Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital anomaly. This anomaly occurs in approximately one in 300,000 live births. Of the children diagnosed with this syndrome, 90% die within the first year of life because of myocardial ischemia and left ventricular failure. Survival into adulthood is rare and depends upon pre-existing or rapidly developing collateral vessels between the right and left coronary artery. This report concerns the surgical case of anomalous origin of the circumflex coronary artery from the left pulmonary artery complicated with atrial septal defect (ASD). A 34-year-old woman was admitted because of dyspnea on exertion. Echocardiography revealed normal cardiac function with secondary ASD. Coronary catheterization revealed an anomalous origin of the left circumflex coronary artery from the left pulmonary artery. Direct closure of the ASD and coronary artery bypass grafting for the circumflex coronary artery using an internal thoracic artery were performed, and the orifice of the circumflex coronary artery was ligated. The postoperative outcome was excellent. Most of the ALCAPA cases shows the main trunk of the left coronary artery arising from the pulmonary artery. This case demonstrates only the left circumflex coronary artery originating from the left pulmonary artery. Moreover ASD coexisted in this case. To the best of our knowledge, this is a very rare case of its type to be diagnosed and reported.

For patients with advanced heart failure, surgical left ventricular restoration (SVR) is an option usually evaluated by nuclear cardiac imaging, magnetic resonance imaging and ultrasonography. The clinical application of multi detector-row computed tomography (MDCT) has been increasingly extended to evaluate not only coronary artery stenosis, but also cardiac function, myocardial perfusion and viability. We report a successful surgical case of ischemic cardiomyopathy evaluated by MDCT in pre- and post-LVR. A 59-year old man was admitted to our hospital because of worsening heart failure. He had a history of coronary artery bypass grafting after myocardial infarction of the anterior wall at age 45 but had discontinued his medication 5 years previously. Ultrasonography showed poor left ventricular function, massive mitral regurgitation and a floating mural thrombus which required emergency surgery. In addition to conventional coronary angiography, electrographically-gated MDCT clearly described the complex coronary anatomy and stenosis, global and regional left ventricular function, and the relation between the mural thrombus and the scarred myocardium. Thrombectomy, LVR (overlapping type), coronary artery bypass grafting and mitral annuloplasty were performed. Postoperative MDCT showed improvement in left ventricular volume and function in the time-volume analysis, in wall thickness and wall thickening in both the SVR site and remote sites in four-dimensional volumetric imaing. Our case suggests that MDCT can be a valuable tool for the cardiac surgeon.

Transvenous pacemaker leads may impair tricuspid valve coaptation, and is a well-known cause of tricuspid regurgitation (TR). The mechanism underlying TR may be the perforation or laceration of the valve leaflets, direct lead interference with the valve closure, or adhesion of scar tissue between the leads of the pacemaker and the valve leaflet. Recently, three-dimensional echocardiography has clarified the pathway of the pacing lead and its interference with the tricuspid valve, but surgical treatment is not conventionally performed in the early stages of TR because of the necessity of the pacing lead. Occasionally, patients with TR develop severe right-sided heart failure, and the operative mortality in such conditions is very high. Thus, it is important to study the relationship between transvenous leads and TR. Tricuspid valve surgery is usually performed after replacing the transvenous lead with an epicardial lead. However removal of the transvenous lead may cause injury to the right ventricle, and ventricular chronic stimulation thresholds with epicardial stimulation have been shown to be significantly higher than those with endocardial stimulation. We performed TR surgery in 5 patients without removing the transvenous leads. To avoid interference with the valve closure, we shifted the pacemaker leads to the commissure and fixed them to the annulus. All the patients underwent successful tricuspid valve repair or replacement, and the symptoms of right-sided heart failure improved after the operation. We concluded that this technique is a very simple, and feasible method for treatment of most patients with TR caused by pacing leads.

A 75-year-old man was admitted to our hospital because of severe aortic stenosis associated with fainting spells. He had undergone coronary artery bypass grafting at the age of 66, and had progressive aortic stenosis for 9 years. Ultrasound showed left ventricular hypertrophy and a calcified aortic valve. The aortic valve area was 0.34 cm² and the mean pressure gradient was 56 mmHg. Multi detector-row computed tomography showed patent bypass grafts (LITA-LAD, SVG-OM-PL, and SVG-RCA) and a persistent left superior vena cava (PLSVC). Coronary angiography revealed total occlusion of all the 3 native coronary arteries, therefore, antegrade cardioplegic perfusion was impossible. Retrograde perfusion was also impossible because of the PLSVC. We had to clamp the LITA and infuse the cardioplegic solution through the SVG graft to obtain cardioplegic arrest. Performing aortic valve replacement (AVR) on a beating heart facilitates the operation, because it negates the need to clamp the patent bypass graft and the PLSVC. We exposed a minimal area of the operating field, ascending aorta, and right atrium. Cardiopulmonary bypass was established by cannulating the ascending aorta and right atrium. The right pulmonary vein was cannulated for left ventricular venting. The ascending aorta was cross clamped on the proximal side of the SVG. AVR was thus performed using the standard approach on the beating heart with coronary perfusion through the bypassed graft. The postoperative course was uneventful, and the patient was discharged 15 days postoperatively. Redo surgery is more complex than primary surgery and is associated with higher mortality and morbidity. Beating heart surgery is one of the optional methods in such a complex case.

A 57-year-old woman was admitted with intermittent bleeding and pus discharge from her right anterior chest. She had undergone radical mastectomy (Halsted operation) and irradiation for breast cancer 11 years previously. Skin ulcer with a bleeding fistula had appeared at the right clavicular region 6 months previously. An emergency operation was performed, since angiography revealed brachiocephalic pseudoaneurysm with fistulation to the skin. The brachiocephalic artery was exposed through a right cervical and middle sternal incision. The brachiocephalic artery was interposed with two segments of the great saphenous vein joined to make a proper graft in size. The infected area was filled by the greater omentum. A pedicle flap was used to close the large skin defect after removing the fistula. The postoperative course was uneventful and infection improved soon after the operation. The patient was discharged about one month after the operation. We reported a rare case of infected brachiocephalic pseudoaneurysm with fistulation to the skin after radical mastectomy and irradiation for breast cancer.

In Western countries, the gold-standard therapeutic strategy for rectal cancer is preoperative chemoradiotherapy (CRT) following total mesorectal excision (TME), without lateral lymph node dissection (LLND). However, preoperative CRT has recently been reported to be insufficient to control lateral lymph node recurrence in cases of enlarged lateral lymph nodes before CRT, and LLND is considered necessary in such cases. We performed a literature review on aspects of pelvic anatomy associated with rectal surgery and LLND, and then combined this information with our experience and knowledge of pelvic anatomy. In this review, drawing upon research using a 3-dimensional anatomical model and actual operative views, we aimed to clarify the essential anatomy for LLND. The LLND procedure was developed in Asian countries and can now be safely performed in terms of functional preservation. Nonetheless, the longer operative time, hemorrhage, and higher complication rates with TME accompanied by LLND than with TME alone indicate that LLND is still a challenging procedure. Laparoscopic or robotic LLND has been shown to be useful and is widely performed; however, without a sufficient understanding of anatomical landmarks, misrecognition of vessels and nerves often occurs. To perform safe and accurate LLND, understanding the landmarks of LLND is essential.

Background/Aims: Restorative proctocolectomy (RPC) with ileal pouch-anal anastomosis and handsewn anastomosis for ulcerative colitis requires pulling down of the ileal pouch into the pelvis, which can be technically challenging. We examined risk factors for the pouch not reaching the anus. Methods: Clinical records of 62 consecutive patients who were scheduled to undergo RPC with handsewn anastomosis at the University of Tokyo Hospital during 1989–2019 were reviewed. Risk factors for non-reaching were analyzed in patients in whom hand sewing was abandoned for stapled anastomosis because of nonreaching. Risk factors for non-reaching in laparoscopic RPC were separately analyzed. Anatomical indicators obtained from presurgical computed tomography (CT) were also evaluated. Results: Thirty-seven of 62 cases underwent laparoscopic procedures. In 6 cases (9.7%), handsewn anastomosis was changed to stapled anastomosis because of non-reaching. Male sex and a laparoscopic approach were independent risk factors of non-reaching. Distance between the terminal of the superior mesenteric artery (SMA) ileal branch and the anus > 11 cm was a risk factor for non-reaching. Conclusions Laparoscopic RPC with handsewn anastomosis may limit extension and induction of the ileal pouch into the anus. Preoperative CT measurement from the terminal SMA to the anus may be useful for predicting non-reaching.

Adenocarcinoma is a common histological type of ulcerative colitis-associated cancer (UCAC), whereas neuroendocrine carcinoma (NEC) is extremely rare. UCAC is generally diagnosed at an advanced stage, even with regular surveillance colonoscopy. A 41-year-old man with a 17-year history of UC began receiving surveillance colonoscopy at the age of 37 years; 2 years later, dysplasia was detected in the sigmoid colon, and he underwent colonoscopy every 3 to 6 months. Approximately 1.5 years thereafter, a flat adenocarcinoma lesion occurred in the rectum. Flat lesions with high-grade dysplasia were found in the sigmoid colon and surrounding area. The patient underwent laparoscopic total proctocolectomy and ileal pouch-anal anastomosis with ileostomy. Adenocarcinoma was diagnosed in the sigmoid colon and NEC in the rectum. One year postoperation, recurrence or metastasis was not evident. Regular surveillance colonoscopy is important in patients with long-term UC. A histological examination of UCAC might demonstrate NEC.