A 62-year-old man was admitted to our hospital because of acute aortic dissection (DeBakey type III b). Inflammatory findings were detected and methicillin-resistant staphylococcus aureus (MRSA) was detected by blood culture. Appropriate antibiotic therapy was begun but was ineffective. Repeated CT scans revealed dilation of the false lumen with thrombus and perianeurysmal inflammatory change in the lung. A diagnosis of infected aortic dissection was made. The patient was treated by resection of the descending aorta and placement of an in situ Dacron graft covered with a pedicled omental flap. An infected thrombus in the false lumen was confirmed by a positive MRSA culture. Computed tomography was found to be more sensitive in the diagnosis of infected aortic dissection. When the infection is not controlled with antibiotics, prompt surgical treatment should be performed.

We treated 261 arteriosclerosis obliterans cases with critical leg ischemia since 1976. Those patients aged 75 years and older were designated as the elderly group and were compared with those under 75 years of age. Among the elderly patients with critical leg ischemia, the percentages of women and Fontaine scale IV cases were higher. The condition of those who had to undergo an initial major amputation was often complicated by cerebrovascular diseases, resulting in a higher early death rate after operation. Therefore, the necessity of early diagnosis and immediate treatment must be emphasized. There were no differences in patency and limb salvage rates between the two groups. In cases of arterial reconstruction however, graft occlusion in the elderly group immediately after operation was frequently observed. It is important to include drug therapy in follow-up to prevent occlusion of the graft following surgery in elderly patients.

A 27-year-old man had received Bentall's operation for annuloaortic ectasia with Marfan's syndrome 4 years previously. He was admitted to our hospital because of sudden abdominal pain and lumbago. The abdominal pulsatile mass with tenderness was palpated and dilatation of abdominal aorta was revealed by abdominal ultrasonography. An emergency operation was performed under a diagnosis of ruptured abdominal aortic aneurysm. At operation, the infrarenal abdominal aorta formed a fusiform aneurysm of which maximum diameter was 6cm. The aneurysm had a thin wall, and ruptured opening about 2cm in diameter at the posterior wall, but no thrombus inside. Graft replacement was done from the infrarenal abdominal aorta to the bilateral common iliac artery using knitted Dacron vascular prosthesis, and reconstruction of inferior mesenteric artery with wrapping of the proximal anastomosis were performed. Histopathological examination of the aneurysmal wall revealed medial necrosis and degeneration, by which Marfan's syndrome was diagnosed. Although abdominal aortic aneurysm is rarely associated with Marfan's syndrome, it often shows rapid development and has a high risk of rupture. Therefore, we suggest that strict observation and early operation are important for abdominal aortic aneurysm associated with Marfan's syndrome.

During 23 years, 224 cases underwent graft replacement of thoracic aortic aneurysms at our institution. Of these, 14 cases suffered postoperative vascular graft infection. Out of the 14 cases, 13 cases had sternal or mediastinal infections, and one case showed sepsis without these deep wound infections. Six cases were positive by blood culture. We thought that sternal or mediastinal infections had a high possibility of contamination of vascular grafts and that cases with these deep wound infections should be treated as cases of graft infection. Reoperation was done urgently soon after the diagnosis of infection was made. When the wound was not so deep, only debridement was performed. In addition to debridement, continuous irrigation through a chest tube and, recently, pedicled omental flap placement were done, when the wound was deep. Except for the one case without deep wound infection, 13 cases were reoperated. There were 4 hospital deaths; 3 operated cases and the nonoperated case, due to lack of control of their infection. Blood culture were positive in all these four cases. The other 10 cases were discharged from hospital without infection. Infection of vascular grafts after operation for thoracic aortic aneurysms is a serious complication and urgent reoperation should be done. However it should be noted that the mortality rate of cases with positive blood culture is high.

Twenty-two patients who underwent vascular reconstruction for carotid occlusive disease by April 1998 were examined in terms of long-term results. The cause of disease was atherosclerosis in 16, and aortitis in 6. The operation method included CEA in 11 and bypass in 5 cases in the atherosclerosis cases, and CEA in 2 and bypass in 6 cases in aortitis. Cases of occlusive disease included 1 early occlusion (atherosclerosis) and 4 late occlusion (atherosclerosis 2, aortitis 2). The cause of early occlusion was considered to be due to technical factors, but late occlusion was thought to be related to progression of disease, anastomotic intimal thickening, and recurrence of inflammation. It is important to enforce strict operative indications, accurate intraoperative monitoring, and perioperative drug control.

A 26-year-old man was suffered a tendon injury in the left knee when playing American football 3 years previously and was treated consevatively. He was admitted to our hospital because of coldness and paresthesia in the left leg since 2 months previously. Femoral angiogram revealed severe stenosis of left popliteal artery and occlusion of the anterior and posterior tibial artery. CT and MRI examination revealed a tumor which protruded into the lumen of the left popliteal artery or dissection of left popliteal artery. Operation was performed by a posterior approach. The left popliteal artery was not compressed from the lateral side and there was a white thrombus in the popliteal artery. Thromboendartherectomy and autologus venous patch plasty was done. Histopathological findings of the stenotic lesion revealed an organizing thrombus, chiefly consisting of fibrin, and intima both of which were infiltrated by granuration tissue. It was suggested that the stenotic lesion was caused by arterial wall hyperplasia or thrombus formation during the healing process after blunt arterial injury. The post-operative course was uneventful.

Endoscopic submucosal dissection (ESD) has enabled en-bloc resection of superficial gastrointestinal tumors regardless of the size or location of the tumor. However ESD still poses a number of challenges for the experienced endoscopist. These challenges include the adaptation of a demanding technique, the higher incidence of complications, and a longer procedure time compared to standard endoscopic procedures. In this article, we describe the performance of ESD using the Flush Knife technique. We emphasize that the most important factor in the performance of ESD using the Flush Knife technique is maintaining the appropriate depth of dissection. Appropriate dissection of the branched vascular network at the mid-submucosal layer is required to reach the avascular stratum just above the muscle layer. This should be accomplished using the horizontal approach, such that the dissection plane remains as horizontal as possible with respect to the muscle layer. This approach will enable the interventional endoscopist to treat difficult cases with large vessels and severe fibrosis. And at the same time will secure high-quality resected specimens with excellent basal margins so that depth of invasion can be assessed very accurately.
Fibrosis* ; Incidence ; Stomach Neoplasms

Purpose: This study investigated the effects of preoperative nutritional status on postoperative outcomes in older adult patients with pancreatic adenocarcinoma. Methods: The background and perioperative factors of patients who underwent pancreatectomy for pancreatic adenocarcinoma between 2007 and 2020 were retrospectively analyzed. Results: Patients aged 75 years or over (older adults) were significantly associated with hypertension, upfront surgery, and lower prognostic nutritional index. In addition, these patients had a significantly lower rate of portal vein resection, less blood loss, and shorter operation time than patients aged less than 75 years (non-older adults). During the postoperative course, older adult patients had a higher rate of pneumonia and lower overall survival than younger patients, although recurrence‐free survival was comparable. In addition, older adult patients showed preoperative malnutrition as a risk factor for postoperative in‐hospital death. Conclusion Surgical treatment for pancreatic cancer in older adult patients was performed safely. However, preoperative malnutrition is a risk factor for in‐hospital death and such patients require nutritional support and less‐invasive surgery.