The treatment for refractory rectovaginal fistula after low anterior resection with estriol, polyglycolic acid sheets and primary closure: A case report.

INTRODUCTION: Rectovaginal fistula (RVF) is a refractory complication that occurs after anastomotic leakage following low anterior resection for rectal disease. Due to its refractory nature, RVF is often managed with surgical treatment, such as stoma creation for fecal diversion, closure of the fistula and/or re-anastomosis, rather than conservative therapy. PRESENTATION OF CASE: A 72-year-old woman who underwent laparoscopic low anterior resection developed RVF on post-operative day (POD) 15. Conservative therapy with the administration of estriol and total parenteral nutrition was started. In addition, a polyglycolic acid (PGA) sheet was inserted into the fistula using colonoscopy, and fibrin glue was applied. However, this treatment with the PGA sheet and fibrin glue seemed to be unsuccessful. Therefore, an operation for simple closure of the RVF was performed on POD47. The PGA sheet was then removed, and primary closure of the RVF from both sides of the rectum and vagina was performed. Following re-operation, solid food with low dietary fiber content was started on original POD55 (POD14 after re-operation), and the dietary fiber content was gradually increased. The patient was discharged from the hospital on original POD 83 (re-operation POD42). DISCUSSION: The administration of estrogen might result in increased vaginal compliance, decreased vaginal pH, increased vaginal blood flow and improved lubrication. Therefore, vaginal suture was made possible because the vaginal extensibility was restored. CONCLUSION: Primary closure of the RVF following administration of estriol may be an effective treatment.

Risk Factors for Post-Endoscopic Retrograde Pancreatography Pancreatitis: A Retrospective Chart Review in a Regional Hospital in Japan.

BACKGROUND: Endoscopic retrograde pancreatography (ERCP) is sometimes complicated by post-ERCP pancreatitis (PEP), which is a severe adverse effect. OBJECTIVE: The present study was performed to (i) evaluate the risk factors for PEP and (ii) compare the risk of PEP after ERCP performed in the off hours versus regular hours. METHODS: This retrospective study included 374 patients who underwent ERCP from January 2013 to December 2017. Among these patients, 38 (10.2%) developed PEP. The potential risk factors for PEP were evaluated by multivariate regression analysis, and the risk of PEP was compared between ERCP performed during regular hours and off hours. RESULTS: The independent risk factors for PEP were a relatively younger age (<75 years; p = 0.024), female sex (p = 0.002), a history of pancreatitis (p = 0.044), and performance of pancreatography (p = 0.010). Use of a diclofenac suppository and performance of pancreatic stenting were not preventive for PEP after ERCP. The complication rate of PEP did not differ between ERCP performed during the off hours versus regular hours. CONCLUSIONS: A relatively younger age (<75 years), female sex, a history of pancreatitis, and performance of pancreatography were potential risk factors for PEP, whereas the risk of PEP was not different between ERCP performed during the off hours versus regular hours.

An Investigation of Nine Patients with Gastrointestinal Immune-Related Adverse Events Caused by Immune Checkpoint Inhibitors.

INTRODUCTION/AIMS: Immune checkpoint inhibitors (ICIs) sometimes cause immune-related adverse events (irAEs), of which there is little information in the literatures. The objective of this study was to characterize the clinical features of gastrointestinal irAEs (GI irAEs). MATERIALS AND METHODS: From a total of 250 patients who were administered anti-PD-1 antibodies (nivolumab and pembrolizumab), we retrospectively identified 9 patients with grade 2 or higher GI irAE based on medical records. Patient characteristics, clinical features, imaging and pathological findings, and treatment course were evaluated. RESULTS: Grade 2 or higher GI irAEs were observed in 9 (3.6%) patients. Of the 9 patients who experienced GI irAE, 8 were male, and mean age was 63.2 years. Five patients received nivolumab and 4 received pembrolizumab. The GI irAEs observed were diarrhea in 7 patients and bloody stool in 2 patients. Grade 2 GI irAEs were identified in 3 patients and grade 3 GI irAEs in 6 patients. The average time from ICI administration to the onset of GI irAEs was 22.2 weeks (range 7-56 weeks) for nivolumab and 19.7 weeks (range 11-28 weeks) for pembrolizumab. Endoscopic findings showed ulcerative colitis-like findings in 3 of 7 patients, and pathological examination revealed crypt epithelial cell apoptosis in 6 of 7 patients. Eight of the 9 patients received steroids, and 2 patients received infliximab additionally. All GI irAEs were manageable. CONCLUSIONS: Because of the lack of specific clinical, imaging, and pathological findings, information of ICI use was indispensable for diagnosis. Although GI irAEs are controllable by steroid and infliximab, further studies regarding management strategy will be needed.

Correlation of Barrett's esophagus with colorectal polyps in Japanese patients: A retrospective chart review.

BACKGROUND AND AIM: Barrett's esophagus and colorectal polyps have several overlapping risk factors. Whereas several reports in Western countries have indicated a close relationship between Barrett's esophagus and colorectal polyps, the relationship between these two diseases remains unclear in Japan. This study was performed to determine whether the prevalence of Barrett's esophagus is related to that of colorectal polyps in Japanese patients. METHODS: The present retrospective chart review included 1582 Japanese patients who underwent both total colonoscopy and esophagogastroduodenoscopy from January 2010 to December 2016. The data on colorectal polyps and Barrett's esophagus were obtained from the endoscopic findings. The medical record of each patient was checked for age, sex, body mass index, smoking, alcohol drinking, use of acid suppression agents, and comorbidities including a history of diabetes, ischemic heart disease, gastroesophageal reflux disease, hiatal hernia, and Helicobacter pylori infection. RESULTS: Colorectal polyps were detected in 789 of the 1582 patients (49.9%). Barrett's esophagus was detected in 233 patients (14.7%), and most cases of Barrett's esophagus (n = 229) were classified as short-segment Barrett's esophagus. Colorectal polyps were more frequent in patients with than without Barrett's esophagus (odds ratio, 1.79; 95% confidence interval, 1.31-2.46; P < 0.001). In addition to Barrett's esophagus, the data indicated that old age, male sex, obesity, smoking, alcohol drinking, diabetes mellitus, and ischemic heart disease were independent risk factors for colorectal polyps. CONCLUSIONS: The present study revealed the correlation between the prevalence of Barrett's esophagus and colorectal polyps in Japanese patients.

Band Alignment of the CdS/Cu2Zn(Sn1- xGe x)Se4 Heterointerface and Electronic Properties at the Cu2Zn(Sn1- xGe x)Se4 Surface: x = 0, 0.2, and 0.4.

The surface electronic properties of the light absorber and band alignment at the p/n heterointerface are key issues for high-performance heterojunction solar cells. We investigated the band alignment of the heterointerface between cadmium sulfide (CdS) and Ge-incorporated Cu2ZnSnSe4 (CZTGSe), with Ge/(Ge + Sn) ratios ( x) between 0 and 0.4, by X-ray photoelectron, ultraviolet, and inversed photoemission spectroscopies (XPS, UPS, and IPES, respectively). In particular, we used interface-induced band bending in order to determine the conduction band offset (CBO) and valence-band offset (VBO), which were calculated from the core-level shifts of each element in both the CdS overlayer and the CZTGSe bottom layer. Moreover, the surface electronic properties of CZTGSe were also investigated by laser-irradiated XPS. The CBO at the CdS/CZTGSe heterointerface decreased linearly, from +0.36 to +0.20 eV, as x was increased from 0 to 0.4; in contrast, the VBO at the CdS/CZTGSe heterointerface was independent of Ge content. Both UPS and IPES revealed that the Fermi level at the CZTGSe surface is located near the center of the band gap. The hole concentration at the CZTGSe surface was on the order of 1011 cm-3, which is much smaller than that of the bulk (∼1016 cm-3). We discuss the differences in hole deficiencies near the surface and in the bulk on the basis of laser-irradiated XPS and conclude that hole deficiencies are due to defects distributed near the surface with densities that are lower than in the bulk, and the Fermi level is not pinned at the CZTGSe surface.

Outcomes of Patients Undergoing Endoscopic Hemostasis for the Upper Gastrointestinal Bleeding Were Not Influenced by the Timing of Hospital Emergency Visits: A Situation Prevailing in Japan.

BACKGROUND: The aim of the present study was to determine differences in the prognosis of patients in Japan who underwent emergency endoscopic hemostasis (i) during regular hours versus off hours and (ii) as outpatients versus hospitalized patients. METHODS: The present retrospective study included 443 patients who underwent emergency endoscopic hemostasis for non-variceal upper gastrointestinal bleeding from January 2008 to December 2014. These patients were classified into 2 groups: hospitalized patients and outpatients. The outpatients were further subclassified into those who visited the hospital during regular hours and those who visited during off hours. RESULTS: The outcomes of outpatients who underwent emergency hemostasis during off hours did not differ from patients treated during regular hours. Multivariate analysis revealed that outcomes of hospitalized patients, including mortality, need for blood transfusion and length of hospitalization, were worse than those of outpatients; it also revealed that patient age, malnutrition rate and prevalence of diabetes and neoplasms were higher among hospitalized patients than those in outpatients. CONCLUSIONS: The clinical outcomes of patients who underwent emergency endoscopic hemostasis for upper gastrointestinal bleeding during off hours did not differ from those of patients treated during regular hours. Outcomes were worse among hospitalized patients, mainly because of their bad general condition.

Orders of Magnitude Reduction of Rapid Coagulation Rate with Decreasing Size of Silica Nanoparticles.

The modification of the classical Smoluchowski theory for the rapid coagulation rate of colloidal particles, which takes account of the effect of the squeezing flow between colliding particles, has been widely accepted because it predicts experimental results adequately. However, it is not clear whether the modified theory, in which the coagulation rate is independent of the particle size, is applicable even to nanoparticles in solutions. In the present study, the rapid coagulation rates of silica particles in various 2 M chloride and 1 M potassium solutions were measured by using a low-angle light-scattering apparatus, and the dependence of rapid coagulation rate on the particle diameter, Dp, was investigated extensively. It was clearly shown that the rapid coagulation rate of spherical silica particles reduces by the orders of magnitude with decreasing particle size at Dp ≤ 300 nm, whereas it coincides with the value predicted by the modified theory at Dp ≥ 300 nm. A possible mechanism is proposed, and an analytical equation, which predicts the dramatic reduction in the rapid coagulation rate with decreasing particle size, is derived.

Histological observations on the microenvironment of osteolytic bone metastasis by breast carcinoma cell line.

Bone tissue, with its dynamic microenvironment featuring osteoclastic bone resorption, angiogenesis and matrix degradation, appears to facilitate proliferation of tumor cells after the onset of bone metastasis. In this study, we examined metastatic lesions in the femora of BALB/c nu/nu mice two weeks after intracardiac injection with human breast carcinoma MDA-231 cells. Histopathological observations showed the metastatic lesions close to the chondro-osseous junction, and revealed MDA-231 cells loosely intermingled with different cell types such as osteoblasts, fibroblastic stromal cells, osteoclasts and endothelial cells. In the metastatic nest, many tartrate resistant acid phosphatase (TRAPase)-positive osteoclasts accumulated in direct contact with or were close to alkaline phosphatase (ALPase)- or receptor activator of NF-kappaB ligand (RANKL)-positive osteoblastic cells. It seems likely that osteoclastogenesis is mediated through cell-to-cell contacts with ALPase- and RANKL-expressing osteoblastic cells. Formation of many capillaries lacking complete basal membranes and pericytes ratified the results of in situ hybridization, which revealed intense expression of VEGF in tumor nests, and therefore, indicated ongoing tumor-induced angiogenesis. The tumor cells possessed matrix metallo-proteinases (MMPs)-1 and -9, and frequently extended their stout cytoplasmic processes into fragmented fibrillar components of the growth plate cartilage, implicating degradation of cartilaginous matrix. Thus, osteolytic bone metastasis has demonstrated pathological features as tumor-induced angiogenesis and degradation of extracellular matrix, in addition to osteoclastogenesis. This complex interplay between tumor cells and host tissues may enable and nourish the establishment of a microenvironment that facilitates tumor progression.