A 50-year-old man with an extensive thoracic aortic aneurysm underwent staged surgery which consisted of preceding total aortic arch replacement with the frozen elephant trunk technique using J Graft Open Stent Graft^®, followed by open thoracoabdominal aortic aneurysm repair. During the second operation, the descending aorta was cross clamped along with the preexisting stent graft, and Dacron graft was anastomosed directly to the stent graft using a running 4-0 monofilament suture. The anastomosis site was then covered with a short piece of Dacron graft identical with the stent graft in size to secure hemostasis. We herein discuss our approach in this complex case, focusing on prevention of inadvertent events such as deformation of the preexisting stent graft and unexpected bleeding.

The patient was a 25-year-old man, who had been stabbed with a weapon siarilar to long ice pick. Thirty minutes later, he was admitted to our emergency center by ambulance. Anchocardiogram on admission revealed moderate pericardial effusion with normal heart function. Contrast medium enhanced computed tomography revealed that the weapon had entered from the left anterolateral chest wall and reached the posterior wall of the aortic root, approximately 1 cm above the left coronary artery orifice, through the left lung. During examinations, he suddenly went into shock and emergency open pericardial drainage was performed immediately. Approximately 400 ml of blood with a clot was removed from the pericardial cavity. After this procedure, there was no continuous bleeding. Subsequently, pseudoaneurysm developed at the aortic root injury site. Twenty seven days later, aortic surgery was performed. The injury site was resected and sutured directly, employing 4-0 polypropylene sutures with felt pledgets. He was discharged 14 days after the operation without any complications.

Recently, arterial keton body ratio (AKBR) has attracted attention as a new indicator of liver function which is in equibilium with the ratio between oxidized and reduced forms of free nicotinamide-adenine dinucleotides (free NAD⁺/NADH ration) in the mitochondria. There are few reports on whether AKBR contributes to the hepatic energy charge in the open heart surgery with extra corporeal circulation (ECC) or not. This study was undertaken to clarify the contribution of AKBR to the hepatic energy charge during ECC and the relationship between AKBR and hepatic blood flow. AKBR was determined before, during and after ECC in the open heart surgery for 14 patients. Furthermore, the blood flow in hepatic artery, portal vein and liver microcirculation was measured before, during and after ECC in canine models. Finally, the pulsatile perfusion was performed in canine models and compared with the conventional non-pulsatile perfusion for the blood flow and AKBR. In clinical cases, AKBR was decreased in all cases during the ECC. AKBR which was measured at 2 or 3hr after weaning from the ECC was negatively correlated to the total perfusion time with -0.57 as the correlation coefficient. Six patients who were on the ECC over 180min did not show a good recovery of the AKBR after weaning from the ECC. Especially, three patients presented a clinical picture of acute hepatic failure with jaundice, elevation of the serum levels of transaminase and direct hyperbililubinemia, but only one showed hypoglycemia. These patients showed no improvement in clinical data and AKBR. The patient with improved AKBR recovered clinically. In our experiment, the blood flow in the hepatic artery, portal vein was measured by electromagnetic blood flow meter and the liver microcirculation was measured by laserdoppler flowmeter. The blood flow was decreased remakably in the non-pulsatile group at all sites of measurement: it recovered after ECC in hepatic artery and portal vein, but liver microcirculation did not improve well. AKBR was decreased during ECC and did not recover after ECC in the non-pulsatile perfusion. When the pulsatile perfusion was performed, liver circulation was maintained well, and AKBR recovered well after ECC. The above results suggest that AKBR reflects the liver microcirculation and pulsatile perfusion is beneficial to the liver microcirculation. Pulsatile circulation, however, involves several problems, hemolysis, the decrease of platelets, and so on, but these problems have been improved gradually. We think that the pulsatile perfusion will be used in clinical operations to maintain the good hepatic circulation.

PURPOSE: The International Organization for Standardization-5fluorouracil (FU) 10 trial found that bolus 5-FU and l-leucovorin was not inferior to S-1 in the treatment of gastric cancer (GC). Continuous 5-FU and the rapid injection of 5-FU have different anti-cancer effects. Thus, bolus 5-FU and l-leucovorin treatment might be useful for oral FU-resistant GC. MATERIALS AND METHODS: We retrospectively analyzed the medical records of all patients with S-1 or capecitabine-resistant, unresectable, or recurrent GC treated with bolus 5-FU and l-leucovorin between January 2010 and December 2015 at Hokkaido University Hospital. The bolus 5-FU and l-leucovorin regimen consisted of intravenous l-leucovorin (250 mg/m²/2 h) and bolus 5-FU (600 mg/m²) administered once weekly followed by a 2-week rest period; each cycle was repeated every 8 weeks. RESULTS: A total of 14 patients were identified. The disease control rate was 35.7%. The median progression-free survival was 1.6 months (95% confidence interval [CI], 1.3~2.0 months), and the median overall survival was 6.3 months (95% CI, 4.7~7.9 months). No patient died from treatment-related causes. The most common severe adverse event associated with bolus 5-FU and l-leucovorin was neutropenia, which occurred in 21.4% of patients. CONCLUSIONS: Bolus 5-FU and l-leucovorin treatment might be useful for oral FU-resistant GC. We are planning a multi-center prospective phase II trial to evaluate the efficacy and safety of bolus 5-FU and l-leucovorin treatment for pre-treated unresectable or recurrent GC to confirm the results of this limited, retrospective study.
Disease-Free Survival ; Drug Therapy* ; Fluorouracil* ; Humans ; Leucovorin ; Medical Records ; Neutropenia ; Prospective Studies ; Retrospective Studies ; Stomach Neoplasms*

Background/Aims: Metabolic dysfunction-associated steatotic liver disease (MASLD) was recently proposed as an alternative disease concept to nonalcoholic fatty liver disease (NAFLD). We aimed to investigate the prognosis of patients with biopsy-confirmed MASLD using data from a multicenter study. Methods: This was a sub-analysis of the Clinical Outcome Nonalcoholic Fatty Liver Disease (CLIONE) study that included 1,398 patients with NAFLD. Liver biopsy specimens were pathologically diagnosed and histologically scored using the NASH Clinical Research Network system, the FLIP algorithm, and the SAF score. Patients who met at least one cardiometabolic criterion were diagnosed with MASLD. Results: Approximately 99% of cases (n=1,381) were classified as MASLD. Patients with no cardiometabolic risk (n=17) had a significantly lower BMI than patients with MASLD (20.9 kg/m2 vs. 28.0 kg/m2, P<0.001), in addition to significantly lower levels of inflammation, ballooning, NAFLD activity score, and fibrosis stage based on liver histology. These 17 patients had a median follow-up of 5.9 years, equivalent to 115 person-years, with no deaths, liver-related events, cardiovascular events, or extrahepatic cancers. The results showed that the prognosis for pure MASLD was similar to that for the original CLIONE cohort, with 47 deaths and one patient who underwent orthotopic liver transplantation. The leading cause of death was extrahepatic cancer (n=10), while the leading causes of liver-related death were liver failure (n=9), hepatocellular carcinoma (n=8), and cholangiocarcinoma (n=4). Conclusions Approximately 99% of NAFLD cases were considered MASLD based on the 2023 liver disease nomenclature. The NAFLD-only group, which is not encompassed by MASLD, had a relatively mild histopathologic severity and a favorable prognosis. Consequently, the prognosis of MASLD is similar to that previously reported for NAFLD.