Objective : In Europe, carbon dioxide therapy has been used for treating cardiac disease and skin problems for a long time. Previously, we demonstrated that transcutaneous carbon dioxide (CO₂) application facilitated dioxygen (O₂) dissociation from hemoglobin (Hb) in the human body. Additionally, we proved that transcutaneous CO₂ application to the lower limbs of rats increased the expression of peroxisome proliferator-activated receptor (PPAR) gamma coactivator-1α (PGC-1α), vascular endothelial growth factor (VEGF) and silent mating type information regulation 2 homologs 1 (SIRT1). It also increased the number of mitochondria, and changed IIB fiber to IIA fiber in similar manner to the change that occurs after exercise. The transcutaneous CO₂ application caused a similar effect to that of exercise training in skeletal muscle and indicated the possibility of improved endurance strength. However, the effect of transcutaneous CO₂ application on endurance exercise and the recovery of muscle fatigue has not been studied. Methods : In this study, we investigated the performance of endurance exercise in rats with/without transcutaneous CO₂ application and analyzed the muscle fiber changes, capillary density and mitochondrial DNA number of the skeletal muscles after training, using activity wheels. Results： Training with CO₂ application resulted in a higher percentage of TA muscle transformed to IIA and/or IID than training alone, suggesting that transcutaneous CO₂ application may increase the production of ATP, mitochondria number, and capillary density. Therefore, transcutaneous CO₂ application might lead to muscle damage recovery. Conclusion : We suggest that transcutaneous CO₂ application has a therapeutic potential for recovery of damaged muscle after excessive exercise and rehabilitation.

Infectious abdominal aortic aneurysm is a relatively rare disease, and there is no consensus regarding its surgical treatment. Medical infectious control should be concerned comparison with surgical treatment if there is sepsis, however we sometimes have no other choice but emergency operation for uncontrollable cases. In many reports, cryopreserved homografts were used as in-situ alternative grafts for infectious aortic aneurysms because they had some merits such as anti-infectious effects, suitability and so on. However the number of in-situ cryopreserved homograft replacement cases are few, and the long term result is unclear. We encountered a ruptured cropreserved homograft case 7 months after urgent in-situ cryopreserved homograft replacement. We report the case and refer to the relevans literature.

A 39-year-old woman was referred for assessment of abnormality of on a CT scan with a vascular anomaly of the aortic arch. This patient was completely asymptomatic with no concomitant pathologies and no reported prior trauma. Laboratory data for syphilitic or other microbial infections were negative. The diagnosis was confirmed by angiographic computed tomographic scan with 3-dimensional reconstruction. This technique documented the presence of the aneurysm and the left subclavian artery arising from the unique form of aneurysm. Early surgery was preferred because of the young age of the patient and the morphology and the size of the aneurysm (50 mm). Surgery was performed by a left postero-lateral thoracotomy through the forth intercostal space. Femoro-femoral partial cardiopulmonary bypass was used for distal perfusion. An aortic clamp was placed just distal to the left carotid artery, and a second clamp was placed in the descending thoracic aorta. The aortic isthmus was replaced with a 20-mm Dacron graft, and the left subclavian artery was reimplanted to the prosthesis with an 8-mm Dacron graft interposition. This aneurysm was the result of abnormal organogenesis of a primitive aortic arch and the remnant of the dorsal aorta, in other words, Kommerell's diverticulum. Microscopic examination demonstrated severe medial layer atrophy. In the light of the high risk of rupture, which was proved to be present by the very thin aneurysm wall at the time of surgery, we suggest early surgical treatment of idiopathic isthmus aneurysms in young patients regardless of aneurysm diameter.

We encountered three cases of infra-renal infected abdominal aortic aneurysm in 2007 and 2008. Preoperative blood culture was positive in two of the three patients. All of the patients presented with fever of unknown origin. We replaced the affected segment of the abdominal aorta with a synthetic graft in 1 patient, and with a cryopreserved arterial homograft in the remaining 2 patients. An infected abdominal aortic aneurysm is a life-threatening condition. Diagnosis is often difficult, and emergency surgery may be necessitated by rupture of the aneurysm. Our experience suggests that computed tomography is effective for the diagnosis of infected aneurysms. The most effective surgical technique consists of complete resection of the aneurysm, in-situ replacement of the affected aortic segment with a synthetic graft or homograft, and omental coverage.

BACKGROUND/AIMS: It is often difficult to manage acute cholecystitis after metal stent (MS) placement in unresectable malignant biliary strictures. The aim of this study was to evaluate the feasibility of endoscopic ultrasonography-guided gallbladder drainage (EUS-GBD) for acute cholecystitis. METHODS: The clinical outcomes of 10 patients who underwent EUS-GBD for acute cholecystitis after MS placement between January 2011 and August 2018 were retrospectively evaluated. The procedural outcomes of percutaneous transhepatic gallbladder drainage (PTGBD) with tube placement (n=11 cases) and aspiration (PTGBA) (n=27 cases) during the study period were evaluated as a reference. RESULTS: The technical success and clinical effectiveness rates of EUS-GBD were 90% (9/10) and 89% (8/9), respectively. Severe bile leakage that required surgical treatment occurred in one case. Acute cholecystitis recurred after stent dislocation in 38% (3/8) of the cases. Both PTGBD and PTGBA were technically successful in all cases without severe adverse events and clinically effective in 91% and 63% of the cases, respectively. CONCLUSIONS: EUS-GBD after MS placement was a feasible option for treating acute cholecystitis. However, it was a rescue technique following the established percutaneous intervention in the current setting because of the immature technical methodology, including dedicated devices, which need further development.
Bile ; Cholecystitis, Acute ; Constriction, Pathologic ; Dislocations ; Drainage ; Gallbladder ; Humans ; Retrospective Studies ; Stents ; Treatment Outcome

Background/Aims: The aim of this study was to evaluate outcomes of inside plastic stents (iPSs) versus those of metal stents (MSs) for treating unresectable perihilar malignant obstructions. Methods: For all patients who underwent endoscopic suprapapillary placement of iPS(s) or MS(s) as the first permanent biliary drainage for unresectable malignant perihilar obstructions between January 2014 and August 2019, clinical outcomes using iPSs (n=20) and MSs (n=85), including clinical efficacy, adverse events, and time to recurrence of biliary obstruction (RBO), were retrospectively evaluated. Results: There were no differences in clinical effectiveness (95% for the iPS group vs. 92% for the MS group, p=1.00). Procedure-related adverse events, including pancreatitis, acute cholangitis, acute cholecystitis, and death, were observed for 8% of the MS group, although no patient in the iPS group developed such adverse events. The median time to RBO was 561 days (95% confidence interval, 0–1,186 days) for iPSs and 209 days (127–291 days) for MSs, showing a significant difference (p=0.008). Conclusions Time to RBO after iPS placement was significantly longer than that after MS placement. IPSs, which are removable, unlike MSs, were an acceptable option.

Background/Aims: Endoscopic biliary drainage using self-expandable metallic stents (SEMSs) for malignant biliary strictures occasionally induces acute cholecystitis (AC). This study evaluated the efficacy of prophylactic gallbladder stents (GBS) during SEMS placement. Methods: Among 158 patients who underwent SEMS placement for malignant biliary strictures between January 2018 and March 2023, 30 patients who attempted to undergo prophylactic GBS placement before SEMS placement were included. Results: Technical success was achieved in 21 cases (70.0%). The mean diameter of the cystic duct was more significant in the successful cases (6.5 mm vs. 3.7 mm, p<0.05). Adverse events occurred for 7 patients (23.3%: acute pancreatitis in 7; non-obstructive cholangitis in 1; perforation of the cystic duct in 1 with an overlap), all of which improved with conservative treatment. No patients developed AC when the GBS placement was successful, whereas 25 of the 128 patients (19.5%) without a prophylactic GBS developed AC during the median follow-up period of 357 days (p=0.043). In the multivariable analysis, GBS placement was a significant factor in preventing AC (hazard ratio, 0.61; 95% confidence interval, 0.37–0.99; p=0.045). Conclusions GBS may contribute to the prevention of AC after SEMS placement for malignant biliary strictures.

Background/Aims: Endoscopic biliary drainage using self-expandable metallic stents (SEMSs) for malignant biliary strictures occasionally induces acute cholecystitis (AC). This study evaluated the efficacy of prophylactic gallbladder stents (GBS) during SEMS placement. Methods: Among 158 patients who underwent SEMS placement for malignant biliary strictures between January 2018 and March 2023, 30 patients who attempted to undergo prophylactic GBS placement before SEMS placement were included. Results: Technical success was achieved in 21 cases (70.0%). The mean diameter of the cystic duct was more significant in the successful cases (6.5 mm vs. 3.7 mm, p<0.05). Adverse events occurred for 7 patients (23.3%: acute pancreatitis in 7; non-obstructive cholangitis in 1; perforation of the cystic duct in 1 with an overlap), all of which improved with conservative treatment. No patients developed AC when the GBS placement was successful, whereas 25 of the 128 patients (19.5%) without a prophylactic GBS developed AC during the median follow-up period of 357 days (p=0.043). In the multivariable analysis, GBS placement was a significant factor in preventing AC (hazard ratio, 0.61; 95% confidence interval, 0.37–0.99; p=0.045). Conclusions GBS may contribute to the prevention of AC after SEMS placement for malignant biliary strictures.

Background/Aims: Endoscopic biliary drainage using self-expandable metallic stents (SEMSs) for malignant biliary strictures occasionally induces acute cholecystitis (AC). This study evaluated the efficacy of prophylactic gallbladder stents (GBS) during SEMS placement. Methods: Among 158 patients who underwent SEMS placement for malignant biliary strictures between January 2018 and March 2023, 30 patients who attempted to undergo prophylactic GBS placement before SEMS placement were included. Results: Technical success was achieved in 21 cases (70.0%). The mean diameter of the cystic duct was more significant in the successful cases (6.5 mm vs. 3.7 mm, p<0.05). Adverse events occurred for 7 patients (23.3%: acute pancreatitis in 7; non-obstructive cholangitis in 1; perforation of the cystic duct in 1 with an overlap), all of which improved with conservative treatment. No patients developed AC when the GBS placement was successful, whereas 25 of the 128 patients (19.5%) without a prophylactic GBS developed AC during the median follow-up period of 357 days (p=0.043). In the multivariable analysis, GBS placement was a significant factor in preventing AC (hazard ratio, 0.61; 95% confidence interval, 0.37–0.99; p=0.045). Conclusions GBS may contribute to the prevention of AC after SEMS placement for malignant biliary strictures.