the positive outcomes observed in the case series.

Background: Surgical interventions are recommended for cases of advanced mitral regurgitation, however, limited facilities are available. The most prominent complication in such procedures is heparin‐derived bleeding. An alternative anticoagulant to heparin, nafamostat mesilate (NM), can reduce the occurrence of complications associated with heparin such as bleeding or shock. Objectives: This study aimed to evaluate the utility and safety of using NM during anaesthesia in canines. Methods: Six healthy adult Beagle dogs were anaesthetised, and NM was administered intravenously as a 10 mg/kg bolus dose over 5 min, followed by a continuous infusion of 10 mg/kg/h over 20 min. Blood tests and blood pressure measurements were performed at 0, 5, 25 and 55 min after NM administration. Results: Activated thromboplastin times at 0, 25 and 55 min were 13.0 ± 0.7 s, 106.7 ± 13.3 s and 28.2 ± 2.9 s, respectively, with a significant difference between 0 and 25 min (p < 0.01) only. No significant differences were observed in prothrombin time, antithrombin, fibrinogen and fibrin degradation product concentrations between timepoints. Activated clotting times (ACTs) at 0, 5, 25 and 55 min were 119.5 ± 9.6 s, 826.7 ± 78.6 s, 924.8 ± 42.4 s and 165.2 ± 13.5 s, respectively. Significant differences were observed between 0 and 5 min (p < 0.05) and between 0 and 25 min (p < 0.05). Blood pressure changes occurred in four dogs (66.7%). No other serious adverse effects were observed. Conclusions: ACT results indicated that NM use in anaesthetised healthy dogs was sufficient to obtain procedural anticoagulation with minimal adverse effects. However, these preliminary data require validation in further studies on cardiopulmonary bypass surgery. [ABSTRACT FROM AUTHOR]

Objectives: Covered self‐expandable metal stent (cSEMS) for gastric outlet obstruction (GOO) has been developed to overcome tumor ingrowth but is prone to be associated with an increased risk of migration. Clinical impact of the novel large‐bore cSEMS for malignant GOO remains unclear. Methods: A total of 117 patients undergoing endoscopic cSEMS placement for malignant GOO were enrolled in this multicenter retrospective study. Technical and clinical success, adverse events, recurrent GOO, and survival after stent placement were compared between 24 mm‐cSEMS (n = 49) and 20 mm‐cSEMS (n = 68). Results: Patient characteristics were well‐balanced and thus similar survival was observed between the two groups (136 days vs. 89 days, P = 0.60). Technical success rate of 100% and clinical success rate of 96% were achieved both in 24 mm‐cSEMS and 20 mm‐cSEMS, respectively. The median cumulative time to recurrent GOO was significantly longer in 24 mm‐cSEMS than in 20 mm‐cSEMS (380 days vs. 138 days, P = 0.01). The incidence of adverse events and recurrent GOO was comparable: 12% vs. 15% (P = 0.91), and 16% vs. 31% (P = 0.11); however, no stent migration was observed in 24 mm‐cSEMS. In a subgroup analysis, the superiority of 24 mm‐cSEMS to 20 mm‐cSEMS was demonstrated in extrinsic cancers (380 days vs. 121 days, P = 0.01) but not in intrinsic cancers (151 days vs. not reached, P = 0.47). Conclusions: The 24 mm‐cSEMS may improve time to recurrent GOO with ensuring acceptable safety in patients with malignant GOO. [ABSTRACT FROM AUTHOR]

Watch a video of this article. [ABSTRACT FROM AUTHOR]

Background and Aim: To clarify whether there were any significant differences in clinical symptoms and eating patterns between functional dyspepsia (FD) patients and FD with pancreatic enzyme abnormalities (FD‐P) patients as refractory FD, we compared these factors in multicenter studies in Singapore and Japan. Methods: One hundred ninety‐eight consecutive patients presenting with FD (n = 88), FD‐P patients (n = 81) based on Rome III classification and controlled group (n = 39) recruited from six institutions in Singapore and Japan. Clinical characteristics, clinical symptoms for dietary fat intake, and eating behaviors were estimated using questionnaires. Anxiety and health‐related quality of life were determined by STAI‐state/‐trait and SF‐8, respectively. Results: There were no significant differences in age, sex, BMI, smoking, alcohol intake, past medical history, and history of allergy in FD and FD‐P patients between Singapore and Japan. There were no significant differences in FD subtypes, gastrointestinal symptom rating scale score, severity of FD symptoms, and eating pattern in Singapore and Japan. Moreover, there were significant differences in certain eating behaviors between FD and FD‐P patients in Singapore and Japan. Interestingly, epigastric pain and early satiety following fat meals in FD‐P patients were significantly (P = 0.003 and P = 0.008, respectively) higher compared with those in FD patients in Japan. Physical component score in FD‐P patients was significantly (P = 0.019) disturbed compared with those in FD patients in Japan. Conclusions: Epigastric pain and early satiety following fat meals in FD‐P patients may be useful tools to differentiate FD‐P patients from FD patients in Japan. [ABSTRACT FROM AUTHOR]

Objectives: The role of a covered vs. an uncovered self‐expandable metal stent (SEMS) for malignant distal biliary obstruction (MDBO) is not clear. This meta‐analysis compared the efficacy of covered vs. uncovered SEMS for patients with MDBO after endoscopic insertion. Methods: A systematic meta‐analysis of all relevant articles listed in PubMed, the Cochrane Library, and Google Scholar databases was performed. Fixed effects or random effects models were used to investigate pooled effects with 95% confidence intervals (CIs). Results: The meta‐analysis included 2358 patients from 12 eligible studies. Time to recurrent biliary obstruction (RBO) was significantly longer for covered SEMS (mean difference, 45.51 days; 95% CI 11.79–79.24). Although there was no significant difference in the RBO rate, subgroup analysis in pancreatic cancer occupying more than 90% (PC) revealed that the RBO rates were significantly lower for covered SEMS (odds ratio [OR] 0.43, 95% CI 0.25–0.74). Stent migration, sludge formation, and overgrowth were significantly more common with a covered SEMS (OR 7.92, 95% CI 4.01–15.64; OR 3.25, 95% CI 1.89–5.59; OR 2.03, 95% CI 1.20–3.43, respectively). The rate of ingrowth was significantly lower for covered SEMS. There was no significant difference in total procedure‐related adverse events between the two types of SEMS. Conclusions: A covered SEMS is superior to an uncovered SEMS with respect to prevention of RBO in patients with MDBO, particularly those caused by PC. [ABSTRACT FROM AUTHOR]

Background: During endoscopic ultrasound‐guided biliary drainage (EUS‐BD), a combination of a 19‐gauge needle and a 0.025‐inch guidewire is generally used. However, a 19‐gauge needle has poor maneuverability because of their stiffness and rigidity and might have poor penetrability in non‐dilated bile ducts because of their large bore. In contrast, the application of a 22‐gauge needle is expected to have improved maneuverability. However, only a 0.018‐inch guidewire, which has less supportability, is applicable in the subsequent guidewire selection. This study aimed to evaluate the feasibility and safety of a dedicated bougie dilator for a 0.018‐inch guidewire. Methods: From September 2019 to May 2020, 26 patients underwent fistula dilation using the dilator after accessing the bile duct using a 22‐gauge needle and a 0.018‐inch guidewire during EUS‐BD. The success and adverse event rates of EUS‐BD were evaluated. Results: Biliary access with a combination of a 22‐gauge needle and a 0.018‐inch guidewire was successful in all with a median bile duct diameter of 5 mm. Dilation of the fistula using the dedicated dilator was also successful in all cases. Subsequently, the dilator was successfully exchanged to an ERCP catheter that allowed for exchange to a 0.025‐inch guidewire, except in one case where the catheter did not cross the fistula and a dilation balloon was inserted for an exchange to a 0.025‐inch guidewire. The technical success rate of the EUS‐BD was 100%. The adverse event rate was 19%. Conclusion: The application of the dedicated dilator for a 0.018‐inch guidewire was considered feasible and safe for EUS‐BD. [ABSTRACT FROM AUTHOR]

Patients with pancreatic ductal adenocarcinoma (PDAC) with peritoneal dissemination have a dismal prognosis because discontinuation of systemic chemotherapy is required for massive ascites or poor performance status. The natural history, diagnosis and treatment of PDAC with peritoneal dissemination have not been fully investigated. We systematically reviewed published information on the clinical diagnosis and treatment of PDAC with peritoneal dissemination using the PubMed database (2000‐2020) and provided recommendations in response to clinical questions. This guideline was created according to the "Minds Clinical Practice Guideline Development Guide 2017". The literature quality and body of evidence were evaluated with the GRADE System and classified into four levels ("strong", "medium", "weak", "very weak"). The strength of each final recommendation was decided by a vote of committee members based on the GRADE Grid method. These guidelines address three subjects: diagnostic, chemotherapeutic, and surgical approaches. They include nine clinical questions and statements with recommendation strengths, evidence levels, and agreement rates, in addition to one "column". This is the English synopsis of the 2021 Japanese clinical practice guideline for PDAC with peritoneal dissemination. It summarizes the clinical evidence for the diagnosis and treatment of PDAC with peritoneal dissemination and provides future perspectives. Highlight On behalf of the Japan Peritoneal Malignancy Study Group, Satoi and colleagues present an English synopsis of the 2021 Japanese clinical practice guidelines for pancreatic ductal adenocarcinoma with peritoneal dissemination. It summarizes the clinical evidence for the diagnosis and treatment of pancreatic ductal adenocarcinoma with peritoneal dissemination and provides future perspectives. [ABSTRACT FROM AUTHOR]

Background: Disconnected pancreatic duct syndrome (DPDS) frequently occurs in patients with acute necrotizing pancreatitis and resultant pancreatic fluid collection (PFC). We performed a systematic review and meta‐analysis to evaluate outcomes of endoscopic ultrasound‐guided treatment of PFCs according to the presence of DPDS. Methods: Using PubMed, Embase, and the Cochrane database, we identified clinical studies published until January 2021 with data comparing outcomes of endoscopic ultrasound‐guided drainage of PFCs between DPDS and non‐DPDS patients. We pooled data on technical and clinical success rates, PFC recurrence, and adverse events using the random‐effects model. Results: We identified five eligible articles including 941 PFC patients treated with endoscopic ultrasound‐guided interventions. Clinical success, defined as resolution of the PFC and symptoms, was achieved in a majority of the cases irrespective of DPDS (pooled odds ratio [OR] comparing DPDS to non‐DPDS patients, 0.77; 95% confidence interval [CI] 0.33–1.81). Compared to patients without DPDS, patients with DPDS were more likely to undergo PFC recurrence (pooled OR 6.72; 95% CI 2.72–16.6) after clinical resolution of PFC. Prolonged plastic stent placement following the clinical resolution was more frequently performed in DPDS patients than in non‐DPDS patients (pooled OR 15.9; 95% CI 2.76–91.9). No statistically significant difference was observed between the groups in terms of the rate of technical success, adverse events, or mortality. Conclusion: Disconnected pancreatic duct syndrome was associated with higher rate of PFC recurrence after successful endoscopic treatment of PFCs. Future studies should evaluate effectiveness and optimal duration of long‐term placement of transmural plastic stents for PFCs with DPDS. [ABSTRACT FROM AUTHOR]

Objectives: The oncological outcomes, especially high recurrence rate, of bridge‐to‐surgery (BTS) self‐expandable metallic stent (SEMS) placement remain concerning, emphasizing the necessity of standardized SEMS placement. However, its impact on long‐term BTS outcomes is unknown. We investigated the long‐term outcomes of BTS colonic stenting using standardized SEMS placement. Methods: This prospective, multicenter cohort study conducted at 46 hospitals in Japan (March 2012 to October 2013) included consecutive patients with stage II and III obstructive colorectal cancer managed with BTS SEMS placement. The SEMS placement technique was standardized by information dissemination among the participating hospitals. The primary outcome was overall survival (OS) after SEMS placement, and the secondary outcomes were relapse‐free survival (RFS), recurrence, and short‐term outcomes of SEMS placement and surgery. Results: The 1‐, 3‐, and 5‐year OS rates were 94.1%, 77.4%, and 67.4% (Kaplan–Meier), respectively, with high technical success (99.0%, 206/208) and low perforation (1.9%, 4/208) rates. The 1‐, 3‐, and 5‐year RFS rates were 81.6%, 65.6%, and 57.9% (Kaplan–Meier), respectively, and the overall recurrence rate was 31.0% (62/200). The RFS rate was significantly poorer in patients with perforation (n = 4) than in those without perforation (n = 196) (log‐rank P = 0.017); moreover, perforation was identified as an independent factor affecting RFS (hazard ratio 3.31; 95% confidence interval 1.03–10.71, multivariate Cox regression). Conclusion: This large, prospective, multicenter study revealed satisfactory long‐term outcomes of BTS colonic stenting using a standardized SEMS insertion method, which might be specifically due to the reduced perforation rate. (UMIN000007953). [ABSTRACT FROM AUTHOR]

The article focuses on the evolving threshold of viability for extremely preterm infants in high-income countries, noting improvements in survival rates. Topics discussed include the recent study on extremely low birthweight infants in Japan, indicating high survival rates at 22-24 weeks gestational age, which sets a benchmark for other countries, and the need for future studies to assess detailed data, including long-term neurodevelopmental outcomes and ethical implications.

We describe the successful management of an obstructive shock case caused by cardiac tamponade following atrial rupture. The dog was an 11‐year‐old female chihuahua with a 1‐year history of mitral valve insufficiency. During a radiographic examination, the dog collapsed. We diagnosed a case of obstructive shock caused by cardiac tamponade following left atrial rupture, secondary to mitral valve regurgitation. After administration of atropine and dobutamine, the blood pressure stabilised. The dog regained consciousness and was discharged 96 hours after collapse. The use of dobutamine should be considered in selected obstructive shock cases and may reduce the high mortality rate associated with atrial rupture. [ABSTRACT FROM AUTHOR]

Background: In Japan, the definition and classification of neonatal chronic lung disease (CLD) used for its diagnosis are a combination of those used in Japan and abroad. Methods: To clarify the current state of CLD diagnosis, a questionnaire survey was conducted. Results: Half of the patients of the medical centers included in the study were diagnosed with CLD in real time, while the other half were diagnosed after discharge. In addition, in approximately 70% of the facilities, diagnosis was made after discussions various among medical teams. In approximately 80% of the centers, the chest radiography used for CLD diagnosis were evaluated by multiple doctors. Furthermore, some centers used chest X-rays that were taken at approximately 28 days of age for CLD diagnosis, whereas at other facilities, diagnosis was made regardless of time at which the chest radiography were obtained. Only a small number of centers have established criteria for determining the necessity of oxygen at the corrected age of 36 weeks, and the target saturation of peripheral oxygen levels also tend to vary for each facility. Whether the conditions wherein the patient receives respiratory support for apnea or respiratory tract diseases should be considered as CLD also differed among the facilities. Conclusions: It is necessary to reassess the definition and classification of CLD in Japan to accurately evaluate and improve the quality of respiratory management based on the long-term prognosis. [ABSTRACT FROM AUTHOR]

Aim: Anti‐ribosomal P protein antibodies (anti‐ribo P) have been reported as one of the specific autoantibodies in patients with systemic lupus erythematosus (SLE) and has been demonstrated to bind and activate macrophages in vitro. Clinically, hyperferritinemia has been known to be a biomarker for macrophage activation. The aim of this study is to clarify the relationship of anti‐ribo P and clinical characteristics and biomarkers including serum ferritin in patients with SLE. Methods: Clinical parameters and laboratory data were measured in patients with active SLE (N = 127) in our university hospital. The risk factors affected by anti‐ribo P were retrospectively calculated by logistic regression analysis, and the correlation of anti‐ribo P and clinical factors was demonstrated. Results: Anti‐ribo P was significantly elevated in active SLE compared to non‐SLE diseases (P <.0001). Sensitivity and the specificity of anti‐ribo P in patients with SLE were 32.0% and 99.3%, respectively. Patients positive for anti‐ribo P had the highest risk for elevated serum ferritin (odds ratio: 8.432). Accordingly, anti‐ribo P positive patients had significantly elevated serum ferritin compared to negative patients (P =.024). A significant positive correlation was observed between the anti‐ribo P titer and the serum ferritin level (r2 =.07, t = 5.22, P =.0081), but not serum interleukin (IL)‐6 in SLE patients. Conclusion: The presence of anti‐ribo P is a risk factor for higher ferritin levels that is independent of systemic inflammation regulated by IL‐6. We speculate that anti‐ribo P could be directly associated with macrophage activation leading to hyperferritinemia in patients with SLE. [ABSTRACT FROM AUTHOR]

Background: Liver failure and biliary tract cancer (BTC) are major life‐threatening events in the clinical course of primary sclerosing cholangitis (PSC). Although these are competing events, they are typically evaluated as a composite prognostic endpoint. In Japan, the clinical characteristics and prognosis of PSC reportedly differ according to age of onset. We compared the prognosis of younger‐ versus older‐onset PSC by competing risk analysis. Methods: This was a retrospective analysis of 144 patients with PSC who were followed up for a median of 6.7 years. The patients were divided into two groups according to a cutoff age of onset of 44 years. We compared the prognosis of younger‐onset PSC (n = 91) and older‐onset PSC (n = 53) by competing risk analysis, incorporating mortality related and that unrelated to BTC as competing events. Results: There was no difference in BTC‐related mortality between patients with younger‐onset and those with older‐onset PSC (subdistribution hazard ratio [SHR], 0.89; 95% confidence interval [CI], 0.17‐4.56, P =.888). The cumulative incidence of mortality due to other causes, including liver transplantation and liver failure, was non‐significantly higher in patients with older‐onset PSC (SHR, 1.58; 95% CI, 0.88‐2.84; P =.129). Conclusions: Although we did not find a significant difference in prognosis by onset age, patients with older‐onset PSC had worse liver‐transplantation‐free survival than those with younger‐onset PSC. A large cohort study is needed to evaluate the clinical outcomes of older‐ and younger‐onset PSC. [ABSTRACT FROM AUTHOR]

Background and Study Aim: Management of bile duct stones (BDSs) in patients with surgically altered anatomies (SAAs) remains challenging. An endoscopic ultrasound‐guided antegrade (EUS‐AG) procedure and double‐balloon enteroscopy‐assisted endoscopic retrograde cholangiography (DB‐ERC) have been used to remove BDSs from patients with SAAs. However, few comparative data have been reported. Therefore, we compared the efficacy and safety of the techniques. Methods: This was a single‐center retrospective study. Patients with SAA who underwent the EUS‐AG procedure or DB‐ERC to remove intra‐ or extra‐BDSs between November 2010 and March 2020 were included. The primary outcome was the technical success rate, defined as stent insertion or stone removal during the initial session. The secondary outcomes were the procedure time, incidence of adverse events (AEs), and complete stone removal rate. Results: Of the 54 patients enrolled, 23 underwent the EUS‐AG procedure and 31 DB‐ERC. The technical success rates of EUS‐AG and DB‐ERC were 87.0% and 64.5%, respectively (P = 0.11). The procedure time was significantly shorter in the EUS‐AG group than in the DB‐ERC group (51.9 ± 15.4 vs 72.6 ± 32.2 min; P = 0.01), and the early AE rates were 26.1% and 12.9%, respectively (P = 0.71). The complete stone removal rates in patients who underwent previous stone removal were 94.1% in the EUS‐AG group and 85.7% in the DB‐ERC group (P = 0.61). Conclusion: The EUS‐AG afforded technical success and complete stone removal rates comparable with those of DB‐ERC, but the former procedure was shorter. The AE rate was acceptable. [ABSTRACT FROM AUTHOR]

Background and Aims: Endoscopic ultrasound‐guided fine‐needle aspiration (EUS‐FNA) is used for the histopathological diagnosis of any type of gastrointestinal disease. Few adverse events are experienced with this procedure; however, the actual rate of adverse events remains unclear. This study aimed to clarify the current status of cases that experienced adverse events related to the EUS‐FNA procedure used for histopathologic diagnoses. Methods: A retrospective analysis of cases with EUS‐FNA‐related adverse events in Japanese tertiary centers was conducted by assessing the following clinical data: basic case information, FNA technique, type of procedural adverse events, and prognosis. Results: Of the 13,566 EUS‐FNA cases overall, the total number of cases in which adverse events related to EUS‐FNA occurred was 234. The incidence of EUS‐FNA‐related adverse events was ~1.7%. Bleeding and pancreatitis cases accounted for ~49.1% and 26.5% of all adverse events, respectively. Bleeding was the most common adverse event with only seven cases requiring blood transfusion. In cases with neuroendocrine tumors, pancreatitis was the most frequent adverse event. Needle tract seeding because of EUS‐FNA was observed during the follow‐up period in only ~0.1% of cases with pancreatic cancer. There was no mortality because of adverse events caused by EUS‐FNA. Conclusions: This study revealed that the adverse events‐related EUS‐FNA for histopathologic diagnoses were not severe conditions, and had low incidence. [ABSTRACT FROM AUTHOR]

Background and Aim: While encouraging data of endoscopic ultrasound (EUS)‐guided fine‐needle biopsy (EUS‐FNB) using a 22‐gauge Franseen needle have been reported, large‐scale data of per pass and quantitative analyses are still lacking. Methods: This was a multicenter prospective study of EUS‐FNB using the 22‐gauge Franseen needle for a pancreatic solid lesion. Cytological and histological analyses per pass were evaluated and semi‐quantitative analyses were performed on core tissue and blood contamination. Primary end‐point was diagnostic accuracy per session. Prognostic factors were analyzed for diagnostic accuracy, sensitivity, core tissue, and blood contamination. Results: A total of 629 passes were performed in 244 cases at 14 centers between 2018 and 2019. The median tumor size was 29 mm, and the puncture was transduodenal in 43%. The median pass number was 2. Diagnostic accuracy per session, at a first pass, and per pass were 93%, 90%, and 88%. In 198 cases with pancreatic cancer, diagnostic sensitivity per session, at a first pass, and per pass were 94%, 89%, and 89%. The rates of core tissue score of 4 and blood contamination score of 3 were 50% and 47%. The adverse event rate was 1.6%. In the multivariate analysis, tumor size ≤20 mm (odds ratio [OR] of 0.46, P = 0.03), transduodenal puncture (OR of 0.53, P = 0.04), and suction (OR of 0.16, P = 0.01) were associated with lower diagnostic accuracy. Conclusions: The EUS‐FNB using the 22‐gauge Franseen needle for pancreatic solid lesions showed high per pass and overall diagnostic accuracy. [ABSTRACT FROM AUTHOR]

Watch a video of this article. [ABSTRACT FROM AUTHOR]

Background and Aim: Although endotherapy for pancreatic stones is less invasive compared with surgical interventions, its recurrence rate is high and residual pancreatic stones can be a cause of recurrence. We previously reported usefulness of a novel basket catheter with nitinol fine reticular structure for pancreatic stone retraction. In this retrospective study, we aimed to evaluate the long‐term outcomes of endotherapy for pancreatic stones with and without the use of this dedicated basket catheter. Methods: We retrospectively compared patients with symptomatic pancreatic stones who underwent the initial endotherapy between 2008 and 2019. The primary outcome was the symptomatic recurrence after complete stone clearance. Secondary outcomes were the rate of complete stone clearance, complications, risk factors for recurrences, and the treatment cost. Results: A total of 101 patients who underwent endotherapy for pancreatic stones were analyzed: 41 patients by using the dedicated basket catheter and 60 patients by only the conventional devices. The complete stone clearance was achieved in 87.8% in the dedicated basket group and 88.3% in the conventional device group. Symptomatic recurrence was observed in 16.7% of the dedicated basket group and 47.2% of the conventional device group (P < 0.01). In the multivariate analysis, the use of the dedicated basket catheter was significantly associated with the reduced risk of symptomatic recurrence (hazard ratio, 0.40; 95% confidence interval, 0.15–0.92, P = 0.031). The complication rate and the cost were comparable between the two groups. Conclusion: The use of this dedicated pancreatic basket catheter significantly reduced symptomatic recurrence after complete pancreatic stone removal. [ABSTRACT FROM AUTHOR]

Background: Vancomycin (VCM) is useful for treating methicillin‐resistant Staphylococcus aureus. In infants, calibrating the initial VCM dose is difficult, and many regimens have been proposed. For instance, our center uses the VCM regimen recommended for infants in the 2012–13 Nelson's Pediatric Antimicrobial Therapy. Nonetheless, our experience has shown that the initial VCM trough concentrations were frequently off target. We therefore analyzed the data on the initial VCM trough concentration in infant patients at our center. Methods: The study subjects were inborn infants born between July 2014 and June 2019 who were given VCM at earlier than day 60 in the neonatal intensive care unit. The primary outcome was the initial VCM trough concentration. The patients were divided into three groups by VCM trough concentration: <10, 10–15, and >15 mg/L. We also estimated VCM trough concentration by one method using Monte Carlo simulation, based on Nelson regimen dosage. Results: Thirty‐three patients were analyzed. The number of patients with <10, 10–15, and >15 mg/L was 24, 4, and 5, respectively. There was no significant difference in clinical characteristics between <10 versus 10–15 and 10–15 versus >15 mg/L. The numbers of patients with <10, 10–15, and >15 mg/L in the simulation were 26, 6, and 1, respectively. Conclusions: Most initial VCM trough concentrations were below the target. We could not find any significant clinical characteristics, which affected VCM trough concentration. Increasing the VCM dosage of the Nelson regimen with simulation should therefore be considered. [ABSTRACT FROM AUTHOR]

Coronavirus disease 2019 (COVID‐19) has spread worldwide within a short period, and there is still no sign of an end to the pandemic. Management of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2)‐infected pregnant women at the time of delivery presents a unique challenge. To fulfill the goal of providing adequate management of such women and their infants, and to decrease the risk of exposure of the healthcare providers, tentative guidelines are needed until more evidence is collected. Practical preventative action is required that takes into account the following infection routes: (i) aerosol transmission from mothers to healthcare providers, (ii) horizontal transmission to healthcare providers from infants infected by their mothers, and (iii) horizontal transmission from mothers to infants. To develop standard operating procedures, briefings/training simulations should be carried out, taking into account the latest information. Briefings should be carefully conducted to clarify the role and procedures. Healthcare providers should wear personal protective equipment. If it is physically possible, neonatal resuscitation should be performed in a separate area next to the delivery room. If a separate area is not available, the infant warmer should be placed at least 2 m away from the delivery table, or partitioned off in the same room. A minimum number of skilled personnel should participate in resuscitation using the latest neonatal resuscitation algorithms. [ABSTRACT FROM AUTHOR]

Objectives: With the emergence of the double‐balloon endoscope (DBE), hepaticojejunostomy anastomotic strictures (HJASs) are increasingly managed endoscopically. However, balloon dilation and/or plastic stent placement may be associated with low stricture resolution rates and long treatment duration. We utilized a fully‐covered metal stent (FCSEMS), which was designed for temporary placement for benign biliary strictures, and assessed its feasibility for patients with HJASs. Methods: We retrospectively studied 20 patients who underwent DBE‐assisted FCSEMS placement for HJASs between June 2017 and March 2019. The FCSEMS was removed endoscopically at three months of stent placement. The outcomes investigated were the stricture resolution at the time of FCSEMS removal, the stricture recurrence, and adverse events. Results: Among 20 patients treated, stricture resolution was achieved in 17 patients (85.0%) at three months of stent placement. The FCSEMS was removed endoscopically without any technical difficulties in all cases except for two with asymptomatic stent migration due to stricture resolution. During a median follow‐up period of 11.9 months (interquartile range, 7.5–18.0 months), an HJAS recurred in one patient (5.9%). For two patients without stricture resolution and one patient with recurrent stricture, another FCSEMS placement for 77, 84, and 186 days resolved the stricture. The overall stricture resolution rate was 95.0%. In one patient with FCSEMS‐induced de novo stricture, long‐term plastic stent placement was required. Procedure‐related adverse events included mild cholangitis in two patients and mild pancreatitis in one patient. Conclusions: Endoscopic treatment using a FCSEMS via DB‐ERCP was a feasible and effective treatment option for a HJAS. [ABSTRACT FROM AUTHOR]

Objectives: In patients with surgically altered anatomy, endoscopic treatment of pancreatic diseases is technically challenging. We aimed to evaluate the feasibility, effectiveness, and safety of an interchangeable combination of double‐balloon endoscope‐assisted ERP (DB‐ERP) and endoscopic ultrasonography‐guided pancreatic duct drainage (EUS‐PD) in this clinical setting. Methods: Consecutive patients with surgically altered anatomy undergoing endoscopic treatment (DB‐ERP, EUS‐PD, or both) for pancreatic diseases were studied. The primary outcome was technical success; secondary outcomes were clinical success and adverse events. Results: Forty patients who underwent DB‐ERP (38) and EUS‐PD (2) as an initial intervention were retrospectively studied. Indications for intervention included 18 pancreaticojejunostomy anastomotic stricture (PJAS), four pancreatic duct stone (PDS), four pancreatic fistula (PF), 11 PJAS with PDS, and three PJAS with PF. Prior surgical reconstruction was 26 Billroth‐II, 13 Roux‐en‐Y, and one Imanaga reconstruction. Along with salvage procedures including three DB‐ERP and seven EUS‐PD, the overall technical success rates of DB‐ERP and EUS‐PD were 70.7% (29/41) and 100% (9/9), respectively. Clinical success was achieved in 85.0% (34/40) by combination of DB‐ERP and EUS‐PD; successful drainage for PJAS, complete removal of PDS, and resolution of PF were achieved in 90.6%, 80.0%, and 71.4%, respectively. Adverse event rates were 12.2% (5/41; one perforation, and four pancreatitis) in DB‐ERP and 55.6% (5/9; three pancreatic leakage, and two abdominal pain) in EUS‐PD. Conclusions: A combination of DB‐ERP and EUS‐PD can achieve high technical and clinical success for pancreatic diseases in surgically altered anatomy patients. A prospective multicenter study to investigate an appropriate treatment algorithm is warranted. [ABSTRACT FROM AUTHOR]

Endoscopic retrograde cholangiopancreatography with stent placement has been utilized as standard palliative management of distal malignant biliary obstruction (MBO). Compared to plastic stents, metal stents can provide longer‐term relief of symptoms. When a large‐bore metal stent is placed across the ampulla, patients are predisposed to the risk of cholangitis or stent dysfunction due to reflux of duodenal contents. To mitigate the risk of adverse events associated with the duodenobiliary reflux, efforts have been directed to development of antireflux metal stents (ARMSs). The antireflux property has been introduced through adding of an antireflux valve to the duodenal stent end. Evidence from clinical studies indicates that ARMSs may not only reduce the risk of ascending cholangitis during follow‐up but also prolong stent patency time. However, the results of clinical studies testing ARMSs are inconsistent owing to heterogeneous designs of antireflux valves and stent bodies. Metal stents are increasingly indicated for benign biliary strictures and MBO in the setting of neoadjuvant chemotherapy, and therefore, research is warranted to evaluate ARMSs for those indications. Given that endoscopic ultrasound (EUS)‐guided transmural biliary drainage has gained popularity, the optimal timing of placing an ARMS in relation to EUS‐guided and percutaneous drainage should be investigated. Development and evaluation of ARMSs require an integrative approach utilizing phantom and animal models, measurements of stent mechanical properties, and in vivo functional study after stent placement. In this review article, we summarize updated evidence on ARMSs for MBO and discuss issues that should be addressed in future studies. [ABSTRACT FROM AUTHOR]

Acute recurrent pancreatitis (ARP) is defined as two distinct episodes of acute pancreatitis (AP), whereas chronic pancreatitis (CP) is caused by persistent inflammation of the pancreas. In children they are caused by genetic mutations, autoimmune pancreatitis, congenital pancreatic abnormalities, and other conditions. Acute recurrent pancreatitis is frequently a precursor to CP, and both are thought to be on the same disease continuum. In particular, genetic factors are associated with early progression of ARP to CP. The diagnosis of CP, as in AP, is based on clinical findings, biochemical tests, and imaging studies. Findings of exocrine pancreatic dysfunction are also important in the diagnosis of CP. A step‐up strategy has become increasingly standard for the treatment of patients with CP. This strategy starts with endoscopic treatment, such as pancreatic sphincterotomy and stenting, and progresses to surgery should endoscopic therapy fail or prove technically impossible. Non‐opioid (e.g. ibuprofen / naproxen) and opioid (e.g. oxycodone) forms of analgesia are widely used in pediatric patients with AP or CP, whereas pancreatic enzyme replacement therapy may be beneficial for patients with abdominal pain, steatorrhea, and malnutrition. Despite the disparity in the age of onset, pediatric CP patients display some similarities to adults in terms of disease progress. To reduce the risk of developing pancreatic exocrine inefficiency, diabetes and pancreatic cancer in the future, clinicians need to be aware of the current diagnostic approach and treatment methods for ARP and CP and refer them to a pediatric gastroenterologist in a timely manner. [ABSTRACT FROM AUTHOR]

Objectives: Colorectal stenting is widely performed using self‐expandable metallic stents (SEMSs), but the mechanical properties have not been evaluated. Therefore, we conducted an in vitro study to evaluate the mechanical properties of colorectal SEMSs. Methods: Eighteen individual types and sizes of uncovered SEMSs were evaluated for their mechanical properties. Radial force was measured using a measurement machine. Axial force (AF) was measured by two methods: a conventional manual method and a new method using a measurement machine. The correlation of these two methods was evaluated. We also proposed an "AF zero border" that was defined as the angle at which the torque force disappeared. Results: Radial force versus diameter curves and AF versus angle curves were influenced by the structure and the size of each stent. There was excellent correlation of AFs measured by the new and conventional manual method (y = 21.434x, R = 0.881, P < 0.0001). Colorectal SEMSs could be categorized into five subgroups according to the mechanical properties. Most hook‐wired SEMSs had the AF of zero border. Conclusions: This is the first report to evaluate the mechanical properties of colorectal SEMSs, and these data may provide useful information for the clinical use and development of colorectal SEMS. Furthermore, the new measurement machine might standardize the measuring method of AF. [ABSTRACT FROM AUTHOR]

Background: The Japanese Society of Hepato‐Biliary‐Pancreatic Surgery launched the clinical practice guidelines for the management of biliary tract cancers (cholangiocarcinoma, gallbladder cancer, and ampullary cancer) in 2007, then published the 2nd version in 2014. Methods: In this 3rd version, clinical questions (CQs) were proposed on six topics. The recommendation, grade for recommendation, and statement for each CQ were discussed and finalized by an evidence‐based approach. Recommendations were graded as Grade 1 (strong) or Grade 2 (weak) according to the concepts of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. Results: The 31 CQs covered the six topics: (a) prophylactic treatment, (b) diagnosis, (c) biliary drainage, (d) surgical treatment, (e) chemotherapy, and (f) radiation therapy. In the 31 CQs, 14 recommendations were rated strong and 14 recommendations weak. The remaining three CQs had no recommendation. Each CQ includes a statement of how the recommendations were graded. Conclusions: This latest guideline provides recommendations for important clinical aspects based on evidence. Future collaboration with the cancer registry will be key for assessing the guidelines and establishing new evidence. [ABSTRACT FROM AUTHOR]

Background and Aim: Lumen‐apposing metal stent is widely used for endoscopic ultrasound‐guided gallbladder drainage (EUS‐GBD) nowadays but not approved in many countries and might be unsuitable for elective laparoscopic cholecystectomy (LC) because of its large enterocholecysto fistula. A combination of double pigtail plastic stent (DPPS) and naso‐cystic tube (NCT) could overcome these problems. The aim of this study was to estimate the efficacy and safety of this method in patients with acute cholecystitis unfit for urgent cholecystectomy both as bridge to surgery and palliation. Methods: This was a prospective, single‐center feasibility study. EUS‐GBD was performed with a 7Fr DPPS followed by an NCT placement. NCT was removed after 1 week. LC was performed 2 or 3 months after EUS‐GBD in eligible patients. In patients who did not underwent cholecystectomy, DPPS was left in place. Results: Twenty‐three patients were enrolled. Both technical and clinical success rates were 96% (22/23). Early adverse events rate was 13% (3/23), including one bile peritonitis, one intraperitoneal abscess, and one melena. LC was attempted in 12 patients, and conversion to open cholecystectomy was required in three (25%). Neither recurrence of cholecystitis nor late adverse event occurred during 6 months of follow up in 10 patients who did not undergo cholecystectomy. Conclusion: EUS‐GBD with a combination of DPPS and NCT is considered an effective and safe technique both as bridge to surgery and palliation. [ABSTRACT FROM AUTHOR]

Background and Aim: Limited data are available on age and comorbidity assessment in patients with biliary tract cancer (BTC). This study aimed to evaluate the association of age and comorbidity burden with clinical outcomes of chemotherapy for BTC. Methods: Consecutive 197 BTC patients undergoing first‐line chemotherapy between 2007 and 2017 were retrospectively studied. Patients were classified to three groups according to the age‐adjusted Charlson comorbidity index (ACCI) excluding the score about BTC and progression‐free survival, overall survival (OS), and safety were compared. Results: Fifty‐one patients (26%) were elderly (≥ 75 years), and ACCI was 0–2 in 73 patients (37%), 3–4 in 98 (50%), and ≥ 5 in 26 (13%). ACCI was associated with the administration of first‐line combination chemotherapy (89% in 0–2, 80% in 3–4, and 64% in ≥ 5, P < 0.01) and second‐line chemotherapy (67% in 0–2, 51% in 3–4, and 35% in ≥ 5, P = 0.01). ACCI was prognostic for OS in addition to performance status, disease status, and CA19‐9: The hazard ratios in ACCI of 3–4 and ≥ 5 were 1.39 and 1.79, compared with ACCI of 0–2 (P = 0.04). While overall safety profile did not differ by ACCI, higher ACCI score group developed Grade 3–4 neutropenia more frequently (26% in 0–2, 42% in 3–4, and 46% in ≥ 5, P = 0.04). Conclusion: Age and comorbidity burden did affect OS and safety profile in BTC patients undergoing first‐line palliative chemotherapy. ACCI can be a simple and useful tool to evaluate the age and comorbidity burden in these patients. [ABSTRACT FROM AUTHOR]

Aim: We surveyed care practices for critically ill very preterm infants admitted to neonatal intensive care units (NICUs) in the International Network for Evaluating Outcomes in Neonates (iNeo) to identify differences relevant to outcome comparisons.Methods: We conducted an online survey on care practices for critically ill very preterm infants and infants with severe intracranial haemorrhage (ICH). The survey was distributed in 2015 to representatives of 390 NICUs in 11 countries. Survey replies were compared with network incidence of death and severe ICH for infants born between 230/7 and 286/7  weeks of gestation from January 1, 2015, to December 31, 2015.Results: Most units in Israel, Japan and Tuscany, Italy, favoured withholding care when care was considered futile, whereas most units in other networks favoured redirection of care. For infants with bilateral grade 4 ICH, redirection of care was very frequently (≥90% of cases) offered in the majority of units in Australia and New Zealand and Switzerland, but rarely in other networks. Networks where redirection of care was frequently offered for severe ICH had lower rates of survivors with severe ICH.Conclusion: We identified marked inter-network differences in care approaches that need to be considered when comparing outcomes. [ABSTRACT FROM AUTHOR]

Background and objective: Idiopathic pulmonary fibrosis (IPF) is a progressive interstitial lung disease with a poor prognosis. There are no established serum biomarkers for predicting the outcomes of IPF. S100 calcium‐binding protein A4 (S100A4) is considered as a marker of fibroblasts; however, its clinical application remains to be investigated. We evaluated the clinical relevance of S100A4 in IPF patients. Methods: Serum S100A4 levels in 95 consecutive IPF patients and 50 healthy controls (HC) were measured using enzyme‐linked immunosorbent assay. S100A4 expression in lung tissues was determined using immunohistochemistry/immunofluorescence and its association with disease progression (defined as deterioration in lung function or death) and mortality was assessed using Kaplan–Meier method and Cox hazards analysis. Results: Serum S100A4 levels were undetectable in all HC but were detectable in 26 (27.3%) of the 95 IPF patients (P < 0.01). Immunostaining of lung tissues from IPF patients showed aggregation of numerous S100A4‐expressing cells around the fibroblastic foci and mature fibrotic regions. IPF patients with higher serum S100A4 levels had a significantly worse prognosis than those with low serum levels (2‐year cumulative survival rate: 41.7% vs 77.0%, respectively, P < 0.01). On multivariate analyses, baseline serum S100A4 levels (per 10 ng/mL increase) were independently associated with higher disease progression rate (odds ratio: 1.06, P = 0.01) and higher mortality (hazard ratio: 1.18, P = 0.03). Conclusion: S100A4 is a promising serum biomarker that may help predict disease progression/mortality. Our findings may help establish treatment strategies for IPF. [ABSTRACT FROM AUTHOR]

Distal biliary strictures (DBS) are common and may be caused by both malignant and benign pathologies. While endoscopic procedures play a major role in their management, a comprehensive review of the subject is still lacking. Our consensus statements were formulated by a group of expert Asian pancreatico‐biliary interventional endoscopists, following a proposal from the Digestive Endoscopy Society of Taiwan, the Thai Association for Gastrointestinal Endoscopy, and the Tokyo Conference of Asian Pancreato‐biliary Interventional Endoscopy. Based on a literature review utilizing Medline, Cochrane library, and Embase databases, a total of 19 consensus statements on DBS were made on diagnosis, endoscopic drainage, benign biliary stricture, malignant biliary stricture, and management of recurrent biliary obstruction and other complications. Our consensus statements provide comprehensive guidance for the endoscopic management of DBS. [ABSTRACT FROM AUTHOR]