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Hepatectomy is currently recommended as the most reliable treatment for hepatocellular carcinoma. However, the association between the choice of treatment for recurrence and the timing of recurrence remains controversial. Three-hundred thirty-nine patients who underwent hepatectomy were retrospectively analyzed using a propensity score matching analysis for the risk factors and outcomes for early recurrences within 6 months. The remnant liver volumes and laboratory data were measured postoperatively using multidetector computed tomography on days 7 and months 1, 2, and 5 after surgery. The Student’s t test and chi-square test, the likelihood-ratio test, Fisher’s exact test, Mann–Whitney U test, or Wilcoxon signed-rank test were used in the statistical analyses. Early recurrence developed in 41/312 patients (13.1%). Vascular invasion and non-curative resection were independent risk factors for the occurrence of early recurrence (P

There is no established view of how gastric acid suppression affects the time for gastric emptying. Vonoprazan fumarate shows potent and durable gastric acid inhibitory effects, but its effects on gastric emptying have not been studied widely. We investigated the effects of vonoprazan fumarate on gastric emptying and measured serum gastrin and plasma ghrelin levels in healthy adults. Ten participants were administered 10 mg vonoprazan fumarate daily for 14 days, then 20 mg vonoprazan fumarate daily for 14 days. The gastric emptying breath test was performed and serum gastrin levels were measured at baseline and after each medication administration period. The protocol was then repeated, with the gastric emptying breath test and serum gastrin and plasma desacyl-ghrelin levels measured at baseline and the end of the medication trial. Mean serum gastrin levels increased in a dose-dependent manner [baseline: 104.7 ± 50.4, after 10 mg protocol: 328 ± 123.8, after 20 mg protocol: 555 ± 378.8 (pg/mL, mean ± standard deviation), p = 0.0008]. There was a significant difference between the gastric emptying breath test Tmax at baseline and just after the 20 mg protocol (baseline: 45.5 ± 15.3, after 20 mg protocol: 60.5 ± 19.6 min, p = 0.0418). Plasma desacyl-ghrelin levels increased significantly just after the 20 mg protocol compared to those at baseline [baseline: 222.3 ± 106.4, after 20 mg protocol: 366.2 ± 178.6 (fmol/mL), p = 0.0008]. In healthy adults, 14 days of vonoprazan fumarate administration at 20 mg/day delayed gastric emptying. This clinical trial was registered in the University hospital Medical Information Network Clinical Trial Registry (Trial No. UMIN000039199 and UMIN000042969).

The aim of this study was to compare ultrasonographic assessment of fecal loading in adults with that of computed tomography. Ultrasonography (US) was performed on 43 adult patients immediately after abdominal computed tomography images had identified fecal loading in their colons. In 18 of 43 patients (haustrations-visualized cases), fecal loading was detected as crescent-shaped acoustic shadows associated with haustrations behind the strong echoes off the colon wall. In the remaining 25 patients (haustrations-not-visualized cases), fecal loading was detected as attenuating echoes with multiple high echoic spots behind weak high echoes off the colon wall in 17 patients and similar to those seen in the haustrations-visualized cases but without haustrations in 8 patients. US can be used for qualitative assessment of fecal loading in the colon. This new technique is simple and noninvasive and can be used concomitantly with physical examination to assess severity of constipation.

Liver abscesses secondary to Salmonella species are rarely described in the general population. We herein describe a case of a liver abscess caused by CTX-M-55-type extended-spectrum β-lactamase (ESBL)-producing Salmonella enteritidis, which has not been reported in the literature. A 54-year-old male was admitted due to a high fever and was clinically diagnosed with a liver abscess. Culture of the fluid from the liver abscess revealed CTX-M-55-type ESBL-producing S. enteritidis. Although the patient underwent percutaneous transhepatic abscess drainage and antibiotic therapy, he died one month later. It should be noted that liver abscesses are potentially fatal depending on the causative pathogen.

A 60-year-old woman was referred to our hospital with swelling of the right leg. After surgery, leiomyosarcoma of the right leg was diagnosed. Computed tomography showed two hypovascular masses in the pancreatic body and tail that were heterogeneously enhanced compared with the pancreatic parenchyma. On endoscopic ultrasonography, the tumors in the pancreatic body and tail both exhibited regular margins and were visualized as well-circumscribed masses with uneven interiors. Distal pancreatectomy was performed under a presumptive diagnosis of metastatic pancreatic leiomyosarcoma diagnosed based on the findings of EUS-FNA. On laparotomy, peritoneal washing cytology yielded negative results, and no dissemination was observed. Ultimately, metastatic pancreatic leiomyosarcoma was histologically diagnosed.

Yersinia enterocolitica (YE) infection is a rare cause of intestinal intussusception, especially in adults. We herein, report a case of adult intussusception due to YE enterocolitis. A 24-year-old woman was admitted because of severe abdominal pain. She was clinically diagnosed with ileocolic intussusception on the basis of the findings of computed tomography (CT) and a gastrografin enema. Manual surgical reduction was sufficient to alleviate the intussusception. A histological examination of the lymph nodes around the ileocecum excluded lymphoma. Serological testing revealed that the cause of the intussusception was a YE infection. The patient's postoperative course was good and no recurrence was seen during the follow-up.

Over the last few decades, the role of endoscopic ultrasound (EUS) in the diagnosis of pancreatic malignancies has greatly increased by allowing earlier diagnosis and appropriate staging. The development of linear array EUS also allows fine needle aspiration (FNA) to be carried out under real-time EUS guidance and offers definitive diagnosis, which has fundamentally changed the diagnostic approach to pancreatic malignancies. Moreover, linear array EUS with the EUS-FNA technique has a therapeutic application that has expanded the role of this procedure in the management of pancreatic malignancies. This review will focus on the features of linear array EUS and discuss the current role of linear array EUS in the diagnosis of pancreatic malignancies.

症例は35歳の女性で切迫早産にて当院産科に入院中であった．妊娠35週6日から急に全身倦怠感と上腹部痛が出現して，急性肝不全，播種性血管内凝固症候群（DIC）の徴候が認められた．腹部超音波検査ではbright liverではなかったが，急性妊娠性脂肪肝と診断されて同日緊急帝王切開術が施行された．しかし，翌日左上腹部痛が増強し，アミラーゼの急上昇が認められた．腹部CTでは膵全体の腫大と膵周辺への炎症の波及が認められた．予後因子3点を満たしたので重症急性膵炎と診断された．保存的治療の経過は良好であり，膵炎診断後18日後には軽快退院となった． 本症例は妊娠時急性膵炎の成因となりうる著明な高脂血症は認められなかった．急性妊娠性脂肪肝は腹腔動脈の攣縮が原因とされる．本症例で合併した急性膵炎も膵臓の栄養動脈の血管攣縮による膵虚血が成因の一つとして考察された．

Background: Although endoscopic naso-gallbladder drainage (ENGBD) for gallbladder disease is useful, the procedure is difficult and investigations involving many cases are lacking. Furthermore, reports on transpapillary intraductal ultrasonography (IDUS) of the gallbladder using a miniature probe are rare. Methods: A total of 150 patients (119 suspected of having gallbladder carcinoma, 24 with acute cholecystitis (AC), and seven with Mirizzi’s syndrome (MS)) were the subject. (i) ENGBD: We attempted to put ENGBD tube into the GB. (ii) IDUS of the gallbladder: Using the previous ENGBD tube, we attempted to insert the miniature probe into the gallbladder and perform transpapillary IDUS of the gallbladder. In five patients, we attempted three-dimensional intraductal ultrasonography (3D-IDUS). Results: (i) ENGBD: Overall success rate was 74.7% (112/150); the rate for the patients suspected of having gallbladder carcinoma was 75.6% (90/119), and was 71.0% (22/31) for the AC and MS patients. Inflammation and jaundice improved in 20/22 successful patients with AC and MS. Success rate was higher when cystic duct branching was from the lower and middle parts of the common bile duct than from the upper part, and was higher when branching was upwards than downwards. (ii) IDUS of the gallbladder: Success rate for miniature probe insertion into the gallbladder was 96.4% (54/56). Lesions could be visualized in 50/54 patients (92.6%). Of these, detailed evaluation of the locus could be performed in 41. In five patients attempted 3D-IDUS, the relationship between the lesion and its location was readily grasped. Conclusion: IDUS of the gallbladder is superior for diagnosing minute images. Improvement on the device will further increase its usefulness.

The authors experienced a case of Mirizzi’s syndrome successfully treated with endoscopic nasogallbladder drainage (ENGBD). The patient was a 63-year-old man. He was admitted with abdominal pain and jaundice. Laboratory data indicated leukocytosis and elevation of serum bilirubin level. Abdominal ultrasound showed marked swelling of gallbladder and debris in the gallbladder, therefore, the authors strongly suspected Mirizzi’s syndrome. He had past history of acute myocardial infarction and treated with anticoagulation therapy. Then, the authors couldn’t perform surgical removal or percutaneous transhepatic drainage, and tried endoscopic transpapillary drainage. Endoscopic retrograde cholangiopancreatography revealed smooth stricture in the superior portion of common bile duct and occlusion of the cystic duct, and ENGBD was then performed. After ENGBD, his complaints, laboratory data, swelling of gallbladder and stricture of common bile duct were all remarkably improved.

Mucinous cystic neoplasm (MCN) of the pancreas is characterized by a multilocular cystic lesion lined by mucin-producing columnar epithelium and an ovarian-type stroma [1]. MCNs are often found incidentally and may occasionally cause symptoms. Rupture of a pancreatic MCN is a rare complication, and only a few cases have been reported to date [2–5]. Many of these cases occurred during pregnancy [2,3,5]. This report is the first to describe a case of ruptured MCN with an associated invasive carcinoma of the pancreas diagnosed by endoscopic retrograde pancreatography (ERP). In a 69-year-old woman complaining of abdominal pain, contrast-enhanced computed tomography (CT) showed a lowdensitymass60mm indiameter that communicated with a dilated main pancreatic duct (●" Fig.1). Contrast-enhanced endoscopic ultrasound (EUS) revealed amixedechopattern in themassandenhancement effects in hyperechoic areas (●" Fig.2). The findings on CT, EUS, and magnetic resonance imaging (not shown) suggested that the tumorwas amultilocular cystic lesion of the pancreas with solid components, but they were atypical, and a diagnosis could not be reached. ERP was then performed and showed leakage of contrast medium from the main pancreatic duct into the peritoneal cavity (●" Fig.3). CT images obtained immediately after ERP showed pooling of contrast medium in the peritoneal cavity around the tumor (●" Fig.4). A body-tail pancreatectomy with splenectomy was performed quasiemergently 5 days after ERP. The definitive pathological diagnosis was mucinous cystadenocarcinoma of the pancreas with foci of ovarian-like stroma (●" Fig.5). After surgery, the patient underwent chemotherapy with 5-fluorouracil and has remained symptom-free, with no detectable tumor recurrence at present, 2 months after surgery. To the best of our knowledge, this is the first report of MCN of the pancreas with spontaneous rupture diagnosed by ERP.

Collagenous colitis (CC) is a well-known cause of chronic non-bloody diarrhea, especially in elderly women. CC is characterized histopathologically by an increase in the thickness of the subepithelial collagen layer to at least 10 µm, epithelial damage, and chronic inflammation of the lamina propria. Generally, the colonic mucosa in CC is macroscopically normal, although minor, non-specific abnormalities may be found. Due to the recent advancement of endoscopic and diagnostic technologies, however, microscopic mucosal abnormalities and specific longitudinal linear lacerations of the mucosa characteristic of CC have been identified. The association of CC with non-steroidal anti-inflammatory drugs and proton pump inhibitors has also been reported. Since definitive diagnosis of CC has to rely on pathologically documented collagen bands and mononuclear infiltration, the efficiency and precision of colonic biopsy need to be improved. Of the 29 CC patients that we have encountered at our institution, it was in 15 of 29 cases that the endoscopic finding that we performed a biopsy on was apparent. Our comparison of the endoscopic and histopathological findings of CC in the 15 patients showed that the mucosa frequently appeared coarse and nodular on the surface of the mucosa, which was also significantly thicker in collagen bands, demonstrating a strong correlation between collagen band formation and CC. Also, the coarse and nodular surface of the mucosa was most frequently seen affecting the proximal colon. The results suggest that endoscopic observation and biopsy of the proximal colon, where a coarse and nodular surface of the mucosa is often found, may be useful for confirmation of the diagnosis in patients with suspected CC.

In bile duct carcinoma (BDC) patients, bile aspiration cytology (BAC) is an established method for cytodiagnosis. However, almost all previous reports investigated the biliary strictures caused not only by BDC but also by gallbladder and pancreatic carcinomas. Therefore, BAC in BDC patients only has not yet been investigated sufficiently. The aim of this study was to evaluate the actual sensitivity of BAC and to evaluate the factors that affect positive yields of BAC in patients with defined BDC. Data on 47 consecutive patients with definite BDC, who underwent BAC via endoscopic nasobiliary drainage (ENBD) or percutaneous transhepatic cholangiodrainage (PTCD), were retrospectively collected. Fourteen factors were studied for association with positive BAC. The number of cytological samplings ranged from 1 to 14 times. The cumulative diagnostic yield was 72.3% (34/47), and 32 positive results were obtained at a maximum of six samplings. Independent factors associated with positive BAC were perihilar location, stricture length ≥2 cm, and macroscopic papillary type. In BDC patients with ENBD or PTCD, repeated BAC is useful, and six times was the optimum number of repeat samplings. Although the sensitivity of BAC is not sufficient for the preoperative diagnosis of malignant biliary stricture, the three independent factors noted above predict positive yields and indicate whether or not BAC should be repeated up to six times.

Background/Aims: We previously reported early-stage pancreatic histological features in an experimental chronic pancreatitis model, prepared by injecting oleic acid into the pancreatic duct. In this model, on day 2 after injection, reactive fibroblasts in association with inflammation appeared in the stroma, however, myofibroblasts, which were activated fibroblasts, were not detected. On day 4, myofibroblasts appeared in the stroma, and the lobular architecture was destroyed. On day 28, pancreatic acinar cells were completely necrotized and exfoliated, and the stroma was replaced by collagen fibers. On the other hand, it is known that the long-term oral administration of a protease inhibitor (PI) to rats causes pancreatic enlargement as a trophic effect. In this study, we investigated the trophic effect of an oral PI on the rat pancreas. And we examined the trophic effect on pancreatic regeneration in a pancreatic fibrosis model. Subjects: Male Wistar rats weighing about 200 g were used. ONO-3403 (Ono Pharmaceutical Co., Ltd., Osaka, Japan) was used as a potent oral PI. The PI action of ONO-3403 is five-fold stronger than that of camostat mesilate, the only oral PI now used clinically in Japan. Methods: (1) Normal rats were fed with standard feed or 0.1% ONO-3403-containing feed. The pancreases were removed on day 7, 14, 25. Pancreatic amylase, protein, and DNA contents, as well as pancreatic wet weights, were measured. (2) The abdominal cavity of rats was opened, 100 μl of oleic acid, a cytotoxic agent, was injected into the pancreatic duct, and the cavity was closed. Administration of 0.1% ONO-3403-containing feed was started from day 2 (A gourp) or from day 4 (B group) after injection. On day 28, the pancreases were removed and examined. Results: (1) On day 25 after ONO-3403 administration, the pancreatic wet weights increased over time by about 2.2 times. The amylase, protein, and DNA contents increased by about 3.7, 2.9, and 1.8 times, respectively. The increased protein content suggestive of “hypertrophy” was more marked than the increased DNA content suggestive of “hyperplasia”. (2) In the A group on day 28, pancreatic histological features showed the inhibition of pancreatic fibrosis and regeneration of pancreatic acinar cells. In addition, the pancreatic wet weights and contents similarly increased. However, in the B group on day 28, no improvement of pancreatic fibrosis was found. Conclusions: (1) The long-term oral administration of a potent PI showed marked trophic effects on the rat pancreas, however, the trophic effects contributed to hypertrophy rather than hyperplasia. (2) In a pancreatic fibrosis model, the long-term oral administration of a potent PI, from an early stage when no myofibroblasts appeared in the pancreatic stoma, also showed pancreatic trophic effects and led to the regeneration of pancreatic acinar cells.

Background: “Bull's eye calculi” and a preserved pancreatic parenchyma have been founded in patients suffering from chronic pancreatitis associated with gene mutation (CPgm+). Aim: To evaluate radiological pancreatic findings in patients suffering from chronic calcifying pancreatitis. Patients and methods: From May 2006 to June 2007, 27 patients suffering from chronic calcifying pancreatitis were prospectively enrolled. Exclusion criteria were: patients with previous pancreatic surgery. All patients were underwent genetic tests (35 main CFTR gene mutations, R121H and N29I gene mutations on PRSS1 gene, and N34S gene mutation on SPINK1 gene) and MDCT. Images analysis was evaluated by two independent radiologists. Qualitative criteria were: structure of the endoductal calculi (homogeneous/ heterogeneous with presence of a non-calcified central core “bull's eye”), pancreatic parenchyma contrast-enhancement in pancreatic phase compared to renal cortex (hypo-/iso-/ hyper-vascular). Quantitative criteria were: number and diameter of endoductal calculi, size of pancreatic parenchyma (head, body, tail), size of main pancreatic duct (MPD). Results: 27 patients (17 males and 10 females mean age 45 ± 12 yrs) were enrolled in the study. We found 8 gene mutations in seven pts (26%) (4 CFTR, 3 SPINK1 and 1 PRSS1). Heterogeneous calculi with non-calcified central core (“bull's eye”) were observed in 7 out of 27 pts (25%), 5 out of 7 in CPgm+ group (71%) and 2 out of 20 (10%) in CPgmgroup (p= 0.005). The 2 CPgmpatients with presence of “bull's eyes” calculi at MDCT had clinical characteristic suggestive for the presence of gene mutations (age at onset 20 and 25 yrs). The other radiological qualitative and quantitative analysis is reported in Table. Conclusions: The presence of “bull's eye” calculi at MDCT are suggestive for chronic pancreatitis associated with gene mutations.