We present the case of a 68-year-old woman with abdominal aortic aneurysm (AAA) complicated by right ectopic kidney, in another term, congenital pelvic kidney. The patient underwent AAA repair and right renal artery reconstruction using renal perfusion with cold Ringer's acetate, and no deterioration of renal function was observed. 3D-CT was essential diagnostic procedure in order to identify the blood supply to the ectopic kidney for planning a careful surgical technique.

A 56-year-old man, who underwent aortic valve replacement with a stentless artificial valve for aortic valve endocarditis at age 52, found to have left ventricular outflow pseudoaneurysm by transthorasic echocardiography, transesophageal echocardiography and enhanced computed tomography. We repaired the pseudoaneurysm, combined with valve re-replacement. Left ventricular outflow pseudoaneurysm is a rare disease, and is often associated with active endocarditis. Transesophageal echocardiography and CT scan are useful to diagnose this disease, especially to rule out annular abscess. Operative indication is recommended soon after the diagnosis was made to prevent rupture of pseudoaneurysm, or development of either mitral regurgitation or coronary ischemia due to compression from the pseudoaneurysm. Combined aortic valve replacement, with or without mitral valve replacement is necessary to repair the pseudoaneurysm.

Intracardiac repair for cardiac anomalies associated with a transposed aorta from the right ventricle is a technically demanding operation. We present two cases of left ventricular outflow tract (LVOT) obstruction after the use of an ePTFE flat patch to reconstruct the LVOT. Case 1 : A 10-year-old boy had undergone the Rastelli operation, VSD enlargement, and intraventricular re-routing using an ePTFE flat patch for repair of the DORV with noncommitted VSD and pulmonary stenosis at the age of 5. Five years later, catheter examination revealed severe LVOT obstruction. Intraventricular re-routing using a part of the ePTFE graft concomitant with re-replacement of an extracardiac conduit was successfully performed. Case 2 : A 13-year-old girl had undergone a double-switch operation (Senning operation, the Rastelli operation, and intraventricular re-routing by the use of an ePTFE flat patch) for the repair of corrected TGA, PA and VSD at the age of 7. Six years later, catheter examination revealed severe LVOT obstruction. Intraventricular re-routing using part of the ePTFE graft concomitant with re-replacement of an extracardiac conduit was successfully performed. We consider that the use of a flat patch for reconstruction of a left ventricular out flow tract in cases with transposition of the aorta from the right ventricle involves a risk of future development of LVOT obstruction.

This report introduces a percutaneous transpedicular interbody fusion (PTPIF) technique in posterior stabilization using percutaneous pedicle screws (PPSs). An 81-year-old man presented with pseudoarthrosis following pyogenic spondylitis 15 months before. Although no relapse of infection was found, he complained of obstinate low back pain and mild neurological symptoms. Radiological evaluations showed a pseudoarthrosis following pyogenic spondylitis at T11–12. Posterior stabilization using PPSs from Th9 to L2 and concomitant PTPIF using autologous iliac bone graft at T11–12 were performed. Low back pain and neurological symptoms were immediately improved after surgery. A solid interbody fusion at T11–12 was completed 9 months after surgery. The patient had no restriction of daily activity and could play golf at one year after surgery. PTPIF might be a useful option for perform segmental fusion in posterior stabilization using PPSs.
Aged, 80 and over ; Golf ; Humans ; Low Back Pain ; Pseudarthrosis* ; Recurrence ; Spinal Fusion ; Spondylitis* ; Transplants

A 79-year-old woman, who had undergone mitral valve replacement with a Björk-Shiley valve 16 years previously, was transferred to our institute due to active prosthetic valve infection associated with severe heart failure on respirator. On admission, her white blood cells and c-reactive protein (CRP) were elevated to 15,700/µl and 7.29 mg/dl, respectively, and she had anemia (hemoglobine 8.1 g/dl), thrombocytopenia (platelets 75,000/µl), and renal dysfunction (blood urea nitrogen 57 mg/dl, creatinine 1.8 mg/dl, estimated glomerular filtration rate 21.5 ml/min/1.73 m²). Her brain natriuretic peptide was elevated to 456.7 pg/dl. Blood culture revealed bacteremia with Streptococcus agalactiae. Though CT scan revealed cerebellum infarction, we decided to perform emergency surgery because of uncontrollable infection and heart failure, even with massive infusion of catecholamine and respiratory support. At surgery, huge vegetation proliferated over the prosthetic valve. The prosthetic valve was detached from approximately two-thirds of the annulus due to an annular abscess. The infected annulus was resected aggressively. Mitral annulus was reconstructed and reinforced with a bovine pericardial patch, and the bioprosthetic valve of 23 mm in size was implanted in an intra-annular position. In the postoperative phase, antibiotics (ampicillin, gentamicin) was given, and CRP became negative 47 days postoperatively, and the patient discharged from the hospital 56 days after the operation.

In this study, we assessed a series of our cases in which endoscopic self-expandable metal stents (SEMSs) were used to treat malignant afferent loop obstruction (ALO) that arose after pancreaticoduodenectomy (PD). We retrospectively examined the records of 7 patients who underwent endoscopic SEMS placement for malignant ALO following PD. Clinical success was achieved in all cases. The median procedure time was 30 min (range, 15–50 min). There were no cases of stent occlusion, and no procedure-related adverse events were encountered. All patients died of their primary disease, and the median overall survival period was 155 days (range, 96–374 days). A re-intervention involving endoscopic ultrasound-guided hepaticogastrostomy combined with antegrade stenting was performed for obstructive jaundice and acute cholangitis in 1 case. In conclusion, endoscopic SEMS placement may be an effective and safe treatment for malignant ALO that arises after PD.

Afferent loop syndrome (ALS) is a mechanical obstruction of the afferent limbs after gastrectomy with gastrojejunostomy reconstruction. Patients with cancer recurrence require immediate and less invasive treatment because of their poor condition. Percutaneous transhepatic/transluminal drainage (PTD) and endoscopic enteral stenting offer reasonable palliative treatment for malignant ALS but are not fully satisfactory in terms of patient quality of life (QoL) and stent patency. Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) using a lumen-apposing metal stent may address these shortcomings. Clinical data from 11 reports showed that all patients who had undergone EUS-GE had positive technical and clinical outcomes. The adverse event rate was 11.4%, including only mild or moderate abdominal pain, with no severe adverse events. Indirect comparative studies indicated that patients who had undergone EUS-GE had a significantly superior QoL, a higher clinical success rate, and a lower reintervention rate than those who had undergone PTD or endoscopic enteral stenting. Although the evidence is limited, EUS-GE may be considered as a first-line treatment for malignant ALS because it has better clinical outcomes than other less invasive treatments, such as PTD or endoscopic enteral stenting. Further prospective randomized control trials are necessary to establish EUS-GE as a standard treatment for ALS.

Methods: Study participants comprised five healthy volunteers (mean age, 27.2 years) and 27 patients with LSS (mean age, 58.4 years) who were individually assessed using 3.0 Tesla magnetic resonance imaging. Intraspinal ADC and FA values of 10 intervertebral discs from healthy volunteers and 52 intervertebral discs from LSS patients were measured. Also, intraspinal canal area, Schizas classification (A: normal, B: mild stenosis, C: severe stenosis) and correlations with symptoms were investigated. Clinical symptoms were checked for the presence of low back pain (LBP), intermittent claudication (IMC), and bladder and bowel dysfunction (BBD). Results: Compared to healthy individuals, LSS patients had significantly lower ADC (p<0.05) and significantly higher FA values (p<0.01). In Schizas classification, stenosis worsened from A to C. ADC values decreased significantly while FA values increased significantly in that order (p<0.05). A positive correlation was found between intraspinal canal area and ADC values (r=0.63, p<0.01) and a negative correlation between intraspinal canal area and FA values (p=−0.61, p<0.01). No correlations were noted between LBP and ADC or FA values. On the other hand, ADC values were significantly lower (p<0.05) and FA values were significantly higher (p<0.05) in patients with IMC or BBD. Conclusions Intraspinal DTI parameters such as ADC and FA values were associated with the Schizas classification, intraspinal canal area, and clinical symptoms, suggesting that ADC and FA may be useful for quantitative assessment of LSS.

Methods: Study participants comprised five healthy volunteers (mean age, 27.2 years) and 27 patients with LSS (mean age, 58.4 years) who were individually assessed using 3.0 Tesla magnetic resonance imaging. Intraspinal ADC and FA values of 10 intervertebral discs from healthy volunteers and 52 intervertebral discs from LSS patients were measured. Also, intraspinal canal area, Schizas classification (A: normal, B: mild stenosis, C: severe stenosis) and correlations with symptoms were investigated. Clinical symptoms were checked for the presence of low back pain (LBP), intermittent claudication (IMC), and bladder and bowel dysfunction (BBD). Results: Compared to healthy individuals, LSS patients had significantly lower ADC (p<0.05) and significantly higher FA values (p<0.01). In Schizas classification, stenosis worsened from A to C. ADC values decreased significantly while FA values increased significantly in that order (p<0.05). A positive correlation was found between intraspinal canal area and ADC values (r=0.63, p<0.01) and a negative correlation between intraspinal canal area and FA values (p=−0.61, p<0.01). No correlations were noted between LBP and ADC or FA values. On the other hand, ADC values were significantly lower (p<0.05) and FA values were significantly higher (p<0.05) in patients with IMC or BBD. Conclusions Intraspinal DTI parameters such as ADC and FA values were associated with the Schizas classification, intraspinal canal area, and clinical symptoms, suggesting that ADC and FA may be useful for quantitative assessment of LSS.

Methods: We performed 3T MRI in 10 healthy volunteers and 13 patients with LSS. The ADC values in the spinal canal were evaluated at 46 vertebrae (L4/5 and L5/S1 for each participant), and the reduced and conventional fields of view were compared. Results: The ADC values were 2.72±0.12 at L4/5 in healthy volunteers, 2.76±0.19 at L5/S1 in healthy volunteers, 1.77±0.58 at L4/5 in patients with LSS, and 2.35±0.29 at L5/S1 in patients with LSS. The ADC value at L4/5 in patients with LSS was significantly lower than that at L5/S1 in patients with LSS and that at L4/5 and L5/S1 in healthy volunteers (p <0.05). With an ADC cutoff value of 2.46 to identify LSS, this approach provided an area under the curve of 0.81, sensitivity of 0.92, and specificity of 0.76 (p <0.05). Conclusions Preoperative examination using ADC maps permits visualization and quantification of spinal canal lesions, thus proving the utility of ADC maps in the selection of decompression surgery for LSS.