Kasugai Municipal Hospital

Bladder rupture is a rare condition, typically associated with trauma but occasionally occurring spontaneously. Non-traumatic bladder rupture is particularly challenging to diagnose due to its non-specific symptoms. This case report presents a bladder rupture initially misdiagnosed as ascites due to alcoholic liver disease. A 59-year-old man presented with progressive abdominal distension without abdominal pain or urinary symptoms. His medical history included diabetes, asthma, dyslipidemia, and chronic alcohol consumption. Laboratory tests showed renal impairment but no significant liver dysfunction. Abdominal CT revealed ascitic fluid, leading to a diagnosis of alcoholic liver disease. He was hospitalized, and conservative treatment was started, but his renal function deteriorated. On the fifth day, however, after urinary catheterization, 10 L of urine were drained within six hours, resulting in a rapid decrease in serum creatinine levels. Retrospective review of imaging revealed a rupture at the bladder apex, likely caused by chronic bladder overdistension due to alcohol use and diabetic autonomic dysfunction. The patient recovered with conservative management, and a follow-up cystogram confirmed bladder healing. This case highlights the diagnostic challenge of non-traumatic bladder rupture, especially in the absence of typical symptoms. Clinicians should consider bladder rupture in patients presenting with unexplained ascites, renal impairment, and an unusual diuretic response to catheterization.

Incarcerated gravid uterus (IGU) is an uncommon but consequential condition in which a retroverted gravid uterus remains trapped within the sacral hollow and may mimic placental location abnormalities, risking iatrogenic injury if unrecognized. We report a 39-year-old primigravida referred at 31 weeks of gestation with a diagnosis of complete placenta previa and uterine myomas. Transvaginal ultrasonography showed placental tissue interposed between the probe and fetus with nonvisualization of the endocervical canal; pelvic examination and transabdominal ultrasonography demonstrated marked rightward, cephalad cervical deviation and an apparent posterior low-lying placenta. Magnetic resonance imaging (MRI) supported uterine incarceration, likely exacerbated by a myoma. At 38+1 weeks, elective cesarean delivery was initiated via a 7-cm infraumbilical vertical skin incision to assess the feasibility of manual reduction; because reduction was difficult, the incision was extended transversely at the umbilical level to optimize exposure. Intraoperative ultrasonography identified the internal os and confirmed rightward, superior displacement of the lower uterine segment, guiding a transverse uterine incision. A healthy male infant weighing 2.892 g was delivered; the placenta was expelled easily, the uterus was repositioned without adhesiolysis, estimated blood loss was 1,113 mL, and no transfusion was required. This case underscores the value of coordinated transvaginal/transabdominal ultrasonography with MRI. It highlights nonvisualization of the endocervical canal between the transvaginal probe and presenting part as a practical red-flag sign of IGU that may aid differentiation from true placenta previa, prompt targeted anatomic assessment, and support safer operative planning.

Metallosis is a rare complication of spinal instrumentation, typically associated with joint arthroplasty or fusionless constructs. Fistula formation due to metallosis is exceptionally uncommon, particularly in cases involving rigid spinal fixation. We report a case of a 48-year-old female patient who developed a cutaneous fistula at the site of a previous thoracic spinal fixation performed for a metastatic spinal tumor. Clinical examination revealed a small granulomatous mass with a fistula. Although dynamic radiographs showed no apparent instability, computed tomography revealed radiolucent halos around the screws in the right T4 and left T3 pedicles, indicating screw loosening. Magnetic resonance imaging demonstrated a sinus tract extending from the skin to the right T3 pedicle screw. Surgical excision of the fistula and hardware revision were performed. Histological analysis confirmed the presence of metal wear debris and a chronic inflammatory response consistent with metallosis. Bacterial cultures were negative. Despite the absence of typical intraoperative signs such as tissue discoloration or necrosis, metallosis was diagnosed pathologically. This case highlights the importance of considering metallosis in the differential diagnosis of unexplained cutaneous lesions overlying spinal instrumentation. Even in the absence of instability or typical intraoperative findings, metallosis may present solely with skin manifestations such as fistula formation. Early recognition is essential for appropriate management.

Several studies have investigated the safety of laparoscopic gastrectomy (LG) for gastric cancer (GC). However, many of these studies excluded older patients, and few multicenter studies have compared LG and open gastrectomy (OG) in older patients with GC. We compared the postoperative short- and long-term outcomes of LG and OG in >75 years old patients with GC in a multicenter study. The study included 926 patients aged >75 years who underwent gastrectomy from January 2003 to December 2017 at 12 regional hospitals. After propensity score-matching (PSM), the two surgical groups' short- and long-term outcomes were analyzed. PSM was applied for variables such as sex, depth of tumor invasion, lymph node metastasis, histologic type, pathological stage, gastrectomy, and lymph node dissection. After 1:1 matching, 258 cases in each group were analyzed. The LG group showed significantly longer surgery times and reduced blood loss (p<0.001). There were no significant differences in the incidence of postoperative complications graded Clavien-Dindo ≥ II between the groups (23.6% vs. 19.4%, p=0.239). However, the LG group had lower and higher incidences of pneumonia (1.9% vs. 5.4%, p=0.035) and pancreatic fistula (PF; 4.7% vs. 0.04%, p=0.003), respectively. The two groups had no significant overall and disease-specific survival differences across all stages. In patients aged >75 years with GC, LG can be a viable approach with careful clinical management for the risk of PF, without compromising long-term survival.

This study evaluates various radiotherapy techniques for treating metastatic brain tumor (BT), focusing on non‐coplanar volumetric modulated arc radiotherapy (NC‐VMAT), coplanar VMAT (C‐VMAT), Helical TomoTherapy (HT), CyberKnife (CK), Gamma Knife (GK), and ZAP‐X. CT images and structures of 12 patients who underwent CK for a single BT were utilized. Twelve treatment plans were created for each planning device. All plans adopted the approach of prescription doses to planning target volume D99.5%. They were divided into stereotactic radiosurgery (SRS) (prescription dose; 21–23 Gy) and stereotactic radiotherapy (SRT) (prescription dose; 30–36.5 Gy) groups and the same parameters evaluated included Gradient Index (GI), Paddick Conformity Index (CI), and treatment time (t‐time). In the SRS group, mean values of GI and CI values were: NC‐VMAT (4.28, 0.60), C‐VMAT (5.61, 0.44), HT (4.68, 0.42), CK (4.31, 0.61), GK (2.81, 0.82), and ZAP‐X (2.99, 0.80). In the SRT group: NC‐VMAT (3.27, 0.84), C‐VMAT (3.81, 0.82), HT (3.76, 0.65), CK (2.98, 0.77), GK (2.61, 0.90), and ZAP‐X (2.80, 0.84). There were no significant differences in the mean values of CI and GI between ZAP‐X and GK in both groups (p > 0.05). NC‐VMAT and C‐VMAT had shorter t‐time than other techniques in both groups. ZAP‐X is relatively superior in CI and GI for small tumors, similar to GK, while differences with NC‐VMAT and CK diminish as tumor volume increases. ZAP‐X, CK, and GK have longer t‐time than other treatment techniques, regardless of volume.

Medial meniscus ramp lesions (MMRLs), lateral meniscus posterior root tears (LMPRTs), and anterolateral complex injuries (ALCIs) are major secondary stabiliser injuries associated with anterior cruciate ligament (ACL) injuries. This study aimed to investigate the effect of the number of secondary stabiliser injuries on knee instability in ACL injuries. Patients who underwent primary ACL reconstruction between January 2017 and May 2023 were enroled in this study. Exclusion criteria encompassed patients with other ligament injuries, a history of contralateral knee injury, hyperextension, flexion contracture and meniscus injuries other than MMRL or LMPRT. Ultimately, 158 patients (mean age: 25.3 years; 81 males and 77 females) were included in this study, and the presence of MMRL, LMPRT and ALCI was investigated. Patients were categorised into four groups based on the number of ACL and secondary stabiliser injuries: single (isolated ACL injury), dual, triad and tetrad. Subsequently, the groups were compared regarding pivot shift grade, quantitative rotational instability measured using an inertial sensor, and anterior tibial translation (ATT). Secondary stabiliser injuries identified included ALCI 85 (53.8%), MMRL 58 (36.7%) and LMPRT 23 (14.6%). The distribution of patients in the single, dual, triad and tetrad groups was 45 (28.5%), 68 (43.0%), 37 (23.4%) and 8 (5.1%), respectively. High-grade pivot shifts were observed in 33.3% (15 out of 45) of the single group, 63.2% (43 out of 68) of the dual group, 67.6% (25 out of 37) of the triad group, and 100% (8 out of 8) of the tetrad group. Quantitative evaluations using the inertial sensor revealed significantly lower acceleration in the isolated ACL injury group compared to the other groups (p < 0.05). No significant difference was observed in ATT measurements (n.s.). The combination of secondary stabiliser injuries led to higher instability. Therefore, it is important to carefully diagnose these injuries and devise appropriate treatment plans, particularly in cases of high knee instability. Level III diagnostic.

Blood pressure (BP) control is an important factor in the management of chronic kidney disease (CKD). Several studies have shown that BP in many patients with CKD remained uncontrolled even with multiple medications. Sacubitril/valsartan, an angiotensin receptor neprilysin inhibitor (ARNI), has been newly approved for treating hypertension in Japan. However, the renoprotective effects remain unclear, particularly in patients with advanced CKD. Here, we investigated the effects on proteinuria of this ARNI in patients with stage 4-5 CKD. We retrospectively collected data from outpatients with stage 4-5 CKD who started ARNI from January until December 2023. The primary outcome was the change in urine protein creatinine ratio (UPCR) at 6months after ARNI initiation. Secondary outcomes were systolic and diastolic BP, estimated glomerular filtration rate (eGFR), serum potassium, and serum uric acid (UA). We analyzed factors associated with 50% UPCR reduction by multivariate analysis. In total, 47 patients were analyzed. ARNI reduced UPCR from 2.14g/gCr (interquartile range; 1.09-2.91) to 1.05g/gCr (0.42-1.95; p < 0.001). Systolic BP fell from 150.0mmHg (139.5-160.0) to 134.0mmHg (124.5-140.0; p < 0.001). No significant changes in eGFR, serum potassium, and serum uric acid were observed, except for a slight decrease in eGFR among patients with conversion from a renin-angiotensin system inhibitor to ARNI. In multivariate regression analysis, higher systolic BP (per 10-mmHg increase) was significantly associated with reduced proteinuria (odds ratio 2.51, 95% confidence interval 1.35-4.66; p = 0.004). ARNI reduced proteinuria in patients with stage 4-5 CKD, particularly for those with uncontrolled hypertension.

BackgroundAtrial fibrillation (AF) and heart failure (HF) often coexist, leading to increased mortality. A cryoballoon-based approach is a potential treatment for patients with HF because of its safety and efficacy. ObjectivesThe authors sought to evaluate the optimal timing of cryoballoon ablation after the first clinical diagnosis of AF and its prognosis for patients with HF. MethodsThis large-scale multicenter study retrospectively collected data of patients with HF who underwent cryoballoon ablation for AF from 17 Japanese institutions. Patients were divided into 2 groups depending on the duration between the first diagnosis and ablation using a median time of 0.5 year (IQR: 0.3-2.0 years). Clinical endpoints of recurrence, mortality, and HF hospitalization were compared between the 2 groups. ResultsAmong 3,655 patients, 543 with HF were included for analysis. During a median follow-up period of 21.3 months (IQR: 12.0-36.8 months), 151 of 520 patients (29%) had a recurrence. The AF recurrence rate was significantly lower in the early-ablation group (≤0.5 year) than in the delayed-ablation group (>0.5 year) (24% [65/266] vs 34% [86/254], respectively; P = 0.018). In the multivariable analysis, early ablation ≤ 0.5 year was independently associated with an absence of recurrence (HR: 0.581; 95% CI: 0.401-0.842; P = 0.004). Delayed time for cryoballoon ablation incrementally increased the risk of postablation recurrence. Antiarrhythmic drug use was independently associated with delayed ablation. No significant differences in mortality or HF hospitalization were observed between the 2 groups. ConclusionsEarly cryoablation reduced the risk of recurrence in patients with HF, which may help improve clinical management.

There is no consensus on the optimal treatment for patients with locoregional recurrence of esophageal cancer after surgery. The objective of this study was to investigate the outcomes and prognostic factors associated with salvage radiotherapy in patients with locoregional recurrence of esophageal cancer after surgery. We reviewed 80 patients with locoregional recurrence of esophageal cancer after surgery who were treated with radiotherapy. The median dose was 60Gy, and 29 patients (36%) received elective nodal irradiation. Fifty-three patients (66%) received concurrent chemotherapy (mostly 5-fluorouracil and cisplatin) during radiotherapy. Overall survival, progression-free survival and in-field recurrence rate were assessed. The median follow-up period was 17months. Two-year overall survival, progression-free survival and in-field recurrence rate were 50.3%, 23.5% and 41.3%, respectively. On multivariate analysis, a maximum diameter of locoregional recurrence lesions <30mm was associated with higher overall survival (P=0.044). Disease-free interval between surgery and locoregional recurrence >14months was associated with higher PFS (P=0.003). Late grade 3 toxicities occurred in three patients (3.8%). No grade 4 or higher toxicity was observed. Salvage radiotherapy demonstrated efficacy in achieving in-field control with acceptable toxicity. However, the high rate of out-of-field metastases led to poor progression-free survival and overall survival, particularly in cases involving large lesions and a short disease-free interval. A prospective study is warranted to establish a treatment strategy, particularly considering the combined use of effective anti-cancer drugs.

症例は70歳代女性．X－1年に悪性リンパ腫と診断され，R-CHOP療法が開始された．化学療法開始時のHBVマーカーは高感度HBs抗原陰性，HBc抗体陰性，HBs抗体基準値内（9.5 mIU/mL，基準値：10 mIU/mL未満）であり，HBV再活性化モニタリングは未施行であった．治療開始から13カ月後に肝機能障害を認め，HBs抗原の陽転化が判明しIgM-HBc抗体は陰性であった．R-CHOP療法前のHBs抗体価が基準値内高値であったことから既往感染からのde novo B型肝炎と診断した．HBs抗体単独陽性の既往感染者において，その判断に用いるHBs抗体価に明確な基準はない．HBs抗体のcut off値10 mIU/mLは最小感染防御抗体価であり既往感染を判断する基準値ではないことに留意し，高リスクな治療を行う際には定量結果にも着目する必要があると考えられた．