We present a very rare case of abdominal aortic aneurysm associated with paraplegia. A 68-year-old man developed paraplegia following resection of a infrarenal abdominal aortic aneurysm. The aorta was clamped just below the renal arteries. In this case interruption of the radicular artery magna (RAM; Adamkiewicz artery) might have caused serious ischemia of the spinal cord. Spinal cord ischemia is a very rare and unpredictable complication in surgery of infrarenal abdominal aortic aneurysms because the spinal cord is generally protected from irreversible ischemia during infrarenal aortic occlusion by the presence of the RAM which arises above the renal artery (Even if RAM interruption might arise, the lower renal artery, and other radicular arteries are usually present above the renal arteries). We feel that reducing aortic cross-clamping time as short as possible and avoiding intra- and postoperative hypotensive episodes to keep adequate blood flow of collaterals seem to be the most important factors to prevent spinal cord ischemia.

The patient was a 71-year-old man who had been treated for Parkinson's disease for 21 years. He was admitted because nocturnal dyspnea occurred several times. Echocardiography revealed congestive heart failure because of combined mitral and aortic regurgitation. Double valve replacement was planned. There was a risk of the occurrence of neuroleptic malignant syndrome (NMS) if his drugs for Parkinson's disease were stopped suddenly, so careful control of drug doses was required. Although the patient developed aggravation of his Parkinson's symptoms, careful observation and adjustment of medications prevented the occurrence of NMS.

Objective To monitor the systemic gene expression profile in a murine model of li-popolysaccharide (LPS)-induced acute lung injury by the recently modified long serial analysis of gene expression (SAGE) so as to discuss the molecular mechanism of acute lung injury. Methods Acute lung injury was induced by intra-tracheal injection of LPS (25 mg/kg). Control mice were given normal saline in same volume. Animals were killed at 24 hours after the administration of LPS and lungs were harvested en bloc for SAGE study. Results A total of 24 670 tags representing 12 168 transcripts in the control mice and 26 378 tags representing 13 397 transcripts in the mice with lung injury were identified respectively. There were 11 transcripts increased more than 10 folds, 107 transcripts 5-10 folds and 2 121 transcripts 2-5 folds in the LPS-treated mice. But seven transcripts decreased to 1/10, 87 transcripts to 1/10-1/5 and 1 571 transcripts to 1/5-1/2. The most overexpressed genes in the lung injury mice mainly included serum amyloid A 3, metallothionein 2, lipocalin 2, cyclin-dependent kinase inhibitor 1A, lactate dehydrogenase 1 , melatonin receptor, SI00 calcium-binding protein A9 and natriuretic pep-tide precursor. Mitogen activated protein kinase 3, serum albumin, complement component 1 inhibitor, and ATP synthase were underexpressed in the lung injury mice. Conclusion The changes of various genes as well as some unreported genes have been confirmed in the LPS-induced acute lung injury. Further studies of these unreported genes are beneficial to better understanding the mechanism of acute lung injury and may provide useful markers for clinical diagnosis.

A study was conducted to evaluate the clinical and hemodynamic performance of the 19-mm Medtronic Mosaic Valve (MMV) in the aortic position, which is a third-generation stented porcine bioprosthesis. Between 2003 and 2006, 9 patients underwent AVR using the 19-mm MMV. None of the patients were suitable for a 19-mm Perimount bioprosthetic valve due to having a small annulus and sinotubular junction. The patients included 3 men and 6 women with a mean age of 73.2±4.97 years and mean body surface area of 1.35±0.11m². Preoperatively, 8 patients were in New York Heart Association class II and 1 was in class III. The reason for surgery was aortic stenosis in 8 patients and aortic regurgitation due to infective endocarditis in 1 patient. Four patients had chronic renal failure and were on hemodialysis, while 1 patient had Crohn's disease. Concomitant coronary artery bypass grafting was performed in 3 patients, and tricuspid valve annuloplasty was done in 1 patient. The follow-up period was 12.0±7.71 months. No deaths occurred, but there was 1 cerebral infarction. Postoperatively, the peak pressure gradient decreased from 81.3±32.7 to 40.3±16.3mmHg (p<0.01). The mean pressure gradient also decreased significantly from 48.8±11.6mmHg to 23.9±9.32mmHg (p<0.01). Left ventricular end-diastolic diameter was 47.9±3.82mm preoperatively and 45.1±7.53mm postoperatively, showing no significant change. The left ventricular mass index also improved from 217.3±46.9 to 160±54.9g/m² (p<0.05). The ejection fraction was 72.0±8.93% preoperatively and 67.6±6.37% postoperatively, showing no difference. Although the postoperative indexed effective orifice area (EOAI) was 0.90±0.11cm²/m², mild patient-prosthesis mismatch (EOAI 0.77cm²/m²) was noted in 1 patient. In conclusion, the early clinical and hemodynamic performance of the 19-mm MMV in small elderly patients was acceptable.

A 38-year-old woman was referred to our hospital for treatment of infective endocarditis associated with abscesses in the brain and the left lower limb. A causative organism had not been detected by serial blood cultures. Preoperative brain CT revealed mycotic aneurysms and echocardiography showed a mobile vegetation (8mm in size) on the anterior leaflet of the mitral valve. We performed resection of the vegetation together with a small triangle of the anterior leaflet, after which the margins of the defect were approximated. Then bilateral Kay procedures and reinforcement with autologous pericardium were done to obtain proper coaptation. The patient's fever, left lower limb pain, and intracerebral mycotic aneurysms resolved after surgery. The brain abscess also became smaller. Mitral valve plasty should sometimes be considered in the active phase of endocarditis, even in patients with cerebral complications and without congestive heart failure.

　　Pancreatic neuroendocrine tumors, relatively rare cancers, mostly arise in the pancreatic parenchyma with infrequent involvement of the main pancreatic duct. Now and then, however, case reports have been published on pancreatic neuroendocrine carcinoma in which the main pancreatic duct is obstructed by tumor cells with severely fibrous stromal cells. Here, in this paper, we report a case of pancreatic neuroendocrine carcinoma with obstruction of the main pancreatic duct. A 59-year-old man complained of right upper abdominal pain. Magnetic resonance cholangiopancreatography and fat-suppressed T1-weighted magnetic resonance imaging showed gallbladder stones, a low-intensity-area measuring 8 mm in diameter in the pancreatic body, and club-shaped dilatation at the distal end of the pancreatic duct. The patient was thus diagnosed with a tumor in the pancreatic body and cholecystolithiasis, and underwent distal pancreatectomy and cholecystectomy. HE-staining showed tumor cells with eosinophilic cytoplasm and nuclear atypia. The infiltrative growth of the cells with severe fibrosis caused stenosis of the pancreatic duct. Based on the positive results of immunohistochemical staining for chromogranin A and synaptophysin and the Ki-67 index, the tumor was finally identified as pancreatic neuroendocrine carcinoma. The patient has been under follow-up with no additional treatment for >3 years since the surgery, without evidence of tumor recurrence.

Perivalvular leakage (PVL) is one of the serious complications of mitral valve replacement. Between 1991 and 2006, 9 patients with mitral PVL underwent reoperation. All of them had severe hemolytic anemia before surgery. The serum lactate dehydrogenase (LDH) level decreased from 2,366±780 IU/l to 599±426 IU/l after surgery. The site of PVL was accurately defined in 7 patients by echocardiography. PVL occurred around the posterior annulus in 3 patients, anterior annulus in 2, anterolateral commissure in 1, and posteromedial commissure in 1. The most frequent cause of PVL was annular calcification in 5 patients. Infection was only noted in 1 patient. In 4 patients, the prosthesis was replaced, while the leak was repaired in 5 patients. There was one operative death, due to multiple organ failure, and 4 late deaths. The cause of late death was cerebral infarction in 1 patient, subarachnoid hemorrhage in 1, sudden death in 1, and congestive heart failure (due to persistent PVL) in 1. Reoperation for PVL due to extensive annular calcification is associated with a high mortality rate and high recurrence rate, making this procedure both challenging and frustrating for surgeons.

　　Among visceral artery aneurysms, those arising in the region of the pancreatic duodenal artery due to celiac artery stenosis are rare. We report a surgical case with stenosis caused by dissecting celiac artery aneurysms and multiple aortic aneurysm rupture in the pancreaticoduodenal region. A 72-year-old man with a history of distal gastrectomy for gastric cancer was carried into our hospital by ambulance for acute abdominal pain. CT scans showed dissected aneurysms of the root of the celiac artery and hepatic artery as well as massive retroperitoneal hematoma around the pancreaticoduodenum and intraperitoneal hemorrhage. Arteriography of the superior mesenteric artery revealed multiple aneurysms of the pancreaticoduodenal artery that might have caused rupture. In the late phase, retrograde flows in the gastroduodenal, hepatic, celiac, and splenic arteries from the pancreaticoduodenal artery were contrast-enhanced. Because it was thought that transcatheter arterial embolization or surgical aneurysmectomy for pancreaticoduodenal aneurysms could prevent blood flow in all circulating branch arteries of the celiac artery, leading to extensive organ ischemia, the gastric pouch, spleen, entire pancreas, and gallbladder were resected. The patient has been doing well.

Carotidynia is characterised by inflammation limited to the common carotid artery, which has been recognised as a distinct disease entity by advanced vascular imaging. Although most cases of carotidynia are idiopathic, we herein present a case of carotidynia after anticancer chemotherapy. A 64-year-old male patient received docetaxel followed by granulocyte-colony stimulating factor (G-CSF) for the treatment of lung squamous carcinoma. After the treatment, bilateral cervical pain developed. Vascular imaging, including magnetic resonance imaging, computed tomography and ultrasonography, showed characteristics specific for carotidynia. Although there was no strong confirmation using tests such as a challenge test, our observations suggest that docetaxel or G-CSF could be a causative drug triggering carotidynia.
Antineoplastic Agents ; adverse effects ; Carotid Artery, Common ; drug effects ; pathology ; Granulocyte Colony-Stimulating Factor ; adverse effects ; Humans ; Inflammation ; chemically induced ; Lung Neoplasms ; drug therapy ; Magnetic Resonance Imaging ; Male ; Middle Aged ; Neoplasms ; drug therapy ; Taxoids ; adverse effects ; therapeutic use ; Tomography, X-Ray Computed ; Treatment Outcome ; Ultrasonography

Background/Aims: Intralesional steroid injections have been administered as prophylaxis for stenosis after esophageal endoscopic submucosal dissection. However, this method carries a risk of potential complications such as perforation because a fine needle is used to directly puncture the postoperative ulcer. We devised a new method of steroid intralesional infusion using a spray tube and evaluated its efficacy and safety. Methods: Intralesional steroid infusion using a spray tube was performed on 27 patients who underwent endoscopic submucosal dissection for superficial esophageal cancer with three-quarters or more of the lumen circumference resected. The presence or absence of stenosis, complications, and the number of endoscopic balloon dilations (EBDs) performed were evaluated after treatment. Results: Although stenosis was not observed in 22 of the 27 patients, five patients had stenosis and dysphagia requiring EBD. The stenosis in these five patients was relieved after four EBDs. No complications related to intralesional steroid infusion using the spray tube were observed. Conclusions Intralesional steroid infusion using a spray tube is a simple and safe technique that is adequately effective in preventing stenosis Clinical trial number (UMIN000037567).