Yuichi Kataoka

Efficacy of Continuous Regional Arterial Infusion of a Protease Inhibitor and Antibiotic for Severe Acute Pancreatitis in Patients Admitted to an Intensive Care Unit

Abstract: To investigate the efficacy of continuous regional arterial infusion (CRAI) of a protease inhibitor and antibiotic for severe acute pancreatitis (SAP) in patients admitted to an intensive care unit (ICU). A total of 51 patients with SAP requiring admission to an ICU were studied. The patients were divided into two groups: one received the protease inhibitor nafamostat mesylate and the antibiotic imipenem by continuous regional arterial infusion (CRAI group) and the other received protease inhibitors and antibiotics by intravenous infusion (non-CRAI group). To evaluate the therapeutic usefulness of CRAI of a protease inhibitor and antibiotic for SAP, the rate of surgery and the cumulative survival rate were compared between the non-CRAI group and the CRAI group. The rate of surgery was 32% in the non-CRAI group and 9% in the CRAI group (P = 0.08). Cumulative survival rates at 1, 6, and 12 months were 77.9%, 48.9%, and 48.9% in the non-CRAI group compared with 100.0%, 100.0%, and 87.1% in the CRAI group. Outcome was thus significantly better in the CRAI group than in the non-CRAI group (P = 0.002). CRAI of a protease inhibitor and antibiotic may decrease the need for surgical therapy and reduce mortality in patients with SAP.

Pancreatographic classification of pancreatic ductal injuries caused by blunt injury to the pancreas.

BACKGROUND In the treatment of patients with pancreatic injury, the focus of attention is usually on main ductal injuries. METHODS To develop a classification system for pancreatic ductal injuries, we retrospectively analyzed blunt pancreatic injuries in 40 patients. We assessed the relationships between findings on pancreatography (36 endoscopic retrograde procedures and 4 transduodenal procedures), the treatment modality, and the clinical course. RESULTS Patients with class 1 injuries (radiographically normal ducts, n = 13) could be treated nonsurgically without major complications. Patients with class 2 injuries (branch injuries, n = 7), in whom contrast medium from ductal branches did not leak from the pancreatic parenchyma (class 2a, n = 3), could be treated nonsurgically. Patients with leaks into the retroperitoneal space (class 2b, n = 4) required at least a drainage laparotomy. Patients with class 3 injuries (main duct injuries, n = 20), including two patients in whom conservative treatment resulted in severe complications, required laparotomy. CONCLUSION This classification system for pancreatic ductal injuries may facilitate the selection of appropriate therapeutic modalities for patients with blunt pancreatic injury.

Iliac vein injuries in hemodynamically unstable patients with pelvic fracture caused by blunt trauma.

BACKGROUND Major pelvic venous injuries secondary to blunt trauma can be a difficult problem in diagnosis and management. This study aimed to elucidate the clinical significance of iliac vein injuries demonstrated by venography in patients with blunt pelvic injuries who remained unstable even after transcatheter arterial embolization (TAE). METHODS We reviewed the records of 72 patients with unstable pelvic fracture who presented with shock at our center after blunt trauma from 1999 through 2003. The average Injury Severity Score was 34.3 in this study population. RESULTS TAE was the first method of choice to control bleeding from pelvic fracture in 61 patients. Thirty-six patients recovered from shock after TAE. Eighteen of 25 who did not recover from shock died. In 11 of these 25, transfemoral venography with a balloon catheter was performed, revealing significant venous extravasation in 9: common iliac vein in 5, internal iliac vein in 3, and external iliac vein in 1. The average Injury Severity Score of patients with iliac vein injury was 45.8. Treatments for venous injuries were laparotomy for hemostasis (n = 1, survivors = 0), retroperitoneal gauze packing (n = 3, survivors = 1), and endovascular stent placement (n = 3, survivors = 3). Two patients suffered from cardiac arrest before treatment for venous injury. External fixations were performed after TAE according to fracture type. CONCLUSION The iliac vein injury is the principal cause of hemorrhagic shock in some patients with unstable pelvic fractures after blunt trauma. Venography is useful for identifying iliac vein injuries.

Miniprobe ultrasonography for determining prognosis in corrosive esophagitis

OBJECTIVE:We evaluated the ability of endoscopic ultrasonography to predict likelihood of stricture formation in patients with corrosive esophagitis.METHODS:Consecutive patients with esophagitis resulting from alkaline or acid chemical ingestion (n = 11) were evaluated prospectively by endoscopic ultrasonography between hospital days 4 and 12. Findings for the most severe lesion were classified according to the appearance of the muscular layers: distinct muscular layers without thickening (grade 0); distinct muscular layers with thickening (grade I); obscured muscular layers with indistinct margins (grade II); and muscular layers that could not be differentiated (grade III). Findings were also classified according to whether apparent damage to muscular layers in the worst-appearing image involved part of the circumference (type a) or the whole circumference (type b). Implications of these findings for subsequent stricture formation were then evaluated.RESULTS:Stricture formation did not occur in patients with grade 0 or grade I images; transient stricture formation occurred in a patient showing grade IIa. Stricture requiring repeated bougie dilation occurred in a patient showing grade IIIb.CONCLUSIONS:Endoscopic ultrasonographic images presumed to reflect the destruction of muscular layers (grades II to III), as opposed to only edema (grade I), may be associated with stricture formation. This modality can accurately visualize deep lesions in corrosive esophagitis, making it prognostically useful.

Hybrid treatment combining emergency surgery and intraoperative interventional radiology for severe trauma

OBJECT To evaluate the efficacy of hybrid treatment combining emergency surgery and intraoperative interventional radiology (IVR) for severe trauma. PATIENTS AND METHODS The records of 63 severely injured patients who underwent concurrent emergency surgery and IVR at our emergency centre from 1999 through 2013 were retrospectively reviewed. Mobile digital subtraction angiography device was used in the operating room when performing IVR. Patients undergoing hybrid treatment combining intraoperative IVR and emergency surgery (intraoperative IVR group) were compared with those undergoing IVR in the angiography suite before or after emergency surgery (control group). RESULTS Thirteen patients underwent hybrid treatment (intraoperative IVR group). Of these 13 patients, 7 underwent treatment for abdominal organ injuries, and 6 for multiregional injuries. Emergency operations were laparotomy (n=12), thoracotomy (n=1), craniotomy (n=1), and haemostasis of the lower extremities (n=1). Five patients underwent damage control surgery. IVR included transarterial embolisation (n=12), endovascular stent or stent-graft placement (n=2), and embolisation of a portal vein by laparotomy (n=2). The mean ISS was 40. The actual overall survival rate was 85%, and the probability of survival (Ps) was 62%. The control group included 45 patients. Five patients who met exclusion criteria were not included in the control group. Age, ISS, RTS, Ps, pH and base excess on arrival, and blood transfusion volume during operation and IVR did not differ significantly between the groups. Total time during operation and IVR was significantly shorter in the intraoperative IVR group than in the control group (229 [SD 72]min vs. 355 [SD 169]min; p=0.007). The mortality were 15 (95% CI 2-45) % in the intraoperative IVR group vs. 36 (95% CI 22-51) % in the control group. CONCLUSION Hybrid treatment combining emergency surgery and intraoperative IVR can be a novel treatment strategy for severe trauma, and it will improve patient outcomes due to reduction of the time for resuscitation.

Impact of Doctor Car with Mobile Cloud ECG in Reducing Door-to- Balloon Time of Japanese ST-Elevation Myocardial Infarction Patients

Early reperfusion by percutaneous coronary intervention (PCI) is the current standard therapy for ST-elevation myocardial infarction (STEMI). To achieve better prognoses for these patients, reducing the door-to-balloon time is essential. As we reported previously, the Kitasato University Hospital Doctor Car (DC), an ambulance with a physician on board, is equipped with a novel mobile cloud 12-lead ECG system. Between September 2011 and August 2013, there were 260 emergency dispatches of our Doctor Car, of which 55 were for suspected acute myocardial infarction with chest pain and cold sweat. Among these 55 calls, 32 patients received emergent PCI due to STEMI (DC Group). We compared their data with those of 76 STEMI patients who were transported directly to our hospital by ambulance around the same period (Non-DC Group). There were no differences in patient age, gender, underlying diseases, or Killip classification between the two groups. The door-to-balloon time in the DC group was 56.1 ± 13.7 minutes and 74.0 ± 14.1 minutes in the Non-DC Group (P < 0.0001). Maximum levels of CPK were 2899 ± 308 and 2876 ± 269 IU/L (P = 0.703), and those of CK-MB were 292 ± 360 and 295 ± 284 ng/mL (P = 0.423), respectively, in the 2 groups. The Doctor Car system with the Mobile Cloud ECG was useful for reducing the door-to-balloon time.

A case of intestinal obstruction due to inflammatory changes in the small intestine from alkaline ingestion

Alkaline ingestion frequently causes corrosive esophagitis but rarely causes lower digestive tract injury. In this case, a 79‐year‐old man accidentally drank kitchen detergent. After 3 h, lower abdominal pain occurred and gradually worsened. He was taking a proton pump inhibitor after proximal gastrectomy for gastric cancer. He had local tenderness in the left lower abdomen. Abdominal computed tomography showed expansion of the small intestine, thickening of the intestinal wall, and inflammatory changes. Upper gastrointestinal endoscopy showed no obvious injury to the esophagus or stomach.

A case of renal vein branch injury identified by multidetector computed tomography

A 39-year-old male fell from a forklift and was urgently transported to our hospital. His vital signs were stable at the initial visit. Contrast imaging computed tomography (CT) showed extravasation (Ev) of contrast medium emigrating outside of the renal capsule and hematoma around the right kidney, and he was diagnosed with traumatic right renal injury, Grade IV laceration [American Association for the Surgery of Trauma classification]. When imaging the inferior renal artery branch extremity perfusing the area where Ev was found in the following blood vessel contrast imaging, obvious Ev was not found in the arterial phase; however, massively spreading Ev was found in the area adjacent to the renal laceration in the venous phase after taking a contrast image of the renal parenchyma. Thus, he was diagnosed with a renal vein branch injury. The transcatheter arterial embolization (TAE) was performed to the area, resulting in the disappearance of Ev. The effectiveness of TAE for renal injury has been established; however, it is only performed for arterial hemorrhage. TAE for venous injury has not previously been considered because a tamponade is supposedly effective for hemostasis of venous hemorrhage due to the anatomy surrounding Gerotas fasciae. This is an extremely rare case in which only venous injury was identified, without obvious arterial hemorrhage. Gerotas fasciae were broken and hemostasis treatment was required. Because the renal artery is the end artery, the venous hemorrhage was controlled with arterial embolization. In our case, renal vein branch injury was identified on CT and hemorrhage was terminated using TAE for the renal artery branch. TAE can be used as a non-operative management for the successful treatment of renal vein branch injury.