Studies have shown that postoperative disseminated intravascular coagulopathy (DIC) occurs in some patients with cardiac disease, acute aortic dissection, and ruptured abdominal aortic aneurysm. The specific pathophysiology of DIC in these settings are related to low cardiac function, shock, infection and sepsis as well as activation of coagulation cascade in the aneurysm sac or dissected aorta. A soluble form of recombinant human thrombomodulin (rhsTM) was approved in 2008 for the treatment of DIC. This report describes the safety and efficacy of rhsTM for the treatment of DIC in patients with cardiovascular disease operated in our department. Between October 2010 and March 2012, 35 patients with postoperative DIC were treated with rhsTM. Diagnosis of DIC was based on the diagnostic criteria for DIC of the Japanese Association for Acute Medicine (JAAM). During the first 6 months of the study period, after a diagnosis of DIC was made, the patients were treated with gabexate mesilate and antithrombin III, and if patients showed no improvement with conventional treatment, they received rhsTM for 6 days. During the last 10 months of the study period, patients received rhsTM soon after a diagnosis of DIC was made. Twenty seven patients survived for 28 days after rhsTM treatment, and the mortality rate was 22.9% (8/35). Patients who survived showed improvement in acute phase DIC scores, FDP levels, D-Dimer, fibrinogen and platelet counts during rhsTM treatment, but no improvement was observed in patients who died. No serious adverse events were found up to 28 days after the start of rhsTM administration. In conclusion, this study showed no adverse events of rhsTM, and further studies are needed to confirm that rhsTM administration is an effective therapeutic modality in the management of DIC after cardiovascular surgery.

The sudden onset of anuria in a 71-year-old man was found to be caused by the non-inflammatory (atherosclerotic) large abdominal aortic aneurysm compressing the bilateral ureters. A computed tomography scan demonstrated the bilateral extrinsic ureteral obstructions due to the large aneurysm of 13cm in diameter, left hydronephrosis and no thick layer of perianeurysmal fibrotic tissue. On the 9th day from the onset of anuria, an emergency operation was performed. There was no fibrotic adhesions around the aneurysm and mobilization of the aorta was easy. A straight Dacron prosthesis was inserted between the infrarenal aorta and the bifurcation of the abdominal aorta following resection of the aneurysm of the atherosclerotic origin. Soon after the operation, the patient had very good urinary output with adequate recovery of renal function. This case seems to be very uncommon, but very important in the surgical management of abdominal aortic aneurysm complicated by oliguria or anuria.

We performed redo coronary artery bypass grafting (CABG) using lateral MIDCAB for 3 patients with severe symptomatic ischemia in the left circumflex system alone. When the descending thoracic aorta had no atherosclerotic lesions on chest CT, it was selected as the inflow of the bypass. According to the location of the target artery, we undertook sequential or T-composite off-pump bypass using the radial artery through a left lateral thoracotomy. On the other hand, when the descending aorta was diseased, the left axillary artery was chosen as the inflow of the bypass. We selected the saphenous vein as a conduit to obtain sufficient graft length. A proximal anastomosis was made through a left infraclavicular incision, and then a distal anastomosis was done through a left lateral thoracotomy without cardiopulmonary bypass. Moreover, care was taken not to kink the grafts. The postoperative course was uneventful in all patients. Lateral MIDCAB technique was useful for redo revascularization to the circumflex system. We believe that selection of bypass conduits, routes, and bypass inflow according to the individual patient is essential for the procedure.

Several prospective studies on laparoscopy-assisted distal gastrectomy for early gastric cancer have been initiated, but no prospective study evaluating laparoscopy-assisted total gastrectomy or laparoscopy-assisted proximal gastrectomy has been completed to date. A non-randomized confirmatory trial was commenced in April 2015 to evaluate the safety of laparoscopy-assisted total gastrectomy and laparoscopy-assisted proximal gastrectomy for clinical stage I gastric cancer. A total of 245 patients will be accrued from 42 Japanese institutions over 3 years. The primary endpoint is the proportion of patients with anastomotic leakage. The secondary endpoints are overall survival, relapse-free survival, proportion of patients with completed laparoscopy-assisted total gastrectomy or laparoscopy-assisted proximal gastrectomy, proportion of patients with conversion to open surgery, adverse events, and short-term clinical outcomes. The UMIN Clinical Trials Registry number is UMIN000017155.
Anastomotic Leak ; Asian Continental Ancestry Group ; Conversion to Open Surgery ; Gastrectomy* ; Humans ; Japan* ; Laparoscopy ; Medical Oncology* ; Non-Randomized Controlled Trials as Topic ; Prospective Studies ; Stomach Neoplasms*

Background/Aims: Proteinase 3 antineutrophil cytoplasmic antibody (PR3-ANCA) is a serologic marker for granulomatosis with polyangiitis. However, recent studies have also shown their role as diagnostic markers for ulcerative colitis (UC). This study was performed to investigate the clinical roles of PR3-ANCAs in the disease severity, disease extension, and clinical course of UC. Methods: Serum PR3-ANCAs were measured in 173 UC patients including 77 patients with new-onset patients UC diagnosed within 1 month, 110 patients with Crohn’s disease, 48 patients with other intestinal diseases, and 71 healthy controls. Associations between the PR3-ANCA titer and clinical data, such as disease severity, disease extension, and clinical course, were assessed. The clinical utility of PR3-ANCA measurement was evaluated by receiver operating characteristic (ROC) analysis. Results: PR3-ANCA ≥3.5 U/mL demonstrated 44.5% sensitivity and 95.6% specificity for thediagnosis of UC in all patients. PR3-ANCA positivity was more prevalent in the 77 new-onset UC patients (58.4%). In this group, the disease severity and extension were more severe in PR3-ANCA positive patients than in PR3-ANCA negative group (p<0.001). After treatment, the partial Mayo scores were significantly decreased with the PR3-ANCA titers. The proportion of patients who required steroids for induction therapy was significantly higher among PR3-ANCA positive than negative group. ROC analysis revealed that PR3-ANCA ≥3.5 U/mL had 75% sensitivity and 69.0% specificity for steroid requirement in new-onset UC patients. Conclusions Our results indicate that PR3-ANCA measurement is useful not only for diagnosing UC but also for evaluating disease severity and extension and predicting the clinical course.

We present the case of a 72-year-old male with Inspiris RESILIA aortic valve (Inspiris) transvalvular leakage during surgical aortic valve replacement (AVR). The patient initially underwent AVR for aortic regurgitation with a bicuspid aortic valve at the age of 64. By the age of 72, the valve had deteriorated and it was assessed that redoing the AVR was necessary. The Inspiris was inserted in the supra-annular position using the non-everting mattress suture technique with a COR-KNOT. During weaning off from cardiopulmonary bypass, transesophageal echocardiography (TEE) captured unfamiliar turbulent flows from the three stent posts. Further TEE revealed that these flows originated from the base of the stent posts, which gradually decreased and disappeared by the end of the surgery after administration of protamine. The patient has been discharged uneventfully. Paravalvular leakage has not been observed during the postoperative course and we could not find TVL in TEE 2 months postoperatively. While considering the detailed mechanism, it is possible that there is no need for re-exploration concerning three directional TVL in the Inspiris.

We present a case of redo aortic valve replacement (AVR) in a 71-year-old man with a Lillehei-Kaster valve implanted 42 years prior. The patient initially underwent AVR and open mitral commissurotomy procedures for aortic regurgitation complicated with mitral stenosis in 1978 at the age of 29. Thereafter, he was followed at our outpatient clinic and treated without anticoagulant therapy for the initial two decades of the postoperative period. During the long-term follow-up, the mean pressure gradient remained between 40 and 60 mmHg and there were no adverse events noted before occurrence of heart failure triggered by tachycardia and pneumonia. Following improvement of heart failure, redo AVR was performed. There was no structural damage, thrombosis, or Lillehei-Kaster valve opening restrictions, though severe pannus growth on the left ventricle side was observed, which was thought to be the cause of the increased pressure gradient. This is the first known report of redo AVR after many years in a patient who underwent Lillehei-Kaster valve implantation. Furthermore, no other study has noted findings regarding pressure gradient change during the long-term follow-up period in such cases.

A 61 year old woman who had been receiving treatment for ulcerative colitis for 14 years complained of respiratory discomfort on exertion and was diagnosed with severe mitral regurgitation due to mitral valve prolapse. Minimally invasive mitral valvuloplasty with right mini-thoracotomy was performed in our facility. Laboratory findings showed elevated levels of serum creatine kinase (CK) and CK-MB immediately after surgery. In addition to elevated levels of myocardial enzymes, ST depression was seen in an electrocardiogram on postoperative day 2 ; therefore, we suspected myocardial ischemia during the surgery. Despite the persistently elevated levels of myocardial enzymes, coronary angiography showed no significant abnormalities. Because of the possibility of false CK elevation, we performed CK electrophoresis, which revealed the presence of macro-CK type 1. CK-MB activity is often falsely elevated when determined by immune-inhibition in macro-CK patients, and that leads to the suspicion of myocardial ischemia. We considered that it may be highly difficult to identify macro-CK in a patient after cardiovascular surgery owing to elevated levels of myocardial enzymes in most such patients.

A 65-year-old male was diagnosed with severe aortic stenosis with an indication for surgery and referred to our department. The patient opted for aortic valve replacement using a bioprosthesis. Due to the patient's relatively small native aortic valve area, a concurrent root dilatation maneuver (Bo Yang method) was performed to prevent patient-prosthetic mismatch and to allow for the implantation of a sufficiently larger bioprosthesis, facilitating the valve-in-valve procedure. The successful implantation of an Inspiris 25-mm bioprosthesis was achieved. Post-operative 3D-computed tomography revealed no tilting or misalignment of the bioprosthesis, and a properly sized, undistorted Valsalva sinus was observed. Aortic valve replacement using the Bo Yang root enlargement technique is considered a promising alternative for relatively younger patients requiring aortic valve intervention.