A 61-year-old man underwent thoracic aortic graft replacement and abdominal aortic graft replacement because of a dissecting aneurysm. He presented with a ruptured residual dissecting thoraco-abdominal aortic aneurysm and underwent emergency thoraco-abdominal aortic graft replacement in February 2007. An inverted bifurcated graft was fashioned by cutting one of the two graft legs and creating an elliptical patch, like a cobra-head. In order to prevent paraplegia after the operation, it was necessary to shorten the duration of spinal cord ischemia. Once the elliptical patch was sutured to the orifices of the internal costal arteries with running sutures, selective intercostal arterial perfusion was initiated by using a cardiopulmonary bypass. After the operation, he did not suffer paraplegia.

Thoracic graft infection is a serious complication and has high mortality. We report a case of successful treatment of graft infection after ascending thoracic aortic reconstruction. A 66-year-old woman underwent surgery for DeBakey type I aortic dissection in June 2007. The ascending aorta was replaced with a prosthetic graft. Although her postoperative course was complicated with Methicillin-resistant Staphylococcus aureus (MRSA) mediastinitis, the infection was conservatively controlled by mediastinal lavage and antibiotics. However, she was readmitted in April 2008 due to lumbar pain and high fever, and was diagnosed with infectious spondylitis. Lumbar plastic surgery was performed. During hospitalization, she underwent total systemic examination. The results indicated aneurysm of the ascending aorta. MRSA was detected from culture fluid of her blood. Taken together, the presence of an infected aortic aneurysm was considered possible. Consequently, reconstruction of the ascending aorta using two allografts was performed after removing the prosthetic graft. The postoperative course was uneventful, and she was discharged on the 71st postoperative day. The patient continues to thrive 9 months after the operation. This case of an infected aortic aneurysm repaired with the use of allografts will be reported together with references to the literature.

Seven patients underwent surgical repair of the distal aortic arch aneurysm from January 1990 to October 1997. They were 5 men and 2 women ranging from 63 to 78 years of age (mean, 72.7 years). All patients were operated with a median sternotomy only. There was one operative death, which was ruptured case. However, there were no major complications in non-ruptured cases. This retrospective study suggests that it is possible to repair the distal aortic arch aneurysm through a median sternotomy approach alone, when 1) descending aorta originates with normal size just distal to sacciform aneurysm, 2) the maximum diameter of the aneurysm is over 70mm and 3) distal involvement of the aneurysm does not extend beyond the bifurcation of the trachea. It is useful to retract descending aorta proximally by three threads with pledget for distal anastomosis in inclusion technique.

Direct coronary artery reimplantation to the aorta and mitral valve repair were successfully performed in a 29-year-old female with Bland-White-Garland syndrome (BWG syndrome). Under cardiopulmonary bypass, the main pulmonary artery was completely transected and the left coronary artery was excised with a cuff of pulmonary artery wall. Then the left coronary artery was directly anastomosed to the ascending aorta. Mitral regurgitation was repaired with valvulo-annuloplasty. The post operative course was excellent.

A 58-year-old man was admitted because of enlargement in diameter of the descending thoracic aorta. Six years previously, he had undergone graft replacement of the proximal descending aorta due to a chronic dissecting aneurysm. During that surgery, distal fenestration involving resection of the intimal flap of the distal anastomotic site and graft replacement with distal anastomosis of the true and false lumen were performed. Our preoperative enhanced computed tomography (eCT) revealed a thoracic aortic aneurysm 58mm in diameter at the site of distal fenestration. Graft replacement through left lateral thoracotomy was considered difficult because of previous occurrence of methicillin-resistant Staphylococcus aureus (MRSA) empyema after the previous operation: hence, endovascular repair was done using a handmade stent graft to interrupt blood flow into the false lumen. The postoperative course was uneventful. Postoperative eCT showed the thrombosed false lumen and the shrinkage of the aneurysm from 58 to 38mm in diameter over a period of 18 months.

We describe a novel method for repeat median sternotomy. We have successfully used ‘finger’ lifting resternotomy technique and achieved zero major cardiovascular injury/catastrophic hemorrhage events at reoperation. After general anesthesia, all patients were placed in the supine position and two external defibrillator pads were placed on the chest wall. We perform a median skin and subcutaneous incision along the previous sternotomy incision extending 3 cm distal to the sternum. The sternal wires that had been used for the previous closure were left in place but untied. Using a long electric cautery, right thoracotomy was performed under the right costal arch approach. Then, the operator could approximate the sternal wires in the retro-sternal space. At the same time, the operator could confirm the retro-sternal adhesion status which by touching with a finger. Resternotomy was performed using an oscillating saw pointed toward the operator's finger, which allowed safe re-median sternotomy from the lower to the upper part of the sternum. This technique of finger-lifting resternotomy has been employed in 50 cardiovascular reoperations and resulted in 0 incident of major cardiac injury or catastrophic hemorrhage. The finger-lifting resternotomy technique is safe and simple in reoperation procedures and yield excellent early outcomes.

The patient was a 52-year-old man with a history of antiphospholipid syndrome (APS), renal dysfunction and myasthenia gravis (MG). On May 2, 1998, he had sudden chest pain while sleeping. Enhanced computed tomography revealed acute aortic dissection (DeBakey type I). We performed emergency graft replacement of the ascending aorta and the aortic arch under extracorporeal circulation. Because of perioperative anuria, we used peritoneal dialysis (PD) just after the operation. Two days after the operation, we performed re-intubation nine hours after the extubation of the tracheal tube, and performed re-extubation three days later. For a while, his postoperative course was uneventful, but because of gradual worsening of APS, we administered more prednisolone, but 74 days after the operation, he died of multiple organ failure caused by an opportunistic infection, sepsis, and disseminated intravascular coagulation. This was very rare case of acute aortic dissection with MG and APS. After administration of more glucocorticoids, it is important to be wary of opportunistic infections.

BACKGROUND/AIMS: Left-sided diverticulitis is increasing in Japan, and many studies report that left-sided diverticulitis is more likely to be severe. Therefore, it is important to identify the features and risk factors for left-sided diverticulitis. We hypothesized that left-sided diverticulitis in Japan is related to obesity and conducted a study of the features and risk factors for this disorder in Japan. METHODS: Right-sided diverticulitis and left-sided diverticulitis patients (total of 215) were compared with respect to background, particularly obesity-related factors to identify risk factors for diverticulitis. RESULTS: There were 166 (77.2%) right-sided diverticulitis patients and 49 (22.8%) left-sided diverticulitis patients. The proportions of obese patients (body mass index > or =25 kg/m2, p=0.0349), viscerally obese patients (visceral fat area > or =100 cm2, p=0.0019), patients of mean age (p=0.0003), and elderly patients (age > or =65 years, p=0.0177) were significantly higher in the left-sided-diverticulitis group than in the right-sided-diverticulitis group. The proportion of viscerally obese patients was significantly higher in the left-sided-diverticulitis group than in the left-sided-diverticulosis group (p=0.0390). CONCLUSIONS: This study showed that obesity, particularly visceral obesity, was a risk factor for left-sided diverticulitis in Japan.
Aged ; Diverticulitis ; Humans ; Japan ; Obesity ; Obesity, Abdominal ; Retrospective Studies ; Risk Factors

Opioids are known to cause dysfunction of the sphincter of Oddi. However, there are no reports on acute cholangitis due to opioid-induced dysfunction of the sphincter of Oddi. A 75-year-old woman with breast cancer, who had been prescribed oxycodone for lower abdominal pain due to unknown causes for 8 years, suddenly developed hypochondriac pain. We diagnosed the patient as having acute cholangitis and performed endoscopic retrograde pancreatography and technetium hepatobiliary iminodiacetic acid scan. The cause of acute cholangitis was considered to be opioid-induced dysfunction of the sphincter of Oddi. Six and nine days after admission, endoscopic sphincterotomy was performed, after which her upper abdominal pain resolved. Opioids increase biliary pressure and delay bile flow into the duodenum in patients after cholecystectomy. However, the actual clinical outcomes of using opioids for acute cholangitis and pancreatitis remain unknown. Thus, although opioid-induced dysfunction of the sphincter of Oddi is uncommon, it should be assessed in patients who are prescribed opioids.