Tokyo Guidelines 2018: initial management of acute biliary infection and flowchart for acute cholangitis

The initial management of patients with suspected acute biliary infection starts with the measurement of vital signs to assess whether or not the situation is urgent. If the case is judged to be urgent, initial medical treatment should be started immediately including respiratory/circulatory management if required, without waiting for a definitive diagnosis. The patient's medical history is then taken; an abdominal examination is performed; blood tests, urinalysis, and diagnostic imaging are carried out; and a diagnosis is made using the diagnostic criteria for cholangitis/cholecystitis. Once the diagnosis has been confirmed, initial medical treatment should be started immediately, severity should be assessed according to the severity grading criteria for acute cholangitis/cholecystitis, and the patient's general status should be evaluated. For mild acute cholangitis, in most cases initial treatment including antibiotics is sufficient, and most patients do not require biliary drainage. However, biliary drainage should be considered if a patient does not respond to initial treatment. For moderate acute cholangitis, early endoscopic or percutaneous transhepatic biliary drainage is indicated. If the underlying etiology requires treatment, this should be provided after the patient's general condition has improved; endoscopic sphincterotomy and subsequent choledocholithotomy may be performed together with biliary drainage. For severe acute cholangitis, appropriate respiratory/circulatory management is required. Biliary drainage should be performed as soon as possible after the patient's general condition has been improved by initial treatment and respiratory/circulatory management. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47 . Related clinical questions and references are also include

Recent trends in organ‐preserving pancreatectomy: Its problems and clinical advantages compared with other standard pancreatectomies

Abstract In this review article, we focus on recent papers on organ‐preserving pancreatectomy procedures published since 2010. When comparing central pancreatectomy (CP) and distal pancreatectomy (DP), most studies have concluded that the CP group exhibited significantly lower incidence of new‐onset diabetes or diabetes exacerbation than the DP group postoperatively. However, because of increased incidence of morbidities such as pancreatic fistula, the surgeon faces a considerable trade‐off between increased short‐term morbidity and long‐term preservation of endocrine function. When the outcomes of two types of spleen‐preserving DP (Kimura and Warshaw procedures) are compared, most studies mentioned the low incidence of postoperative gastric varices and splenic infarction with the Kimura procedure. Although there are several reports regarding the effect of spleen preservation on prevention of postoperative infections, no report on the contribution of spleen preservation to the prevention of overwhelming post‐splenectomy infection is seen. The advantages of duodenum‐preserving pancreatic head resection (DPPHR) concerning endocrine and exocrine functions continue to be subjects of discussion, mainly due to the limited number of institutions that have adopted this approach; however, DPPHR should be presented as an option for patients due to its low incidence of postoperative cholangitis. Organ‐preserving pancreatectomy requires meticulous surgical techniques, and postoperative complications may increase with this surgery compared with standard pancreatectomy, which may be influenced by the surgeon's skill and the surgical facility where the procedure is performed. Nonetheless, this technique has significant long‐term advantages in terms of endocrine and exocrine functions and its wider adoption in the future is expected

Functional Design of Mitigation Measures: From Design Event Definition to Targeted Process Modifications

International audienceStructural and non-structural measures might be implemented to protect elements at risk against debris-flow hazards. However, despite centuries of forestry and empirical soil conservation works, as well as decades of research on debris-flow processes, defining protection strategies against debris flows remains complicated. How to select and tailor protection measures is still a very active research topic. This chapter covers recent advances regarding the design and maintenance of structural mitigation measures. In essence, we provide a framework and elements to help define mitigation strategies. We briefly describe how design events can be selected in view of the mitigation of adverse consequences and risk (see Strouth et al., this volume). We also discuss the importance of accounting for routine events and rare events stronger than the design events to increase the robustness of the system against operational failure (e.g., excessive maintenance costs and environmental side effects), sudden failure or unexpected behaviour during overloading. The second part explains how functional analysis of the current debris-flow channel must be conducted to understand the initiation of channel malfunctioning and the associated cascading processes leading to widespread debris-flow hazards. This step enables one to identify the adaptations required to mitigate them with minimal actions. The main part of the chapter is then a review of the various types of structural measures than can be implemented, explaining in detail their main function, and how they can be used to cope with specific, targeted malfunctions. This framework and catalogue will help users select the type, location and main features of the measures to implement

Quality control for clinical islet transplantation: organ procurement and preservation, the islet processing facility, isolation, and potency tests

Pancreatic islet transplantation has become one of the ideal treatments for patients with type 1 diabetes mellitus due to improvements in isolation techniques and immunosuppression regimens. In order to ensure the safety and rights of patients, isolated islets need to meet the criteria for regulation as both a biological product and a drug product. For the constant success of transplantation, therefore, all investigators involved in clinical islet transplantation must strive to ensure the safety, purity, and potency of islets in all the phases of clinical islet isolation and transplantation. In this review, we summarize the quality control for clinical islet isolation and transplantation, and the latest topics of pre-transplant islet assessment

Transclival clipping for giant vertebral artery aneurysm: A case report

Background: Endovascular treatment often achieves complete obliteration of VA giant aneurysm; however, retreatmentmay be required because of late recanalization. We report a case of giant VA aneurysm that showedregrowth after endovascular treatment and was treated with VA clipping using the endoscopic endonasaltransclival approach.Case description: A 47-year-old man with chief complaint of ataxia underwent endovascular treatment of giantVA aneurysm. One year later, he needed additional treatment to regrowth of the aneurysm. We were not able toaccomplish aneurysmectomy via the transcondylar fossa approach because of difficulty in achieving hemostasisand ended with partial thrombectomy. Digital subtraction angiography (DSA) performed after 4 months revealedcoil compaction and distal flow due to recanalization. Right VA elongation and position of anterior spinal artery(ASA), these factors made possible for us to perform transclival approach to VA. Despite the limited indicationsfor its use, endonasal endoscopic transclival clipping may be effective in limited anatomical cases.Conclusion: We report the use of endonasal endoscopic transclival clipping for giant VA aneurysm. This endonasalendoscopic treatment may be an optional alternative in only limited cases depending upon the anatomicallocation of the lesion because of limitations of vascular control and the inability to visualize the field in thepresence of major bleeding. For treatment of progressive giant VA aneurysm, it is very important to avoidoptimistic strategy for giant VA aneurysm initially