The persistent fifth aortic arch is rare vascular anomaly. To our knowledge, this is the 24th reported case of the persistent fifth aortic arch. This patient was a 31 days old male infant and had the persistent fifth aortic arch associated with atresia of the fourth aortic arch, patent ductus arteriosus, a double-outlet right ventricle, and a mesocardia. He underwent a fifth aortic arch division and an extended aortic arch anastomosis with a division of ductus arteriosus. There was no blood pressure gradient between upper and lower limbs after the repair. However, no weaning from a cardiopulmonary bypass after the subsequent radical operation for double-outlet right ventricle caused his death.

Pre- and postoperative left ventricular (LV) function was assessed by Doppler echocardiography in 95 infants who underwent open heart surgery during the past two and half years. The patients were divided into three groups: 43 patients with ventricular septal defect (VSD group), 37 with atrial septal defect (ASD group) and 15 with the tetralogy of Fallot (TOF group). Echocardiography was performed before and at an early stage after surgery (average: 11.6 days) in all cases. The forward flow velocity pattern was evaluated by Doppler echocardiography, placing the sample volume at the pulmonary vein (PV) and the LV inflow portion. At the PV, the peak velocity of the S wave during systole (p-PV_S) and the D wave during diastole (p-PV_D) in patients with ASD were significantly lower (p<0.01) postoperatively. In patients with VSD, only p-PV_D was significantly lower (p<0.05) postoperatively, showing a decrease of pulmonary blood flow. These results are thought to reflect a difference in the compliance of the left atrium between the two groups. At the LV inflow portion, the ratio of peak velocity of the wave during atrial systole to R wave on rapid inflow during diastole (A/R) was significantly lower in patients with VSD (p <0.01) postoperatively. At the same time, LV ejection fraction and fractional shortening were significantly lower (p<0.01), but these values remained within the normal range. These results suggest that LV can maintain a sufficient systolic performance against the decrease in preload and the increase in afterload as well as the improvement of diastolic function during the early period after surgery in the VSD group. In patients with ASD or TOF, there were no significant differences in parameters of LV function between preoperative and postoperative periods.

A case of Budd-Chiari syndrome in which direct surgical intervention was successfully performed is reported. A 43-year-old female who had had a history of hepatic coma was pointed out complete obstruction of inferior vena cava (IVC) between the right atrium and diaphragma, associated with hepatic dysfunction and esophageal varices. At operation, the IVC lesion was visualized directly by thoracotomy through midsternal incision and by laparotomy through right hypochondrial oblique incision, with the liver retracted. Under partial extracorporeal circulation with suction of blood from hepatic vein, the IVC was incised, 3cm in length, and membranous tissue causing obstruction was resected. The defect of the IVC wall was repaired with ringed EPTFE patch. Postoperatively, both central venous and portal pressure were decreased, 21 mmHg to 10mmHg and 26cm H₂O to 21cm H₂O, respectively, with good patency of the IVC on venogram. Now the patient is up and well, 11 months after operation. Thus, complete removal of obstruction under direct vision is thought to be important for surgical treatment of Budd-Chiari syndrome.

A lower abdominal tumor with thrill and bruit was pointed out in a 59-year-old female. Angiography showed a pelvic arteriovenous malformation (AVM) with remarkably dilated vessels resembling an aneurysm. Feeding arteries for this AVM originated from the right internal iliac artery, right lumbar artery and right renal artery, and drainage blood flowed into the inferior vena cava from the dilated vessel via a large vein. At operation the right internal iliac artery and right lumbar artery were ligated and the dilated vessel with AVM, which connected with the right renal artery, was resected. An angiography 16 days after the operation revealed the normal arteries without AVM and the right internaal iliac artery filled through collateral arteries. Recently catheter embolization in frequently the first choice for treatment of AVM. However, in the case of AVM with aneurysmal dilated vessels, surgical resection should be selected.

A case of non-anastomotic aneurysms of a knitted Dacron graft is reported. The patient, a 35-year-old female, had had a bypass operation with a Cooley double velour knitted Dacron graft 11 years previously for stenosis of the descending thoracic aorta caused by aortitis syndrome, was admitted complaining of a painful pulsating tumor of the left hypochondral region. We diagnosed multiple aneurysms of Dacron graft with computerized tomography and aortography. The dilated Dacron graft was resected and replaced by a woven polyester graft. The resected specimen showed longitudinal ruptures macroscopically and a decrease of the number of Dacron fibers at the dilated portion was detected microscopically. The nonuniformity of the diameter of Dacron fibers and cracks in the fibers were observed with a scanning electron microscope. Thus, for patients implanted with a knitted Dacron graft, periodical careful follow-up is required for early detection of aneurysmal changes of the graft.

Purpose: Dental floss clip (DFC) traction-assisted endoscopic submucosal dissection (ESD) is widely performed owing to its simplicity. This study aimed to clarify the appropriate indications for the DFC traction method in early gastric cancer when ESD is performed by less-experienced endoscopists. Methods: and Methods: We retrospectively analyzed 1,014 consecutive patients who had undergone gastric ESD performed by less-experienced endoscopists between January 2015 and December 2020. Gastric ESD was performed without DFC in all cases before December 2017 [DFC (−) group, 376 cases], and ESD was performed with DFC in all cases after January 2018 [DFC (+) group, 436 cases]. The procedure time and rates of en bloc resection, complete resection, and adverse events of the groups were compared. Results: The procedure time did not differ significantly between the 2 groups. However, when comparing lesions >20 mm, the procedure time in the DFC (+) group was significantly shorter than that in the DFC (−) group (95±46 vs. 75±31, P<0.01). The procedure time for lesions located in the greater curvature of the upper or middle stomach and lesions >20 mm located in the lesser curvature side of the stomach in the DFC (+) group was significantly shorter than that in the DFC (−) group. Conclusions The indications for DFC during gastric ESD by less-experienced endoscopists include lesions located in the greater curvature of the upper or middle stomach, and lesions >20 mm located in the lesser curvature of the stomach.

Background/Aims: Dual red imaging (DRI) is a new, image-enhanced endoscopy technique. There are few reports about the usefulness of DRI during gastric endoscopic submucosal dissection (ESD). We aimed to examine the usefulness of DRI in endoscopic hemostasis during gastric ESD. Methods: We enrolled a total of 20 consecutive patients who underwent gastric ESD. Five endoscopists compared DRI with white light imaging (WLI) for the visibility of blood vessels and bleeding points while performing endoscopic hemostasis. Results: The visibility of blood vessels was increased in 56% (19/34) of the cases, and the visibility of bleeding points was improved in 55% (11/20) of the cases with the use of DRI compared with the use of WLI. Conclusions DRI improved the visibility of blood vessels and bleeding points in cases with oozing bleeding, blood pooling around the bleeding points, and multiple bleeding points.