Showing papers by "Tadahiro Takada published in 2010"
TL;DR: Judging whether it is gallstone-induced or not is most urgent and crucial for deciding treatment policy including the assessment of whether endoscopic papillary treatment should be conducted or not.
Abstract: Practical guidelines for the diagnosis of acute pancreatitis are presented so that a rapid and adequate diagnosis can be made. When acute pancreatitis is suspected in patients with acute onset of abdominal pain and tenderness mainly in the upper abdomen, the diagnosis of acute pancreatitis is made on the basis of elevated levels of pancreatic enzymes in the blood and/or urine. Furthermore, other acute abdominal diseases are ruled out if local findings associated with pancreatitis are confirmed by diagnostic imaging. According to the diagnostic criteria established in Japan, patients who present with two of the following three manifestations are diagnosed as having acute pancreatitis: characteristic upper abdominal pain, elevated levels of pancreatic enzymes, and findings of ultrasonography (US), CT or MRI suggesting acute pancreatitis. Detection of elevated levels of blood pancreatic enzymes is crucial in the diagnosis of acute pancreatitis. Measurement of blood lipase is recommended, because it is reported to be superior to all other pancreatic enzymes in terms of sensitivity and specificity. For measurements of the blood amylase level widely used in Japan, it should be cautioned that, because of its low specificity, abnormal high values are also often obtained in diseases other than pancreatitis. The cut-off level of blood pancreatic enzymes for the diagnosis of acute pancreatitis is not able to be set because of lack of sufficient evidence and consensus to date. CT study is the most appropriate procedure to confirm image findings of acute pancreatitis. Elucidation of the etiology of acute pancreatitis should be continued after a diagnosis of acute pancreatitis. In the process of the etiologic elucidation of acute pancreatitis, judgment whether it is gallstone-induced or not is most urgent and crucial for deciding treatment policy including the assessment of whether endoscopic papillary treatment should be conducted or not. The diagnosis of gallstone-induced acute pancreatitis can be made by combining detection of elevated levels of bilirubin, transamylase (ALT, AST) and ALP detected by hematological examination and the visualization of gallstones by US.
89 citations
TL;DR: In Japan, severe acute pancreatitis is recognized as being a specified intractable disease on the basis of these criteria, so medical expenses associated with severe acute Pancreatitis are covered by Government payment.
Abstract: The assessment of severity at the initial medical examination plays an important role in introducing adequate early treatment and the transfer of patients to a medical facility that can cope with severe acute pancreatitis. Under these circumstances, “criteria for severity assessment” have been prepared in various countries, including Japan, and these criteria are now being evaluated. The criteria for severity assessment of acute pancreatitis in Japan were determined in 1990 (of which a partial revision was made in 1999). In 2008, an overall revision was made and the new Japanese criteria for severity assessment of acute pancreatitis were prepared. In the new criteria for severity assessment, the diagnosis of severe acute pancreatitis can be made according to 9 prognostic factors and/or the computed tomography (CT) grades based on contrast-enhanced CT. Patients with severe acute pancreatitis are expected to be transferred to a specialist medical center or to an intensive care unit to receive adequate treatment there. In Japan, severe acute pancreatitis is recognized as being a specified intractable disease on the basis of these criteria, so medical expenses associated with severe acute pancreatitis are covered by Government payment.
83 citations
TL;DR: In this article, the authors present guidelines for the diagnostic criteria of post-ERCP pancreatitis, and its incidence, risk factors, and prophylactic procedures that are supported by evidence.
Abstract: Pancreatitis remains the most common severe complication of endoscopic retrograde cholangiopancreatography (ERCP). Detailed information about the findings of previous studies concerning post-ERCP pancreatitis has not been utilized sufficiently. The purpose of the present article was to present guidelines for the diagnostic criteria of post-ERCP pancreatitis, and its incidence, risk factors, and prophylactic procedures that are supported by evidence. To achieve this purpose, a critical examination was made of the articles on post-ERCP pancreatitis, based on the data obtained by research studies published up to 2009. At present, there are no standardized diagnostic criteria for post-ERCP pancreatitis. It is appropriate that post-ERCP pancreatitis is defined as acute pancreatitis that has developed following ERCP, and its diagnosis and severity assessment should be made according to the diagnostic criteria and severity assessment of the Japanese Ministry of Health, Labour and Welfare. The incidence of acute pancreatitis associated with diagnostic and therapeutic ERCP is 0.4–1.5 and 1.6–5.4%, respectively. Endoscopic papillary balloon dilation is associated with a high risk of acute pancreatitis compared with endoscopic sphincterotomy. It was made clear that important risk factors include dysfunction of the Oddi sphincter, being of the female sex, past history of post-ERCP pancreatitis, and performance of pancreaticography. Temporary prophylactic placement of pancreatic stents in the high-risk group is useful for the prevention of post-ERCP pancreatitis [odds ratio (OR) 3.2, 95% confidence interval (CI) 1.6–6.4, number needed to treat (NNT) 10]. Use of nonsteroidal anti-inflammatory drugs (NSAIDs) is associated with a reduction in the development of post-ERCP pancreatitis (OR 0.46, 95% CI 0.32–0.65). Single rectal administration of NSAIDs is useful for the prevention of post-ERCP pancreatitis [relative risk (RR) 0.36, 95% CI 0.22–0.60, NNT 15] and decreases the development of pancreatitis in both the low-risk group (RR 0.29, 95% CI 0.12–0.71) and the high-risk group (RR 0.40, 95% CI 0.23–0.72) of post-ERCP pancreatitis. As for somatostatin, a bolus injection may be most useful compared with short- or long-term infusion (OR 0.271, 95% CI 0.138–0.536, risk difference 8.2%, 95% CI 4.4–12.0%). The usefulness of gabexate mesilate was not apparent in any of the following conditions: acute pancreatitis (control 5.7 vs. 4.8% for gabexate mesilate), hyperamylasemia (40.6 vs. 36.9%), and abdominal pain (1.7 vs. 8.9%). Formulation of diagnostic criteria for post-ERCP pancreatitis is needed. Temporary prophylactic placement of pancreatic stents in the high-risk group offers the most promise as a means of preventing post-ERCP pancreatitis. As for pharmacological attempts, there are high expectations concerning NSAIDs because they are excellent in terms of cost-effectiveness, ease of use, and safety. There was no evidence of effective prophylaxis with the use of protease inhibitors, especially gabexate mesilate.
71 citations
TL;DR: The Japanese (JPN) Guidelines were designed to provide recommendations regarding the management of acute pancreatitis in patients having a variety of clinical characteristics and the latest evidence for the management is incorporated in the Japanese-language version of JPN guidelines 2010.
Abstract: The clinical course of acute pancreatitis varies from mild to severe. Assessment of severity and etiology of acute pancreatitis is important to determine the strategy of management for acute pancreatitis. Acute pancreatitis is classified according to its morphology into edematous pancreatitis and necrotizing pancreatitis. Edematous pancreatitis accounts for 80–90% of acute pancreatitis and remission can be achieved in most of the patients without receiving any special treatment. Necrotizing pancreatitis occupies 10–20% of acute pancreatitis and the mortality rate is reported to be 14–25%. The mortality rate is particularly high (34–40%) for infected pancreatic necrosis that is accompanied by bacterial infection in the necrotic tissue of the pancreas (Widdison and Karanjia in Br J Surg 80:148–154, 1993; Ogawa et al. in Research of the actual situations of acute pancreatitis. Research Group for Specific Retractable Diseases, Specific Disease Measure Research Work Sponsored by Ministry of Health, Labour, and Welfare. Heisei 12 Research Report, pp 17–33, 2001). On the other hand, the mortality rate is reported to be 0–11% for sterile pancreatic necrosis which is not accompanied by bacterial infection (Ogawa et al. 2001; Bradely and Allen in Am J Surg 161:19–24, 1991; Rattner et al. in Am J Surg 163:105–109, 1992). The Japanese (JPN) Guidelines were designed to provide recommendations regarding the management of acute pancreatitis in patients having a variety of clinical characteristics. This article describes the guidelines for the surgical management and interventional therapy of acute pancreatitis by incorporating the latest evidence for the management of acute pancreatitis in the Japanese-language version of JPN guidelines 2010. Eleven clinical questions (CQ) are proposed: (1) worsening clinical manifestations and hematological data, positive blood bacteria culture test, positive blood endotoxin test, and the presence of gas bubbles in and around the pancreas on CT scan are indirect findings of infected pancreatic necrosis; (2) bacteriological examination by fine needle aspiration is useful for making a definitive diagnosis of infected pancreatic necrosis; (3) conservative treatment should be performed in sterile pancreatic necrosis; (4) infected pancreatic necrosis is an indication for interventional therapy. However, conservative treatment by antibiotic administration is also available in patients who are in stable general condition; (5) early surgery for necrotizing pancreatitis is not recommended, and it should be delayed as long as possible; (6) necrosectomy is recommended as a surgical procedure for infected necrosis; (7) after necrosectomy, a long-term follow-up paying attention to pancreatic function and complications including the stricture of the bile duct and the pancreatic duct is necessary; (8) drainage including percutaneous, endoscopic and surgical procedure should be performed for pancreatic abscess; (9) if the clinical findings of pancreatic abscess are not improved by percutaneous or endoscopic drainage, surgical drainage should be performed; (10) interventional treatment should be performed for pancreatic pseudocysts that give rise to symptoms, accompany complications or increase the diameter of cysts and (11) percutaneous drainage, endoscopic drainage or surgical procedures are selected in accordance with the conditions of individual cases.
52 citations
TL;DR: There is a consensus in Japan that a large dose of a synthetic protease inhibitor should be given to patients with severe acute pancreatitis in order to prevent organ failure and other complications.
Abstract: Patients who have been diagnosed as having acute pancreatitis should be, on principle, hospitalized. Crucial fundamental management is required soon after a diagnosis of acute pancreatitis has been made and includes monitoring of the conscious state, the respiratory and cardiovascular system, the urinary output, adequate fluid replacement and pain control. Along with such management, etiologic diagnosis and severity assessment should be conducted. Patients with a diagnosis of severe acute pancreatitis should be transferred to a medical facility where intensive respiratory and cardiovascular management as well as interventional treatment, blood purification therapy and nutritional support are available. The disease condition in acute pancreatitis changes every moment and even symptoms that are mild at the time of diagnosis may become severe later. Therefore, severity assessment should be conducted repeatedly at least within 48 h following diagnosis. An adequate dose of fluid replacement is essential to stabilize cardiovascular dynamics and the dose should be adjusted while assessing circulatory dynamics constantly. A large dose of fluid replacement is usually required in patients with severe acute pancreatitis. Prophylactic antibiotic administration is recommended to prevent infectious complications in patients with severe acute pancreatitis. Although the efficacy of intravenous administration of protease inhibitors is still a matter of controversy, there is a consensus in Japan that a large dose of a synthetic protease inhibitor should be given to patients with severe acute pancreatitis in order to prevent organ failure and other complications. Enteral feeding is superior to parenteral nutrition when it comes to the nutritional support of patients with severe acute pancreatitis. The JPN Guidelines recommend, as optional continuous regional arterial infusion and blood purification therapy.
50 citations
TL;DR: When a diagnosis of acute pancreatitis (AP) is made, fundamental medical treatment consisting of fasting, intravenous (IV) fluid replacement, and analgesics with a close monitoring of vital signs should be immediately started and assessment of severity based on clinical signs, blood test, urinalysis and imaging tests should be performed to determine the way of treatment for each patient.
Abstract: When a diagnosis of acute pancreatitis (AP) is made, fundamental medical treatment consisting of fasting, intravenous (IV) fluid replacement, and analgesics with a close monitoring of vital signs should be immediately started. In parallel with fundamental medical treatment, assessment of severity based on clinical signs, blood test, urinalysis and imaging tests should be performed to determine the way of treatment for each patient. A repeat evaluation of severity is important since the condition is unstable especially in the early stage of AP. At the time of initial diagnosis, the etiology should be investigated by means of blood test, urinalysis and diagnostic imaging. If a biliary pancreatitis accompanied with acute cholangitis or biliary stasis is diagnosed or suspected, an early endoscopic retrograde cholangiopancreatography with or without endoscopic sphincterotomy (ERCP/ES) is recommended in addition to the fundamental medical treatment. In mild cases, the fundamental medical treatment should be continued until clinical symptom is subsided with normal laboratory data. In cases with severe acute pancreatitis (SAP) referral should be considered to medical centers experienced in the treatment of SAP, and intensive care is recommended for preventing both organ failures and infectious complications. Hemodynamic stabilization with vigorous fluid resuscitation, respiratory support and antibiotics are the major parts of intensive care in the early period of SAP. Continuous hemodiafiltration (CHDF) and continuous regional arterial infusion (CRAI) of protease inhibitor and/or antibiotics may be effective to improve pathophysiology of AP especially in the early stage of the disease. In the late stage of AP, infectious complications are critical. If an infectious complication is suspected based on clinical signs, blood test and imaging, a fine needle aspiration (FNA) is recommended to establish a diagnosis. The accuracy of FNA is reported to be 89 ~ 100%. For patients with sterile pancreatitis, non-surgical treatment should be indicated. For patients with infected pancreatic necrosis, therapeutic intervention either by percutaneous, endoscopic, laparoscopic or surgical approach are indicated. The most preferred surgical intervention is necrosectomy, however, non-surgical treatment with antibiotics is still the treatment of choice if the general condition is stable. Necrosectomy should be performed as late as possible. For patients with pancreatic abscess, drainage is recommended.
42 citations
TL;DR: The treatment for bile duct stones with the use of ERCP/ES alone is not recommended in cases of gallstone-induced acute pancreatitis with gallbladder stones.
Abstract: In the care of acute pancreatitis, a prompt search for the etiologic condition of the disease should be conducted. A differentiation of gallstone-induced acute pancreatitis should be given top priority in its etiologic diagnosis because it is related to the decision of treatment policy. Examinations necessary for diagnosing gallstone-induced acute pancreatitis include blood tests and ultrasonography. Early ERCP/ES should be performed in patients with gallstone-induced acute pancreatitis if a complication of cholangitis and a prolonged passage disorder of the biliary tract are suspected. The treatment for bile duct stones with the use of ERCP/ES alone is not recommended in cases of gallstone-induced pancreatitis with gallbladder stones. Cholecystectomy for gallstone-induced acute pancreatitis should be performed using a laparoscopic procedure as the first option as soon as the disease has subsided.
34 citations
TL;DR: Changes were observed in performance of clinical practices before and after publication of the Japanese Guidelines for the Management of Acute Pancreatitis in accordance with recommendations of the Guidelines.
Abstract: The Japanese Guidelines for the Management of Acute Pancreatitis was published in 2003. However, the impact of the guidelines on physicians’ practice patterns has not been well known. To examine the current clinical practices in the management of acute pancreatitis, we conducted a questionnaire survey with members of three societies involved in the treatment of pancreatic diseases and abdominal emergency medical care. Questions included diagnostic and treatment processes considered important in the management of acute pancreatitis in addition to demographic data, experience in medical care, and areas of specialty of respondents. We also examined changes in the treatment of acute pancreatitis before and after publication of the Guidelines. Of 1,000 society members to whom questionnaires were mailed, 590 responded. Respondents who had read the Guidelines also handled significantly more cases in the most recent 3 years. A variety of changes were observed in the performance of clinical practices before and after publication of the Guidelines. The use of amylase in the assessment of severity decreased significantly, while its use for determination of severity scores increased significantly after publication of the Guidelines. In treatment, use of a nasogastric tube in mild and moderate cases deceased after the Guidelines. The frequency of prophylactic use of antibiotics decreased with mild pancreatitis after publication of the Guidelines. Although it is difficult to attribute these changes to the direct influence of the Guidelines, several changes were observed in performance of clinical practices in accordance with recommendations of the Guidelines.
32 citations
TL;DR: Patients with advanced GBC are expected to survive long if only 1 of hepatic invasion, hepatoduodenal ligament invasion, or lymph node metastasis is positive, andMultivariate analysis revealed that F classification was the most important independent risk factor to predict survival.
27 citations
TL;DR: Attention should be paid to inadvertent injury of hepatic artery to prevent hepatic infarctions after pancreato-biliary surgery.
26 citations
TL;DR: In the present revised edition of the JPN guidelines, post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis is treated as an independent item and clinical indicators are presented to improve the quality of the management of acute pancreatitis and to increase adherence to new guidelines.
Abstract: Considering that the Japanese (JPN) guidelines for the management of acute pancreatitis were published in Takada et al. (J HepatoBiliary Pancreat Surg 13:2–6, 2006), doubts will be cast as to the reason for publishing a revised edition of the Guidelines for the management of acute pancreatitis: the JPN guidelines 2010, at this time. The rationale for this is that new criteria for the severity assessment of acute pancreatitis were made public on the basis of a summary of activities and reports of shared studies that were conducted in 2008. The new severity classification is entirely different from that adopted in the 2006 guidelines. A drastic revision was made in the new criteria. For example, about half of the cases that have been assessed previously as being ‘severe’ are assessed as being ‘mild’ in the new criteria. The JPN guidelines 2010 are published so that consistency between the criteria for severity assessment in the first edition and the new criteria will be maintained. In the new criteria, severity assessment can be made only by calculating the 9 scored prognostic factors. Severity assessment according to the contrast-enhanced computed tomography (CT) grade was made by scoring the poorly visualized pancreatic area in addition to determining the degree of extrapancreatic progress of inflammation and its extent. Changes made in accordance with the new criteria are seen in various parts of the guidelines. In the present revised edition, post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis is treated as an independent item. Furthermore, clinical indicators (pancreatitis bundles) are presented to improve the quality of the management of acute pancreatitis and to increase adherence to new guidelines.
TL;DR: The medical insurance system of Japan is based on the Universal Medical Care System guaranteed by the provision of the Article 25 of the Constitution of Japan, which states that “All the people shall have the right to live a healthy, cultural and minimum standard of life.”
Abstract: The medical insurance system of Japan is based on the Universal Medical Care System guaranteed by the provision of the Article 25 of the Constitution of Japan, which states that “All the people shall have the right to live a healthy, cultural and minimum standard of life.” The health insurance system of Japan comprises the medical insurance system and the health care system for the long-lived. Medical care insurance includes the employees’ health insurance (Social Insurance) that covers employees of private companies and their families and community insurance (National Health Insurance) that covers the self-employed. Each medical insurance system has its own medical care system for the retired and their families. The health care system for the long-lived covers people of over 75 years of age (over 65 years in people with a certain handicap). There is also a system under which all or part of the medical expenses is reimbursed by public expenditure or the cost of medical care not covered by health insurance is paid by the government. This system is referred to collectively as the “the public payment system of medical expenses.” To support the realization of the purpose of this system, there is a treatment research enterprise for specified diseases (intractable diseases). Because of the high mortality rate, acute pancreatitis is specified as an intractable disease for the purpose of reducing its mortality rate, and treatment expenses of patients are paid in full by the government dating back to the day when the application was made for a certificate verifying that he or she has severe acute pancreatitis.
TL;DR: A case of arterio-biliary fistula after CRT for unresectable ICC demonstrated by angiographic examinations and successfully treated by endovascular embolization is reported.
Abstract: Significant hemobilia due to arterio-biliary fistula is a very rare complication of chemoradiation therapy (CRT) for unresectable intrahepatic cholangiocarcinoma (ICC) Here we report a case of arterio-biliary fistula after CRT for unresectable ICC demonstrated by angiographic examinations This fistula was successfully treated by endovascular embolization Hemobilia is a rare complication, but arterio-biliary fistula should be considered after CRT of ICC
TL;DR: The undersigned editors of the member journals of the Surgery Journal Editors Group (SJEG), in the furtherance of integrity in surgical and scientific publication, agree to adopt the COPE guidelines.
Abstract: We the undersigned editors of the member journals of the Surgery Journal Editors Group (SJEG), in the furtherance of integrity in surgical and scientific publication, agree to adopt the guidelines established by the Committee on Publication Ethics (COPE) [1]. The COPE guidelines represent a means of addressing a variety of ethical concerns, including duplicate publication and authorship misconduct issues, which have, unfortunately, become more prevalent. This statement is being simultaneously published in the respective journals of the members of the Surgery Journal Editors Group, as follows:
01 Jan 2010
TL;DR: Kanehara et al. as discussed by the authors published a revised edition of the Guidelines for the management of acute pan-creatitis: the JPN guidelines 2010, at this time, and the rationale for this is that new criteria for the severity assessment of acute pancreatitis were made public on the basis of a sum-mary of activities and reports of shared studies that wereconducted in 2008.
Abstract: Considering that the Japanese (JPN) guidelinesfor the management of acute pancreatitis were published inTakada et al. (J HepatoBiliary Pancreat Surg 13:2–6, 2006),doubts will be cast as to the reason for publishing a revisededition of the Guidelines for the management of acute pan-creatitis: the JPN guidelines 2010, at this time. The rationalefor this is that new criteria for the severity assessment ofacute pancreatitis were made public on the basis of a sum-mary of activities and reports of shared studies that wereconductedin2008.Thenewseverityclassificationisentirelydifferent from that adopted in the 2006 guidelines. A drasticrevision was made in the new criteria. For example, abouthalf of the cases that have been assessed previously as being‘severe’ are assessed as being ‘mild’ in the new criteria. TheJPN guidelines 2010 are published so that consistency This article is based on the studies first reported in the JPN guidelinesfor the management of acute pancreatitis. 3rd ed. JPN Guidelines2010 (in Japanese). Tokyo: Kanehara; 2009.T. Takada (
TL;DR: A 41-year-old woman was referred to the authors' hospital for evaluation of an abdominal tumor suspected to be a mucinous cystic adenocarcinoma and performed en bloc distal pancreatectomy and splenectomy.
Abstract: pected to be a mucinous cystic adenocarcinoma. We performed en bloc distal pancreatectomy and splenectomy. The macroscopic appearance was consistent with mucinous cystic neoplasm ( fig. 3 ). Microscopy showed epithelium composed of mucin-secreting cells and a dense cellular ovarian-type stroma ( fig. 4 ). Adenocarcinoma was A 41-year-old woman was referred to our hospital for evaluation of an abdominal tumor. Contrast-enhanced CT and MRI showed a cystic tumor, 21 cm in diameter, with internal septa localized in the tail of the pancreas ( fig. 1 ). FDG-PET revealed significantly increased uptake in the solid component ( fig. 2 ). Thus, this tumor was susPublished online: November 10, 2010
01 Jan 2010
TL;DR: Kanehara et al. as mentioned in this paper presented guidelines for the diagnostic criteria of post-ERCP pancreatitis, and its incidence, risk factors, and prophylactic procedures that are supported by evi- dence.
Abstract: Pancreatitis remains the most common severe complication of endoscopic retrograde cholangiopancrea- tography (ERCP). Detailed information about the findings of previous studies concerning post-ERCP pancreatitis has not been utilized sufficiently. The purpose of the present article was to present guidelines for the diagnostic criteria of post-ERCP pancreatitis, and its incidence, risk factors, and prophylactic procedures that are supported by evi- dence. To achieve this purpose, a critical examination was made of the articles on post-ERCP pancreatitis, based on the data obtained by research studies published up to 2009. At present, there are no standardized diagnostic criteria for post-ERCP pancreatitis. It is appropriate that post-ERCP pancreatitis is defined as acute pancreatitis that has This article is based on the studies first reported in the JPN guidelines for the management of acute pancreatitis. 3rd ed. JPN Guidelines 2010 (in Japanese). Tokyo: Kanehara; 2009.