Incidence and Outcomes of Central Venous Catheter-related Blood Stream Infection in Patients with Inflammatory Bowel Disease in Routine Clinical Practice Setting.

BACKGROUND: Patients with inflammatory bowel disease (IBD) occasionally require central venous catheter (CVC) placement to support a therapeutic plan. Given that CVC can predispose patients to infection, this investigation was undertaken to assess the incidence, risk factors, and outcomes of CVC-related blood stream infection (CRBSI) in patients with IBD during routine clinical practice. METHODS: Data were compiled using retrospective chart reviews of 1367 patients treated at our IBD center between 2007 and 2012 during routine clinical practice. Among the 1367 patients, 314 who had received CVC placements were included. Patients with positive blood culture were considered as "definite" CRBSI, whereas "possible" CRBSI was defined as patients in whom fever alleviated within 48 hours post-CVC without any other infection. Patients' demographic variables including age, body mass index, serum albumin, duration of CVC placement, use of antibiotics, medications for IBD, and perioperative status between CRBSI and non-CRBSI subgroups were compared by applying a multivariate Poisson logistic regression model. RESULTS: Among the 314 patients with CVC placement, there were 83 CRBSI cases (26.4%). The average time to the onset of CRBSI was 22.5 days (range 4-105 days). The jugular vein access was found to be the most serious risk of CRBSI (risk ratio 2.041 versus subclavian vein). All patients with CRBSI fully recovered. CONCLUSIONS: In this investigation, regardless of the patients' demographic features including immunosuppressive therapy, up to 30% of febrile IBD patients with CVC showed CRBSI. It is believed that CVC placement per se is a risk of CRBSI in patients with IBD.

Postoperative bleeding in patients on antithrombotic therapy after gastric endoscopic submucosal dissection.

AIM: To investigated the relationship between postoperative bleeding following gastric endoscopic submucosal dissection (ESD) and individual antithrombotic agents. METHODS: A total of 2488 gastric neoplasms in 2148 consecutive patients treated between May 2001 and June 2016 were studied. The antithrombotic agents were categorized into antiplatelet agents, anticoagulants, and other antithrombotic agents, and we included combination therapies [e.g., dual antiplatelet therapy (DAPT)]. The risk factors associated with post-ESD bleeding, namely, antithrombotic agents overall, individual antithrombotic agents, withdrawal or continuation of antithrombotic agents, and bleeding onset period (during the first six days or thereafter), were analyzed using univariate and multivariate analyses. RESULTS: The en bloc resection and complete curative resection rates were 99.2% and 91.9%, respectively. Postoperative bleeding occurred in 5.1% cases. Bleeding occurred in 10.3% of the patients administered antithrombotic agents. Being male (P = 0.007), specimen size (P < 0.001), and antithrombotic agent used (P < 0.001) were independent risk factors for postoperative bleeding. Heparin bridging therapy (HBT) (P = 0.002) and DAPT/multidrug combinations (P < 0.001) were independent risk factors associated with postoperative bleeding. The bleeding rate of the antithrombotic agent continuation group was significantly higher than that of the withdrawal group (P < 0.01). Bleeding within postoperative day (POD) 6 was significantly higher in warfarin (P = 0.015), and bleeding after POD 7 was significantly higher in DAPT/multidrug combinations (P = 0.007). No thromboembolic events were reported. CONCLUSION: We must closely monitor patients administered HBT and DAPT/multidrug combinations after gastric ESD, particularly those administered multidrug combinations after discharge.

Treatment outcomes of endoscopic resection for rectal carcinoid tumors: an analysis of the resectability and long-term results from 46 consecutive cases.

AIM: In Japan, most of colorectal carcinoid tumors developed in rectum. The choice of treatment is important because surgical treatment may need to construct artificial anus. Although curative endoscopic resection (ER) is desirable from the point of quality of life, sufficient evidence of endoscopic treatment for rectal carcinoid tumors is not fully obtained. METHODS: Between April 2001 and August 2013, 46 rectal carcinoid tumors in 46 patients who underwent either with endoscopic mucosal resection with a ligation device (EMR-L) or endoscopic submucosal dissection (ESD) were analyzed retrospectively. The rates of en bloc resection, positive for lateral and/or vertical margin, curative resection, local recurrence, additional treatments, overall and disease-specific survival rate after ER were evaluated during follow-up (median observation period 61.6 months). RESULTS: Twenty-two lesions were treated by EMR-L and 24 lesions were treated by ESD. Both groups had similar mean tumor size (EMR-L: 6.2 mm, ESD: 6.0 mm). The rate of en bloc resection, negative for both lateral and vertical margins, and curative resection were, respectively, 73%, 63%, and 50% for EMR-L, 100%, 100%, and 83% for ESD. These results suggested that the rate of resectability and curability for ESD was significantly higher than EMR-L (p < 0.05). Complications such as perforation and bleeding did not occur in both groups. Fifteen patients were judged as non-curative and 3 patients underwent additional surgery and lymph node metastasis was evident in 1 patient. Remained 11 patients were carefully followed-up, and so far no obvious recurrence was found. Thirty-two patients (84%) were eligible for long-term follow-up and 5-year overall and disease-specific survival rates were 100% and 100%, respectively. CONCLUSION: The long-term outcomes of ER for rectal carcinoid tumors were excellent. ESD has advantage for resectability and curability compared with EMR-L; therefore, ESD is more favorable procedure as treatment for rectal carcinoid tumors.

Efficacy of plastic stent placement inside bile ducts for the treatment of unresectable malignant hilar obstruction (with videos).

BACKGROUND: Recent reports have addressed the utility of plastic stent (PS) placement inside bile ducts for treating biliary obstructions. Here, we evaluated the utility and safety of PS placement inside bile ducts for treating unresectable malignant hilar biliary obstruction. METHODS: We conducted a retrospective study of 27 patients with unresectable malignant hilar biliary obstruction who underwent intraductal modified PS placement. We modified the PS, by cutting off the distal end to facilitate insertion through the papilla of Vater, and attached a nylon thread to the distal end for removal. We evaluated complications, the time to recurrent biliary obstruction (TRBO), and removability. RESULTS: Bilateral stenting was performed in nine of the 27 patients. Mild acute pancreatitis occurred in one patient (4%). Recurrent biliary obstruction (RBO) occurred in 16 patients (59%), with a median TRBO of 190 days (95% confidence interval: 174-205 days). Reintervention was necessary in 13 of the 16 patients (81%) with RBO, and we were able to remove the initial stents in all the patients who required reintervention. CONCLUSIONS: A relatively long stent patency period (>6 months) and removability make placement of a modified PS inside bile ducts a viable treatment for unresectable malignant hilar biliary obstruction.

Antithrombotic drugs are risk factors for delayed postoperative bleeding after endoscopic submucosal dissection for gastric neoplasms.

BACKGROUND: The discontinuation of antithrombotic drugs is recommended during endoscopic submucosal dissection (ESD) for gastric neoplasms; however, controversy remains as to whether antithrombotic drugs are risk factors for postoperative bleeding. OBJECTIVE: To determine the risk factors for post-ESD bleeding. DESIGN: Single-institution, retrospective review. SETTING: University hospital. PATIENTS: From June 2000 to December 2010, we treated 1192 gastric neoplasms in 1032 consecutive patients. INTERVENTION: The ESD procedures were performed by using the standard techniques. Antithrombotic drug therapy was principally interrupted preoperatively and was restarted when hemostasis was confirmed by second-look endoscopy. MAIN OUTCOME MEASUREMENTS: Risk factors for postoperative bleeding after ESD (early, delayed, and overall [combined] occurrence of bleeding during the first 5 postoperative days or thereafter) were analyzed by using logistic regression analysis. RESULTS: Among 1166 ESD-induced ulcer lesions, overall postoperative bleeding was evident in 62 lesions (5.3%); early and delayed bleeding occurred in 30 and 32 lesions (2.6% and 2.7%), respectively. Based on a multivariate analysis, a specimen size of >40 mm was the sole independent risk factor for overall bleeding. Moreover, oral antithrombotic drug therapy was selected as independent risk factor for delayed but not early bleeding, according to the multivariate analysis. The delayed bleeding rate in patients who had a specimen size of >40 mm and who used antithrombotic drugs was 11.6%. LIMITATIONS: Retrospective design and single-site data collection. CONCLUSION: Interruption of antithrombotic drug therapy may be adequate for preventing early post-ESD bleeding; however, reinitiating antithrombotic drug therapy is a significant independent risk factor for delayed post-ESD bleeding.

Adenocarcinoma arising from short-segment Barrett's esophagus in a young man.

We report herein a case of adenocarcinoma arising from short-segment Barrett's esophagus (SSBE) in a 36-year-old man. An elevated tumor was found at the esophagogastric junction, and a histological evaluation of the biopsy specimen led to a diagnosis of adenocarcinoma. The tumor was found to be confined to the mucosa surrounding the SSBE, and endoscopic submucosal dissection was done without complications. Histological examination of the resected specimen showed that the adenocarcinoma had also invaded the muscularis mucosae and provided evidence of lymphovascular invasion. Additional surgical resection and regional lymph node dissection were therefore carried out; however, no lymph node metastasis was found. Adenocarcinoma arising from Barrett's mucosa is rare in young patients, especially in Japan, and this case is therefore particularly noteworthy.

[Combination chemotherapy of S-1 and CPT-11 for advanced recurrent gastric cancer].

We performed combination chemotherapy using S-1 and CPT-11 for advanced and recurrent stomach carcinoma in order to study the clinical efficacy thereof. The subjects comprised 13 patients aged 55 to 78 with a PS of 0 to 2, who had histologically confirmed unresectable stomach carcinoma or who had undergone a non curative resection with postoperative recurrence, all having measurable or assessable lesions with no severe damage in the principal organ, and from whom informed consent in writing had been obtained. 80 to 120 mg/day of S-1 were orally administered daily for 21 days according to the body surface area. 60 mg/m2 of CPT-11 was administered on Days 1 and 15. After the administration of S-1 for 3 weeks, from 1- to 2-week-long drug holidays were provided, thereby establishing a total of 4 to 5 weeks as 1 course. This was repeated as many times as possible. Thirteen subjects were registered during the period from November 2001 to February 2004. The details thereof are as follows: 9 male subjects and 4 female subjects with a median age of 65 years, wherein 1 subject had a PS of 0, 3 subjects had a PS of 1, and 9 subjects had a PS of 2. The results for all of the subjects showed that 5 subjects had PR, and the response rate was 38%. Grade 3 or higher adverse events consisted of leucopenia in 38.5%, neutropenia in 46.2%, anemia in 15.4%, and diarrhea in 7.7%. The median survival time (MST) for all of the subjects was 259 days. Specifically, the MST was 248 days for the subjects with a PS of 2 for whom 2 drugs were concomitantly used, and it was equal or longer for the subjects with a PS of 2 who were treated under the sole regimen of S-1. A review of this study showed that side effects were more frequently observed in the subjects with a PS of 2 than in those with a PS of 0 to 1. Furthermore, the average number of courses that were administered to the subjects with a PS of 0 to 1 was 8.5, against 3.6 courses on average in subjects with a PS of 2, thus showing a significant difference between the 2 groups. According to the above results, it is believed that there is a difference in the tolerability of the anticancer drugs between subjects with a PS of 0 to 1 and those with a PS of 2. It is also considered necessary to adjust the dosage of the anticancer drugs and the dosing period for patients with a PS of 2 when preparing a chemotherapeutic regimen for digestive carcinoma, including stomach carcinoma. The present regimen will be further studied to evaluate its potential use after second-line therapy for advanced and recurrent stomach carcinoma.

Successful initial ablation therapy contributes to survival in patients with hepatocellular carcinoma.

AIM: To evaluate the outcome predictors of percutaneous ablation therapy in patients with unresectable hepatocellular carcinoma (HCC), especially to identify whether the initial treatment response contributes to the survival of the patients. METHODS: The study cohort included 153 patients with single (102) and two or three (51) HCC nodules 5 cm or less in maximum diameter. As an initial treatment, 110 patients received radiofrequency ablation and 43 patients received percutaneous ethanol injection. RESULTS: The Kaplan-Meier estimates of overall 3- and 5-year survival rates were 75% and 59%, respectively. The log-rank test revealed statistically significant differences in the overall survivals according to Child-Pugh class (P = 0.0275), tumor size (P = 0.0130), serum albumin level (P = 0.0060), serum protein induced by vitamin K absence or antagonist II level (P = 0.0486), and initial treatment response (P = 0.0130). The independent predictors of survival were serum albumin level (risk ratio, 3.216; 95% CI, 1.407-7.353; P = 0.0056) and initial treatment response (risk ratio, 2.474; 95% CI, 1.076-5.692; P = 0.0330) based on the Cox proportional hazards regression models. The patients had a serum albumin level 3.5 g/dL and the 3- and 5-year survival rates of 86% and 82%. CONCLUSION: In HCC patients treated with percutaneous ablation therapy, serum albumin level and initial treatment response are the independent outcome predictors.