A 76-year-old man with a history of total esophagectomy and retrosternal gastric tube reconstruction for esophageal cancer was transferred to our hospital because of consciousness disorder. It became an emergency operation on diagnosis of Stanford type A acute aortic dissection on enhanced CT. Because CT showed the retrosternal gastric tube ran along the right side of the body of the sternum through the back side of the manubrium, we opted for skin and the suprasternal incision on the left side from center. We could perform total aortic arch replacement without the damage of the gastric tube except that the right side of the operative view was slightly poor. We did not recognize digestive organ symptoms such as postoperative passage disorders nor mediastinitis. The patient was discharged from our hospital on postoperative day 24.

Introduction: We report a case of intractable nausea of a terminal malignant lymphoma patient with diabetes, which improved by sublingual administration of asenapine. Case: A 78-year-old man suffering from diffuse large B-cell lymphoma with diabetes presented intractable nausea and vomiting. Those symptoms were thought to be due to masses and nodules in the right frontal lobe and the cerebellum, and/or due to edema in the peripheral brain parenchyma. Because it was difficult to take medicines orally, we selected injections to control those symptoms. However, the combination of metoclopramide, haloperidol, and hydroxyzine injections failed to relieve nausea. Olanzapine is effective against nausea but is contraindicated for diabetic patients, so asenapine, one of the multi-acting receptor-targeted antipsychotics the same as olanzapine, was expected alternatively. The patient was administrated asenapine sublingually 5mg once a day before bedtime. This administration of asenapine remarkably improved his nausea. Discussion: Sublingual asenapine dose may be an effective therapeutic option for intractable nausea.

In aortic surgery involving shaggy aorta, surgical strategy to avoid embolism is crucial for each case. We applied the frozen elephant trunk technique to a patient with shaggy aorta. A 79-year-old man was admitted to our hospital for conservative treatment of acute Type B aortic dissection. Dissecting aneurysms of the aortic arch and descending aorta were shown to have rapidly dilated according to CT three weeks later. Preoperative contrast CT showed an ulcerated shaggy aorta from the aortic arch to the mid portion of the descending aorta. To utilize the benefit of the stent compared with the classical elephant trunk technique, we proposed that the frozen elephant trunk technique would be helpful in prevention of embolism. We therefore planned total arch replacement with the frozen elephant trunk technique and performed thoracic endovascular aortic repair. We employed the frozen elephant trunk technique in the first operation and balloon protection of the superior mesenteric artery and the renal artery in the second operation. The patient had an uneventful postoperative course without thromboembolism. The frozen elephant trunk technique may be helpful for patients with shaggy aorta to avoid thromboembolic events.