A 48-year-old woman with a history of recurrent alcoholic pancreatitis was found to have a pancreatic pseudocyst. In November 20XX, she visited the emergency department due to sudden abdominal pain. Contrast-enhanced computed tomography showed a pancreatic pseudocyst with a maximum diameter of 67 mm and ascites. A ruptured pancreatic pseudocyst was suspected and abdominal paracentesis was performed. The amylase level in the ascitic fluid was high (3444 IU/L), leading to a diagnosis of acute generalized peritonitis due to rupture of a pancreatic pseudocyst. Intraoperative findings revealed 500 mL of ascites mixed with pancreatic juice and turbid cyst contents, and distal pancreatectomy was performed. The postoperative course was favorable, and the patient was discharged on hospital day 14. Rupture of pancreatic pseudocyst is rare. In this case, it was promptly diagnosed and successfully treated with emergency surgery.

A 66-year-old, postmenopausal woman was referred to our hospital because of abnormal breast cancer screening results. A tumor was found in the upper outer part of the left breast. Biopsy revealed papillotubular carcinoma, ER (Allred score total score [TS] 3 = proportion score [PS] 2 + intensity score [IS] 1), PgR (Allred score TS 3 = PS 2 + IS 1), HER2 (2+), fluorescent in situ hybridization 1.1 (negative), and Ki-67 labeling index 15%. In diagnostic imaging, the tumor size was 35 mm. The diagnosis was T2N0M0 Stage IIA, luminal B-like breast cancer. First, letrozole 2.5 mg/day was administered as preoperative hormone therapy. After 2 months of treatment with letrozole, the tumor size had increased to 44 mm and preoperative hormone therapy was discontinued. She was started on preoperative chemotherapy (4 courses of epirubicin plus cyclophsphamide followed by 4 courses of triweekly docetaxel). The tumor size decreased, becoming undetectable. After these preoperative treatments, nipple-sparing mastectomy, sentinel lymph node biopsy, and breast reconstruction with a primary latissimus dorsi flap were performed. As of 3 years and 6 months after the operation, there has been no recurrence. At first, preoperative hormone therapy is performed for Luminal B-like breast cancer as in this case, if the response is insufficient, preoperative chemotherapy after hormone therapy may be a therapeutic option.

Here, we report 3 cases of conservatively treated ischemic colitis with hepatic portal venous gas. In Case 1, an 84-year-old man visited the emergency department because of fatigue, vomiting, and upper abdominal pain. In Case 2, a 72-year-old man was hospitalized for rehabilitation in another hospital following cervical spine trauma. He had diarrhea and mesogastric pain for 2 days and was transferred to our hospital. In Case 3, an 89-year-old woman visited the emergency department because of upper abdominal pain and vomiting. In all cases, we diagnosed the illness as ischemic colitis with hepatic portal venous gas based on computed tomography findings, and the vital signs of all patients were stable. They were treated conservatively. They were able to resume oral intake and were discharged or transferred to another hospital. Hepatic portal venous gas has been considered a poor prognostic sign of severe diseases such as intestinal necrosis. However, recently, reports of cases treated conservatively have been increasing. Conservative treatment may be selected for ischemic colitis associated with hepatic portal venous gas taking into account the patient’s general condition.

A 14-year-old girl (Case 1) with respiratory distress during exercise was referred to our department after a pancreatic mass was detected by computed tomography (CT). Contrastenhanced CT scan showed a low-density mass measuring 2.5 × 2 cm in the body of the pancreas. Low signal intensity was seen on T1-weighted magnetic resonance imaging (MRI) and high signal intensity on T2-weighted MRI. We suspected solid-pseudopapillary neoplasm (SPN) of the pancreas and performed laparoscopy-assisted spleen-preserving distal pancreatectomy. The postoperative course was uneventful, and she was discharged on postoperative day 13. A 15-yearold girl (Case 2) with abdominal pain and fever was referred to our department after an abdominal cystic mass was detected by ultrasound examination. Contrast-enhanced CT showed a 4-cm well-circumscribed mass. Higher signal intensity was seen on T2-weighted MRI. We suspected SPN of the pancreas and performed laparoscopic spleen-preserving distal pancreatectomy. The postoperative course was uneventful, and she was discharged on postoperative day 8. Laparoscopic or laparoscopy-assisted surgery should be considered for SPN of the pancreas.

Primary mesenteric neuroendocrine tumor is extremely rare. Here we describe 2 cases of this disease. Case 1 was a 66-year-old man with a working diagnosis of gastrointestinal stromal tumor or mesenteric tumor who underwent laparoscopic tumor resection. Immunohistochemically, the final diagnosis was primary mesenteric neuroendocrine tumor G1. There has been no recurrence as of 25 months after surgery. Case 2 was an 80-year-old man with a working diagnosis of gastrointestinal stromal tumor or mesenteric tumor who also underwent laparoscopic tumor resection. Immunohistochemically, the final diagnosis was primary mesenteric neuroendocrine tumor G1. This is recurrence-free as of 36 months after surgery. Several cases of primary mesenteric neuroendocrine tumor have been reported, but most have been treated with open surgery. To date, there has been only 1 case of primary mesenteric NET that was resected in a pure laparoscopic procedure. In all 3 cases (including our 2 cases), the largest tumor diameter was 4 cm. It appears that laparoscopic surgery can be used to treat primary mesenteric neuroendocrine tumor of small size (＜ 4 cm) with minimal invasion.

Background: and Purpose Although numerous measures for stroke exist, stroke remains one of the leading causes of death in Japan. In this study, we aimed to determine the long-term survival rate after first-ever stroke using data from a large-scale population-based stroke registry study in Japan. Methods: Part of the Shiga Stroke and Heart Attack Registry, the Shiga Stroke Registry is an ongoing population-based registry study of stroke, which covers approximately 1.4 million residents of Shiga Prefecture in Japan. A total 1,880 patients with non-fatal first-ever stroke (among 29-day survivors after stroke onset) registered in 2011 were followed up until December 2016. Five-year cumulative survival rates were estimated using the Kaplan-Meier method, according to subtype of the index stroke. Cox proportional hazards models were used to assess predictors of subsequent all-cause death. Results: During an average 4.3-year follow-up period, 677 patients died. The 5-year cumulative survival rate after non-fatal first-ever stroke was 65.9%. Heterogeneity was present in 5-year cumulative survival according to stroke subtype: lacunar infarction, 75.1%; large-artery infarction, 61.5%; cardioembolic infarction, 44.9%; intracerebral hemorrhage, 69.1%; and subarachnoid hemorrhage, 77.9%. Age, male sex, Japan Coma Scale score on admission, and modified Rankin Scale score before stroke onset were associated with increased mortality during the chronic phase of ischemic and hemorrhagic stroke. Conclusions In this study conducted in a real-world setting of Japan, the 5-year survival rate after non-fatal first-ever stroke remained low, particularly among patients with cardioembolic infarction and large-artery infarction in the present population-based stroke registry.

Infective endocarditis of the aortic valve tends to cause structural damage such as aortic root abscess, and aortic valve replacement is the standard treatment. However, there have been several reports on aortic valve repair for the treatment of infective endocarditis, and it has subsequently emerged as a feasible alternative to aortic valve replacement in selected patients. We report a case of aortic valve repair for infective endocarditis of the aortic valve caused by α-hemolytic Streptococcus. A 50-year-old man was admitted to our hospital with a two-month history of fever of unidentified origin. Transthoracic echocardiography revealed infective endocarditis of the aortic valve. Transesophageal echocardiography confirmed vegetation in the right coronary and non-coronary cusps, and mild aortic regurgitation. Although infection was controlled by approximately one month of antibiotic treatment, there was markedly more severe aortic regurgitation compared to the previous examination. These findings were confirmed on transesophageal echocardiography, and residual vegetation on the right coronary cusp as well as a perforation in the non-coronary cusp were confirmed. Intraoperative findings revealed a perforation in the non-coronary cusp and dehiscence, with vegetation on the right coronary cusp. The vegetation was carefully removed, the non-coronary cusp perforation was repaired with a pericardium patch, and the defect on the right coronary cusp was directly sutured with 6-0 polypropylene. Intraoperative transesophageal echocardiography revealed trivial aortic regurgitation. The postoperative course was uneventful and the patient was discharged 7 days after surgery without any complications. Antibiotics were prescribed for 3 months, and transthoracic echocardiography was performed 5 days, 1 month, and 3 months after surgery. No evidence of recurrence of aortic regurgitation or infection of the aortic valve was observed.

We report a rare case of paraplegia after emergency total arch replacement for type A acute aortic dissection. A 52-year-old man was referred to our hospital for acute aortic dissection. Contrast-enhanced computed tomography showed a type A aortic dissection extending from the aortic root into the right iliac arteries. The true lumen of the descending and abdominal aorta was collapsed and blood flow to the right lower limb had decreased. Large entry and re-entry tears were revealed in the ascending and distal arch aorta, respectively. His preoperative consciousness was clear, hemodynamics were stable, and there was no evidence of paraplegia or paraparesis. Extracorporeal circulation was established by femoral artery and right atrium cannulation. Total arch replacement was performed under moderate hypothermic circulatory arrest (lowest bladder temperature : 21.9°C). The postoperative course was uneventful and he was extubated 6 h postoperatively. Postoperative hemodynamic parameters were stable, the mean blood pressure was maintained at around 70 mmHg, and limb movements were confirmed at that time. Although there was no abnormality of lower limb movement until the following morning, paraplegia occurred about 17 h after surgery. While maintaining a mean blood pressure of over 90 mmHg, urgent cerebrospinal drainage was immediately performed and combined with steroid treatment and a continuous infusion of naloxone. The neurological defect was resolved immediately after cerebrospinal drainage, and neurological function steadily improved through rehabilitation. He was discharged 20 days after surgery with no neurological defects. Late paraplegia after total replacement for type A acute aortic dissection is a rare complication. From our experience, it is suggested that early diagnosis and treatment are important for improving paraplegia.

Reoperative valve surgery is known to be more complex and associated with increased morbidity and mortality, especially for patients with patent coronary artery bypass grafts. A 69-year old man with a history of coronary artery bypass grafting was referred to our hospital with breathing difficulties and a heart murmur. Bypass grafts were all patent, but due to severe ischemic mitral valve regurgitation, we performed beating heart mitral valve replacement via right thoracotomy. The procedure was performed with video assistance, and both the anterior and the posterior chordae tendineae were preserved. The postoperative course was uneventful. He was discharged 7 days after surgery without any complications. This technique is a safe and feasible option for a mitral valve reoperation that avoids graft injuries, minimizes the risks of bleeding, and shortens the operative time.