Keiyukai Sapporo Hospital

Percutaneous radiofrequency ablation (RFA) is a widely accepted, minimally invasive treatment for hepatic tumors. However, it can rarely cause severe complications, including visceral and diaphragmatic perforation leading to acute empyema. Such complex scenarios, particularly in patients with underlying liver cirrhosis and malignancy, require a highly specialized management strategy. We report a successful treatment case utilizing a staged, multidisciplinary approach prioritizing source control. A 76-year-old man with Child-Pugh B cirrhosis, previously treated for descending colon cancer and liver metastases, presented with fever and malaise 90 days after his third RFA session. Imaging revealed a right subphrenic abscess contiguous with the transverse colon and right pleural space, suggesting a delayed iatrogenic perforation caused by thermal injury. We diagnosed acute empyema secondary to pleuro-colonic communication. Given the severe infection and extensive adhesions, we executed a three-stage therapeutic strategy. Stage 1 involved thoracic infection control via drainage and thoracoscopic debridement. Stage 2 addressed the abdominal source; a diverting ileostomy was created to mitigate contamination, followed later by a right hemicolectomy and diaphragmatic repair using a Gerota's fascia patch. Stage 3 managed the residual refractory empyema and persistent air leak through an open window thoracostomy, followed by bronchial occlusion using endobronchial Watanabe spigots. The patient fully recovered, was discharged on day 162, and remains recurrence-free at the 15-month follow-up. Delayed colonic and diaphragmatic perforation is a rare but life-threatening complication of hepatic RFA. A rigorous staged, multidisciplinary approach focused on definitive source control and management of chronic pleural complications is essential for a favorable outcome in such complex cases.

ABSTRACTBackgroundRare pathogenic variations of desmosomal genes, particularly in plakophilin‐2 (PKP2) and desmoglein‐2 (DSG2), have been implicated in arrhythmogenic cardiomyopathy (ACM); however, their potential polygenic contribution remains unclear.MethodsWe performed a genome‐wide association study of 104 Japanese patients with ACM and 46 527 controls, adjusting for case–control imbalance.ResultsThe strongest association was observed upstream of DSG2 (rs182626537, p = 2.3 × 10−42), but the signal was abolished after excluding carriers of pathogenic DSG2 variants, suggesting a synthetic association driven by linkage disequilibrium.ConclusionsThese findings highlight a population‐specific genetic architecture of ACM, with DSG2 predominating in the Japanese population.

Abstract We analyzed the differences in bacterial composition between 475 Japanese patients with advanced gastric cancer (median age 70 years, median BMI 20.0) and 106 healthy individuals using a comprehensive metagenome shotgun analysis. Among the patients with advanced gastric cancer, 71% were male, 37.% patients had relapsed, and 55.5% previously underwent gastrectomy. Bifidobacterium , Anaerostipes , and Parabacteroides were predominant in healthy individuals, whereas Streptococcus , Lactobacillus , and Odoribacter were predominant in patients with advanced gastric cancer. Additionally, Kyoto Encyclopedia of Genes and Genomes pathway analysis showed that butanoate and pyruvate metabolism was enriched in healthy individuals, whereas factors such as ABC transporters and ribosomes were enriched in patients with advanced gastric cancer. Clustering analysis broadly classified patients with advanced gastric cancer and healthy individuals into two clusters; however, clustering using pathway data enabled a clearer classification of patients with advanced gastric cancer and healthy individuals than clustering using flora analysis. Moreover, healthy individuals showed higher bacterial flora diversity than patients with advanced gastric cancer. Thus, we successfully identified the molecular characteristics of microbial genera and functional pathways in the gut of patients with advanced gastric cancer. Our results suggest that fecal metagenomic shotgun sequencing analysis can be used to detect gastric cancer.

Double anastomosis Superficial Temporal Artery-Middle Cerebral Artery (STA-MCA) bypass in Moyamoya disease (MMD) and cerebral atherosclerosis disease (CAD) remains underexplored. We aim to evaluate the clinical efficacy and vascular dynamics of double anastomosis STA-MCA bypass in each group, MMD and CAD. A systematic search was conducted in ScienceDirect, Embase, PubMed, and Cochrane databases until September 2024. Efficacy outcomes included stroke occurrences, patency, modified Rankin Scale (mRS), and complications. Vascular parameters included cerebral blood flow (CBF), cut flow index (CFI), MCA perfusion, and mean transit time (MTT). The meta-analysis included 15 studies with 417 patients (46.18 ± 4.69 years). At final follow-up, the MMD group showed lower total stroke (12 ± 7% vs. 20 ± 9%; p = 0.63), ischemic stroke (8 ± 5% vs. 18 ± 8%; p = 0.26), hemorrhagic stroke (4 ± 3% vs. 10 ± 7%; p = 0.49), and patency (85 ± 11% vs. 98 ± 8%; p = 0.10) compared to CAD group, without statistical difference. The MMD group exhibited reduced mRS (MD: -0.57; 95%CI: -0.95 to -0.19; p = 0.003), increased CBF (MD: 14.75; 95%CI: 2.32 to 27.19; p = 0.020), and increased MCA perfusion (MD: 9.28; 95%CI: 1.19 to 17.37; p = 0.025). CFI (1.30 ± 0.11 vs. 1.08 ± 0.13; p = 0.02) and MTT (4.49 ± 0.5 vs. 1.27 ± 0.27; p < 0.001) were significantly higher in the CAD group. Both 1D2R (MD: 27.59; 95%CI: 4.88 to 50.30; p = 0.017) and 2D2R (MD: 14.75; 95%CI: 2.32 to 27.19; p = 0.020) techniques exhibited increase in CBF. Additionally, double anastomosis showed a higher CFI compared to single anastomosis (MD: 0.25; 95%CI: 0.12-0.38; p < 0.001). Double anastomosis STA-MCA bypass demonstrated comparable stroke and patency rates between groups. MMD patients had significantly higher CFI and MTT values, with double anastomosis yielding superior CFI compared to single anastomosis.

The introduction of biological agents has significantly improved therapeutic outcomes for patients with psoriasis. However, the long-term use of biologics may present substantial burdens for patients due to various factors. Therefore, identifying effective maintenance therapy is important to reduce treatment burden while maintaining disease control. We conducted a questionnaire-based study to assess patient satisfaction, quality of life, and concerns with ongoing biologic therapy, an oral treatment, as maintenance therapy in psoriasis vulgaris patients in remission. We first surveyed patient-reported outcomes, including treatment satisfaction, quality of life, and concerns with ongoing biologic therapy. Between December 2020 and June 2022, a total of 209 patients with psoriasis vulgaris, including those with joint symptoms, were enrolled. The mean Psoriasis Area and Severity Index score was 0.30, and the mean Dermatology Life Quality Index score was 0.25, confirming that patients remained in remission. The majority of patients (96.1%) reported overall satisfaction with biologic therapy, while 98.6% were satisfied with the therapeutic efficacy. However, 18.2% of patients reported pain, distress, or anxiety related to injection administration, 8.2% expressed concerns regarding treatment safety, and 38.0% reported dissatisfaction with the financial burden of biologic therapy. While patient satisfaction with the therapeutic effects of biologic agents was high, concerns regarding treatment cost and uncertainty about the duration of therapy remained prominent. These findings underscore the need for alternative maintenance strategies, such as oral therapies, to optimize long-term disease management and improve patient adherence and quality of life. Although this questionnaire-based analysis did not include the administration of oral therapies such as apremilast, it provides insights that may support future consideration of oral maintenance treatments for patients with psoriasis. Trial Registration: Japan Registry of Clinical Trials: jRCTs031200238.

Clazosentan (CLZ) therapy prevents delayed ischemia following aneurysmal subarachnoid hemorrhage (aSAH), but non-ischemic adverse events necessitate optimized protocols. This study presents outcomes of contemporary CLZ therapy under a unified protocol and identifies factors influencing delayed ischemic and non-ischemic adverse events following aSAH. This multicenter prospective registry analyzed data from 80 aSAH patients receiving CLZ therapy (April 2023 - October 2024). Primary endpoints were delayed ischemic events and non-ischemic adverse events; secondary endpoint was favorable outcome (modified Rankin Scale 0-2) at discharge or six weeks post-onset. Delayed ischemic events occurred in 19 patients (23.8%), including delayed ischemic neurological deterioration (8.8%), moderate-to-severe cerebral vasospasm (20.0%), and symptomatic delayed cerebral infarction (7.5%). Non-ischemic adverse events were observed in 22 patients (27.5%). Favorable outcomes were achieved in 52 patients (65.0%). Delayed ischemic events were associated with female sex, poor severity grades, higher Fischer scale scores, and elevated neutrophil-to-lymphocyte ratios. Non-ischemic adverse events were associated with older age, anemia, hypoproteinemia, and elevated cardiothoracic ratios. Multivariate analysis identified non-ischemic adverse events as significant for unfavorable outcomes (FDR p <.001), whereas delayed ischemic events were not (FDR p =.705). Among non-ischemic adverse events, pulmonary edema was the strongest factor associated with unfavorable outcomes. In conclusion, CLZ therapy with appropriate candidate selection and management protocol appears promising as a treatment option to prevent delayed ischemia after aSAH, though potential confounders warrant careful consideration. Addressing clinical risk factors for non-ischemic adverse events may further enhance treatment outcomes. Clinical trial number Not applicable.

In cases of recurrent laryngeal nerve invasion due to thyroid cancer, resection of the recurrent laryngeal nerve is necessary. Immediate reconstruction of the recurrent laryngeal nerve is often performed in such cases. Our hospital has also been proactive in performing immediate reconstruction (e.g., recurrent laryngeal nerve end-to-end anastomosis, and ansa cervicalis-recurrent laryngeal nerve anastomosis). On the other hand, reports from basic research using animals have shown that reconstruction using artificial nerve tubes is more useful for promoting nerve regeneration than existing methods. Furthermore, artificial nerve tubes are used in clinical practice in other fields and their safety is guaranteed. In this study, we encountered a case in which the recurrent laryngeal nerve was reconstructed using an artificial nerve after recurrent laryngeal nerve resection due to thyroid cancer. We present the results of our hospital and consider and report the possibility of recurrent laryngeal nerve regeneration in the future.

Esophageal cancer is a major cause of cancer mortality worldwide. Endoscopic resection (ER) is a curative treatment for esophageal squamous cell carcinoma (ESCC). Predicting risk of metastasis is crucial for post-ER management. In this study, we aimed to identify predictors of metastasis by examining endoscopically resected specimens. The cohort of this retrospective multicenter study comprised 422 patients who had undergone ER for ESCC from 1994 to 2017. Inclusion required a histological diagnosis of pT1a-muscularis mucosa or pT1b-submucosa (SM) cancer. Central pathological review comprehensively evaluated depth of invasion, lymphovascular invasion (LVI), droplet infiltration (DI), infiltrative growth pattern, histological differentiation, intraductal and intraglandular involvement, solitary nest, resected margin, and other factors. Logistic regression was used to identify predictors of metastasis. Metastases were identified in 103 patients. Univariate analysis identified LVI, depth of invasion, and DI as significant predictive factors. Multivariate analysis identified LVI, depth of invasion pT1b-SM2 (odds ratio 2.72) and indeterminate (positive vertical margin) (odds ratio 3.63) compared with the reference category of pT1b-SM1 as independent predictors of metastasis. Conversely, there were no significant associations between metastasis and lesion size, differentiation, cytological atypia, or infiltration pattern. Subgroup analysis showed that both the number and layer of LVI were associated with metastasis risk. In addition, four or more foci of DI was an independent predictor of LVI. LVI and depth of invasion were significant predictors of metastasis in ESCC. Detailed pathological evaluation and standardized criteria are essential for accurately assessing risk of metastasis and guiding post-ER treatment strategies.