A 62-year-old man with ischemic heart disease suffered from a poststernotomy wound trouble after coronary artery bypass grafting. We performed vacuum-assisted closure (VAC), minimally invasive treatment for difficult wounds, because he had severe heart failure and depressive disorder. This therapy assists in wound healing by applying localized negative pressure to the surface of the wound, and its effectiveness for poststernotomy mediastinitis has already been reported in several countries. It is, however, very difficult for us to obtain a manufactured device, the V. A. C.® system (KCI, San Antonio, Texas), which is not available in Japan yet. Therefore, we had to make a self-made system which combined RetractorPad® polyvinyl alcohol hydrofoam (Mondomed NV, Harmont, Belgium) and J-VAC® closed wound drainage system (Johnson & Johnson, Tokyo, Japan). This self-made system, without a vacuum pump machine, was small and light enough to be carried by the patient even in the early postoperative period. In this case, VAC resulted in complete healing of the wound in about 3 weeks with little pain, stress, effort and time, and with reasonable cost in comparison to conventional treatment. This is a useful and hopeful option in the treatment of not only sternum dehiscence but also mediastinitis after cardiac surgery, especially for high-risk patients.

Causative factors for thrombi formation in left atria of 38 patients with mitral stenosis who underwent mitral valve surgery (open mitral commissurotomy or mitral valve replacement) alone or in combination with other procedures were studied. There were 9 cases of left atrial thrombosis (LAT). Left atrial diameter was increased in LAT(+) group (6.1±1.6cm) compared with LAT(-) group (4.6±0.7cm). There was significant difference in the left atrial diameter between the two groups of patients (p<0.01). Cardiac output was decreased in LAT(+) group (3.04±0.74l/min) compared with LAT(-) group (3.99±1.07l/min). Cardiac output of LAT (-) group was significantly larger than that of LAT(+) group (p<0.05). Mean transition time of blood through left atrium (MTT_LA) was calculated using left atrial volume and cardiac output. In LAT (+) group, MTT_LA was significantly increased (6.2±3.9sec) compared with LAT(-) group (2.9±1.6sec). It is considered that, in mitral stenosis, prolongation of MTT_LA is one of the risk factors for thrombi formation in the left atrium.

The Japanese Society of Hepato-Biliary-Pancreatic Surgery launched the clinical practice guidelines for the management of biliary tract cancers (cholangiocarcinoma, gallbladder cancer, and ampullary cancer) in 2007, then published the 2nd version in 2014. In this 3rd version, clinical questions (CQs) were proposed on six topics. The recommendation, grade for recommendation, and statement for each CQ were discussed and finalized by an evidence-based approach. Recommendations were graded as grade 1 (strong) or grade 2 (weak) according to the concepts of the grading of recommendations assessment, development, and evaluation system. The 31 CQs covered the six topics: (1) prophylactic treatment, (2) diagnosis, (3) biliary drainage, (4) surgical treatment, (5) chemotherapy, and (6) radiation therapy. In the 31 CQs, 14 recommendations were rated strong and 14 recommendations weak. The remaining three CQs had no recommendation. Each CQ includes a statement of how the recommendations were graded. This latest guideline provides recommendations for important clinical aspects based on evidence. Future collaboration with the cancer registry will be key for assessing the guidelines and establishing new evidence.