The Endologix AFX is a bifurcated unibody endovascular aortic repair （EVAR） system used for the treatment of abdominal aortic aneurysms （AAA）. It consists of an inner metal endoskeleton with multiple metal struts covered by a polytetrafluoroethylene graft fabric, which is suitable for treating AAA with narrowed abdominal aortic bifurcations. However, the risk of type 3 endoleak （T3EL） has been alerted and it is recommended that a sufficient overlap length be considered when using a cuff device on the central side. We present the case of an 81-year-old man with a 45 mm AAA who underwent EVAR with an AFX2 main body device and AFX proximal cuff extension device, adhering to the recommended overlap length. However, postoperative aneurysm enlargement occurred gradually, and complete uncoupling of the main body and cuff was observed 4 years later. A retrospective review of 4 years of computed tomography （CT） scans revealed potential caudal migration of the main body device and cranial migration of the cuff device, potentially resulting in a type 3a endoleak （T3aEL）. An additional device was deployed to bridge both components, and the patient was discharged without complications. In cases where an AFX2 main body device and a cuff device are used on the central side, even with adequate overlap, careful follow-up is necessary because of the potential for sideways displacement or craniocaudal migration. The observation of device displacement using 3D reconstruction CT imaging is particularly useful.

Herein, we describe a novel posterior lumbar interbody fusion (PLIF) technique with annulus fibrosus (AF) release and the use of expandable cages (called “anterior-release PLIF” [ARPLIF]). In this technique, posterior column osteotomy (PCO) and AF release provide excellent intervertebral mobility. AF release involves circumferentially peeling off the AF above or below the endplate between the fixed vertebrae under radiographic guidance without cutting the AF and anterior longitudinal ligament. Subsequently, high-angle variable-angle expandable cages are used to simultaneously expand both sides before inserting the percutaneous pedicle screws and correcting to achieve good local lumbar lordosis. PCO and AF release achieve excellent intervertebral mobility. Intervertebral mobility and simultaneous expansion of both cages disperse the force on the endplates, reducing cage subsidence, and the high-angle cages facilitate high intervertebral angle creation. The novel ARPLIF intervertebral manipulation technique can promote good local lumbar lordosis formation.

Background/Aims: Metabolic dysfunction-associated steatotic liver disease (MASLD) was recently proposed as an alternative disease concept to nonalcoholic fatty liver disease (NAFLD). We aimed to investigate the prognosis of patients with biopsy-confirmed MASLD using data from a multicenter study. Methods: This was a sub-analysis of the Clinical Outcome Nonalcoholic Fatty Liver Disease (CLIONE) study that included 1,398 patients with NAFLD. Liver biopsy specimens were pathologically diagnosed and histologically scored using the NASH Clinical Research Network system, the FLIP algorithm, and the SAF score. Patients who met at least one cardiometabolic criterion were diagnosed with MASLD. Results: Approximately 99% of cases (n=1,381) were classified as MASLD. Patients with no cardiometabolic risk (n=17) had a significantly lower BMI than patients with MASLD (20.9 kg/m2 vs. 28.0 kg/m2, P<0.001), in addition to significantly lower levels of inflammation, ballooning, NAFLD activity score, and fibrosis stage based on liver histology. These 17 patients had a median follow-up of 5.9 years, equivalent to 115 person-years, with no deaths, liver-related events, cardiovascular events, or extrahepatic cancers. The results showed that the prognosis for pure MASLD was similar to that for the original CLIONE cohort, with 47 deaths and one patient who underwent orthotopic liver transplantation. The leading cause of death was extrahepatic cancer (n=10), while the leading causes of liver-related death were liver failure (n=9), hepatocellular carcinoma (n=8), and cholangiocarcinoma (n=4). Conclusions Approximately 99% of NAFLD cases were considered MASLD based on the 2023 liver disease nomenclature. The NAFLD-only group, which is not encompassed by MASLD, had a relatively mild histopathologic severity and a favorable prognosis. Consequently, the prognosis of MASLD is similar to that previously reported for NAFLD.

BACKGROUND: Studies on the adverse effects of Asian dust (AD) on respiratory function in children are scarce. The objective of this study was to examine the association between AD and respiratory function by measuring peak expiratory flow rates (PEFRs) in asthmatic children. METHODS: The study was carried out from March to May from 2014 through 2016. One hundred ten children with bronchial asthma were recruited from four hospitals in the Goto Islands and south Nagasaki area in Nagasaki prefecture. The parents were asked to record their children's PEFRs every morning/evening and clinical symptoms in an asthma diary. AD was assessed from light detection and ranging data, and a linear mixed-effects model was used to estimate the effects of AD on daily PEFR. Time-stratified case-crossover analyses were performed to examine the association between AD and asthma attacks defined by reduction levels in PEFR. RESULTS: AD was detected on 11 days in the Goto Islands, and on 23 days in the south Nagasaki area. After adjusting for age, sex, temperature, and daily oxidants, we found a consistent association between AD and a 1.1% to 1.7% decrease in PEFR in the mornings and a 0.7% to 1.3% decrease in the evenings at a lag of 0 to 5 days. AD was not associated with the number of asthma attacks, respiratory symptoms, or other symptoms at any lag days examined. CONCLUSIONS Exposure to AD was associated with reduced PEFR, although the effects were not large enough to induce clinically apparent symptoms, in clinically well-controlled asthmatic children.

A 57-year-old man, who had suffered chest, back and right leg pain about 10 years before, underwent CT and was found a chronic type B aortic dissection with an enlarged false lumen and a narrowed true lumen that was occluded at the infrarenal abdominal aorta. A conventional surgical repair seemed to be too high risk considering his comorbidities, thus we chose a staged hybrid repair. First, surgical repair of the abdominal aorta with an abdominal aortic fenestration was performed. Then, one month after the first operation, zone 2 thoracic endovascular aortic repair with left carotid-axillary artery bypass was performed. At the second operation, the stent graft was purposely deployed from zone 2 into Th12 level of a false lumen through the fenestration followed by coil embolization of a true lumen just distal to the entry tear. The postoperative course was uneventful and he had no complications at 6 months follow-up. Deploying stent graft into a false lumen could be a feasible option in case deploying into a true lumen is not suitable if the anatomical condition permits.

We report a 48-year-old man who underwent hybrid aortic repair for visceral aortic patch (VAP) aneurysm. He had undergone descending thoracic aortic repair for post-dissection aneurysm at the age of 25, ascending aorta and proximal aortic arch aneurysm repair at the age of 27, and residual thoracoabdominal dissecting aortic aneurysm repair with VAP reconstruction at the age of 28. During 20 years of follow-up, the VAP gradually enlarged and eventually reached 70×61 mm in diameter. Considering a possible severe adhesion after 2 previous left thoracotomies, we planned a 2-staged hybrid aortic repair. First, we performed reno-visceral debranching and as a second stage operation, endovascular aortic repair was performed successfully 39 days after the first-stage operation.

A 27-year-old man who presented with worsening dyspnea was transferred to our hospital due to congestive heart failure with multiple organ dysfunction. Echocardiogram showed severe left ventricular systolic dysfunction and a huge thrombus in the left ventricle. An urgent operation was performed to remove the thrombus simultaneously with the placement of bilateral extracorporeal ventricular assist devices. After the operation, despite a rapid improvement in the liver function, renal dysfunction persisted and he remained anuric for nearly a month. We continued maximal circulatory support with biventricular assist device to optimize his end-organ function. His renal function gradually improved, allowing him to be registered as a heart transplant candidate on the 140th postoperative day. On the 146th postoperative day, the patient underwent successful removal of the right ventricular assist device, and the left extracorporeal device was replaced by an implantable device (HeartMate II). He was discharged 78 days after the implantation. We present here a case where adequate support with biventricular assist device enabled a successful bridge to transplantation even in a patient with end-stage heart failure having end-organ dysfunction.

We report a case of prolonged lumbago with severe cold intolerance successfully treated with keppuchikuoto and uzushakusekishigan. The patient was a 71-year-old female with lumbar spinal canal stenosis which was refractory to several nerve and intervertebral disc block therapies and oral medications. She had been also suffering from constipation, leg cramps, intermittent chest pains, and severe cold intolerance. We prescribed keppuchikuoto for chronic blood stagnation and deficiency and uzushakusekishigan for intermittent chest pains in order to improve those symptoms all together. The severity of her lumbago and severe cold intolerance were remarkably reduced after the administration of the two formulas. This case suggests that the two formulas exerted their effectiveness by ameliorating chronic severe cold intolerance, blood stagnation, and blood deficiency and resulted in remarkable improvement in lumbago.

Enterovaginal fistula, which causes uncontrollable symptoms such as gas release, vaginal defecation, perineal erosion, and vaginitis, markedly reduces patients' quality of life. In this report, we present a case of successful treatment for enterovaginal fistula with Kampo medicine.
A 62 year-old female who had ileoanal canal anastomosis for ulcerative colitis developed symptoms of gas release and defecation from the vagina. Although these symptoms had disappeared with conventional medicine previously, they recurred 7 years later. There was no medical indication for surgery because the fistula could not be located by barium enema or endoscopic examination. She, therefore, visited our outpatient clinic 1 and a half years after all conventional management had ended in vain.
Her symptoms were slightly improved by the administration of ifutokaogi, a Kampo formula, although they persisted. Three months after switching her prescription to another Kampo formula, goreisan, her symptoms completely disappeared.
In recent years, there has been no report on goreisan for the successful treatment of enterovaginal fistulae. Our case suggests that Kampo medicine can be an option for the treatment of enterovaginal fistula refractory to conventional treatments.

Background : Acute massive pulmonary embolism is a life-threatening disease. It is often treated with thrombolytic therapy, however, the mortality rates are unsatisfactorily high in patients who developed shock and subsequent cardiac arrest. Surgical pulmonary embolectomy is a last resort for patients with hemodynamic instability. We studied the outcomes of our patients who underwent pulmonary embolectomy for acute pulmonary embolism. Methods : Eight patients who underwent pulmonary embolectomy between January 2011 and December 2014 were studied. Our surgical indications were as follows. Patients who experienced cardiac arrest and treated with PCPS, and those in persistent vital shock, with contraindications of thrombolytic therapy, or with right heart floating thrombus. However, patients with ischemic encephalopathy or acute exacerbation of chronic thromboembolic pulmonary hypertension, and those who had already been treated with thrombolytic therapy were excluded. Preoperative ECMO was indicated for those in sustained shock. Pulmonary embolectomy was performed through median sternotomy and with cardiopulmonary bypass. After antegrade cardiac arrest, all clots were removed with forceps under direct vision through incisions in the bilateral main pulmonary arteries. IVC filter (Günther Tulip) was placed through the right atrial appendage. In our early cases, IVC filter (Neuhaus Protect) was placed after chest closure. Anticoagulation was not administered until hemostasis was achieved. Results : Seven patients underwent pulmonary embolectomy for massive pulmonary embolism, and in one patient pulmonary embolectomy was indicated for right heart floating thrombi although the pulmonary embolism was submassive. Three patients underwent cardiopulmonary resuscitation and were treated with ECMO. Other 3 patients in sustained shock vital were electively treated with ECMO. The other patient developed cardiopulmonary arrest shortly after anesthetic induction and intubation, and suffered disturbance of consciousness postoperatively. All patients were successfully weaned from cardiopulmonary bypass and underwent IVC filter placement (5 Neuhaus Protect, and 3 GProtec Tulip). One patient died due to a vascular complication associated with catheter insertion (retroperitoneal hematoma). No patients developed residual pulmonary hypertension. There were postoperative complications including pneumonia in 5 patients, tracheostomy in 2 patients, atrial fibrillation in 3 patients, and pericardial effusion in 1 patient. One patient who suffered disturbance of consciousness died 2.4 months after the surgery. Other patients had not developed any thrombotic and hemorrhagic complications during a median follow-up of 13.1 months. Conclusions : Pulmonary embolectomy is an effective treatment of acute massive pulmonary embolism. We believe that our strategy is useful, consisting of preoperative hemodynamic stability by an institution of ECMO, complete removal of clots by bilateral main pulmonary incisions, and prevention of recurrence by IVC filter placement.