Search

Background and study aims Combined use of thienopyridine derivatives and other antithrombotic agents is reported to be a risk factor for postoperative bleeding after gastric endoscopic submucosal dissection (ESD). However, risk associated with a single thienopyridine derivative has not been evaluated. In this study, we aimed to evaluate bleeding risks of gastric ESD without discontinuation of a single thienopyridine derivative agent. Patients and methods This multicenter, prospective, observational cohort study included patients who had undergone implantation of a coronary artery stent and who were taking a combination of aspirin antiplatelet therapy and a thienopyridine derivative agent. Enrolled patients discontinued aspirin and underwent gastric ESD without the discontinuation of a single thienopyridine derivative agent. The primary endpoint was the major bleeding complication rate after gastric ESD. Results Eleven patients were enrolled in this study from April 2015 to November 2016 after written informed consent was obtained. Among them, 1 patient, who had undergone surgery for a primary cardiac tumor before ESD, was excluded from the study. Ten patients underwent gastric ESD for neoplasms. En-bloc resections were achieved in all cases without intraoperative bleeding complications. Two patients experienced postoperative bleeding although neither case required a blood transfusion (95 % CI 2.5 – 55.6 %). Conclusion En-bloc resections were possible although the postoperative bleeding rate tended to be higher in gastric ESD without discontinuation of a single thienopyridine derivative agent. Additional preventive measures are mandatory to carry out safe gastric ESD in such settings.

Background and study aims Endosurgical devices with injection function have been reported to decrease endoscopic submucosal dissection (ESD) operation times for experts, but the efficacy of these devices for inexperienced endoscopists is unclear. The aim of this study was to evaluate the feasibility of ESD using a novel ESD knife (DN-D2718B). Patients and methods This is a single-center prospective pilot clinical feasibility study. Patients diagnosed with superficial gastrointestinal neoplasms were enrolled. A pre-specified group of ESD trainees with ESD experience on a porcine gastric model and fewer than 30 cases of ESD in their selected fields performed ESD under expert supervision, using the DN-D2718B. En bloc resection rates, R0 resection rates, procedure times, and incidence of intra-operational/post-operational adverse events were assessed. Results Between June 2015 and January 2016, 13 esophageal, 27 gastric, and 14 colorectal ESD cases were performed per-protocol with mean resection speeds of 10.2, 12.0, and 15.5 mm2/min, respectively. There were no intra-operational complications. Conclusion ESD with this novel knife is feasible even when performed by non-experts.

IntroductionPatients scheduled to undergo oesophageal, gastric and colorectal endoscopic submucosal dissection (ESD) are to be investigated to verify the efficacy of dual red imaging (DRI) for establishing haemostasis during ESD.Methods and analysisThe trial is designed as a multicentre, open-label randomised, parallel-group, controlled intervention study. Registered patients will be randomly assigned to DRI and white light imaging (WLI) groups. In the DRI group, the mucosal incision and submucosal dissection will be performed by WLI, and haemostasis will be managed by DRI when bleeding occurs. In the WLI group, the mucosal incision and submucosal dissection are to be performed by WLI and the haemostasis management is to be performed by WLI. The primary endpoint is the time from the recognition of bleeding up to the achievement of complete haemostasis (haemostasis time). The secondary endpoints are the operation time, the proportion of cases in which perforation occurs, and the psychological stress experienced by the endoscopist during haemostasis treatment.Ethics and disseminationThis trial was approved by the Keio University Review Board for Clinical Trials (5 December 2016).DiscussionThis will be the first multicentre collaborative research using DRI for haemostasis treatment during ESD. When the safety and simplicity of DRI as a treatment for haemostasis during ESD can be proven, the ESD procedure can be simplified and disseminated more widely in clinical practice.Trial registration numberUMIN000025134

Double-contrast upper gastrointestinal barium X-ray radiography (UGI-XR) is the standard gastric cancer screening method in Japan. Atrophic gastritis and enlarged gastric folds are considered the two major features of Helicobacter pylori-induced chronic gastritis, but the clinical meaning of evaluating them by UGI-XR has not been elucidated. We analyzed healthy UGI-XR examinees without a history of gastrectomy, previous Helicobacter pylori eradication and usage of gastric acid suppressants. Of the 6433 subjects, 1936 (30.1 %) had atrophic gastritis and 1253 (19.5 %) had enlarged gastric folds. During the 3-year prospective observational follow-up, gastric cancer developed in seven subjects, six of whom (85.7 %) had atrophic gastritis with H. pylori infection and five of whom (71.4 %) had enlarged gastric folds with H. pylori infection. The Kaplan-Meier method with log-rank testing revealed that both UGI-XR-based atrophic gastritis (p = 0.0011) and enlarged gastric folds (p = 0.0003) are significant predictors for future gastric cancer incidence.

Background and study aims: Suitable techniques for the prevention of stricture formation after esophageal endoscopic submucosal dissection (ESD) are still lacking. We investigated the efficacy of polyglycolic acid (PGA) sheets with fibrin glue to prevent post-ESD stricture. Patients and methods: We conducted a pilot study on a total of eight consecutive patients who underwent esophageal ESD that left a mucosal defect of more than three-quarters of the esophageal circumference. PGA sheets were attached to the defect with fibrin glue immediately after the completion of ESD. The primary endpoint was the incidence of post-ESD stricture. The secondary endpoints were the number of sessions of endoscopic balloon dilation (EBD) required to resolve any stricture and the rate of complications. Results: There were no adverse events related to the use of PGA sheets and fibrin glue. Post-ESD stricture occurred in 37.5 % of the subjects and 0.8 ± 1.2 sessions of EBD were required. Conclusion: The use of PGA sheets and fibrin glue after esophageal ESD is a novel method that radically decreases the incidence of esophageal stricture and the number of EBD sessions subsequently required. University Hospital Medical Network Clinical Trial Registry (UMIN000011058).

The management of antithrombotics during the periendoscopic period is traditionally represented as a doubleedged sword for cardiologists and endoscopists. Appropriate administration prevents thromboembolic events, whereas excessive administration provokes bleeding events. Therefore, cardiologists and endoscopists must consider the risks of bleeding and thromboembolism in individual cases, before deciding whether to continue antithrombotic use. Several guidelines exist concerning antithrombotic management in Asian and Western countries. These guidelines generally classify procedural bleeding risk and thromboembolic risk into high risk and low risk groups and recommend that the two risks be weighed when managing a given patient. Moreover, they generally do not recommend interrupting antithrombotics during the periendoscopic period unless absolutely necessary; however, the details surrounding this point differ among the guidelines after several revisions. In this review, we describe the present state, problems, and future perspectives concerning the management of antithrombotics in patients with cardiovascular disease undergoing gastrointestinal endoscopy.

Triamcinolone Injection and Shielding with Polyglycolic Acid Sheets and Fibrin Glue for Postoperative Stricture Prevention after Esophageal Endoscopic Resection: A Pilot Study

The current study tested the hypothesis that voluntary activation during maximal voluntary contraction (MVC) conditionally depends on sex and joint action. Twenty-eight healthy adults (14 of each sex) performed knee extensor MVC and plantar flexor MVC at extended and flexed knee positions. Voluntary activation during MVC was assessed using a twitch interpolation technique. The voluntary activation during plantar flexor MVC at the extended knee position was significantly lower (P = 0.020, 95% confidence interval 1.4 to 14.6, Cohen’s d for between-subject design = 0.94) in women (88.3% ± 10.0%) than in men (96.2% ± 6.6%). In contrast, no significant sex differences were shown in the voluntary activation during knee extensor MVC (93.7% ± 5.9% (women) vs. 95.0% ± 3.9% (men)) and during plantar flexor MVC at the flexed knee position (90.4% ± 12.2% (women) vs. 96.8% ± 5.6% (men)). The voluntary activation during knee extensor MVC was significantly higher (P = 0.001, 95% confidence interval 2.1 to 8.8, Cohen’s d for within-subject design = 0.69) than that during plantar flexor MVC at the extended knee position in women, whereas the corresponding difference was not observed in men. The results revealed that the existence of sex difference in the voluntary activation during MVC depends on joint action and joint angle.

Background Despite the marked increase of diverticulosis, its risk factors have not been adequately elucidated. We therefore aim to identify significantly associated factors with diverticulosis. We also aim to investigate the present state of diverticulosis in Japan. Methods We reviewed the medical records from 1990 to 2010 that included the data of consecutive 62,503 asymptomatic colonoscopy examinees from the general population in Japan. Most recent 3,327 examinees were analyzed with 16 background factors. Results Among the 62,503 subjects (47,325 men and 15,178 women; 52.1 ± 9.2 years old), diverticulosis was detected in 11,771 subjects (18.8%; 10,023 men and 1,748 women). The incidences of diverticulosis in 1990-2000 and 2001-2010 were respectively 13.0% (3,771 of 29,071) and 23.9% (8,000 of 33,432): the latter was much higher than the former in all age groups and for both genders. Considering the anatomical locations of colorectal diverticula, left-sided ones have markedly increased with age but not significantly changed with times. Univariate analyses of the 3,327 subjects showed significant association of diverticulosis with four basic factors (age, sex, body mass index, blood pressure), three life style-related factor (smoking, drinking, severe weight increase in adulthood), and two blood test values (triglyceride, HbA1c). The multiple logistic analysis calculating standardized coefficients (β) and odds ratio (OR) demonstrated that age (β = 0.217-0.674, OR = 1.24-1.96), male gender (β = 0.185, OR = 1.20), smoking (β = 0.142-0.200, OR = 1.15-1.22), severe weight increase in adulthood (β = 0.153, OR = 1.17), HbA1c (β = 0.136, OR = 1.15), drinking (β = 0.109, OR = 1.11), and serum triglyceride (β = 0.098, OR = 1.10) showed significantly positive association with diverticulosis whereas body mass index and blood pressure did not. Conclusions The large-scale data of asymptomatic colonoscopy examinees from the general population from 1990 to 2010 indicated that the prevalence of diverticulosis is still increasing in Japan. Age, male gender, smoking, severe weight increase in adulthood, serum HbA1c, drinking, and serum triglyceride showed significant positive association with diverticulosis.

The aim of this study is to assess whether the risk or types of suicide change in Fukushima in the aftermath of a series of disaster, including earthquake, tsunami and nuclear accident in March 2011. The clinical records of all patients visited to the medical centre near the nuclear plant from 1 year before to 1 year after the disaster were reviewed (n = 981). Patients with non-fatal suicide attempt were divided into two categories depending on their method of suicide attempt. Standardised mortality ratios were calculated to adjust for changes in demographic profiles. The risk of non-fatal suicide attempts using high-mortality methods was significantly higher for 4 months, by three to four times after the series of disasters, and then decreased. There was no significant increase of non-fatal suicide attempts using low-mortality methods after the disaster. After such a disaster, immediate psychiatric support may be required because of the increased risk of non-fatal suicide attempts in the immediate aftermath.

The Japan Society of Mechanical Engineers (JSME) Committee on Power Generation Facility Codes recognizes the importance of fatigue evaluation methods based on the latest knowledge and is developing a fatigue evaluation method by flaw tolerance. The ASME B&PV Code Section XI has Non-mandatory Appendix L, “Operating Plant Fatigue Assessment” (hereinafter “App. L”), which provides a flaw tolerance method for fatigue evaluation when a cumulative usage factor (CUF) of a component is greater than 1.0. In order to develop a flaw tolerance method for the JSME Codes for nuclear power generation facilities, postulated initial flaws, capability of nondestructive examination, compatibility to rules and flaw tolerance codes are discussed.Copyright © 2013 by ASME

Although pancreatic cancer produces upstream obstructive pancreatitis, acute pancreatitis is a less common manifestation of pancreatic cancer. This study aimed to clarify the subgroup of pancreatic cancer patients who present with an episode of acute pancreatitis (Group I) in comparison with a matched group of pancreatic cancer patients without pancreatitis (Group II) and another group of acute pancreatitis patients without pancreatic cancer (Group III).This was a retrospective comparative study of 18 patients in Group I, 300 patients in Group II and 141 patients in Group III.The mean age of Group I was 63.7 years and the male to female ration was 1:0.3. Serum CA 19-9 levels were elevated in 80 %. The main pancreatic duct was incompletely obstructed in 7 patients. There were no significant differences in location of tumor, clinical stage, resection rate and survival months between Group I and II. Acute pancreatitis secondary to pancreatic cancer was more likely to be mild (94 vs. 72 %,p0.05) and relapsed (39 vs. 16 %,p0.05) compared with Group III.Anatomic evaluation of the pancreas should be performed in patients with acute pancreatitis with no obvious etiology, even if the pancreatitis is mild, to search for underlying malignancy.

The patient was a 67-year-old man who showed right massive haemothorax after being run over by a low-speed vehicle. In the ambulance, his Glasgow Coma Scale score was 15/15 (eyes: 4; verbal: 5; motor: 6) and he was able to speak. However, he went into cardiopulmonary arrest during transportation. On admission to our hospital 40 min after arrest, right massive haemothorax was detected. The …

This paper provides failure probability assessment results for piping systems affected by stress corrosion cracking (SCC) and pipe wall thinning in nuclear power plants. On the basis of the results, considerations for applying the leak-before-break (LBB) concept in actual plants are presented. The failure probability for SCC satisfies the target failure probability even if conservative conditions are assumed. Moreover, for pipe wall thinning analysis, pre-service inspection is important for satisfying the target failure probability because the initial wall thickness affects the accuracy of the wall thinning rate. The pipe wall thinning analysis revealed that the failure probability is higher than the target probability if the bending stress in the pipe is large.Copyright © 2011 by ASME

Flow fields and tube exciting forces were investigated in straight tube-bundles and in a U-bend tube-bundle for several conditions of air-water two-phase flow. The two-phase turbulent exciting forces were correlated with the local flow behavior to elucidate the excitation mechanism. In the straight tube-bundles, the excitation was found to be due to the impact force of water slugs passing around the tubes, which is proportional to the dynamic pressure of the water slug. The estimation formula thus obtained was applied to the U-bend environment and it agreed fairly well with the measured result. Thus the excitation mechanism and its relation with the local flow field has become clear

The Master Curve Approach for assessing fracture toughness of reactor pressure vessel (RPV) steels has been accepted throughout the world. The Master Curve Approach using fracture toughness data obtained from RPV steels in Japan has been investigated in order to incorporate this approach into the Japanese Electric Association (JEA) Code 4206, “Method of Verification Tests of the Fracture Toughness for Nuclear Power Plant Components”. This paper presents the applicability of the Master Curve Approach for Japanese RPV steels.Copyright © 2008 by ASME

The JSME (Japan Society of Mechanical Engineers) published the rules on design and construction for nuclear power plants in 2001. The basic concept of this rule originates in the ASME Boiler & Pressure Vessel Code Section III, however, some articles in the JSME rules are modified from the ASME rules depending on the Japanese own investigations and thoughts. This paper presents the outline of the JSME rules and discussed the comparison between the JSME rules and the ASME rules. In Japan, rules for the design and construction for nuclear power plants had been used in the Japanese regulatory standards known as Notification 501 of MITI (Ministry of international Trade and Industry) for over 30 years. And the JSME code is also based on the Notification 501. Recently the Japanese regulatory authority had announced new policy to adapt non-government voluntary rules for the design and construction taking advantage of reflecting new technology and the code revision quickly. And, in November 2003, the new JSME rules are endorsed by the Japanese regulatory authorities as alternate rules of the Notification 501.

Japanese utilities and vendors have taken environmental effects on fatigue (EF) into consideration in the plant life management (PLM) activity of operating plants for several years. In Sep. 2000 MITI notified the utilities to adopt “The Guidelines for Evaluating Fatigue Initiation Life Reduction in LWR Environment (MITI guidelines)” for PLM evaluation of operating plants [1]. In April 2001, the study started to establish detailed procedures for EF evaluation and the committee was organized for developing detailed guidelines at Thermal and Nuclear Power Engineering Society (TENPES). The evaluation guidelines were completed and published as TENPES guidelines [2]. These guidelines proposed several practical options to apply fatigue life reduction factor for environmental effects (Fen) on actual operating plant fatigue evaluation.Copyright © 2003 by ASME

Endoscopic submucosal dissection (ESD) for early gastric cancer is a well-established procedure with the advantage of resection in an en bloc fashion, regardless of the size, shape, coexisting ulcer, and location of the lesion. However, gastric ESD is a more difficult and meticulous technique, and also requires a longer procedure time, than conventional endoscopic mucosal resection. These factors naturally increase the risk of various complications. The two most common complications accompanying gastric ESD are bleeding and perforation. These complications are known to occur both intraoperatively and postoperatively. However, there are other rare but serious complications related to gastric ESD, including aspiration pneumonia, stenosis, venous thromboembolism, and air embolism. Endoscopists should have sufficient knowledge about such complications and be prepared to deal with them appropriately, as successful management of complications is necessary for the successful completion of the entire ESD procedure.

A 64-year-old woman had an ulcerated tumor of 5 years' duration on her left foot. Histological examination revealed a eccrine poroma with bowenoid changes at one edge, which had invaded the dermis. We consider this case to be malignant eccrine poroma (porocarcinoma).