Novel anti-reflux biliary metal stent with a distal tapered end for distal malignant biliary obstruction: a feasibility study

Background and study aims  We developed a self-expandable metallic stent (SEMS) with a distal tapered end to reproduce the physiological bile flow with a pressure gradient due to the difference in the diameter. We aimed to evaluate the safety and efficacy of the newly developed distal tapered covered metal stent (TMS) for distal malignant biliary obstruction (DMBO). Patients and methods  This single-center, prospective, single-arm study was conducted in patients with DMBO. The primary endpoint was time to recurrent biliary obstruction (TRBO), and the secondary endpoints were the survival time and incidence of adverse events (AEs). Results  Thirty-five patients (15 men, 20 women; median age, 81 years [range: 53-92]) were enrolled between December 2017 and December 2019. The primary diseases were pancreatic head cancer in 25 cases, bile duct cancer in eight cases, and ampullary cancer in two cases. TMS was successfully placed in all cases. Acute cholecystitis occurred as an early AE (within 30 days) in two cases (5.7 %). The median TRBO was 503 days, median survival time was 239 days. RBO was observed in 10 cases (28.6 %), and the causes were distal migration in six cases, proximal migration in two cases, biliary sludge in one case, and tumor overgrowth in one case. Conclusions  Endoscopic placement of the newly developed TMS in patients with DMBO is technically feasible and safe, and the TRBO was remarkably long. The anti-reflux mechanism based on the difference in diameter may be effective, and a randomized controlled trial with a conventional SEMS is required.

Histological improvement in chronic hepatitis C-autoimmune hepatitis overlap syndrome by glecaprevir and pibrentasvir

A 60-year-old man with type-2 diabetes and chronic hepatitis C (HCV) was diagnosed with single hepatocellular carcinoma (HCC) of 67 mm in the hepatic posterior right lobe. Lenvatinib 8 mg was initiated but discontinued because of grade 3 liver injury. The patient continued to have prolonged liver injury and persistently high immunoglobulin G levels. Antinuclear antibody titer increased from 1:40 to 1:320. Histopathological examination of a liver biopsy specimen revealed interface hepatitis with lymphocyte and plasma cell infiltration, rosette formation, and emperipolesis, suggesting the possibility of autoimmune hepatitis (AIH). First, treatment with prednisolone was initiated; however, the response was poor. After starting glecaprevir/pibrentasvir (GLE/PIB) as direct-acting antivirals (DAA), HCV RNA rapidly disappeared, and serological liver function improved. After confirmation of sustained virological response 24, HCC recurrence was observed, and partial hepatectomy was performed. Background liver findings showed that liver parenchymal inflammation improved compared with that before DAA treatment. This is the first case of HCV-AIH overlap syndrome treated with DAA using GLE/PIB. Liver function improved within a short treatment period of 8 weeks, as confirmed using serology and histology.

Chemotherapy with gemcitabine for unresectable intrahepatic cholangiocarcinoma in a patient undergoing maintenance hemodialysis

A 56-year-old man with chronic renal failure due to diabetic nephropathy had received maintenance dialysis (every 4 h, three times/week). A hypoechoic tumor measuring 67 × 50 mm in the right lobe of the liver was discovered following routine abdominal ultrasonography. Dynamic computed tomography showed a low-density liver tumor, enlarged hilar lymph node, and a small nodule on the dorsal side of the lower lobe of the left lung. Histopathological examination of the liver tumor revealed intrahepatic cholangiocarcinoma. We developed a chemotherapy treatment plan with gemcitabine, which can be performed concurrently with hemodialysis. Gemcitabine (1000 mg/m², three times/cycle) was administered on Friday afternoon, and hemodialysis was performed on Tuesday, Thursday, and Saturday. Anemia and hypotension occurred after gemcitabine administration. Therefore, the dose of darbepoetin alpha was increased, and packed red blood cells were transfused. The patient was treated with gemcitabine for approximately 5 and a half months until computed tomography findings showed progressive disease; the survival time after treatment start was 8 months. Chemotherapy using gemcitabine has not been established in dialysis patients and has little evidence. We report a case of unresectable intrahepatic cholangiocarcinoma that developed during maintenance dialysis and was treated using gemcitabine chemotherapy.

The excitability of blink reflexes in patients with neurologic and psychiatric disorders

The blink reflex and its recovery curve were studied in 12 patients with neurologic and psychiatric disorders, i.e., juvenile Parkinson's disease (case 1), Gilles de la Tourette's syndrome (case 2), anorexia nervosa (case 3), mild developmental delay (cases 4 and 5), a meningomyelocele with winking spasms (case 6), Parkinson's disease (cases 7-10) and OPCA (cases 11 and 12). The cases were divided into 4 groups on the basis of the results, (1) hyperexcitability of facial motoneurons only (case 6), (2) hyperexcitability of facial motoneurons and brainstem interneurons (case 1 and 2), (3) hyperexcitability of brainstem interneurons only (cases 4, 5 and 7-12) and (4) hypoexcitability of both sides (case 3). Therefore, as to the excitability an abnormal pattern of blink reflexes could be a neurophysiologic marker of some neurologic and psychiatric disorders.

LTC4/LTB4 alterations in rat forebrain ischemia and reperfusion and effects of AA-861, CV-3988

LTC4, which enhances vascular permeability and promotes tissue edema, and LTB4, which is a potent chemotactic and activating factor for leukocytes, were measured in rat brain after ischemia and several time periods of reperfusion. Forebrain ischemia was induced by 4-vessel occlusion. LTC4/LTB4 in the brain were measured by RIA. We also studied the effects of a 5-lipoxygenase inhibitor, AA-861 and a PAF antagonist, CV-3988 on LTC4/LTB4 concentrations. LTC4 in brain tissue increased during 30 min forebrain ischemia (p < 0.001). After reperfusion, LTC4 increased further, but at 15 min reperfusion LTC4 returned to the control level. Tissue levels of LTB4 in the brain increased during 30 min ischemia and remained high until 5 min after reperfusion (p < 0.01) returning at 15 min reperfusion to the control level. AA-861 inhibited elevation of LTC4/LTB4 in the reperfusion phase, but was not effective during ischemia. CV-3988 had a similar effect. LTC4 and LTB4 may be involved in the pathogenesis of ischemia brain edema and leukocyte infiltration. Further, PAF and LTs have many similarities of their pathophysiological properties, and may interact therefore in pathologic process.

Beneficial effect of prostaglandin E1 in three cases of lupus nephritis with nephrotic syndrome

Prostaglandin E1 was intravenously injected daily for 4 weeks to three patients with lupus nephritis accompanied by severe nephrotic syndrome. Histologic examination revealed diffuse proliferative or membranous glomerulonephritis. Proteinuria decreased markedly 1 year after the treatment with improvement in hypoproteinemia in all three patients. Five years later, the conditions of three cases ameliorated further.

CT demonstration of calcification within old cerebral infarcts

Calcifications within old cerebral infarcts were demonstrated by CT in three patients who had suffered strokes probably due to emboli from a carotid or cardiac source. In two of them, calcifications were not shown on CT at onset but were first noted on follow-up CT approximately 2 years later in one, and 5 years later in the other. In the third case a large solitary calcification was found on the first CT carried out 13 years after onset. To our knowledge, these findings have not been described previously.