The patient was 62-year-old woman was brought to the emergency room with chest pain and dyspnea. Computed tomography revealed a hematoma around the ascending aorta, a notch in the aortic wall, pericardial effusion and a hematoma around the pulmonary artery. We diagnosed early thrombotic type of acute aortic dissection. An ascending aorta replacement was performed via median sternotomy under hypothermic circulatory arrest. Upon operation, there was a 1.0 cm intimal tear just above the left main trunk and there was no specific evidence of aortic dissection. So we diagnosed spontaneous aortic rapture. Her postoperative course was uneventful and she was discharged 18 days after surgery.

To study diffrences in dietary factors among communities with different living environments, we carried out a survey by the Cardiac Study method in 241 people (106 men and 135 women) aged between 50 and 54 years who were selected by random sampling from a total of 37, 000 inhabitants in a small city. The city was geographically divided into town, flatland farming area, and mountainous farming area, and the results of the survey were compared among these areas.
The mean Na excretion in 24-hour specimens of urine was slightly higher in the mountainous farming area than in the other two-areas. The mean serum total cholesterol was higher in men in the town than in those in the other areas.
Factor analysis of the data for nutrient intake patterns revealed a lower fat intake in the two farming areas than in the town in the men, and a higher intake of animal foods in the town and a lower fat intake in the mountainous area in the women.
These results show that risk factors for circulatory diseases such as urinary Na excretion, serum cholesterol level, and nutrient intake patterns differ even among small areas if the living environment differs.

Aortic dissection is one cause of acute aortic regurgitation, and transthoracic echocardiography and computed tomography are useful for diagnosis. We report a case of intraoperatively discovered acute aortic regurgitation caused by aortic dissection limited to the sinus of Valsalva. The patient was a 71-year-old man who regularly visited his local doctor for hypertension and diabetes mellitus. He visited the doctor with a week-long history of cough and dyspnea, and was referred to our hospital due to acute congestive heart failure. We diagnosed severe acute aortic regurgitation as the cause of the heart failure, but the aortic root dissection was not detected by transthoracic echocardiography or plain computed tomography. Since his heart failure progressively worsened even with intensive medical therapy, urgent surgery was decided on the 6th day after hospitalization. Intraoperatively, we noted that the aortic dissection was limited to the sinus of Valsalva, and had induced aortic regurgitation due to dissected and separated aortic commissure. We changed the surgical procedure from aortic valve replacement to the Bentall procedure (Piehler method). Postoperatively, the patient was intubated for 7 days and stayed in the ICU for 14 days due to treatment for pneumothorax and organizing pneumonia. He was successfully transferred to a rehabilitation hospital on the 35th postoperative day. Acute aortic regurgitation caused by aortic dissection limited to the sinus of Valsalva is rare, so we report the case based on literature reviews and as a heart team.

A newly developed short double-balloon enteroscope with a working channel enlarged to a diameter of 3.2 mm is a novel innovation in stent placement for patients with surgically altered anatomies. Herein, we report three patients in whom this new scope contributed to an efficient technique and ideal treatment. In the first case, the double guidewire technique was efficient and effective for multiple stent placements. In the second case, covered self-expandable metal stent (SEMS) placement, which is the standard treatment for malignant biliary obstruction, could be performed in a technologically sound and safe manner. In the third case, SEMS placement was performed as palliative treatment for malignant afferent-loop obstruction; this procedure could be performed soundly and safely using the through-the-scope technique. The wider working channel of this new scope also facilitates a smoother accessory insertion and high suction performance, which reduces procedure time and stress on endoscopists. Furthermore, this new scope, which has advanced force transmission, adaptive bending, and a smaller turning radius, is expected to be highly successful in both diagnosis and therapy for various digestive diseases in patients with surgically altered anatomies.
Cholangiopancreatography, Endoscopic Retrograde ; Diagnosis ; Double-Balloon Enteroscopy ; Gastric Outlet Obstruction ; Humans ; Palliative Care ; Radius ; Stents* ; Suction

1）We had the opportunity to study medical education in Thailand and Singapore while we visited medical schools in those countries as a member of the Japan Tropical Medicine Association.
2）In Thailand, undergraduate medical education last for 6 years, which is the same length as in Japan. All lectures are in English. Medical students in Thailand are more deeply related to patients at bedside learning than are students in Japan. In Singapore, undergraduate education lasts for 5 years, and lectures are in English. In the third year, medical students start clinical medicine. Recently, a new program has been adopted in which medical students can easily choose their specialties right after graduation.
3）Japanese medical students study medicine in Japanese. In contrast, greater emphasis should be placed in Japan on medical education in English.

Background/Aims: Bilateral endoscopic drainage with self-expanding metallic stent (SEMS) can be used to effectively manage hilar malignant biliary obstruction. However, the benefits of using a trisegment drainage method remain unknown. Methods: This study retrospectively reviewed the data of 125 patients with Bismuth type IIIa or IV unresectable malignant strictures who underwent bilateral endoscopic drainage using SEMSs at four tertiary centers. The patients were divided into the bilateral and trisegment drainage groups for comparison. The primary endpoint was stent patency and the secondary endpoints were technical success, technical and clinical success of reintervention, and overall survival. Results: The technical success rates of the bilateral and trisegment drainage groups were 95% (34/36) and 90% (80/89) (p=0.41), respectively, with median stent patency durations of 226 and 170 days (p=0.26), respectively. Although the technical success of reintervention was not significantly different between the two groups (p=0.51), the clinical success rate of reintrvention was significantly higher in the trisegment drainage group (73% [11/15] vs 96% [47/49], p=0.009). The median survival times were 324 and 323 days in the bilateral and trisegment drainage groups, respectively (p=0.72). Multivariate Cox hazards model revealed no stent patency-associated factor; however, chemotherapy was associated with longer survival. Conclusions Although no significant difference was noted with respect to stent patency, significantly higher clinical success rates were achieved with reintervention using the trisegment drainage method than using the bilateral drainage method alone.

INTRODUCTION: Recently, remnant-preserving anterior cruciate ligament (ACL) reconstruction has been increasingly performed to achieve revascularization, cell proliferation, and recovery of high-quality proprioception. However, poor arthroscopic visualization makes accurate socket placement during remnant-preserving ACL reconstruction difficult. This study describes a surgical technique used to create an anatomical femoral socket with a three-dimensional (3D) fluoroscopy based navigation system during technically demanding remnant-preserving ACL reconstruction. SURGICAL TECHNIQUE: After a reference frame was attached to the femur, an intraoperative image of the distal femur was obtained, transferred to the navigation system and reconstructed into a 3D image. A navigation computer helped the surgeon visualize the entire lateral wall of the femoral notch and lateral intercondylar ridge, even when the remnant of the ruptured ACL impeded arthroscopic visualization of the bone surface. When a guide was placed, the virtual femoral tunnel overlapped the reconstructed 3D image in real time; therefore, only minimal soft tissue debridement was required. MATERIALS AND METHODS: We treated 47 patients with remnant-preserving ACL reconstruction using this system. The center of the femoral socket aperture was calculated according to the quadrant technique using 3D computed tomography imaging. RESULTS: The femoral socket locations were considered to be an anatomical footprint in accordance with previous cadaveric studies. CONCLUSIONS: The 3D fluoroscopy-based navigation can assist surgeons in creating anatomical femoral sockets during remnant-preserving ACL reconstruction.
Anterior Cruciate Ligament ; Anterior Cruciate Ligament Reconstruction ; Cadaver ; Cell Proliferation ; Debridement ; Femur ; Fluoroscopy ; Humans ; Proprioception ; Surgery, Computer-Assisted