Fifty-two year-old woman was operated for type A acute dissection of the aorta superimposed on pre-existing post-stenotic dilatation dut to congenital aortic valve stenosis. The left main coronary artery was discontinued by dissection. Aortic valve replacement, replacement of ascending aorta by woven-Dacron graft and saphenous vein graft between the left anterior discending artery and the prosthetic graft. Compression gauze around the site of the anastomoses and the prosthetic graft was useful to control of intractable bleeding. The gauze could be extracted twenty-eight hours after the operation by platelet and plasma transfusion. She was well eleven months after the operation.

Microvascular free flap transfers have become a preferred reconstructive technique; however, rare complications may still prove devastating. This study reviewed 213 consecutive free-tissue transfers in order to assess the incidence and causes of complications in patients undergoing microvascular free flap reconstruction in the oral and maxillofacial region. In most cases, reconstruction was undertaken after resection of a malignant tumor. The flap donor sites were the radial forearm (n=111), rectus abdominis (n=88), scapula (n=13), and latissimus dorsi (n=1). The superior thyroid artery and the external jugular vein were commonly used as recipient vessels for anastomosis. The overall flap success rate was 99%. There were 7 cases of postoperative vascular thrombosis (6 venous and 1 arterial), constituting 3.3% of the entire series. Five flaps were salvaged, representing a 71.4% successful salvage rate in cases of vascular complications. Most of the successful salvage attempts were made within 24 hours of the end of the initial operation, and the successful salvage rate for re-exploration was 100%. Finally, the total flap loss rate was 0.9% and the partial flap loss rate was 2.3%. We conclude that early re-exploration should be the first choice for management of vascular compromised flaps. Complications at the donor site occurred in 17 cases (8.0%), the most common complication of which was partial skin graft loss after harvesting a radial forearm flap (n=10; 9.0%). Recipient and donor site morbidity was limited and considered acceptable.

A 78-year-old man underwent successful removal of a contaminated pacemaker in a case of methicillin-resistant Staphylococcus aureus (MRSA) septicemia. Septicemia was due to a subcutaneous abscess at the site of old cut electrodes. Following debridement of the infected pacemaker pocket, residual leads and the pacemaker system were removed under cardiopulmonary bypass. Bacterial examination of arterial blood and vegetation attached to the leads showed septicemia caused by MRSA. After the operation, antibiotic therapy with vancomycin, arbekacin and minocycline was performed for several weeks. His postoperative course was uneventful without the recurrence of infection. In cases of pacemaker contamination, with septicemia, total removal of the pacemaker system and adequate antibiotic therapy are necessary.

Background: and Purpose To assess the long-term outcomes of intracranial dural arteriovenous fistula (DAVF) treated with stereotactic radiosurgery (SRS) alone or embolization and SRS (Emb-SRS) and to develop a grading system for predicting DAVF obliteration. Methods: This multi-institutional retrospective study included 200 patients with DAVF treated with SRS or Emb-SRS. We investigated the long-term obliteration rate and obliteration-associated factors. We developed a new grading system to estimate the obliteration rate. Additionally, we compared the outcomes of SRS and Emb-SRS by using propensity score matching. Results: The 3- and 4-year obliteration rates were 66.3% and 78.8%, respectively. The post-SRS hemorrhage rate was 2%. In the matched cohort, the SRS and Emb-SRS groups did not differ in the rates of obliteration (P=0.54) or post-SRS hemorrhage (P=0.50). In multivariable analysis, DAVF location and cortical venous reflux (CVR) were independently associated with obliteration. The new grading system assigned 2, 1, and 0 points to DAVFs in the anterior skull base or middle fossa, DAVFs with CVR or DAVFs in the superior sagittal sinus or tentorium, and DAVFs without these factors, respectively. Using the total points, patients were stratified into the highest (0 points), intermediate (1 point), or lowest (≥2 points) obliteration rate groups that exhibited 4-year obliteration rates of 94.4%, 71.3%, and 60.4%, respectively (P<0.01). Conclusions SRS-based therapy achieved DAVF obliteration in more than three-quarters of the patients at 4 years of age. Our grading system can stratify the obliteration rate and may guide physicians in treatment selection.

A 71-year-old woman with a history of closed commissurotomy for mitral valve stenosis 44 year ago, was diagnosed with left ventricular aneurysm by transthoracic echocardiography. She had no symptom of left ventricular aneurysm. Since there was a high risk of left ventricular rupture, we decided to undertake surgical treatment. During the surgery, we found artificial material near the left ventricular aneurysm. We resected the aneurysm wall and closed the ventricular wall using felt strip reinforcement. The wall of the aneurysm had no myocardium upon pathological examination. We diagnosed that it was a left ventricular pseudoaneurysm, and it seemed to be formed by blood oozing from the apical repair point of the hole for the dilator to perform mitral valvulotomy. The postoperative course was uneventful and she was discharged on postoperative day 20. Left ventricular pseudoaneurysm often results after myocardial infarction, and reports after cardiac surgery are rare, except in cases after mitral valve replacement. We hereby report our experience with this rare case

STUDY DESIGN: Retrospective case series. PURPOSE: To investigate the oncological outcomes, including distant relapse, after en bloc spondylectomy (EBS) for spinal metastases in patients with a minimum of 2-year follow-up. OVERVIEW OF LITERATURE: Although EBS has been reported to be locally curative and extend survival in select patients with spinal metastases, detailed reports regarding the control of distant relapse after EBS are lacking. METHODS: We conducted a retrospective review of 18 consecutive patients (median age at EBS, 62 years; range, 40–77 years) who underwent EBS for spinal metastases between 1991 and 2015. The primary cancer sites included the kidney (n=7), thyroid (n=4), liver (n=3), and other locations (n=4). Survival rates were estimated using the Kaplan–Meier method, and groups were compared using the log-rank method. RESULTS: The median operative time and intraoperative blood loss were 767.5 minutes and 2,375 g, respectively. Twelve patients (66.7%) experienced perioperative complications. Five patients (27.8%) experienced local recurrence of the tumor at a median of 12.5 months after EBS, four of which had a positive resection margin status. Thirteen patients (72.2%) experienced distant relapse at a median of 21 months after EBS. The estimated median survival period after distant relapse was 20 months (95% confidence interval, 0.71–39.29 months). No association was found between resection margin status and distant relapse. Overall, the 2-year, 5-year, and 10-year survival rates after EBS were 72.2%, 48.8%, and 27.1%, respectively. Importantly, the era in which EBS was performed did not impact the oncological outcomes. CONCLUSIONS: Our results suggest that EBS by itself, even if margin-free, cannot prevent further dissemination, which occurred in >70% of patients at a median of 21 months after EBS. These results should be considered and conveyed to patients for clinical decision-making.
Clinical Decision-Making ; Follow-Up Studies ; Humans ; Kidney ; Liver ; Methods ; Neoplasm Metastasis ; Operative Time ; Recurrence ; Retrospective Studies ; Spine ; Survival Rate ; Thyroid Gland

Background/Aims: Multiple white and flat elevated lesions (MWFL) that develop from the gastric corpus to the fornix may be strongly associated with oral antacid intake. Therefore, this study aimed to determine the association between the occurrence of MWFL and oral proton pump inhibitor (PPI) intake and clarify the endoscopic and clinicopathological characteristics of MWFL. Methods: The study included 163 patients. The history of oral drug intake was collected, and serum gastrin levels and anti-Helicobacter pylori immunoglobulin G antibody titers were measured. Upper gastrointestinal endoscopy was performed. The primary study endpoint was the association between MWFL and oral PPI intake. Results: In the univariate analyses, MWFL were observed in 35 (49.3%) of 71 patients who received oral PPIs and 10 (10.9%) of 92 patients who did not receive oral PPIs. The occurrence of MWFL was significantly higher among patients who received PPIs than in those who did not (p<0.001). Moreover, the occurrence of MWFL was significantly higher in patients with hypergastrinemia (p=0.005). In the multivariate analyses, oral PPI intake was the only significant independent factor associated with the presence of MWFL (p=0.001; odds ratio, 5.78; 95% confidence interval, 2.06–16.2). Conclusions Our findings suggest that oral PPI intake is associated with the presence of MWFL (UMINCTR 000030144).

Objective: The primary objective of this study was to evaluate the safety of niraparib 300 mg/day in Japanese patients with platinum-sensitive, relapsed ovarian cancer in a maintenance setting. Methods: Phase 2, multicenter, open-label, single-arm study enrolled Japanese patients with platinum-sensitive, relapsed ovarian cancer who had received ≥2 platinum-based regimens.The primary endpoint (incidence of grade 3 or 4 thrombocytopenia-related events within 30 days after initial niraparib administration) was justified by the incidences of a global pivotal phase 3 study and its post-hoc safety analysis on thrombocytopenia, the major hematological adverse event of niraparib. The overall safety analysis examined other treatment-emergent adverse events (TEAEs). Results: Enrolled patients (n=19) had a median (min, max) body weight of 53.9 (40.8–79.1) kg; all but one patient weighed <77 kg. Most (94.7%) patients initially received niraparib 300 mg/day but this decreased in subsequent cycles (mean±standard deviation dose intensity, 191.6±65.7 mg/day). In total, 6/19 (31.6%) patients experienced grade 3 or 4 thrombocytopenia-related events within 30 days of initial niraparib administration.Other common TEAEs included nausea, and decreased platelet or neutrophil counts. No progression-free or overall survival events occurred; only 1 of 4 response-evaluable patients had a post-baseline tumor assessment (stable disease). Conclusion The incidence of grade 3 or 4 thrombocytopenia-related events in Japanese ovarian cancer patients was similar to that in the corresponding non-Japanese study. Overall, the safety profile was acceptable and consistent with the known safety profile and previous experience with niraparib.

Objective: To evaluate the efficacy and safety of niraparib in Japanese women with heavily pretreated ovarian cancer. Methods: This Phase 2 open-label, single-arm study enrolled Japanese women with homologous recombination deficiency-positive relapsed, high-grade serous ovarian, fallopian tube, or primary peritoneal cancer who had completed 3–4 lines of therapy. The starting dose of niraparib was 300 mg administered once daily in continuous 28-day cycles until objective progressive disease, unacceptable toxicity, consent withdrawal or discontinuation. The primary endpoint, objective response rate (ORR), was assessed by the investigator using RECIST version 1.1. Safety evaluations included the incidence of treatment-emergent adverse events (TEAEs), including serious TEAEs. Results: Twenty women were enrolled and the confirmed ORR in the full analysis set (FAS) was 35.0% (7/20), consisting of 1 complete response and 6 partial responses. Disease control rate in the FAS was 90.0%. The most frequently reported TEAEs (>50%) were anemia, nausea, and platelet count decreased. One patient (5.0%) had TEAEs leading to discontinuation of niraparib whereas reductions or interruptions were reported in 14 (70.0%) and 15 (75.0%) patients, respectively. The median dose intensity (202.9 mg daily) corresponded to a relative dose intensity of 67.6%. Conclusion Efficacy and safety of niraparib in heavily pretreated Japanese women was comparable to that seen in an equivalent population of non-Japanese women. No new safety signals were identified.

A 72-year-old man presented with a thoracoabdominal aortic aneurysm which had been diagnosed six years earlier. Surgical intervention was planned due to aortic diameter enlargement up to 57 mm and back pain. Although he had a shaggy aorta, a preoperative work-up revealed pulmonary dysfunction, which made open repair via thoracotomy challenging. Therefore, a decision was made to proceed with two-stage thoracic endovascular aortic repair (TEVAR) with debranching and functional brain isolation. In the first operation, iliofemoral bypass with debranching of four abdominal vessels was performed via median laparotomy to secure the access route and distal landing zone. In the second operation, two debranching TEVAR was performed. The functional brain isolation technique was employed using cardiopulmonary bypass and balloon occlusion of the left subclavian artery to prevent an embolic stroke from the shaggy aorta during the stent graft deployment. In addition, embolic protection of abdominal branches and lower extremities was established using a balloon occlusion and a sheath in the iliac arteries. The postoperative course was uneventful with no embolic complications. Although the shaggy aorta is not evaluated in Japan SCORE or Euro SCORE, it is a risk factor for perioperative stroke. Those patients would benefit from a tailored approach to prevent embolic complications.