DSpace at Tokyo Dental College

加藤, 芳実

山下, 秀一郎

パーシャルデンチャー補綴学

Correction of the occlusal vertical dimension and occlusal plane using removable dentures : A case report

Satou, R

Yamagishi, A

Takayanagi, A

Iwasaki, M

Kamijo, H

Sugihara, N

衛生学

歯科社会保障学

Improved Enamel Acid Resistance by Highly Concentrated Acidulated Phosphate Sodium Monofluorophosphate Solution

Nakamura, K

Tsubata, S

Arahata, K

Asahara, F

Takarabe, S

Kishikawa, H

Nishida, J

市病消化器内科

外科学

Posted at the Institutional Resources for Unique Collection and Academic Archives at Tokyo Dental College,
Available from http://ir.tdc.ac.jp/
Title
Self-expandable metal stent placement for malignant
obstruction of the proximal colon using single-
balloon enteroscopy
Author(s)
Nakamura, K; Tsubata, S; Arahata, K; Asahara, F;
Takarabe, S; Kishikawa, H; Nishida, J
Journal Endoscopy, 55(S 01): E496-E498
URL http://hdl.handle.net/10130/6318
Right
This is an open access article published by Thieme
under the terms of the Creative Commons
Attribution-NonDerivative- NonCommercial License,
permitting copying and reproduction so long as the
original work is given appropriate credit. Contents
may not be used for commercial purposes, or
adapted, remixed, transformed or built upon.
(https://creativecommons.org/licenses/by-nc-
nd/4.0/)
Description
Self-expandable metal stent placement for malignant obstruction
of the proximal colon using single-balloon enteroscopy
Self-expandable metal stents (SEMSs) are
widely used around the world for malig-
nant colonic and extracolonic obstruc-
tion; however, malignant obstruction in
the proximal colon, and complicated
and long-segment stenoses are difficult
cases [1, 2]. Several articles have report-
ed SEMS placement in the proximal colon
using a balloon enteroscopy overtube
and the over-the-[guide]wire technique
under fluoroscopic guidance, and with-
out endoscopic guidance [3, 4]. The out-
er sheaths of SEMSs have become thin-
ner, reducing from 10Fr to 9 Fr, and the
short-type single-balloon enteroscope
with a 3.2-mm working channel is now
available for SEMS placement using a
combination of the through-the-scope
and over-the-wire techniques.
An 88-year-old man presented with ab-
dominal fullness and postprandial vomit-
ing. Contrast-enhanced computed to-
mography (CECT) showed wall thickening
in the ascending colon and dilatation
from the lesion to the small bowel
(▶Fig. 1). The patient was diagnosed
with cancer of the ascending colon, with
tumor thrombosis in the superior mesen-
teric vein. SEMS placement with a stand-
ard colonoscope was attempted, but was
unsuccessful. Transnasal ileus tube place-
ment was performed for decompression
of the small- and large-bowel (▶Fig. 2).
Repeat CECT showed decompression of
the small- and large-bowel, along with an
extremely complicated ascending colonic
route (▶Fig. 3).
The patient was unfit for surgery because
of his age, frailty, and progressive disease
status. Therefore, a SEMS was placed for
palliation using short-type single-balloon
enteroscopy (SBE; SIF-H290S; Olympus
Corp., Japan) (▶Video 1). The short-type
single-balloon enteroscope reached the
lesion with the use of the overtube. Al-
though it was difficult to obtain a stable
endoscopic position with a view from the
front because of the extremely com-
▶ Fig. 1 Contrast-enhanced computed tomography images showing the dilated small bowel
and ascending colon, along with wall thickening of the ascending colon (red arrowheads) and
tumor thrombosis in the superior mesenteric vein on: a axial view; b coronal view.
▶ Fig. 2 Fluoroscopic view with contrast
media showing the stenosis of the as-
cending colon (red arrowheads) and com-
plicated ascending colon route on the anal
side of the lesion (yellow arrowheads).
Video 1 Successful self-expandable metal stent placement for malignant obstruction of
the proximal colon using single-balloon enteroscopy.
E-Videos
E496 Nakamura Kenji et al. Self-expandable metal stent… Endoscopy 2023; 55: E496–E498 | © 2023. The Author(s).
Article published online: 2023-03-09
plicated colonic route (▶Fig. 4), a guide-
wire was successfully passed through the
stenosis. A SEMS (Hanarostent Naturfit;
Boston Scientific, USA), with a diameter
of 22mm and length of 12 cm, was placed
across the 6-cm stenosis using the
through-the-scope and over-the-wire
techniques (▶Fig. 5).
Colonic stent placement using short-
type SBE may be a useful treatment
option for malignant obstruction of the
proximal colon with a complicated
colonic route.
Endoscopy_UCTN_Code_TTT_1AQ_2AF
Competing interests
The authors declare that they have no con-
flict of interest.
▶ Fig. 3 Contrast-enhanced computed tomography images after ileal tube placement showing wall thickening of the ascending colon (red ar-
rowheads), decompression of the small bowel and ascending colon (green arrowheads), and the complex route of the anal side of the colon from
the lesion in the ascending colon (yellow arrowheads).
Cranial side
Foot side
a b
Left sideRight 
side
Dorsal 
side
Ventral 
side
▶ Fig. 4 Schema of the colon showing: a frontal view; b right anterior oblique view of the
complex route of the colon on the anal side of the lesion from the ventral caudal side to the
right dorsal and cranial side, then dorsal to the ventral midline side at the hepatic flexure.
Nakamura Kenji et al. Self-expandable metal stent… Endoscopy 2023; 55: E496–E498 | © 2023. The Author(s). E497
The authors
Kenji Nakamura1 , Shiori Tsubata1, Kyoko
Arahata1, Fumitaka Asahara2, Sakiko
Takarabe1, Hiroshi Kishikawa1, Jiro Nishida1
1 Department of Gastroenterology, Tokyo
Dental College, Ichikawa General Hospital,
Chiba, Japan
2 Department of Surgery, Tokyo Dental
College, Ichikawa General Hospital, Chiba,
Japan
Corresponding author
Kenji Nakamura, MD, PhD
Department of Gastroenterology, Tokyo
Dental College, Ichikawa General Hospital,
5-11-13, Sugano, Ichikawa, 272-8513,
Chiba, Japan
kenakamura@tdc.ac.jp
References
[1] van Hooft JE, Veld JV, Arnold D et al. Self-
expandable metal stents for obstructive
colonic and extracolonic cancer: European
Society of Gastrointestinal Endoscopy
(ESGE) Guideline – Update 2020. Endoscopy
2020; 52: 389–407
[2] Kuwai T, Yamaguchi T, Imagawa H et al.
Factor related to difficult self-expandable
metallic stent placement for malignant
colonic obstruction: A post-hoc analysis
of a multicenter study across Japan. Dig
Endosc 2019; 31: 51–58
[3] Fähndrich M, Sandmann M, Heike M. A new
method for placement of covered colorectal
stents in the proximal colon using double
balloon enteroscopy. Endoscopy 2011; 43:
E23
[4] Kobayashi Y, Komazawa Y, Kusunoki M et al.
Novel stenting method for malignant right
colonic stenosis using ultra-thin endoscopy:
Report of four cases. Dig Endosc 2015; 27:
704–707
Bibliography
Endoscopy 2023; 55: E496–E498
DOI 10.1055/a-2026-1118
ISSN 0013-726X
© 2023. The Author(s).
This is an open access article published by Thieme under the
terms of the Creative Commons Attribution-NonDerivative-
NonCommercial License, permitting copying and reproduc-
tion so long as the original work is given appropriate credit.
Contents may not be used for commercial purposes, or
adapted, remixed, transformed or built upon. (https://
creativecommons.org/licenses/by-nc-nd/4.0/)
Georg Thieme Verlag KG, Rüdigerstraße 14,
70469 Stuttgart, Germany
ENDOSCOPY E-VIDEOS
https://eref.thieme.de/e-videos
Endoscopy E-Videos is an
open access online section,
reporting on interesting cases
and new techniques in gastroenterological
endoscopy. All papers include a high
quality video and all contributions are
freely accessible online. Processing charges
apply, discounts and wavers acc. to HINARI
are available.
This section has its own submission
website at
https://mc.manuscriptcentral.com/e-videos
▶ Fig. 5 Images during the balloon enteroscopy procedure showing: a an endoscopic view
of the colonic ulceration that was suspected to be a colonic cancer; b a fluoroscopic view,
with contrast media, of the enteroscope reaching the lesion and the stenosis (red arrow-
heads) in the ascending colon; c a fluoroscopic view of the loop-shaped sheath (black arrow)
of the self-expandable metal stent (SEMS) straddling the stenosis caused by the lesion;
d a fluoroscopic view after placement of the SEMS across the stenosis (black arrowheads).
E498 Nakamura Kenji et al. Self-expandable metal stent… Endoscopy 2023; 55: E496–E498 | © 2023. The Author(s).
E-Videos


Self-expandable metal stent placement for malignant obstruction of the proximal colon using single-balloon enteroscopy

Sato, H

Wada, H

Matsumoto, H

Takagiwa, M

Goto, TK

歯科放射線学

数学

研究ブランディング事業

Differences in dynamic perception of salty taste intensity between young and older adults

Yamamoto, M

Jin, ZW

Hayashi, S

Rodríguez-Vázquez, JF

Murakami, G

Abe, S

解剖学

Association between the developing sphenoid and adult morphology: A study using sagittal sections of the skull base from human embryos and fetuses

Ohta, M

Imamura, Y

Chebib, N

Schulte-Eickhoff, RM

Allain, S

Genton, L

Mojon, P

Graf, C

Ueda, T

Müller, F

老年歯科補綴学

Oral function and nutritional status in non-acute hospitalised elders

Nozawa, Y

Masuda, K

Katayama, T

Kobashi, Y

Ikeda, K

Suzuki, T

Fukuda, T

市病・消化器内科

市病・放射線科

Posted at the Institutional Resources for Unique Collection and Academic Archives at Tokyo Dental College,
Available from http://ir.tdc.ac.jp/
Title
Percutaneous transhepatic obliteration of a large
portosystemic shunt associated with hepatic
encephalopathy using a technique of n-butyl-2-
cyanoacrylate injection inside hydrogel-coated
coils: A case report
Author(s)
Alternative
Nozawa, Y; Masuda, K; Katayama, T; Kobashi, Y;
Ikeda, K; Suzuki, T; Fukuda, T
Journal Radiology case reports, 17(12): 4738-4741
URL http://hdl.handle.net/10130/6194
Right
©c2022 The Authors. Published by Elsevier Inc. on
behalf of University of Washington. This is an open
access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/)
Description
R a d i o l o g y  C a s e  R e p o r t s  1 7  ( 2 0 2 2 )  4 7 3 8 – 4 7 4 1  
Available online at www.sciencedirect.com 
journal homepage: www.elsevier.com/locate/radcr 
Case Report 
Percutaneous transhepatic obliteration of a large 
portosystemic shunt associated with hepatic 
encephalopathy using a technique of 
n-butyl-2-cyanoacrylate injection inside 
hydrogel-coated coils: A case report ✩ , ✩✩ 
Yosuke Nozawa, MD a , ∗, Koichi Masuda, MD a , Tadashi Katayama, MD b , Yuko Kobashi, MD, 
PhD a , Koshi Ikeda, MD, PhD a , Taiga Suzuki, MD a , Takeshi Fukuda, MD, PhD c 
a Department of Radiology, Tokyo Dental College Ichikawa General Hospital, 5-11-13 Sugano, Ichikawa-shi, 
Chiba 272-8513, Japan 
b Department of Gastroenterology, Tokyo Dental College Ichikawa General Hospital, 5-11-13 Sugano, Ichikawa-shi, 
Chiba 272-8513, Japan 
c Department of Radiology, Jikei University, Jikei University Hospital, 3-19-18 Nishishinbashi, Minato-ku, 
Tokyo 105-8471, Japan 
a r t i c l e i n f o 
Article history: 
Received 31 August 2022 
Accepted 11 September 2022 
Available online 4 October 2022 
Keywords: 
Hepatic encephalopathy 
Percutaneous transhepatic 
obliteration 
n-butyl-2-cyanoacrylate 
Hydrogel-coated coil 
a b s t r a c t 
Portosystemic shunts with cirrhosis may lead to hepatic encephalopathy (HE), which is of- 
ten pharmacotherapy-resistant. We report a case of a 66-year-old female patient diagnosed 
with alcoholic cirrhosis and uncontrolled HE. She underwent percutaneous transhepatic 
obliteration (PTO) for treatment of a large portosystemic shunt from the left and right gas- 
tric veins to the azygos vein. We embolized the target veins using hydro-coated coils and 
filled them with n-butyl-2-cyanoacrylate (NBCA), leading to firmed obstruction of the large 
portosystemic shunt without NBCA migration, thus reducing the number of coils required. 
The HE symptoms improved after PTO and could thereafter be controlled with conservative 
therapy. Our results showed that PTO using an NBCA injection inside hydrogel-coated coils 
for a large portosystemic shunt associated with HE is effective and safe. 
© 2022 The Authors. Published by Elsevier Inc. on behalf of University of Washington. 
This is an open access article under the CC BY-NC-ND license 
( http://creativecommons.org/licenses/by-nc-nd/4.0/ ) 
✩ Competing Interests: This case report did not result from any specific grant funding agencies in the public, commercial, or not-for- 
profit sectors. None of the authors have industry relationships to report. 
✩✩ Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. 
∗ Corresponding author. 
E-mail address: nozawaivr@gmail.com (Y. Nozawa). 
https://doi.org/10.1016/j.radcr.2022.09.041 
1930-0433/© 2022 The Authors. Published by Elsevier Inc. on behalf of University of Washington. This is an open access article under the 
CC BY-NC-ND license ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ) 
R a d i o l o g y  C a s e  R e p o r t s  1 7  ( 2 0 2 2 )  4 7 3 8 – 4 7 4 1  4739 
Introduction 
Hepatic encephalopathy (HE) is a severe complication of cir- 
rhosis. The prevalence of overt HE ranges between 30% and 
45% [1] . HE is defined as brain dysfunction caused by liver in- 
sufficiency and/or portal-systemic blood shunting and is clas- 
sified as following: type A, if it occurs in acute liver failure; 
type B, if there are portosystemic bypasses without intrinsic 
hepatocellular disease; and type C, the presence of cirrhosis 
and portal hypertension with portosystemic shunts [2 ,3] . 
The efficacy of balloon-occluded retrograde transvenous 
obliteration (BRTO) for treatment of portosystemic shunts in 
type C HE is well documented [4] . However, BRTO has several 
limitations in the case of absence of available drainer veins [5] . 
Herein, we report a case of a 66-year-old female patient who 
had HE due to a large portosystemic shunt from the left and 
right gastric veins to the azygos vein and underwent percuta- 
neous transhepatic obliteration (PTO) using a hydrogel-coated 
coil filled with n-butyl-2-cyanoacrylate (NBCA). 
Case report 
A 66-year-old female patient presented with alcoholic cir- 
rhosis (Child-Pugh score, 10C status) and hyperammonemia 
(maximum ammonia level up to 452 μg/dL at presentation), 
suspected to be due to a large portosystemic shunt [6] . The 
patient also had symptoms of HE that corresponded to the 
stage 3 classification of the West Haven criteria [7] , which were 
not sufficiently controlled by conventional medical treatment 
alone. Abdominal intervention for HE was requested by the 
physician. Computed tomography (CT) angiography revealed a 
large portosystemic shunt from the left and right gastric veins 
to the azygos vein. Owing to the severe tortuosity of the azygos 
vein as a drainer vein, an effective BRTO was considered to be 
very difficult. Therefore, we decided to perform a PTO via the 
anterior branch of the right portal vein instead. Esophageal 
varices were treated endoscopically. 
After local anesthesia, an 8-Fr sheath was inserted into the 
anterior branch of the right portal vein under ultrasound guid- 
ance. Pre-interventional portal venography demonstrated a 
large portosystemic shunt from the left and right gastric veins 
to the azygos vein and reflux portal vein flow due to portal hy- 
pertension ( Fig. 1 ). We intended to embolize the proximal part 
of the left and right gastric veins, including the anastomosis 
points of these veins. The maximum diameter of the target 
vein to be embolized was 16.6 mm. In this PTO procedure, de- 
tachable coils (AZUR CX35 20-mm ∼ 10-mm, Terumo, Tokyo, 
Japan and Target XXL 20-mm, Stryker, MI) were first used at 
the target vein under balloon occlusion (Selecon mp catheter 
Ⅱ 20-mm, Terumo, Tokyo, Japan), and the inside of the coils 
was filled with 1:1 or 1:2 NBCA (Histoacryl, B. Braun, Hessen, 
Germany). The NBCA adhered to the coils without non-target 
embolization ( Fig. 2 ). A total of 24 coils were used in this pro- 
cedure. Post-interventional portal venography demonstrated 
a large decrease in the portosystemic shunt and normal por- 
tal vein re-flow ( Fig. 3 ). The AZUR CX 35 series and NBCA were 
used for sheath tract embolization. 
After PTO, the symptoms of HE improved from stage 3 to 
almost normal, according to the West Haven criteria [6] . More- 
over, the ammonia level rapidly decreased before and after the 
intervention (from 148 μg/dL to 32 μg/dL). The patient was 
also diagnosed with anemia caused by hemorrhagic ascites 
without extravasation on CT angiography and hepatic failure, 
which was treated using platelets, coagulants, and diuretics. 
Finally, the symptoms of HE were well controlled with the use 
of branched-chain amino acid preparations from the central 
venous port. The patient was discharged 97 days after PTO. 
During the follow-up period, which was 157 days, the symp- 
toms of HE were also under control with conservative therapy 
alone. 
Discussion 
In various cases of HE, symptoms are controlled by conser- 
vative therapy. However, even if the state of consciousness is 
temporarily improved by conservative therapy, it is not un- 
common for shunt blood flow to increase excessively, result- 
ing in persistent hyperammonemia causing a change in men- 
tal status [1] . Therefore, in cases where it is difficult to perform 
Fig. 1 – Preinterventional portal venography demonstrating a large portosystemic shunt from the left and right gastric veins 
to the azygos vein connecting to the superior vena cava (white arrow) and reflux portal vein flow due to portal hypertension 
(white arrow head). 
4740 R a d i o l o g y  C a s e  R e p o r t s  1 7  ( 2 0 2 2 )  4 7 3 8 – 4 7 4 1  
Fig. 2 – 1:2 n-butyl-2-cyanoacrylate (NBCA) surrounded by hydrogel-coated coils gradually spreading and adhering to the 
coils, avoiding non-target embolization (white arrow). 
Fig. 3 – Postinterventional portal venography 
demonstrating a huge decrease in portosystemic shunt and 
normal portal vein re-flow. 
an effective BRTO, PTO can be considered as a secondary treat- 
ment option for managing HE. 
The findings of our study demonstrated that our new PTO 
method using an NBCA injection inside hydrogel-coated coils 
was adequate and effective for large portosystemic shunts as- 
sociated with HE. Various types of embolic agents, such as bare 
coils, ethanol, ethanolamine oleate, and NBCA, are used in 
PTO [8] . Although liquid agents such as ethanol, ethanolamine 
oleate, and NBCA have high obstruction effect, embolization 
with a liquid agent alone is not suitable for large portosys- 
temic shunts with high blood flow, given the risk of non-target 
embolization to other organs. 
Ishikawa et al. utilized a hydrogel-coated coil to enhance 
the obstructive effect in a portosystemic shunt and demon- 
strated its superiority over embolization with bare coil alone 
in PTO and BRTO cases [3] . The advantage of a hydrogel-coated 
coil is that it can expand in volume, thus enhancing its ob- 
struction effect [9 ,10] . In our case, we performed embolization 
of the target veins using hydro-coated coils under balloon oc- 
clusion and filled 1:1 or 1:2 NBCA inside the coils. This pro- 
cedure could lead to more confirmed obstruction of a large 
portosystemic shunt without NBCA migration and reduce the 
number of coils used. In addition, the hydrogel part of this coil 
may have a high affinity for NBCA. 
A previous study has also reported improvement in hep- 
atic function reserve after PTO in patients with HE and gastric 
varices with Child-Pugh scores of A, B, and C [11] . In contrast, 
hepatic failure developed in our patient leading to bleeding 
tendency and occlusion of the portosystemic shunt caused 
worsening of portal vein pressure, which resulted in hemor- 
rhagic ascites that was treated with conservative therapy for 
approximately 3 months. These results might be owing to the 
use of a relatively large 8-Fr sheath to utilize a 20-mm balloon 
catheter and the lower hepatic function reserve before PTO. 
In conclusion, PTO using NBCA injection inside hydrogel- 
coated coils for large portosystemic shunts associated with HE 
can be effective and safe and can reduce the number of coils 
used intraoperatively. 
Ethical approval 
All procedures performed in studies involving human partici- 
pants were in accordance with the ethical standards of the in- 
stitutional and/or national research committee and with the 
1964 Helsinki declaration and its later amendments or com- 
parable ethical standards. The Institutional Review Board ap- 
proval was not required for the study because it was a case 
report. 
Patient consent 
Written informed consent was obtained from the patient for 
the publication of this report and any accompanying images. 
R E F E R E N C E S  
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management of hepatic encephalopathy. Clin Liver Dis 
2021;25:393–417 [Epub 2021 March 11]. 
doi: 10.1016/j.cld.2021.01.008 .
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[2] Weissenborn K. Hepatic encephalopathy: definition, clinical 
grading and diagnostic principles. Drugs 2019;79(Suppl 
1):5–9. doi: 10.1007/s40265- 018- 1018- z .
[3] Wright G, Jalan R. Management of hepatic 
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Percutaneous transhepatic obliteration of a large portosystemic shunt associated with hepatic encephalopathy using a technique of n-butyl-2-cyanoacrylate injection inside hydrogel-coated coils: A case report

山下, 悠

中村, 貴

奥平, 貴人

溝口, 利英

東, 俊文

西井, 康

歯科矯正学

生化学

口腔科学研究センター

№２０：骨芽細胞におけるメカニカルストレス応答分子機構の解明

倉持, 仁

岩澤, 弘樹

江澤, 奈穂

山本, 圭

明石, 良彦

中島, 啓

國分, 克寿

古澤, 成博

松坂, 賢一

歯内療法学

病理学

№２：Lypopolysaccharide 存在環境下においてResolvin E１およびMaresin１がヒト歯根膜線維芽細胞に与える影響

門田, 佳子

市病・臨床薬学科

病院薬剤師の役割の深化

Tokyo Dental College

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