Tadashi Sakurai

Causes of Death in Autopsied Patients with Rheumatoid Arthritis in Japan

Objective: To investigate causes of death in Japanese patients with Rheumatoid Arthritis (RA) and whether recent RA treatment has been associated with a decrease in AA-amyloidosis among RA patients. nMethods: Data from records of RA patients autopsied in Japan during 2000-2004 and 1985-1989 were analyzed. Cause of death, age at death, gender, and incidence of amyloidosis were assessed. nResults: The average age at death in the recent RA group was 69.1 years in 817 females and 70.1 years in 408 males. Unlike the general population, RA females died earlier than males. In the past 15 years, a survival rate of RA patients has improved. The leading cause of death of recently diagnosed RA patients was infection (32.8%), respiratory diseases (20.2%), and AA-amyloidosis (11.3%). In comparison with patients surveyed in 1985-1989 this represents an increase in deaths from infection and respiratory diseases, a decrease in deaths from RA itself and renal diseases, and no change in deaths from AA-amyloidosis. In RA, more males died of interstitial lung disease (odds 2.94) and more females died from AA-amyloidosis (odds 3.52). nConclusion: Cause of death is significantly different in RA patients compared to the general population. Although outcomes of RA patients have been improving, the incidence of AA-amyloidosis remains high in Japan.

Combined thoracoscopic and endoscopic surgery for a large esophageal schwannoma

A 47-year-old woman presented to our hospital with complaints of dysphagia. Esophagogastroduodenoscopy identified a submucosal tumor in the left wall of the esophagus that was diagnosed as a benign schwannoma on biopsy. Computed tomography revealed a tumor of length 60 mm in the thoracic esophagus, with its cranial edge at the level of the aortic arch. On endoscopy, a submucosal tunnel was created 40 mm proximal to the cranial edge of the tumor, and its oral end was dissected from the mucosal and muscular layers. This was followed by the resection of the entire tumor by left-sided thoracoscopy. The esophageal defect was closed in layer by continuous suture from the thoracic side. Endoscopic closure was achieved by using clips. No postoperative complications were observed. Oral diet was resumed from postoperative day 7 and the patient was discharged on postoperative day 9. This combined approach has not been described for similar tumors. Our experience demonstrated that large esophageal tumors can be safely excised with minimally invasive surgery by using a combination of thoracoscopy and endoscopy.

Hiatal hernia involving prolapse of the entire stomach into the mediastinum after distal gastrectomy: a case report

BackgroundProlapse of a small part of the proximal stomach through the hiatus into the mediastinum is relatively common. Hiatal hernia involving the postoperative stomach has been reported previously, but the degree of hernia was not so severe, and hiatal hernia involving the prolapse of the entire stomach following gastrectomy into the mediastinum has never been reported. We describe a very rare case of large hiatal hernia involving the entire postoperative stomach.Case presentationA 79-year-old man with a history of distal gastrectomy for submucosal benign tumor 40xa0years ago was referred to our hospital because of dysphagia and weight loss. Computed tomography revealed prolapse of the entire postoperative stomach into the mediastinum, and a radical operation was performed. There was a strong adhesion in the hernial sac of the mediastinum, but only little adhesion due to a previous open surgery in the abdominal cavity was present. After the stomach was pulled into the abdominal cavity, suture cruroplasty and Toupet fundoplication without dissection of the short gastric artery were performed. The patient experienced postoperative paralytic ileus, but the rest of the postoperative course was uneventful and the symptom of dysphagia improved.ConclusionsWe presented a very rare large hiatal hernia involving the entire postoperative stomach. Toupet fundoplication preserving the short gastric artery could be one of the optimal surgeries to prevent postoperative regurgitation of the remnant stomach.

Treatment of spontaneous esophageal rupture (Boerhaave syndrome) using thoracoscopic surgery and sivelestat sodium hydrate

BackgroundnThe mortality rate of spontaneous esophageal rupture remains 20% to 40% due to severe respiratory failure. We have performed thoracoscopic surgery for esophageal disease at our department since 1994. Sivelestat sodium hydrate reportedly improves the pulmonary outcome in the patients with acute lung injury (ALI).nnnMethodsnWe retrospectively evaluated the usefulness of thoracoscopic surgery and perioperative administration of sivelestat sodium hydrate for spontaneous esophageal rupture in 12 patients who underwent thoracoscopy at our department between 2002 and 2014.nnnResultsnThe patient cohort included 11 males and one female (median age, 61 years). The lower left esophageal wall was perforated in all patients. Surgical procedures consisted of thoracoscopic suture and thoracic drainage in six patients, transhiatal suture and thoracoscopic thoracic drainage in five, and thoracoscopic esophagectomy and thoracic drainage in one. The median time from onset to surgery was 8 hours with a surgical duration of 210 minutes, blood loss 260 mL, postoperative ventilator management 1 day, intensive care unit (ICU) stay 5 days, and interval to restoration of oral ingestion 13 days. Postoperative complications included respiratory failure in four patients, pyothorax in three, and leakage in one. There was no instance of perioperative mortality. Regarding perioperative administration of sivelestat sodium hydrate, the postoperative arterial oxygen partial pressure-to-fractional inspired oxygen ratio (P/F) and C-reactive protein (CRP) levels in the administration group were significantly better than those in the non-administration group on postoperative days 4 (P=0.035) and 5 (P=0.037), respectively. In contrast, there was no significant difference between the groups in median time of ventilator management, ICU stay, oral ingestion following surgery, or hospital stay.nnnConclusionsnThoracoscopic surgery obtained acceptable results in all patients, including two with a significant time elapse from onset to treatment. Furthermore, sivelestat sodium hydrate was suggested to help improve postoperative respiration and inflammatory response.

Thoracoscopic primary repair with mediastinal drainage is a viable option for patients with Boerhaave’s syndrome

BackgroundnSpontaneous esophageal rupture (Boerhaaves syndrome) is an emergency that can cause life-threatening conditions. Various procedures have been used to treat Boerhaaves syndrome. However, a standard surgical procedure has not been established. Herein, we report our experience with primary suture of the ruptured esophagus via a thoracoscopy or laparotomy.nnnMethodsnBetween November 2002 and May 2015, 11 patients with Boerhaaves syndrome presented to our department and were managed using one of two surgical procedures based on the surgeons discretion. Six patients underwent a thoracoscopic primary suture and drainage (group A); 5 patients underwent a primary suture via laparotomy followed by thoracoscopic drainage (group B). Patient medical records were retrospectively reviewed.nnnResultsnThe mean interval between initial perforation and surgery was 13.7 h (group A) and 17.2 h (group B) (P=0.7307). The mean operative time was 190 min (group A) and 249 min (group B) (P=0.106). Patient baseline characteristics and surgical outcomes were similar for both surgical procedures. One patient in each group experienced postoperative leakage that did not require surgical intervention.nnnConclusionsnThe results suggest that thoracoscopic esophageal repair, as well as suturing via laparotomy, is a good surgical alternative for patients with Boerhaaves syndrome.

Different strategy of salvage esophagectomy between residual and recurrent esophageal cancer after definitive chemoradiotherapy

BackgroundnClinical outcomes appear to differ between patients with residual or recurrent esophageal cancer after definitive chemoradiotherapy. We aimed to identify the patients most likely to benefit from this high-risk surgery, divided by the patients whose cancer was residual and recurrent groups, respectively.nnnMethodsnWe retrospectively examined 100 cases of patients who failed to respond to definitive chemoradiotherapy for thoracic esophageal squamous cell carcinoma and subsequently underwent salvage transthoracic esophagectomy.nnnResultsnIn-hospital morbidity was similar in both groups. T status prior to administration of chemoradiotherapy correlated with survival in the group with residual cancer (P=0.010), but this relationship was not significant in the group with recurrent cancer (P=0.635). On the other hand, pathological T status showed a significant correlation with survival in both the residual (P<0.001) and recurrent groups (P=0.001). Patients with T3 disease in the recurrent group showed better survival, similar to T0-2 patients, while worse survival was demonstrated in the residual group. In the recurrent group, N status before chemoradiotherapy did not correlate with survival (P=0.895).nnnConclusionsnPatients with residual cancer would have good prognosis by salvage esophagectomy in cases in which the cancer had not invaded to the adventitia at the time of chemoradiotherapy and surgery. Conversely, patients whose cancer was recurrent might benefit from salvage surgery if the cancer appears to be resectable. T and N status before chemoradiotherapy are not important factors in consideration of salvage esophagectomy in cases of recurrent cancer.

Thoracoscopic esophageal repair with barbed suture material in a case of Boerhaave’s syndrome

A 53-year-old man was referred to our hospital with Boerhaaves syndrome. Thirty hours after onset, a left thoracoscopic operation was performed, with carbon dioxide pneumothorax and the patient in right semi-prone position. The thoracic cavity was copiously irrigated with physiological saline and a 4-cm longitudinal rupture was identified on the left side of the lower esophagus. The esophageal injury was repaired in 2 layers by using barbed absorbable suture material. The patient was allowed oral feeds after contrast esophagography confirmed the absence of contrast leak at the sutured site on postoperative day 7, and discharged by day 28. Suturing of the ruptured esophagus under thoracoscopic guidance is considered to be difficult and requires expertise. This case report demonstrates that the use of a barbed suture material simplifies thoracoscopic esophageal repair and also highlights the importance of pneumothorax and patient position in improving access to the esophagus.

The efficacy of mizoribine for the treatment of rheumatoid arthritis and its correlation with renal function.

Abstract Objectives. To evaluate the correlation between the efficacy of mizoribine (MZR) and the factors that might effect MZR concentration: renal function and dosage and administration of MZR in patients with rheumatoid arthritis (RA). Methods. The efficacy of MZR treatment was prospectively evaluated in 97 RA regardless of dosage, at the 14 participated institutions. The Disease Activity Score 28-CRP3 was used to assess RA activity. The renal function was evaluated based on the serum creatinine and serum cystatin-C (Cys-C). The patients were followed up for 24 weeks. Results. The patients with a mean age 66.2 years included 18 male. The renal function assessment showed increased creatinine in 16.4% of patients and increased Cys-C in 54.5%, suggesting the higher sensitivity of Cys-C to detect impaired renal function than creatinine. In patients with good or moderate response according to the European League against Rheumatism classification criteria, the Cys-C was significantly higher compared with those with no response. MZR treatment was significantly more effective in patients with an arithmetic product of the single MZR dose used and Cys-C of 179 or more. Conclusions. The efficacy of MZR may increase in proportion to its single dose, or increased Cys-C level in patients with impaired renal function.

A case of verrucous carcinoma of the esophagus associated with difficult histopathological diagnosis of endoscopic biopsy specimens

Verrucous carcinoma of the esophagus (VCE) is a rare, slow-growing, well-differentiated squamous cell carcinoma. Histologically, superficial layers of this cancer tend to have less atypical epithelium with non-specific inflammatory change, which therefore makes diagnosis of malignancy extremely difficult unless a surgical specimen is obtained. We recently encountered a case in which a malignant tumor was suspected on initial endoscopic evaluation, but two biopsies revealed no carcinoma cells. Analysis of a third biopsy finally suggested the possibility of squamous cell carcinoma. A subsequent surgical specimen revealed the tumor as VCE. In addition, immunohistochemical examination revealed that Ki67 immunopositive cells were distributed along the basal layer of the VCE, regarded as a pattern unique to this type of cancer. It is important to know of the existence of VCE. In cases in which this tumor is endoscopically suspected, repeated deep biopsy is strongly recommended and the only curative treatment for this type of cancer is resection.

Chance Finding of Proteinuria Leads to the Diagnosis of ANCA Associated Vasculitis

Microscopic polyangiitis (MPA) was recognised with a high early mortality rate and the renal involvement was characterised by segmental necrotizing glomerulonephritis with high positivity of antineutrophil cytoplasmic antibody (ANCA) and a broad spectrum of signs and symptoms including fever and malaise. We reported here a woman with ANCA associated with MPA diagnosed by a chance finding of proteinuria. To the best of our knowledge, early diagnosis of this disorder only by the presence of proteinuria has not been reported previously in the English literature.