Chronic contained rupture of an abdominal aortic aneurysm （AAA） is a rare condition that can present with atypical symptoms, making diagnosis challenging. We report a case of chronic contained rupture of an AAA with vertebral destruction presenting as right lower extremity pain. A 78-year-old man with a history of mitral valve replacement and pyogenic spondylitis （L2-L3） presented with a two-month history of low back pain and a four-day history of right lower extremity pain and numbness. Computed tomography revealed a 61 mm diameter ruptured AAA with an irregular margin. Magnetic resonance imaging demonstrated vertebral destruction at L4-L5. The patient underwent open surgical repair with a rifampicin-soaked graft and debridement. Intraoperatively, a large defect was found at the posterior aspect of the aneurysm, exposing the destroyed vertebral bodies. Postoperatively, the patient required spinal immobilization for persistent neurological symptoms, which improved and the patient was discharged on postoperative day 55.

Herein, we describe a novel posterior lumbar interbody fusion (PLIF) technique with annulus fibrosus (AF) release and the use of expandable cages (called “anterior-release PLIF” [ARPLIF]). In this technique, posterior column osteotomy (PCO) and AF release provide excellent intervertebral mobility. AF release involves circumferentially peeling off the AF above or below the endplate between the fixed vertebrae under radiographic guidance without cutting the AF and anterior longitudinal ligament. Subsequently, high-angle variable-angle expandable cages are used to simultaneously expand both sides before inserting the percutaneous pedicle screws and correcting to achieve good local lumbar lordosis. PCO and AF release achieve excellent intervertebral mobility. Intervertebral mobility and simultaneous expansion of both cages disperse the force on the endplates, reducing cage subsidence, and the high-angle cages facilitate high intervertebral angle creation. The novel ARPLIF intervertebral manipulation technique can promote good local lumbar lordosis formation.

Background/Aims: Asymptomatic esophageal eosinophilia (aEE) is considered to be a potential precursor of eosinophilic esophagitis (EoE). However, there are few clinical parameters that can be used to evaluate the disease. Therefore, we aimed to clarify the factors involved in the symptoms of EoE by examining the clinicopathological differences between aEE and EoE. Methods: We reviewed 41 patients with esophageal eosinophilia who underwent endoscopic ultrasonography and high-resolution manometry. They were divided into the aEE group (n=16) and the EoE group (n=25) using the Frequency Scale for the Symptoms of Gastroesophageal Reflux Disease score. The patients’ clinicopathological findings were collected and examined. Results: The median Frequency Scale for the Symptoms of Gastroesophageal Reflux Disease score was 3.0 in the aEE group and 10.0 in the EoE group. There was no significant difference in patient characteristics, endoscopic findings and pathological findings. The cutoff value for wall thickening was 3.13 mm for the total esophageal wall thickness and 2.30 mm for the thickness from the surface to the muscular layer (total esophageal wall thickness: 84.0% sensitivity, 75.0% specificity; thickness from the surface to the muscular layer: 84.0% sensitivity, 68.7% specificity).The high-resolution manometry study was abnormal in seven patients (43.8%) in the aEE group and in 12 (48.0%) in the EoE group. The contractile front velocity was slower in the EoE group (p=0.026). Conclusions The esophageal wall thickening in the lower portion of the esophagus is an important clinical factors related to the symptoms in patients with EoE.

Vertebral artery stump syndrome (VASS) is a rare condition that can cause posterior circulation ischemic stroke due to occlusion of the ipsilateral vertebral artery (VA) orifice, resulting in blood flow stagnation and embolus formation. Although there is no established treatment for this condition, we observed 3 cases of VASS out of 326 acute ischemic stroke cases at a single institution from April 2021 to October 2022. Despite the best possible antithrombotic treatment, all 3 patients had recurrent ischemic strokes. One patient underwent drug-eluting stenting of the VA orifice to relieve occlusive flow. The other 2 patients received coil embolization, which resulted in the disappearance of their culprit collateral flow. None of the patients had recurrent ischemic strokes after endovascular intervention. Based on our observations, stenting and coil embolization are effective methods for preventing future recurrences of VASS.

Background/Aims: Diarrhea-predominant irritable bowel syndrome (IBS-D)-like symptoms frequently occur in patients with quiescent Crohn’s disease (CD). To investigate the factors underlying IBS-D-like symptoms in patients with quiescent CD, we performed a comprehensive analysis of the clinical features and intestinal environment in those patients. Methods: We performed a prospective observational study of 27 patients with quiescent CD (CD activity index [CDAI] ≤ 150; C-reactive protein ≤ 0.3 mg/dL). The presence and severity of IBS-D-like symptoms, health-related quality of life, disease-specific quality of life, andstatus of depression and anxiety were evaluated. The level of intestinal permeability, fecal calprotectin and organic acids and the profiles of gut microbiome were analyzed. Results: Twelve of the 27 patients with quiescent CD (44.4%) had IBS-like symptoms, and these patients showed a significantly higher CDAI, IBS severity index and anxiety score than those without. The inflammatory bowel disease questionnaire score was significantly lower in the patients with IBS-D-like symptoms. There were no significant differences in small intestinal/colonic permeability or the levels of organic acids between the patients with and without IBS-D-like symptoms. Fusicatenibacter was significantly less abundant in the patients with IBS-D-like symptoms whereas their fecal calprotectin level was significantly higher (384.8 ± 310.6 mg/kg) than in patients without (161.0 ± 251.0 mg/kg). The receiver operating characteristic curve constructed to predict IBS-D-like symptoms in patients with quiescent CD using the fecal calprotectin level (cutoff, 125 mg/kg) showed a sensitivity and specificity of 73.3% and 91.7%, respectively. Conclusion Minimal inflammation is closely associated with the development of IBS-D-like symptoms in patients with quiescent CD.

Background/Aims: The frequency and details of nonalcoholic fatty liver disease (NAFLD) complications in patients with inflammatory bowel disease (IBD) remain unclear. This study aimed to clarify characteristics of NAFLD in patients with IBD. Methods: We retrospectively identified and enrolled patients with IBD diagnosed with or without NAFLD by undergoing abdominal computed tomography (CT) at our institution between 2005 and 2020. The primary endpoint was the complication rate of NAFLD in patients with IBD. Secondary endpoints were the clinical characteristics of nonobese patients with IBD and comorbid NAFLD and their association with nutritional and inflammatory parameters. Results: Twenty-one (21.9%) of 96 eligible patients with IBD also had NAFLD. In nonobese patients (defined as patients with a body mass index <25 kg/m2), C-reactive protein (CRP; P<0.001) and alanine aminotransferase (P=0.018) levels were higher and the albumin level (P=0.005) and prognostic nutritional index (PNI; P=0.002) values were lower in patients with NAFLD than in those without NAFLD. The PNI value was positively correlated (P<0.001) and the CRP level was negatively correlated (P=0.001) with the hepatosplenic ratio. However, in the NAFLD combined group, PNI (P<0.05) and CRP values (P<0.001) were improved over time after CT imaging by continuing IBD treatment. Conclusions Worsening nutritional and inflammatory status in IBD patients is associated with complications of NAFLD. Diagnosis of NAFLD in IBD patients using CT imaging might be useful not only for early detection of NAFLD but also in assessing the need for therapeutic intervention for IBD.

Methods: We included 62 patients who underwent combined LLIF surgery and PPS fixation for degenerative lumbar spondylolisthesis with spinal canal stenosis. We compared the patient demographics and the accuracy of fluoroscopy-guided PPS placement between two groups: patients who remained in the lateral decubitus position for the pedicle screw fixation (single-position surgery [SPS] group) and those who were turned to the prone position (dual-position surgery [DPS] group). Results: There were 40 patients in the DPS group and 22 in the SPS group. Of the 292 PPSs, only 12 were misplaced. In other words, 280/292 screws (95.9%) were placed correctly in the pedicle’s cortical shell (grade 0). PPS insertion did not cause neurological, vascular, or visceral injuries in either group. The breach rates for the DPS and SPS groups were 4.1% (grade 1, 5 screws; grade 2, 3 screws; grade 3, 0 screw) and 4.1% (grade 1, 2 screws; grade 2, 2 screws; grade 3, 0 screw), respectively. Although there were no statistically significant differences, the downside PPS had more screw malpositioning than the upside PPS. Conclusions We found that PPS insertion with the patient in the decubitus position under fluoroscopic guidance might be as safe and reliable a technique as PPS insertion in the prone position, with a misplacement rate similar to that previously published.

Knee rotationplasty is a surgery wherein the rotated ankle serves as the new knee joint after resecting the original knee joint and lesion. However, details of postoperative rehabilitation treatment in a convalescent rehabilitation ward are not well-known. Therefore, we reported the rehabilitation progress of a 36-year-old man who underwent knee rotationplasty in the convalescent rehabilitation ward. In the early postoperative period, the surgery required no weight bearing on the operated lower limb until bone healing. Even during this period, we conducted physical therapies such as joint range of motion training and muscle strength training as outpatient rehabilitation therapy. After being admitted to the convalescent rehabilitation ward, physical therapy was intensified and the patient's rotationplasty prosthesis was then fabricated and fitted by a prosthetist and orthotist. The patient was discharged 80 days after his hospitalization and could eventually walk stably with his prosthesis and returned to work. In Japan, the length of stay in a convalescent rehabilitation ward is limited. If patients are provided with enough physical therapy during the postoperative course and rotationplasty prosthesis by a skilled prosthetist and orthotist, rehabilitation treatment after knee rotationplasty can achieve good results in a convalescent rehabilitation ward.

Prospective clinical study.