A 65-year-old man, who had undergone the aortic valve replacement with a Carpentier-Edwards pericardial bioprosthesis (CEP 25 mm) 18 years previously (at age 48), was admitted to our hospital with a diagnosis of acute heart failure due to acute aortic regurgitation. Redo surgery was performed. The ascending aorta was cross clamped, and cardiac arrest was induced, and aortotomy was done. One of the leaflets of the CEP was entirely collapsed and dislocated to the LV side, which caused acute aortic regurgitation. Although there was no evidence of endocarditis, the other two leaflets of CEP were severely calcified. Aortic valve replacement was performed with a CEP 23 mm. He was discharged in good condition on the 16th post-operative day.

We reported an operative case of bilateral coronary arteries to pulmonary artery fistula with giant saccular aneurysm. This 68 year-old female was admitted for evaluation of chest oppression and heart murmur. On coronary angiography, the diagnosis was made as a coronary artery fistula originating from right coronary artery and left anterior descending artery, and draining into the main pulmonary artery. The operation was indicated by giant saccular aneurysm, high shunt ratio, and positive finding of ischemic change on exercise electrocardiogram. The closure of coronary fistula and aneurysmorrhaphy were performed under cardiopulmonary bypass. The aneurysm was 25×30mm diamater, and not found arteriosclerotic change in operative finding. The fistula was completely disappeared by postopertive coronary angiography. We concluded that curative operation for coronary artery fistula with giant aneurysm can be done with minimal risk under cardiopulmonary bypass.

An 89-year-old woman had undergone a medical examination and treatment due to exertional dyspnea symptom and cardiac enlargement, but her symptoms had not improved. According to images from a computed tomography scan, a huge intrapercardial mass excluding the heart was detected, and the patient was referred to our department for surgical treatment. Because of cardiac failure due to the mass excluding the heart, we planned to excise the tumor for cure and also for diagnosis. We did not distinguish the tumor before operation as is often the case with cardiac tumor. The tumor arose from the epicardium of the left ventricular (LV) anterior wall, and was attached to the LV wall with a broad stalk (approximately 3×10 cm) along the left anterior descending coronary artery (LAD). We had to operate under cardiopulmonary bypass and cardiac arrest, since the tumor involved the LAD, so we underwent resection of a part of the LAD. The patient was discharged uneventfully on postoperative day 37. On histopathology, the tumor was diagnosed as a solitary fibrous tumor (SFT) of the epicardium. Cardiac SFTs are rare. Above all, SFTs arising from LV epicardium are very rare. We report this case with some literature review.

Behcet's disease is generally recognized as a chronic multi-system disease. Approxymately 8% of patients with Behct's disease will have serious vascular compilcations which is called vasculo-Behcet's disease. A male patient of 41 year old was admitted to our clinic, complaining pain of left popliteal fossa and hypesthesia of left lower leg. A popliteal aneurysm was found. Resection of the aneurysm and a saphenous vein graft were successfully performed. Neuropathy disappeared after the surgery. Aneurysms in Behcet's disease mainly appear in major arteries, and rarely in peripheral arteries. Compression neuropathy in the popliteal aneurysm of Behcet's disease has been rarely reported. Early resection of aneurysm before completion of neuropathy is recommended for succsessful outcome.

A 69-year-old man was admitted for treatment of thoracic aneurysm. DSA revealed multiple aortic aneurysms: three true aneurysms which were located at the distal arch, the thoraco-abdominal aorta at the diaphragm level and the infrarenal abdominal aorta, 60mm, 55mm and 55mm in diameter, respectively and two pseudo-aneurysms which were located in the abdominal aorta just below the right renal artery and the right common iliac artery. We decided to perform a two-staged operation. Before the first operation, 1, 200ml of autologous blood was stored for perioperative blood transfusion. Initially, total arch replacement was performed using deep hypothermic circulatory arrest and antegrade selective cerebral perfusion. One month after the first operation, total thoraco-abdominal aorta replacement was performed by a retroperitoneal approach with mild hypothermia. The Th 9, 10 and 11 intercostal arteries were reconstructed. Distal anastomosis was performed at both common iliac arteries. Blood transfusion was not required for blood pooling and reduction of priming volume in the cardiopulmonary bypass system.

  The incidence of fever in children admitted to general hospitals is very high. Provision of adequate nutrition and fluid supplements to febrile children is very important, but with some children it is difficult to maintain an adequate intake. To address this problem, we devised a new ‘febrile children's menu’, utilizing preparation methods and foods to produce a palatable menu for patients with fever.
  We introduced this ‘febrile children's menu‘ on January 6, 2011, providing it to 109 patients (age range: 1 to 8 years, average age: 3.3±1.9 years) over the ensuing 3-month period. We provided a mean 4.0±2.9 meals per day to each patient during their febrile stage (≥37.5°C). To evaluate the usefulness of the ‘febrile children's menu’, we investigated eating rates during the febrile period in all patients who had been provided with the menu, and performed a questiomaire survey on their parents/guardians. The mean eating rates during the febrile period were 39±30% for main meals, and 28±22% for side dishes. No significant difference was seen in the eating rates during the febrile period recorded over the 2-month period prior to introduction of the new menu to 112 febrile children (age range: 1 to 8 years, average age: 3.3±2.1 years), 39±30% for main meals, and 29±22% for side dishes. The questionnaire survey was responded by 43 parents/guardians (a recovery rate of 39%). The ‘febrile children's menu’ was assessed as ‘good’ by 67% of respondents, representing an overall favourable impression from the parents/guardians. With reference to the survey results, we will attempt to further improve the ‘febrile children's menu’ with the aim of increasing eating rates during the febrile period.

OBJECTIVES: As the population ages, the number of lumbar spinal surgeries performed on sarcopenic patients will increase. The purpose of this study was to investigate the prevalence of sarcopenia and evaluated its impact on the results of lumbar spinal surgery. METHODS: This study included 2 groups: One group consisted of patients who underwent whole-body dual-energy X-ray absorptiometry (DXA) scanning before the option of undergoing surgery for lumbar spinal disease (LSD group) and a second group consisted of patients underwent DXA scanning for osteoporosis screening under hospital watch at the geriatric medicine department (control group). In order to evaluate the impact of sarcopenia on the clinical outcome of lumbar spinal surgery, the Japanese Orthopedic Association (JOA) score, the recovery rate based on the JOA score, and visual analogue scale (VAS) scores for lower back pain, lower extremity pain, and lower extremity numbness were compared within the LSD group. RESULTS: The prevalence of sarcopenia showed no statistical difference between groups (control group, 50.7%; LSD group, 46.5%). In the LSD group, while the changes in VAS scores showed no statistical difference between the nonsarcopenia subgroup and sarcopenia subgroup, the sarcopenia subgroup demonstrated inferior JOA scores and recovery rates at the final follow-up when compared with the nonsarcopenia subgroup (P < 0.05). CONCLUSIONS: This study demonstrated a high prevalence of sarcopenia among the elderly populations in Japan and a negative impact of sarcopenia on clinical outcomes after lumbar spinal surgery.
Absorptiometry, Photon ; Aged ; Asian Continental Ancestry Group ; Follow-Up Studies ; Humans ; Hypesthesia ; Japan ; Low Back Pain ; Lower Extremity ; Lysergic Acid Diethylamide ; Mass Screening ; Orthopedics ; Osteoporosis ; Prevalence ; Sarcopenia ; Spinal Diseases

A 69-year-old woman was referred on suspicion of multiple bone metastases. She had undergone modified radical mastectomy for right breast cancer at age 40 years. Positron emission tomography revealed multiple bone metastases, and serum levels of CEA, CA15-3, and NCCST439 were elevated. The diagnosis was metastatic breast cancer. Pathological re-examination confirmed that the tumor cells were positive for estrogen receptor and progesterone receptor, and negative for HER2. Endocrine therapy with letrozole was initiated, followed by toremifene citrate as second-line therapy and exemestane as third-line therapy. Seventeen months later, she developed trouble walking because of lower-extremity edema, which was caused by a synovial cyst of the left hip joint. Although no other metastases were detected, S-1 was introduced (2 weeks followed by 1 week of rest) due to severe decline in quality of life. Six months after initiation of S-1, the synovial cyst disappeared and lower-extremity edema was improved. At 11 months after initiation of S-1, serum CA15-3 level had fallen to approximately within normal limits. As of now, although the tumor marker level has been rising gradually, no other metastases except for bone metastases have been detected and treatment is continuing.

Background/Aims: Digital single-operator cholangioscopy (DSOC)-guided mapping biopsy (DMB) and tube-assisted mapping biopsy (TMB) are two techniques used for preoperative evaluation of biliary tract cancer (BTC). However, data regarding the diagnostic performance of these techniques are limited. Methods: We retrospectively examined consecutive patients with BTC who underwent either technique at our institution between 2018 and 2020. We evaluated the technical success rate, adequate tissue acquisition rate, and diagnostic performance of these techniques for the evaluation of lateral spread of BTC. Results: A total of 54 patients were included in the study. The technical success rate of reaching the target sites was 95% for DMB and 100% for TMB. The adequate tissue acquisition rate was 61% for DMB and 69% for TMB. The adequate tissue acquisition rate was low, especially for target sites beyond the secondary biliary radicles. The sensitivity of DMB alone was 39%, which improved to 65% when combined with visual impression. Experts demonstrated a higher negative predictive value and diagnostic accuracy with respect to both DSOC visual impression and DMB for the evaluation of lateral spread of BTC compared to trainees. Conclusions Adequate tissue acquisition rates were similar between the two techniques. Since DMB requires expertise, TMB may be an acceptable option when DSOC is unavailable or when DSOC expertise is limited.

Background/Aims: Selective bile duct or pancreatic duct cannulation remains a significant initial hurdle in endoscopic retrograde cholangiopancreatography (ERCP) despite advances in endoscopy and accessories. This study evaluated our experience with a rotatable sphincterotome in cases of difficult cannulation. Methods: We retrospectively reviewed ERCP cases using TRUEtome, a rotatable sphincterotome, as a rescue device for cannulation at a cancer institute in Japan from October 2014 to December 2021. Results: TRUEtome was used in 88 patients. Duodenoscopes were used for 51 patients, while single-balloon enteroscopes (SBE) were used for 37 patients. TRUEtome was used for biliary and pancreatic duct cannulation (84.1%), intrahepatic bile duct selection (12.5%), and strictures of the afferent limb (3.4%). Cannulation success rates were similar in the duodenoscope and SBE groups (86.3% vs. 75.7%, p=0.213). TRUEtome was more commonly used in cases with steep cannulation angles in the duodenoscope group and in cases requiring cannulation in different directions in the SBE group. There were no significant differences in adverse events between the two groups. Conclusions The cannulation sphincterotome was useful for difficult cannulations in both unaltered and surgically altered anatomies. It may be an option to consider before high-risk procedures such as precut and endoscopic ultrasound-guided rendezvous techniques.