Hemolysis, hemoglobinuria, skin eruption and hypotension were noticed following transfusion of 11 units of fresh blood during mitral valve replacement in a 57-year-old man. Irregular antibody incompatibility was suspected. Further investigation revealed anti Lewis-a antibody. Three of 11 units of transfused blood were positive for the indirect Coombs test. The patient recovered without renal failure, and was discharged. One year later, he had urgent re-MVR due to malfunction of the prosthetic valve. Hemolytic transfusion reaction had occured after the administration of donor blood which had been showed to be compatible by cross matching. This means that antibody titer diminishes with time, and that posttransfusion screening tests should minimize the unexpected hazards of incompatible blood transfusion. We recommend that antibody screening tests should be routinely performed after open heart surgery, to minimize the risk of hemolysis during future reoperation.

Problems with postoperative respiratory management of three patients after division of double aortic arch are described. Tracheomalacia was present in two of three cases with intracardiac anomalies of different types. Intracardiac anomalies of each patient were as follows: Patient 1, ventricular septal defect (VSD), atrial septal defect and pulmonary valve stenosis (PS); Patient 2, VSD, corrected transposition of the great arteries with PS; Patient 3, VSD with pulmonary hypertension (PH). In patient 1 and 2, no concomitant surgical intervention was performed for tracheomalacia. In these patients respiratory support had been continued for 41 and 60 days respectively. In patient 3, remaining VSD with PH was the cause of unexpected respiratory problem even after the successful division of the double aortic arch, and necessitated emergency VSD closure 49 days after the initial operation. The patient was extubated on postoperative day 12. Tracheomalacia is a life-threatening problem even after surgical division of the double aortic arch. Although prolonged respiratory support was needed, our two cases were successfully extubated without concomitant surgical intervention of tracheomalacia. Severe cases should be operated on simultaneously with the relief of vascular ring and tracheomalacia. Intracardiac anomalies are also the causes of prolonged intubation. Patient 3 should have been treated by pulmonary artery banding along with the division of aortic arch. In conclusion, precise evaluation of the existence and severity of the tracheomalacia and intracardiac anomalies is of utmost importance to overcome postoperative respiratory failure and for eventual satisfactory results.

From January 1979 through May 1982, 36 premature infants less than 2.5kg and less than 35 weeks of gestation, including 24 patients with respiratory distress syndrome, underwent ligation of patent ductus arteriosus (PDA) due to being unresponsive to medical treatment. Ten patients died postoperatively mainly from intracranial hemorrhage and necrotizing enterocolitis. Surviving 26 patients were examined for developmental sequelae based on questionnaire survey. One infant died of respiratory failure secondary to severe bronchopulmonary dysplasia 28th month after operation. We found no evidence of recurrent ductal patency following ligation during the follow-up period. Twenty four patients exhibited normal motor and mental development to attend the ordinary elementary school everyday, but one patient shows mental retardation. Most of patients suffered from the frequent upper respiratory infection in childhood to require rehospitalization. There are no patients with hoarseness, but 2 patients developed funnel chest and one required the operation. One third of the patients had ophthalmological handicap (myopia or strabismus). Surgical ligation of PDA in premature infants seems to reduce the duration of postoperative mechanical ventilation and the incidence of bronchopulmonary dysplasia. Analyzing long-term follow-up indicates that infants who undergo PDA ligation grow almost normally and do not appear to be at increased risk for sensorineural handicaps. Therefore we emphasize that surgical ligation of PDA is an effective and appropriate treatment of choice for significant PDA in premature infants.

A 63-year-old woman who was diagnosed a having impending rupture of abdominal aortic aneurysm underwent urgent anatomic reconstruction. Histopathological findings revealed abscess formation around the aneurysmal wall, and a definitive diagnosis of mycotic aneurysm was established. Successful management of this rare aortic disease depends on early accurate diagnosis, control of infection and careful surgical management.

Background/Aims: Acute cholangitis (AC) is a potentially life-threatening bacterial infection, and timely antimicrobial treatment, faster than that achieved with bacterial cultures, is recommended.Although the current guidelines refer to empirical antimicrobial treatment, various kinds of antimicrobial agents have been cited because of insufficient analyses on the spectrum of pathogens in AC. Enterococcus spp. is one of the most frequently isolated Gram-positive bacteria from the bile of patients with AC, but its risk factors have not been extensively studied. This study aimed to analyze the risk factors of AC caused by Enterococcus faecalis and Enterococcus faecium. Methods: Patients with AC who were hospitalized in a Japanese tertiary center between 2010 and 2015 were retrospectively analyzed. Patients’ first AC episodes in the hospital were evaluated. Results: A total of 266 patients with AC were identified. E. faecalis and/or E. faecium was isolated in 56 (21%) episodes of AC. Prior endoscopic sphincterotomy (EST), the presence of a biliary stent, prior cholecystectomy, and past intensive care unit admission were more frequently observed in AC patients with E. faecalis and/orE. faecium than in those without such bacteria. Prior EST was identified as an independent risk factor for AC caused by E. faecalis and/or E. faecium in the multivariate analysis. Conclusions Given the intrinsic resistance of E. faecalis and E. faecium to antibiotics, clinicians should consider empirical therapy with anti-enterococcal antibiotics for patients with prior EST.

Background/Aims: Acute cholangitis (AC) is a potentially life-threatening bacterial infection, and timely antimicrobial treatment, faster than that achieved with bacterial cultures, is recommended.Although the current guidelines refer to empirical antimicrobial treatment, various kinds of antimicrobial agents have been cited because of insufficient analyses on the spectrum of pathogens in AC. Enterococcus spp. is one of the most frequently isolated Gram-positive bacteria from the bile of patients with AC, but its risk factors have not been extensively studied. This study aimed to analyze the risk factors of AC caused by Enterococcus faecalis and Enterococcus faecium. Methods: Patients with AC who were hospitalized in a Japanese tertiary center between 2010 and 2015 were retrospectively analyzed. Patients’ first AC episodes in the hospital were evaluated. Results: A total of 266 patients with AC were identified. E. faecalis and/or E. faecium was isolated in 56 (21%) episodes of AC. Prior endoscopic sphincterotomy (EST), the presence of a biliary stent, prior cholecystectomy, and past intensive care unit admission were more frequently observed in AC patients with E. faecalis and/orE. faecium than in those without such bacteria. Prior EST was identified as an independent risk factor for AC caused by E. faecalis and/or E. faecium in the multivariate analysis. Conclusions Given the intrinsic resistance of E. faecalis and E. faecium to antibiotics, clinicians should consider empirical therapy with anti-enterococcal antibiotics for patients with prior EST.

A 75-year-old woman visited a hospital complaining of nausea and anorexia. She was diagnosed with stomach malignant lymphoma, and 6 courses of R-CHOP therapy were performed. Since complete remission was obtained, consolidation radiotherapy was decided. When performing radiation therapy on the stomach, it is desirable to carry it out in an empty stomach. For this reason, it is necessary to skip meals before irradiation. However, in this case, scar stenosis remained in gastric vestibular, and there was always a complaint of stomach discomfort. The treatment plan CT was taken without meals, and full stomach was observed. The patient was judged to be unavoidable due to an organic passage disorder, and a treatment plan was made with a full stomach, and radiotherapy was started. However, she was administered hangeshashinto from the first day of radiation therapy, and stomach discomfort quickly improved. CT was performed again, confirming that the stomach volume was reduced. In this case, in addition to scar stenosis in the stomach, it seems that functional dyspepsia was also involved. It is considered that the promoting effect on gastric emptying function of hangeshashinto was confirmed by CT images.

Background/Aims: Empiric antibiotics are given in combina-tion with biliary drainage for acute cholangitis but sometimes turn out to be insensitive to microorganisms in blood and bile. Clinical outcomes were compared according to sensitiv-ity to microorganisms detected in blood and bile culture to evaluate the impact of sensitivity to empiric antibiotics in cholangitis. Methods: Consecutive patients who underwent biliary drainage for acute cholangitis were retrospectively studied. Clinical outcomes such as 30-day mortality, length of hospital stay and high care unit stay, organ dysfunction and duration of fever were compared in three groups: group A (sensitive to both blood and bile culture), group B (sensitive to blood culture alone) and group C (insensitive to both blood and bile culture). Results: Eighty episodes of cholangitis were classified according to sensitivity results: 42, 32 and six in groups A, B and C. Escherichia coli and Klebsiella were two major pathogens. There were no significant differences in 30-day mortality rate (7%, 0%, and 0%, p=0.244), length of hospital stay (28.5, 21.0, and 20.5 days, p=0.369), organ dysfunc­tion rate (14%, 25%, and 17%, p=0.500), duration of fever (4.3, 3.2, and 3.5 days, p=0.921) and length of high care unit stay (1.4, 1.2, and 1.7 days, p=0.070) in groups A, B and C. Empiric antibiotics were changed in 11 episodes but clinical outcomes appeared to be non-inferior even in 31episodes of cholangitis who were on inadequate antibiotics throughout the course. Conclusions Sensitivity of empiric antibiotics was not associated with clinical outcomes in acute cholangitis.

It has been reported that physical fitness of breast cancer patients is relatively lower due to the cancer treatment such as surgery, chemotherapy, or endocrine therapy. Previous studies have revealed that not only cardiorespiratory fitness but also muscle strength is lower among breast cancer patients than no disease women and these symptoms may aggravate the health-related quality of life. However, there is no study which has focused the physical fitness level in Japanese breast cancer survivors. The purpose of this study was to investigate the physical fitness level and the relationship between exercise habituation and physical fitness level in Japanese breast cancer survivors. Fifty breast cancer survivors participated in this study. Participants were assigned to either exercise habituation group (n=25) or non-exercise group (n=25). We evaluated exercise habituation using an original questionnaire and examined various physical fitness level. Body weight, body mass index, and percent body fat were significantly lower in the exercise habituation group than non-exercise group. T-score of cardiorespiratory fitness was significantly higher in the exercise habituation group than average Japanese women. These results suggested that exercise habituation is relative to body weight and cardiorespiratory fitness level in Japanese breast cancer survivors.