ハンカイ シンケイ ドウテイ ニ NIMシステム オ モチイタ Zenkerケイシツ ノ 1レイ

　Zenker憩室はKillian’s間隙に発生した憩室であり，全消化管憩室の0.1%の頻度と稀である．今回われわれは，術中神経モニタリングシステムであるNIMシステム(NERVE INTEGRITY MONITORING SYSTEM；以下，NIMと略記)をZenker憩室の手術で使用し，反回神経を容易に同定することが可能であったので報告する．　症例は67歳，女性．数年前から咽頭部の違和感を自覚し，２カ月前から増悪したため当院外来を受診した．精査の結果，症状を認めるZenker憩室と診断し，手術を施行した．NIMを使用して反回神経の走行を確認しつつ憩室を同定した．憩室を切除後，二層縫合(Albert-Lembert吻合)して閉鎖した．術中内視鏡検査を施行し，食道に狭窄や漏れがないことを確認した．輪状咽頭筋切開を追加し，甲状腺を縫合部の前面で固定して縫合部を補強した．ドレーンを留置して手術を終了した．術後経過は良好で手術から14日目に退院とし，退院後１ヶ月の時点で症状は改善していることを確認した．　Zenker憩室の手術で反回神経損傷は回避すべき合併症のひとつである．甲状腺手術で使用するNIMはZenker憩室の手術においても反回神経の同定に使用することで，神経損傷のリスクを下げる可能性がある．　Zenker’s diverticulum is a diverticulum that develops in the Killian’s gap. The frequency of its occurrence is 0.1% of all digestive tract diverticulum. The present study reports that the NIM system can be useful during Zenker’s diverticulum surgery for easily identifying recurrent laryngeal nerve.　The present case is of a 67-year-old woman. She was aware of discomfort in her pharyngeal region for several years. She had been aggrieved for the past 2 months, and therefore was admitted to our hospital’s outpatient clinic. Following examination, we diagnosed Zenker’s diverticulum and performed surgery. We identified recurrent laryngeal nerve using NIM. We dissected the diverticulum and sutured in layers and closed. Intraoperative endoscopy was performed to confirm that there was no stenosis or leakage in the esophagus. We performed ring pharyngeal muscle incision. We fixed the thyroid gland in front of the suture to reinforce it. There was no untoward event postoperatively, and the patient was discharged from the hospital on day 14 after the surgery. We confirmed that the symptom had improved at 1 month after discharge.　NIM used in thyroid surgery is also useful in identifying the recurrent laryngeal nerve during Zenker’s diverticula surgery and may help reduce the risk of nerve damage

Association of Matrix Metalloproteinase-2 mRNA Expression with Subtypes of Pediatric Cholesteatoma

Objective. Cholesteatoma is a clinically heterogeneous disease, with some patients showing spontaneous regression, while others experiencing an aggressive, lethal disease. Cholesteatoma in children can be divided into two types: congenital and acquired. Identifying good prognostic markers is needed to help select patients who will require immediate surgical intervention. Matrix metalloproteinase-2 (MMP2) was previously reported to play an important role in cholesteatoma progression, by promoting bone destruction and keratinocyte infiltration. Herein, we analyzed MMP2 mRNA expression level in cholesteatoma using RNA-in situ hybridization in formalin-fixed, paraffin-embedded (FFPE) tissue samples. Methods. Sixty patients with cholesteatoma under 15 years old, who underwent their primary surgery at Aichi Medical University’s Otolaryngology Department, were analyzed for MMP2 expression level, using RNA-in situ hybridization. Results. There were no significant differences in MMP2 mRNA expression level between congenital cholesteatoma and acquired cholesteatomas. In congenital cholesteatoma, higher MMP2 signals were observed in the open type than in the closed type (p<0.001). In acquired cholesteatoma, higher MMP2 signals were observed in the pars tensa than in the pars flaccida (p<0.001). MMP2 mRNA expression level was almost exclusively found in the fibroblasts or in the inflammatory cells in the stroma, but not in the epithelium. Conclusion. Our study reveals that MMP2 mRNA expression level is strongly associated with the subtypes of cholesteatoma. The findings suggest that the level of expression of MMP2 mRNA may be related to the pathogenesis and aggressive features of cholesteatoma

反回神経同定にNIMシステムを用いたZenker憩室の１切除例

　Zenker憩室はKillian’s間隙に発生した憩室であり，全消化管憩室の0.1%の頻度と稀である．今回われわれは，術中神経モニタリングシステムであるNIMシステム(NERVE INTEGRITY MONITORING SYSTEM；以下，NIMと略記)をZenker憩室の手術で使用し，反回神経を容易に同定することが可能であったので報告する．　症例は67歳，女性．数年前から咽頭部の違和感を自覚し，２カ月前から増悪したため当院外来を受診した．精査の結果，症状を認めるZenker憩室と診断し，手術を施行した．NIMを使用して反回神経の走行を確認しつつ憩室を同定した．憩室を切除後，二層縫合(Albert-Lembert吻合)して閉鎖した．術中内視鏡検査を施行し，食道に狭窄や漏れがないことを確認した．輪状咽頭筋切開を追加し，甲状腺を縫合部の前面で固定して縫合部を補強した．ドレーンを留置して手術を終了した．術後経過は良好で手術から14日目に退院とし，退院後１ヶ月の時点で症状は改善していることを確認した．　Zenker憩室の手術で反回神経損傷は回避すべき合併症のひとつである．甲状腺手術で使用するNIMはZenker憩室の手術においても反回神経の同定に使用することで，神経損傷のリスクを下げる可能性がある．　Zenker’s diverticulum is a diverticulum that develops in the Killian’s gap. The frequency of its occurrence is 0.1% of all digestive tract diverticulum. The present study reports that the NIM system can be useful during Zenker’s diverticulum surgery for easily identifying recurrent laryngeal nerve.　The present case is of a 67-year-old woman. She was aware of discomfort in her pharyngeal region for several years. She had been aggrieved for the past 2 months, and therefore was admitted to our hospital’s outpatient clinic. Following examination, we diagnosed Zenker’s diverticulum and performed surgery. We identified recurrent laryngeal nerve using NIM. We dissected the diverticulum and sutured in layers and closed. Intraoperative endoscopy was performed to confirm that there was no stenosis or leakage in the esophagus. We performed ring pharyngeal muscle incision. We fixed the thyroid gland in front of the suture to reinforce it. There was no untoward event postoperatively, and the patient was discharged from the hospital on day 14 after the surgery. We confirmed that the symptom had improved at 1 month after discharge.　NIM used in thyroid surgery is also useful in identifying the recurrent laryngeal nerve during Zenker’s diverticula surgery and may help reduce the risk of nerve damage

Long-term safety and efficacy of alogliptin, a DPP-4 inhibitor, in patients with type 2 diabetes: a 3-year prospective, controlled, observational study (J-BRAND Registry)

Introduction Given an increasing use of dipeptidyl peptidase-4 (DPP-4) inhibitors to treat patients with type 2 diabetes mellitus in the real-world setting, we conducted a prospective observational study (Japan-based Clinical Research Network for Diabetes Registry: J-BRAND Registry) to elucidate the safety and efficacy profile of long-term usage of alogliptin.Research design and methods We registered 5969 patients from April 2012 through September 2014, who started receiving alogliptin (group A) or other classes of oral hypoglycemic agents (OHAs; group B), and were followed for 3 years at 239 sites nationwide. Safety was the primary outcome. Symptomatic hypoglycemia, pancreatitis, skin disorders of non-extrinsic origin, severe infections, and cancer were collected as major adverse events (AEs). Efficacy assessment was the secondary outcome and included changes in hemoglobin A1c (HbA1c), fasting blood glucose, fasting insulin and urinary albumin.Results Of the registered, 5150 (group A: 3395 and group B: 1755) and 5096 (3358 and 1738) were included for safety and efficacy analysis, respectively. Group A patients mostly (&gt;90%) continued to use alogliptin. In group B, biguanides were the primary agents, while DPP-4 inhibitors were added in up to ~36% of patients. The overall incidence of AEs was similar between the two groups (42.7% vs 42.2%). Kaplan-Meier analysis revealed the incidence of cancer was significantly higher in group A than in group B (7.4% vs 4.8%, p=0.040), while no significant incidence difference was observed in the individual cancer. Multivariate Cox regression analysis revealed that the imbalanced patient distribution (more elderly patients in group A than in group B), but not alogliptin usage per se, contributed to cancer development. The incidence of other major AE categories was with no between-group difference. Between-group difference was not detected, either, in the incidence of microvascular and macrovascular complications. HbA1c and fasting glucose decreased significantly at the 0.5-year visit and nearly plateaued thereafter in both groups.Conclusions Alogliptin as a representative of DPP-4 inhibitors was safe and durably efficacious when used alone or with other OHAs for patients with type 2 diabetes in the real world setting