VOLUME 79 NUMBER 4 November 2017
ORIGINAL PAPERS
Mesh hiatal reinforcement in laparoscopic Nissen fundoplication for neurologically impaired children is safe and feasible
Hizuru Amano, Yujiro Tanaka, Hiroshi Kawashima, Kyoichi Deie, Keisuke Suzuki,
Michimasa Fujiogi, Kaori Morita, Tadashi Iwanaka and Hiroo Uchida
pg(s) 427 - 433
Fundoplication is a standard treatment for gastroesophageal reflux disease (GERD) in neurologically
impaired children. However, it has a high recurrence rate due to wrap herniation and disruption resulting
from the failure or enlargement of the esophageal hiatus suture site. In adult patients with GERD,
reinforcement of the sutured esophageal hiatus with a mesh significantly reduces the recurrence rate after
surgery for esophageal hiatus hernia. In children, there are no big series of fundoplication with mesh
reinforcement. Therefore, we confirmed the safety and feasibility of an expanded polytetrafluoroethylene
mesh hiatal reinforcement with fundoplication as an additional procedure for neurologically impaired
children. Neurologically impaired children (age, ≥5 years) who underwent laparoscopic fundoplication and
gastrostomy at our institution between 2011 and 2013 were included in this study. The operative time,
bleeding amount, complications, and recurrence were retrospectively evaluated. Thirteen patients were
included in this study. The mean age at operation was 147.2 ± 37.8 months, and mean body weight was
18.5 ± 7.9 kg. The complication rate of epilepsy and scoliosis was 100% and 84.6%, respectively. The
operative time was 265.1 ± 38.1 minutes, and mean blood loss was 26.5 ± 34.7 mL. There were no
peri- or postoperative complications. None of the patients showed recurrent symptoms such as repeated
vomiting and aspiration pneumonia during the mean follow-up period of 2.5 ± 0.6 years. The mesh hiatal
reinforcement with fundoplication for neurologically impaired children is safe and feasible.
8-F balloon guide catheter for embolization of anterior circulation aneurysms: an institutional experience in 152 patients
Tomotaka Ohshima, Chinmaya Dash, Andrey Belayev, Taiki Yamamoto,
Shunsaku Goto and Yoko Kato
pg(s) 435 - 441
The use of 8-F balloon guide catheter (BGC) for proximal flow control was previously shown to prevent
distal embolic complications during mechanical clot retrieval in patients with acute ischemic stroke. In
this retrospective study, the utility of 8-F BGCs for proximal flow control during endovascular coiling of
anterior circulation aneurysms was investigated. Patients who underwent endovascular coiling for anterior
circulation aneurysms between August 2013 and December 2016 were retrospectively analyzed. Among a
total of 152 patients included in this series, 64 patients presented with aneurysmal rupture, whereas the
aneurysms were detected incidentally or due to mass effects in the remaining patients. 8-F BGCs were
successfully navigated in all patients. The balloon was inflated during navigation in 19 patients. Inflation
of the catheter balloon during coil embolization was required in 34 patients; this was performed as an
emergency maneuver in six of these patients. Thromboembolic complications occurred in one patient.
8-F BGC can be effectively used for proximal flow control during endovascular treatment of anterior
circulation aneurysms. The other advantages included improved navigation of tortuous arterial anatomy,
coil stabilization during aneurysmal coiling, and freedom to utilize aneurysmal neck-remodeling balloons
for additional adjunctive techniques or to deploy rescue stents. This novel approach might be safely and
effectively used in patients undergoing endovascular treatment for anterior circulation aneurysms.
Clinical outcomes and quality of life after surgery for dilated ascending aorta at the time of aortic valve replacement; wrapping versus graft replacement
Tomonobu Abe, Sachie Terazawa, Hideki Ito, Yoshiyuki Tokuda, Kazuro Fujimoto,
Masato Mutsuga, Yuji Narita, Hideki Oshima and Akihiko Usui
pg(s) 443 - 451
Wrapping and graft replacement are two optional procedures for the treatment of dilated ascending
aorta at the time of aortic valve replacement (AVR). Wrapping is considered less invasive. The aim of
this study was to compare the short- and long-term clinical outcomes as well as the long-term quality of
life in patients undergoing these two procedures.This study enrolled 40 consecutive patients with dilated
ascending aorta who had undergone either wrapping (WAA group, n=20) or replacement (RAA group,
n=20) of the ascending aorta at the time of AVR. Short-term outcomes, long-term deaths, and aortic
events were evaluated, as was quality of life using the SF-36 Short Form. Long-term maximal proximal
aortic diameter was also obtained.There were no early deaths in either group. Pump time was shorter,
and transfusion (55% vs. 95%, p=0.035) and postoperative atrial fibrillation (5% vs. 30%, p=0.036) rates
were lower, in the WAA than in the RAA group. At a mean follow-up of 4.9 years, the overall 5 year
survival rates in the WAA and RAA groups were 78.1% and 87.5%, respectively. There were no significant
between group differences in SF-36 scores in any subcategory of this survey. Long-term maximal aortic
diameter remained stable in both groups. Both surgical interventions for dilated ascending aorta at the
time of AVR yield favorable and comparable results in patients with suitable anatomy. Furthermore, we
found no differences in quality of life between these procedures.
Feasibility of the unilateral-flange stent for the treatment of benign pancreatic duct stricture: a pilot study
Patommatat Bhanthumkomol, Kazuo Hara, Nobumasa Mizuno, Susumu Hijioka,
Nozomi Okuno, Tsukasa Yoshida, Junya Tokuhisa, Sith Siramolpiwat,
Ratha-korn Vilaichone, Bubpha Pornthisarn, Yasumasa Niwa, Masahiro Tajika,
Tsutomu Tanaka, Makoto Ishihara, Yutaka Hirayama and Kenji Yamao
pg(s) 453 - 458
Endoscopic placement of the plastic stent has been adopted as an initial treatment for chronic pancreatitis
with pancreatic duct stricture. Stent fracture while attempting removal is one of the complications of stent
exchange. The use of the unilateral-flange stent in these patients has never been reported. We investigated
the outcomes associated with the use of this stent with regard to stent exchange and stent-related adverse
events. From 2011 to 2015, 9 patients with chronic pancreatitis and main pancreatic duct (MPD) stricture
treated with the unilateral-flange stent were included. Eleven endoscopic treatment sessions, 53 endoscopic
stent deployments or exchange procedures were analyzed. Technical success rate was 100%. Forty-eight
stents were exchanged on a regular basis in 1 to 6-month intervals. Another 5 stent exchange procedures
were urgently performed due to stent obstruction and caused pancreatitis (n=2), symptomatic external stent
migration (n=2), and concurrent cholangitis (n=1). The rate of symptomatic migration was 3.7%. The mean
duration for stent exchange was 29 minutes and no stent fracture occurred during the procedure. Of 11
endoscopic treatment sessions, 7 were successful, 3 were changed to the metallic stents, and 1 was lost to
follow-up. According to this study, unilateral-flange stent placement for benign MPD stricture is technically
feasible and effective. Stent removal during the exchange period is unchallenging and without stent fracture.
Prevention and prediction of postoperative bowel bladder disorder using an anal plug electrode with Tc-MsEP monitoring during spine surgery
Kazuyoshi Kobayashi, Kei Ando, Hideki Yagi, Kenyu Ito, Mikito Tsushima,
Masayoshi Morozumi, Satoshi Tanaka, Masaaki Machino, Kyotaro Ota,
Yukihiro Matsuyama, Naoki Ishiguro and Shiro Imagama
pg(s) 459 - 466
A retrospective study was performed to examine the efficacy of intraoperative monitoring of the external
anal sphincter (EAS) muscle-evoked potential after a transcranial muscle-action potential (Tc-MsEP) in
spinal cord surgery, and to evaluate alarm points for EAS waveform deterioration related to postoperative
bowel bladder disorder (BBD). BBD is caused by damage to the hypogastric, pelvic, and pudendal nerves
and leads to a significant reduction in quality of life. Intraoperative Tc-MsEP monitoring using the EAS
is common to prevent neurological deficit, but the relationship of BBD with intraoperative monitoring of
the EAS has not been examined. Waveform derivation from the EAS using a plug-type surface electrode
was investigated in 123 spine surgeries in which Tc-MsEP was recorded intraoperatively outside the anal
sphincter. An acceptable baseline waveform from the EAS was detected in 105 of the 123 cases (85.3%).
Preoperative BBD was present in 16 cases, postoperative BBD occurred in 8 cases, and intraoperative
waveform deterioration from the EAS was detected in 25 cases. The derivation rate was significantly lower
in cases with preoperative BBD compared to those without BBD (62.5% vs. 88.9%, p<0.01). Waveform
deterioration from the EAS had a sensitivity of 100%, specificity of 93.0%, positive predictive value of
50%, and negative predictive value of 100% for detection of postoperative BBD. All postoperative BBD
was detected with an EAS amplitude decrease to <30% of baseline. Therefore, in spine surgery, a Tc-MsEP
intraoperative EAS amplitude decrease to <30% of the control waveform may be useful for prediction of
postoperative BBD.
Clinical features of patients with infective endocarditis presenting to the emergency department: a retrospective case series
Naruhiro Jingushi, Mitsunaga Iwata and Teruhiko Terasawa
pg(s) 467 - 476
Infective endocarditis (IE) is an uncommon clinical problem with diverse, nonspecific presentations.
Therefore, information on the clinical features of IE patients presenting to emergency departments (EDs)
is scarce. To descriptively analyze the pertinent data, we performed a retrospective chart review. We
reviewed 15 consecutive IE patients admitted directly from ED in a university hospital in Japan between
2013 and 2015. We compared their clinical features with those of 14 IE patients admitted during the same
period without ED presentations. Patients admitted directly from ED were older than those without ED
presentations (median, 78 vs. 52 years; adjusted p = 0.036) and were more likely to have come without
referrals (referral rate, 21% vs. 86%; adjusted p = 0.012). These patients were less likely to have been
treated with antibiotics before admission (antibiotic-exposure rate, 7% vs. 64%; adjusted p = 0.013) and
had earlier blood-culture positivity (median, 2 vs. 5 days; adjusted p = 0.012), resulting in earlier diagnosis
(median duration of symptoms before diagnosis, 5 vs. 30 days; adjusted p = 0.012). Other clinical features,
including causative pathogens and IE-related comorbidities, were similar between the groups, consistent
with previous a nationwide Japanese study. In conclusion, most IE patients admitted to the hospital from
ED were elderly, were antibiotic-naïve, and had presented without a referral. Relatively few patients had
classical presentations of IE. Given the limited data, more research is needed to confirm that IE patients
presenting to EDs constitute a unique group of elderly patients with specific clinical features.
Indole-3-propionic acid suppresses indoxyl sulfate-induced expression of fibrotic and inflammatory genes in proximal tubular cells
Maimaiti Yisireyili, Kyosuke Takeshita, Shinichi Saito, Toyoaki Murohara
and Toshimitsu Niwa
pg(s) 477 - 486
Indoxyl sulfate (IS) induces fibrosis and inflammation in kidneys via oxidative stress through the induction
of transforming growth factor-β1 (TGF-β1) and monocyte chemotactic protein-1 (MCP-1). Furthermore,
IS is a potent endogenous agonist for aryl hydrocarbon receptor (AHR), which regulates the transcription
of genes such as cytochrome P450 (CYP) 1A1. Indole-3-propionic acid (IPA) is an antioxidant and has
been reported to be neuroprotective. We determined whether IPA suppresses IS-induced expression of AHR,
CYP1A1, TGF-β1, and MCP-1 in proximal tubular cells. The effects of IS on the expression of AHR,
CYP1A1, TGF-β1, and MCP-1 were studied using normotensive rats and hypertensive rats. The effects
of IPA on IS-induced expression of AHR, CYP1A1, TGF-β1, and MCP-1 were studied using proximal
tubular cells (HK-2). Furthermore, the effects of IPA on IS-induced expression and phosphorylation of
signal transducer and activator of transcription 3 (Stat3) were studied in HK-2 cells. Administration of
IS induced the expression of AHR, CYP1A1, TGF-β1, and MCP-1 in the tubular cells of rat kidneys.
IPA significantly suppressed IS-induced mRNA and protein expression of AHR, CYP1A1, TGF-β1, and
MCP-1 in HK-2 cells. IPA suppressed the IS-induced expression and phosphorylation of Stat3 in HK-2
cells. Furthermore, knockdown of Stat3 inhibited the IS-induced mRNA and protein expression of AHR,
CYP1A1, TGF-β1, and MCP-1 in HK-2 cells. In conclusion, IPA suppressed the IS-induced expression of
AHR, CYP1A1, TGF-β1, and MCP-1 through suppression of Stat3 in proximal tubular cells. Thus, IPA
suppresses IS-induced expression of fibrotic and inflammatory genes in proximal tubular cells.
Relationship between patellar mobility and patellofemoral joint cartilage degeneration after anterior cruciate ligament reconstruction
Susumu Ota, Kazutoshi Kurokouchi, Shigeo Takahashi, Masaki Yoda,
Ryuichiro Yamamoto and Tadahiro Sakai
pg(s) 487 - 495
Patellofemoral cartilage degeneration is a potential complication of anterior cruciate ligament reconstruction
(ACLR) surgery. Hypomobility of the patella in the coronal plane is often observed after ACLR. Few
studies, however, have examined the relationship between cartilage degeneration in the patellofemoral joint
and mobility after ACLR. The present study investigated 1) the coronal mobility of the patella after ACLR,
2) the relationship between patellar mobility and cartilage degeneration of the patellofemoral joint, and 3)
the relationship between patellar mobility and knee joint function after ACLR. Forty patients who underwent
medial hamstring-based ACLR participated in the study. Lateral and medial patellar displacements were
assessed with a modified patellofemoral arthrometer, and the absolute values of the displacements were
normalized to patient height. The International Cartilage Repair Society (ICRS) cartilage injury classification
of the patellar and femoral (trochlear) surfaces, and the Lysholm Knee Scoring Scale were used to evaluate
knee function. Lateral and medial patellar displacements were reduced compared with the non-operated knee
at the second-look arthroscopy and bone staple extraction operation (second operation; 24.4 ± 7.9 months
after ACLR, P<0.01). The ICRS grades of the patellofemoral joint (patella and trochlea) were significantly
worse than those pre-ACLR. Neither lateral nor medial patellar mobility, however, were significantly correlated
with the ICRS grade or the Lysholm score. Although patellar mobility at approximately 2 years
after ACLR was decreased compared to the non-operated knee, small displacement of the patella was not
related to cartilage degeneration or knee joint function at the time of the second operation.
Measures and effects on prevention of fall: the role of a fall working group at a university hospital
Kazuyoshi Kobayashi, Kei Ando, Yuko Inagaki, Yusuke Suzuki, Yoshimasa Nagao,
Naoki Ishiguro and Shiro Imagama
pg(s) 497 - 504
Fall in hospitalized patients can cause trauma and fractures, which can reduce ADL and QOL, whereas
prevention of fall decreases medical expenses. The purpose of this study is to examine prevention of fall
due to intervention from a fall working group established in our hospital. The working group focused on
three main points. First, colored wrist bands for patients classified as grade 3 risk for fall are used to
alert medical staff. Second, information on fall prevention was distributed to patients. Third, standardization
of two bed fences and reduced use of slippers for inpatients have been introduced. We investigated falls
during hospitalization for 5 years from April 2012 to March 2017. The risk of fall was evaluated as grade
1 (mild) to grade 3 (severe) using an assessment sheet developed by the working group. The incidence
of fall decreased over time, with a significant decrease from 2.1% in 2012 to 1.3% in 2016 (p<0.01).
Slipper use in fall cases showed a significant decrease from 45.8% in 2012 to 11.0% in 2016 (p<0.01).
Among all falls, the percentage of cases with fall risks grade 1 and 2 decreased, while that for grade 3
risk increased from 32.0% in 2012 to 40.3% in 2016 (p<0.05). These results support the efforts of the fall
working group have reduced the overall incidence of fall. However, fall in patients with grade 3 risk has
not decreased, which suggests that better sharing of information is needed for patients at high risk for fall.
Hemispheric divided coiling technique for coil embolization of middle- and large-sized intracranial aneurysms
Tomotaka Ohshima, Shunsaku Goto, Taiki Yamamoto and Kojiro Ishikawa
pg(s) 505 - 513
Despite major developments in treating intracranial aneurysms by endovascular coil embolization,
complete occlusion of the entire aneurysmal neck remains a problem. We present a novel endovascular
strategy for middle- and large sized aneurysms called the “hemispheric divided coiling technique” and
compare the short-term follow-up results of this technique with those of conventional coil embolization.
Ten patients (mean age, 69.7 ± 9.7 years) with middle- or large-sized ruptured or unruptured intracranial
aneurysms (mean maximum aneurysmal diameter, 12.09 ± 3.6 mm) were treated by the hemispheric divided
coiling technique, in combination with various adjunctive techniques. We compared the initial occlusion
grade, volume embolization ratio, and recurrence rate in this group of patients (hemispheric group) with
the results from 20 previous cases (conventional group: mean age, 62.8 ± 9.8 years; mean maximum
aneurysmal diameter, 11.43 ± 3.5 mm). The mean volume embolization ratio of the hemispheric group
was significantly higher than that of the conventional group (42.3% vs. 31.1%). The hemispheric divided
coiling technique achieved a high volume embolization ratio for middle- and large sized intracranial
aneurysms, with a low recurrence rate.
REVIEW ARTICLES
Medical facility statistics in Japan
Nobuyuki Hamajima, Takuya Sugimoto, Ryo Hasebe, Su Myat Cho, Moe Khaing,
Tetsuyoshi Kariya, Yu Mon Saw and Eiko Yamamoto
pg(s) 515 - 525
Medical facility statistics provide essential information to policymakers, administrators, academics, and
practitioners in the field of health services. In Japan, the Health Statistics Office of the Director-General
for Statistics and Information Policy at the Ministry of Health, Labour and Welfare is generating these
statistics. Although the statistics are widely available in both Japanese and English, the methodology
described in the technical reports are primarily in Japanese, and are not fully described in English. This
article aimed to describe these processes for readers in the English-speaking world. The Health Statistics
Office routinely conduct two surveys called the Hospital Report and the Survey of Medical Institutions. The
subjects of the former are all the hospitals and clinics with long-term care beds in Japan. It comprises a
Patient Questionnaire focusing on the numbers of inpatients, admissions, discharges, and outpatients in one
month, and an Employee Questionnaire, which asks about the number of employees as of October 1. The
Survey of Medical Institutions consists of the Dynamic Survey, which focuses on the opening and closing
of facilities every month, and the Static Survey, which focuses on staff, facilities, and services as of October
1, as well as the number of inpatients as of September 30 and the total number of outpatients during
September. All hospitals, clinics, and dental clinics are requested to submit the Static Survey questionnaire
every three years. These surveys are useful tools for collecting essential information, as well as providing
occasions to implicitly inform facilities of the movements of government policy.
Present and future roles of FDG-PET/CT imaging in the management of gastrointestinal cancer: an update
Kazuhiro Kitajima, Masatoyo Nakajo, Hayato Kaida, Ryogo Minamimoto,
Kenji Hirata, Masakatsu Tsurusaki, Hiroshi Doi, Yoshiko Ueno, Keitaro Sofue,
Yukihisa Tamaki and Koichiro Yamakado
pg(s) 527 - 543
Positron emission tomography/computed tomography (PET/CT) integrated with 2-[18F]fluoro-2-deoxy-
D-glucose (FDG) is a useful tool for acquisition of both glucose metabolism and anatomic imaging
data, as only a single device and one diagnostic session is required, thus opening a new field in clinical
oncologic imaging. FDG-PET/CT has been successfully used for initial staging, restaging, assessment
of early treatment response, evaluation of metastatic disease response, and prognostication of intestinal
cancer as well as various malignant tumors. We reviewed the current status and role of FDG-PET/CT for
management of patients with esophageal cancer, gastric cancer, and colorectal cancer, with focus on both
its usefulness and limitations.
SHORT COMMUNICATION
Intrawound Vancomycin powder as the prophylaxis of surgical site infection after invasive spine surgery with a high risk of infection
Tetsuro Hida, Kei Ando, Kazuyoshi Kobayashi, Kenyu Ito, Mikito Tsushima,
Akiyuki Matsumoto, Masayoshi Morozumi, Satoshi Tanaka, Masaaki Machino,
Kyotaro Ota, Shunsuke Kanbara, Sadayuki Ito, Yoshihiro Nishida, Naoki Ishiguro
and Shiro Imagama
pg(s) 545 - 550
Surgical site infections (SSIs) are one of the most serious complications in spine surgery. We investigated
the efficacy of locally administered vancomycin (VCM) powder for prophylaxis on SSI after invasive spine
surgery. We retrospectively studied 174 consecutive patients who underwent spine surgery. In patients of
the VCM group (n = 81), VCM powder was administered in the wound before closing wound. Patients
who did not receive VCM treatment were set as a control group (n = 93). We compared the patients’
background, operation time, intraoperative blood loss, usage of implants, presence of deep SSI, and side
effects between the two groups. There were no significant differences between the groups in age, gender,
and BMI. The operation time and the intraoperative blood loss were longer and greater in the VCM group
than in the control group (P < 0.005, P < 0.001, respectively). Implants were used in 85% of the VCM
group, and in 31% of the control group (P < 0.001). Deep SSI was not observed in the VCM group,
whereas it was observed in 4 patients in the control group. No side effects were observed in any of the
cases. In conclusion, surgeons applied VCM for cases which were invasive or had a high risk of infection.
However, deep SSI was not observed in anyone in the VCM group. The intrawound administration of
VCM might be effective to prevent SSI in cases with high risks of infection.
CASE REPORTS
Distal radius nonunion after volar locking plate fixation of a distal radius fracture: a case report
Takaaki Shinohara and Hitoshi Hirata
pg(s) 551 - 557
We describe a 59-year-old man who had nonunion of a right distal radius fracture after volar locking
plate fixation. He underwent open reduction and internal fixation with a volar locking plate system for a
dorsally displaced, unstable distal radius fracture at a previous hospital 5 months ago. Radiographs of the
injured wrist showed nonunion of the distal radius with 1.5-mm ulnar minus variance. Radiographs of the
unaffected wrist showed 3.5-mm ulnar plus variance. Intraoperative findings of surgical revision showed
an unstable nonunion; thus, debridement of the nonunion, autogenous inlay bone grafting, and internal
fixation using another type of volar locking plate system were performed. Healing of the re-operative site
was confirmed radiographically 3 months postoperatively. We considered that volar locking plate fixation
with excessive distraction of the fracture may lead to nonunion.
Crevice sign as an indicator of plaque laceration associated with postoperative severe thromboembolism after carotid artery stenting: a case report
Tomotaka Ohshima, Taiki Yamamoto, Shunsaku Goto, Kojiro Ishikawa,
Toshihisa Nishizawa, and Shinji Shimato
pg(s) 559 - 564
Carotid artery stenting (CAS) is increasingly utilized in patients with carotid artery stenosis. Various
intraprocedural and postprocedural complications have been reported in the literature. We present a case of
symptomatic major thromboembolism after CAS. The intraprocedural angiogram showed extraordinary slow
filling of the contrast medium into the plaque, which we named as “crevice sign.” An 83-year-old man
presented repeat right amaurosis fugax for 6 months. The radiological examinations revealed 85% stenosis
of the origin of the right internal carotid artery. The patient underwent right CAS. The procedure was
performed without any problems; however, the angiogram showed slow filling of contrast medium into the
carotid plaque through the stent (crevice sign). Sixty minutes later in the ward, the patient presented sudden
onset of left hemiparesis and aphasia. Emergency catheter angiography did not show in-stent thrombus,
major artery occlusion, or the crevice sign. Magnetic resonance imaging on the next day revealed wide
acute infarction of the right cerebral hemisphere. Physicians should be aware of the intraprocedural crevice
sign so that a subsequent catastrophic ischemic event can be prevented.