Introduction: Most literatures researched radiofrequency ablation (RFA) for early hepatocellular carcinoma (HCC) defined the early tumor size as 3cm or less. However, detection rate of HCC smaller than 2 cm became increasing since high risk patients had received regular screening and the imaging techniques has been much improved. Whether RFA or percutaneous ethanol injection (PEI) is better for a patient with such a small HCC is still controversial. Methods: We retrospectively obtained patients with single HCC 2 cm in diameter or smaller from the computerized medical records database in a local teaching hospital located at southern Taiwan, diagnosed during January 1, 2002 to April 30, 2008. Those patients received RFA (RFA group) or PEI (PEI group) as the first-line nonsurgical treatments were enrolled for further analysis. We compared baseline characteristics of RFA and PEI groups, including gender, age, possible risk factors of recurrence, and prognostic factors. Then, we analyzed recurrent rate, time to recurrence, survival rate, complication rate, mean cost of each treatment, and hospital stay of RFA and PEI groups. Results: There were 32 patients qualified for the study design, including 22 in PEI group¡G13 males and 9 females with mean age was 63.73 years; and 10 in RFA group¡G7 males and 3 females with mea age was 58.30 years¡CNo statistically significant differences between RFA and PEI groups were observed with respect to baseline characteristics. Nevertheless, there was significant difference between these two groups with respect to mean hospital stay (p=0.007) and mean cost (p¡Õ0.001): mean cost of PEI was NTD $16934.7; mean cost of RFA was NTD $51677.6, the difference was NTD $34732.9. There was no difference respect to complication rate, recurrent rate, time to recurrence and overall survival rate between RFA and PEI groups. Conclusion: For patients with single HCC 2 cm in diameter or smaller (i.e. very early HCC), we concluded that: if under similar basic background, the cost of RFA was much higher than that of PEI, but no difference in the complication rate, recurrent rate, time to recurrence and overall survival rate between these two treatment.

Metallic implants called stents are an important part of the treatment of coronary heart disease. While clinical trials are excellent indicators of outcomes, microscopic evaluation of the host tissue response to the implant is required to assess their safety and efficacy. However, the evaluation of human autopsy tissue containing metal implants presents unique challenges in order to obtain the best results. We used integrated microscopy techniques incorporating microCT and novel plastic histology techniques to demonstrate its effectiveness on human stented vessels obtained at autopsy. A total of seven cases are demonstrated where our analysis techniques were able to elucidate the pathogenesis of the host response and identify the specific cause of the complications with the stented vessel seen clinically. These techniques are more cost effective and efficient than other techniques currently in use, which could enable them to be used as part of routine autopsy evaluation. The expansion of the pool of stented vessels able to be analyzed to include the often overlooked large population of autopsy cases could provide an enormous amount of data to guide future clinical trials and improve patient care.

As lesões estenóticas ou oclusivas das artérias renais podem levar à isquemia do parênquima renal com conseqüente hipertensão arterial (hipertensão arterial renovascular) e perda de função renal (nefropatia isquêmica). Estas duas entidades podem ser tratadas por medicamentos, cirurgia ou angioplastia transluminal percutânea. O objetivo deste trabalho foi avaliar o sucesso técnico e funcional da angioplastia em lesões estenóticas ou oclusivas das artérias renais em doentes portadores de hipertensão arterial renovascular e nefropatia isquêmica. Tratamos 131 doentes hipertensos com ou sem alteração da função renal (55 do sexo masculino e 76 feminino), que apresentavam 191 artérias renais comprometidas (148 estenoses e 43 oclusões) e com média de idade de 45,83 ± 17,4 anos (4 a 77 anos). A etiologia da lesão da artéria renal foi a aterosclerose em 65 doentes (49,61%), displasia fibromuscular em 41 (31,29%), arterite de Takayasu em 13 (9,92%) e outras causas em 12 (9,16%). O nível sérico de creatinina era normal em 70 (53,43%) e alterado em 61 (46,58%). O sucesso técnico foi obtido em 93 doentes (70,99%) e em 123 artérias renais (75,46%). O seguimento foi, em média, de quatro anos (2 a 8 anos), sendo que ao final deste período houve redução de 37,80 ± 33,46 mmHg e 28,66 ± 24,74 mmHg nos níveis da PA sistólica e diastólica, respectivamente. Houve cura da hipertensão arterial em nove doentes (11,25%), melhora em 59 (73,75%), permaneceu inalterada em oito (10%) e piorou em quatro (5%). A função renal ficou normal em 36 doentes (45%), melhorou em 11 (13,75%), manteve-se em 26 (32,5%) e piorou em sete (8,75%). Houve recidiva em 14 casos (17,5%), sendo 11 casos (78,57%) tratados com sucesso com nova angioplastia. Conclusão: consideramos que a angioplastia transluminal percutânea pode ser indicada como opção para o tratamento das lesões estenóticas e/ou oclusivas das artérias renais nos doentes com hipertensão renovascular e nefropatia isquêmica / The occlusive and stenotic lesions of the renal arteries can lead to a renal parenchyma ischemia with vascular hypertension resultant (reno vascular hypertension) and loss of renal function (nephropathy ischemic). These two conditions can be treated by medications, surgery or Percutaneous Transluminal Angioplasty (PTA). The objective of this work was assessing the technical and functional success of PTA in stenotic or occlusive lesions of renal arteries in patients having renovascular hypertension and nephropathy ischemic. We treated 131 hypertensive ill people with or without alteration in the renal function (55 males and 76 females) who presented 191 damaged renal arteries (148 stenosis and 43 occlusions) and age range of 45.83+ 17.4 years old (4 to 77 years old). The etiology of the lesion in the renal artery was atherosclerosis in 65 ill people (49.61%), fibro muscular dysplasia in 41 (31.29%), Takayasu\'s disease in 13 (9.92%), and other causes in 12 (9.16%). The plasma creatinine level was normal in 70 (53.43%) and altered in 61 (46.58%). The technical success was obtained in 93 ill people (70.99%) and in 123 renal arteries (75.46%). The follow-up lasted in average for 4 years (2 to 8 years), in which the end of the period there was a decrease of 37.80+33.46 mmHg and 28.66+24.74 mmHg in the systolic and diastolic blood pressure levels respectively. There was a cure of artery hypertension in 9 ill people (11.25%), better results in 59 (73.75%), no alteration in 8 (10%) and worsening in 4 (5%). The plasma creatinine level increased in 10% (SD), although the renal function remained normal in 36 ill people (45%), better in 11 (13.75%), remained the same in 26 (32.5%) and got worse in 7 (8.75%). There was a reoccurrence in 14 cases (17.5%), in which 11 cases (78.57%) were treated successfully with new PTA. Conclusion: it was considered that PTA can be indicated as an option for the treatment of stenotic and occlusive lesions of the renal arteries in ill people with renovascular hypertension and nephropathy ischemic

A nefrolitotripsia percutânea (NP) é uma das principais formas de tratamento de cálculos renais volumosos. O acesso percutâneo lateral é feito com o paciente em decúbito dorsal horizontal. O estudo objetivou avaliar os resultados de acesso lateral, em posição modificada, no tratamento percutâneo de cálculos renais e também o mesmo associado ao ureteroscópico, em caso de cálculos renais e ureterais concomitantes. Estudou-se 88 pacientes e os resultados foram considerados bem sucedidos em 69,32%. As complicações mais comuns foram febre e sangramento. Concluímos que a NP com acesso lateral apresenta sucesso no tratamento da litíase oferecendo vantagens no posicionamento para realização de procedimento associado à ureteroscopia / Percutaneous nephrolithotripsy (PN) is one of the main alternatives for the treatment of large renal stones. The present study aimed to evoluate the results of the lateral percutaneous approach, in a modified position, for the treatment of kidney stones. We also evaluated the association of the percutaneous with the uretroscopic treatment in patients with concomitant kidney and ureteral stones. A total of 88 patients selected, 69,32% of patients were considered complete success. The most common complication was the development fever and bleeding. In conclusion the PN using the lateral approach is a safe procedure with a high success rate in the treatment of kidney stones and is a advantageous, for patient positioning especially for the performance of ureteroscopic procedures

京都大学 / 0048 / 新制・課程博士 / 博士(医学) / 甲第22353号 / 医博第4594号 / 新制||医||1042(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 佐藤 俊哉, 教授 湊谷 謙司, 教授 福原 俊一 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

Mediastinal pancreatic pseudocyst (MPP) is a rare, but known, complication of both acute and chronic pancreatitis. Most pseudocysts are associated with alcoholic pancreatitis. Recent advances in endoscopic techniques have shown promising results, with reduced chances of infection and recurrence than with percutaneous drainage, but limited availability restricts widespread use. Left gastric artery pseudoaneurysm with mediastinal pseudocyst has not been described in the literature to date. We report a successful resolution of hemorrhagic MPP with embolization of pseudoaneurysm and percutaneous trans-hepatic pseudocyst drainage.

Percutaneous endoscopic gastrostomy (PEG) is currently a popular method of administering enteral feeding. Most of these patients are elderly, debilitated, and chronically ill. They are on a number of medications and have multiple diseases. With impaired consciousness and swallowing disability, these patients are prone to develop pneumonia. In order to identify possible risk factors, we followed 24 men who underwent PEG for the occurrence of pneumonia or until they died. We then analyzed the medical records of these patients for potential risk factors for pneumonia. The presence of esophagitis during PEG placement endoscopy and history of pneumonia prior to PEG were significant risk factors. Advanced age and cerebrovascular accident (CVA) tended to indicate a higher risk of pneumonia. Taking these risk factors into consideration may be beneficial in the management of such patients.

Background: The recent literature has shown that triple antiplatelet therapy with cilostazol in addition to the standard dual antiplatelet therapy with aspirin and clopidogrel may reduce platelet reactivity and improve clinical outcomes following percutaneous coronary intervention. The purpose of this meta-analysis is to compare the efficacy of triple antiplatelet therapy and dual antiplatelet therapy in regard to on-treatment platelet reactivity. Methods: Nine studies (n = 2179) comparing on-treatment platelet reactivity between dual antiplatelet therapy (n = 1193) and triple antiplatelet therapy (n = 986) in patients undergoing percutaneous coronary intervention were included. Primary end points were P2Y12 reaction unit (PRU) and platelet reactivity index (PRI). Secondary end points were platelet aggregation with adenosine diphosphate (ADP) 5 and 20 μmol/L and P2Y12% inhibition. Mean difference (MD) and 95% confidence intervals (CI) were computed and 2-sided α error <.05 was considered as a level of significance. Results: Compared to dual antiplatelet therapy, triple antiplatelet therapy had significantly lower maximum platelet aggregation with ADP 5 μmol/L (MD: -14.4, CI: -21.6 to -7.2, P < .001) and 20 mmol/L (MD: -14.9, CI: -22.9 to -6.8, P < .001), significantly lower PRUs (MD: -45, CI: -59.4 to -30.6, P < .001) and PRI (MD: -26, CI: -36.8 to -15.2, P < .001), and significantly higher P2Y12% inhibition (MD: 18.5, CI: 2.3 to 34.6, P = .025). Conclusion: Addition of cilostazol to conventional dual antiplatelet therapy significantly lowers platelet reactivity and may explain a decrease in thromboembolic events following coronary intervention; however, additional studies evaluating clinical outcomes will be helpful to determine the benefit of triple antiplatelet therapy.

The purpose of this study is to summarize the results of percutaneous nephrolithotomy (PCNL) for renal stones following failed extracorporeal shockwave lithotripsy (SWL), and to investigate the effect of previous SWL on the performances and morbidities of subsequent PCNL. Sixty-two patients with a history of failed SWL who underwent PCNL on the same kidney (group 1) were compared to 273 patients who had received PCNL as first treatment choice (group 2). Patient demographics, stone characteristics, operative findings, and complications were documented and compared. Groups 1 and 2 had similar patient demographics and stone characteristics. Mean time to establish access was comparable in both groups (10.5 ± 4.2 vs. 9.6 ± 4.5 min, p = 0.894). Time required to remove stones and total operative time were longer in group 1 (71.5 ± 10.3 vs. 62.3 ± 8.6 min, p = 0.011 and 95.8 ± 12.0 vs. 80.6 ± 13.2 min., p = 0.018, respectively). Group 1 had lower clearance rate compared to group 2 (83.9 vs. 93.4 %, p = 0.021), while postoperative complications were similar in both groups. Scattered stone fragments buried within the tissues made the procedure more difficult for stone fragmenting and extracting, which lead to longer operative time and inferior stone free rate. However, the PCNL procedure was safe and effective in patients with failed SWL. The risk of complications was similar and clearance rate was encouraging.

Background: The recent literature has shown that triple antiplatelet therapy with cilostazol in addition to the standard dual antiplatelet therapy with aspirin and clopidogrel may reduce platelet reactivity and improve clinical outcomes following percutaneous coronary intervention. The purpose of this meta-analysis is to compare the efficacy of triple antiplatelet therapy and dual antiplatelet therapy in regard to on-treatment platelet reactivity. Methods: Nine studies (n = 2179) comparing on-treatment platelet reactivity between dual antiplatelet therapy (n = 1193) and triple antiplatelet therapy (n = 986) in patients undergoing percutaneous coronary intervention were included. Primary end points were P2Y12 reaction unit (PRU) and platelet reactivity index (PRI). Secondary end points were platelet aggregation with adenosine diphosphate (ADP) 5 and 20 μmol/L and P2Y12% inhibition. Mean difference (MD) and 95% confidence intervals (CI) were computed and 2-sided α error <.05 was considered as a level of significance. Results: Compared to dual antiplatelet therapy, triple antiplatelet therapy had significantly lower maximum platelet aggregation with ADP 5 μmol/L (MD: -14.4, CI: -21.6 to -7.2, P < .001) and 20 mmol/L (MD: -14.9, CI: -22.9 to -6.8, P < .001), significantly lower PRUs (MD: -45, CI: -59.4 to -30.6, P < .001) and PRI (MD: -26, CI: -36.8 to -15.2, P < .001), and significantly higher P2Y12% inhibition (MD: 18.5, CI: 2.3 to 34.6, P = .025). Conclusion: Addition of cilostazol to conventional dual antiplatelet therapy significantly lowers platelet reactivity and may explain a decrease in thromboembolic events following coronary intervention; however, additional studies evaluating clinical outcomes will be helpful to determine the benefit of triple antiplatelet therapy.