Background/Aims: We aimed to clarify the clinicopathological characteristics and causes of Barrett’s esophageal adenocarcinoma (BEA) with unclear demarcation. Methods: We reviewed BEA cases between January 2010 and August 2022. The lesions were classified into the following two groups: clear demarcation (CD group) and unclear demarcation (UD group). We compared the clinicopathological findings between the two groups. Furthermore, we measured the length and width of the foveolar structures, as well as the width of marginal crypt epithelium (MCE). Results: We analyzed data from 68 patients with BEA, including 47 and 21 in the CD and UD groups, respectively. Multivariate analysis revealed long-segment Barrett’s esophagus (LSBE) as the sole significant risk factor for BEA (odds ratio, 12.17; 95% confidence interval, 2.84–47.6; p=0.001). Regarding pathological analysis, significant differences were observed in the length and width of the foveolar structure between cancerous and surrounding mucosa in the CD group (p=0.03 and p=0.00, respectively); however, no significant difference was observed in the UD group (p=0.53 and p=0.72, respectively). Nevertheless, the width of MCE in the cancerous area was significantly shorter than that in the surrounding mucosa in both groups (p<0.05, and p<0.05, respectively). Conclusions LSBE is a significant risk factor for BEA in the UD group. The width of MCE may be an important factor in the endoscopic diagnosis of BEA.

Background/Aims: We aimed to clarify the clinicopathological characteristics and causes of Barrett’s esophageal adenocarcinoma (BEA) with unclear demarcation. Methods: We reviewed BEA cases between January 2010 and August 2022. The lesions were classified into the following two groups: clear demarcation (CD group) and unclear demarcation (UD group). We compared the clinicopathological findings between the two groups. Furthermore, we measured the length and width of the foveolar structures, as well as the width of marginal crypt epithelium (MCE). Results: We analyzed data from 68 patients with BEA, including 47 and 21 in the CD and UD groups, respectively. Multivariate analysis revealed long-segment Barrett’s esophagus (LSBE) as the sole significant risk factor for BEA (odds ratio, 12.17; 95% confidence interval, 2.84–47.6; p=0.001). Regarding pathological analysis, significant differences were observed in the length and width of the foveolar structure between cancerous and surrounding mucosa in the CD group (p=0.03 and p=0.00, respectively); however, no significant difference was observed in the UD group (p=0.53 and p=0.72, respectively). Nevertheless, the width of MCE in the cancerous area was significantly shorter than that in the surrounding mucosa in both groups (p<0.05, and p<0.05, respectively). Conclusions LSBE is a significant risk factor for BEA in the UD group. The width of MCE may be an important factor in the endoscopic diagnosis of BEA.

Background/Aims: We aimed to clarify the clinicopathological characteristics and causes of Barrett’s esophageal adenocarcinoma (BEA) with unclear demarcation. Methods: We reviewed BEA cases between January 2010 and August 2022. The lesions were classified into the following two groups: clear demarcation (CD group) and unclear demarcation (UD group). We compared the clinicopathological findings between the two groups. Furthermore, we measured the length and width of the foveolar structures, as well as the width of marginal crypt epithelium (MCE). Results: We analyzed data from 68 patients with BEA, including 47 and 21 in the CD and UD groups, respectively. Multivariate analysis revealed long-segment Barrett’s esophagus (LSBE) as the sole significant risk factor for BEA (odds ratio, 12.17; 95% confidence interval, 2.84–47.6; p=0.001). Regarding pathological analysis, significant differences were observed in the length and width of the foveolar structure between cancerous and surrounding mucosa in the CD group (p=0.03 and p=0.00, respectively); however, no significant difference was observed in the UD group (p=0.53 and p=0.72, respectively). Nevertheless, the width of MCE in the cancerous area was significantly shorter than that in the surrounding mucosa in both groups (p<0.05, and p<0.05, respectively). Conclusions LSBE is a significant risk factor for BEA in the UD group. The width of MCE may be an important factor in the endoscopic diagnosis of BEA.

When performing aortic valve replacement in young patients, mechanical valves are recommended due to their durability. However, because mechanical valves require lifelong use of warfarin and carry risks such as easy bleeding, bioprosthetic valve replacement may be performed in some cases even in young patients. In this report, we describe a case of a patient who underwent bioprosthetic aortic valve replacement with aortic annular enlargement in anticipation of TAV in SAV and had a good postoperative course. The patient is a 51-year-old male. He was referred to our hospital for surgical treatment of severe aortic stenosis. The patient strongly preferred a bioprosthetic valve due to the disadvantage of taking warfarin. Therefore, we considered the possibility of TAV in SAV due to his young age, and decided to perform aortic annular enlargement if necessary. Intraoperatively, after resection and decalcification of the valve, a sizer was inserted, but the 19 mm sizer could not pass through, so we decided to perform aortic annular enlargement. Aortic annular enlargement was performed by suturing a Dacron patch and implantation of a 23 mm bioprosthetic valve. The patient had no major postoperative problems and was discharged home on the 14th day after surgery. In order to avoid PPM in the future when TAVI is performed, aortic annular enlargement should be considered in young patients undergoing aortic valve replacement using a bioprosthetic valve if TAV in SAV is considered to be difficult.

Pericardial pacing wire placement may occasionally result in intravascular or intratracheal wire migration, infective endocarditis, and sepsis; reportedly, the incidence of complications is approximately 0.09 to 0.4%. We report a case of a retained epicardial pacing wire that migrated into the pulmonary artery. A 66-year-old man underwent coronary artery bypass grafting for angina pectoris, with placement of an epicardial pacing wire on the right ventricular epicardium, 6 years prior to presentation. Some resistance was encountered during wire extraction; therefore, it was cut off at the cutaneous level on postoperative day 8. Computed tomography performed 6 years postoperatively revealed migration of the pacing wire into the pulmonary artery, and it was removed using catheter intervention. Surgeons should be aware of complications associated with retained pacing wires in patients in whom epicardial wires are retained after cardiac surgery.

A 71-year-old man underwent a medical checkup at another hospital with principal complaint of chest discomfort, and was diagnosed by computed tomography (CT) to have a left subclavian artery aneurysm. The CT revealed a 33-mm saccular aneurysm that was located at the proximal portion of the left subclavian artery. Because of the high risk of surgery, we planned to insert a stent graft into the left subclavian artery. We could not avoid occluding the ostium of the left vertebral artery with commercially-available stent grafts, and so decided to insert a surgeon-modified stent graft, in which the fabric of the distal portion of the stent graft was stripped away. The surgeon-modified stent graft was inserted from the conduit of the left axillary artery. Postoperative course was uneventful and the postoperative examination confirmed complete exclusion of the aneurysm and patency of the left vertebral artery.

Hospitalized patients often have insomnia, and in many cases it is necessary to administer hypnotics. Although the hypnotics currently used in Japan are mainly benzodiazepine receptor agonists, there is an associated risk of falling due to muscle relaxant action, and carryover effect. It is believed that orexin receptor antagonists, which have a different mechanism of action from conventional hypnotics, have no muscle relaxant action and are thus considered to be much safer. Therefore, in this study we compared fall rate according to the class of hypnotics that the patient had been taking. 　　We analyzed hospitalized patients taking orexin receptor antagonists (ORB), benzodiazepines (BZDs), and non-BZDs, who had falls and were treated in our hospital from April 1, 2017 to December 31, 2017. Patients were grouped according to the drug they were taking before the fall occurred and the fall rate was calculated and compared. The total number of falls in the target patients was 45, and the total number of people prescribed hypnotics in the study period was 1682. Fall rate by classification of hypnotics was the lowest in the ORB group at 1.45％, which was significantly lower than that of the BZD group, suggesting the possibility that ORBs have minimal influence on falls. In addition, the fall rate in the non-BZD group was significantly lower than that of the BZD group.

We report two cases with postoperative sternal osteomyelitis after coronary artery bypass graft (CABG), in whom successful two-stage reconstruction was performed via negative pressure wound therapy (NPWT) and pectoralis major myocutaneous flaps. Two patients underwent CABG using bilateral internal thoracic arteries, after which they had surgical site infection (SSI). The intractable wound did not heal with irrigation and NPWT. Then, sternal osteomyelitis was observed via magnetic resonance imaging (MRI), so we planned two-stage reconstruction. The first stage of treatment consisted of complete debridement (including removal of sternal wires and necrosectomy of soft tissue and sequestrum) and application of NPWT until the remission of inflammation. The second stage consisted of wound closure with pectoralis major myocutaneous advancement flaps. After wound closure, the two patients were given 2 months of oral antibiotics, and the postoperative results were good. Two-stage reconstruction with NPWT and pectoralis major myocutaneous flaps results in excellent clinical outcome. In the first stage, the key to the successful management of postoperative sternal osteomyelitis is infection control. This includes surgical debridement and wound-bed preparation with NPWT. The pectoralis major myocutaneous flap technique is brief and does not require a second cutaneous incision or an intact internal thoracic artery. In conclusion, the pectoralis major myocutaneous flap is a useful option in two-stage reconstruction after CABG.

We report two cases of total arch replacement with open stent graft for the aberrant right subclavian artery (ARSA). Case 1 was a thoracic artery aneurysm with an ARSA. We thought it would be difficult to perform in-situ reconstruction of ARSA via median sternotomy, so we performed total arch replacement with the open stent-grafting technique. Therefore the right axillary artery was reconstructed by extra-anatomical bypass and coil embolization of the ARSA proximal to the vertebral artery to achieve complete thrombosis of the ARSA. The postoperative course was uneventful. Case 2 was a Stanford type A acute aortic dissection involving an ARSA with the entry located near the ARSA. Total arch replacement was performed using the open stent-grafting technique to close the entry site and origin of the ARSA. Then the right axillary artery was reconstructed by extra-anatomical bypass and coil embolization of the ARSA. The postoperative course was uneventful. The open stent-grafting technique might be an effective alternative management of thoracic aortic disease with ARSA.

BACKGROUND/AIMS: Few reports have described the long-term treatment outcomes of the anti-tumor necrosis factor-α antibody for Japanese Crohn’s disease (CD) patients. The aim of this study was to evaluate them and clarify the clinical factors that affect the long-term prognosis of the anti-tumor necrosis factor-α treatments. METHODS: This was a retrospective, observational, single-center cohort study. Japanese CD patients treated with either infliximab or adalimumab as a first-line therapy were analyzed. The cumulative retention rates of the biologics, relapse-free survival, and surgery-free survival were analyzed using Kaplan-Meier methods. The clinical factors associated with the long-term outcomes were estimated by both the log-rank test and Cox proportional hazard model. RESULTS: The cumulative retention rate was significantly higher in the group with a concomitant elemental diet of ≥900 kcal/day, baseline C-reactive protein (CRP) levels < 2.6 mg/dL, and baseline serum albumin levels ≥3.5 g/dL, respectively. The baseline serum albumin levels were also associated with both relapse-free and surgery-free survival. The lack of concomitant use of an elemental diet ≥900 kcal/day was identified as the only independent risk factor for the withdrawal of the biologics. CONCLUSIONS: Baseline CRP levels and serum albumin levels could affect the long-term outcomes in CD patients. Concomitant elemental diet of ≥900 kcal/day could have a positive influence on clinical treatment course.
Adalimumab ; Antibodies ; Asian Continental Ancestry Group ; Biological Products ; C-Reactive Protein ; Cohort Studies ; Crohn Disease ; Food, Formulated ; Humans ; Infliximab ; Necrosis ; Prognosis ; Proportional Hazards Models ; Retrospective Studies ; Risk Factors ; Serum Albumin