Background/Aims: High-grade pancreatic intraepithelial neoplasia and invasive pancreatic duc-tal adenocarcinoma ≤10 mm are targets for early detection of pancreatic cancer. However, their imaging characteristics are unknown. We aimed to identify endoscopic ultrasound findings for the detection of these lesions. Methods: Patients diagnosed with high-grade pancreatic intraepithelial neoplasia (n=29), pan-creatic ductal adenocarcinoma ≤10 mm (n=11) (who underwent surgical resection), or benignmain pancreatic duct stenosis (n=20) between January 2014 and January 2021 were retrospectively included. Six features differentiating these lesions were examined by endoscopic ultraso-nography: main pancreatic duct stenosis, upstream main pancreatic duct dilation, hypoechoic areas surrounding the main pancreatic duct irregularities (mottled areas without demarcation or round areas with demarcation), branch duct dilation, prominent lobular segmentation, and atrophy. Interobserver agreement was assessed by two independent observers. Results: Hypoechoic areas surrounding the main pancreatic duct irregularities were observedmore frequently in high-grade pancreatic intraepithelial neoplasia (82.8%) and pancreatic ductal adenocarcinoma ≤10 mm (90.9%) than in benign stenosis (15.0%) (p<0.001). High-grade pan-creatic intraepithelial neoplasia exhibited mottled hypoechoic areas more frequently (79.3% vs 18.9%, p<0.001), and round hypoechoic areas less frequently (3.4% vs 72.7%, p<0.001), than pancreatic ductal adenocarcinoma ≤10 mm. The sensitivity and specificity of hypoechoic areas for differentiating high-grade pancreatic intraepithelial neoplasia, pancreatic ductal adenocarci-noma ≤10 mm, and benign stenosis were both 85.0%, with moderate interobserver agreement. Conclusions The hypoechoic areas surrounding main pancreatic duct irregularities on endo-scopic ultrasound may differentiate between high-grade pancreatic intraepithelial neoplasia, pan-creatic ductal adenocarcinoma ≤10 mm, and benign stenosis (Trial Registration: UMIN Clinical Trials Registry (UMIN000044789).

A 77-year-old man underwent aortic valve replacement with a Carpentier-Edwards Pericardial Magna (19 mm) for aortic stenosis. He presented with a low grade fever and congestive heart failure 6 months after the initial valve replacement. Staphylococcus aureus was detected in blood culture, and peri-valvular leakage was revealed by echocardiography. Prosthetic valve endocarditis was diagnosed and underwent re-aortic valve replacement with Medtronic Mosaic 21 mm bioprothesis. Six months after the re-do operation, perivalvular leakage was newly observed between the right and non-coronary cusps, which was opposite to endocarditis affected cusps. The peri-valvular leakage was considered to have resulted from the fragile valve annulus because he did not have fever, and repeated blood culture showed no bacterial growth. We performed a third surgery and repaired the leakage by adding sutures through the right atrium and the interventricular septum to avoid directly suturing the fragile annulus. The post-operative course was uncomplicated, and no sign of endocarditis nor perivalvular leakage was observed during 9-months of observation. It is considered that the aortic valve fixation sutures through the right atrium and inter-ventricular septum are useful alternatives for fragile aortic annulus after prosthetic valve endocarditis.

Infectious endocarditis (IE) concomitant with patent ductus arteriosus (PDA) is now considered rare because the early treatment of PDA in infancy has become standard. We report a case of PDA with IE diagnosed by computed tomography (CT). A 51-year-old man complained of arthralgia and numbness of the left extremities. He had fever of 39°C and left hemiplegia, and was referred to our hospital. A chest X-ray film showed infiltration in both lungs. CT revealed a mass lesion in the main pulmonary artery and a tubular connection between the main pulmonary artery and the aortic arch. Multiple small infarctions were also found in the brain, lungs, kidneys and spleen. Ultrasonic cardiography revealed a bi-leaflet aortic valve, and vegetations on the aortic and mitral valves. Staphylococcus aureus was detected by culture of an intravenous catheter tip. These findings suggested IE concomitant with PDA, and we started intravenous administration of antibiotics. However, congestive heart failure occurred due to severe aortic and mitral regurgitation 2 days after hospital admission, and therefore, we performed emergency surgery. The main pulmonary artery was incised after cardiopulmonary bypass was initiated. A 20-mm length of vegetation was found on the orifice of the PDA. The vegetation was removed and the PDA directly closed. Aortic and mitral valve replacement was then performed. The post-operative course was uneventful and his neurological symptoms did not exacerbate. No sign of IE recurrence was observed 2 years after the surgery. CT clearly showed PDA and vegetation in the main pulmonary artery, although ultrasonic cardiography did not. CT was useful to make a diagnosis of PDA with IE in the present case.

 Infertility in developing countries is important but neglected, while the issues of population growth control have been paid much attention. Female infertility rates in African countries were about 30 percent, which were three times higher than those of industrialized countries. It was reported that the most common cause of infertility was tubal dysfunction due to sexually transmitted infections, unhygienic delivery management, and unsafe abortion. The second common causes were male factors, which had been underestimated in developing countries. Thus, women were always blamed and often abused by their husbands and in-laws. Furthermore, infertile couples suffered from social discrimination and economic disadvantages.
 Infertilities were often treated without appropriate examinations of both husbands and wives. Inexpensive treatments were commonly applied: e.g., treatment of sexually transmitted infections, encouraging timing intercourse, hormonal therapies. Assisted reproductive technology (ART) would be effective in developing countries where main causes of infertility were tubal dysfunction and male factors. ART has been performed in urban areas in some developing countries. However, it is difficult to promote ART in developing countries, because of high costs and lack of sufficient technical and ethical regulations. To decrease the burden of infertility in developing countries, first, both developing and industrialized countries have to recognize the significance of the issue. Then, it is needed to evaluate accurate rates of infertility, causes of infertility, and effectiveness of current treatment, so that the countries could develop prioritized strategies and interventions.
 Infertility rates could be decreased with relatively low cost through building a system of proper diagnosis and treatment. International assistance might be required to negotiate the drug prices and to establish technical and ethical review mechanisms, which are the prerequisites of promoting ART. It is also important to provide people with knowledge and information regarding infertility, their causes and treatment.

We report a case of successful one-stage resection of intravenous leiomyomatosis (IVL) with extension into the main pulmonary artery. The patient was a 50-year-old woman, who was admitted to our hospital with clinical signs of syncope. Computed tomography (CT) and 3 D helical CT images showed a tumor arising in the left side of the uterus with extension into the pulmonary outflow tract. One-stage radical operation with cardiopulmonary bypass was performed. Because IVL is related to many fields concerning various organs, it is important that general surgeons, gynecologists and cardiovascular surgeons cooperate with each other.

A 44-year-old man was given a diagnosis of severe ischemic heart disease and Leriche's syndrome. He had critical ischemia in the lower extremities and ischemic gangrene in a toe of the left foot. We planned a one-stage operation for these fatal diseases. To prevent irreversible ischemia of the lower limbs after mobilization of internal thoracic arteries or during extracorporeal circulation, we performed aorto-ilio femoral bypass grafting with extra-peritoneal approach first. Then conventional coronary artery bypass grafting was carried out for three coronary arteries with bilateral internal thoracic arteries (ITAs) and the saphenous vein. The postoperative course was uneventful.

The patient was a 52-year-old man with a history of antiphospholipid syndrome (APS), renal dysfunction and myasthenia gravis (MG). On May 2, 1998, he had sudden chest pain while sleeping. Enhanced computed tomography revealed acute aortic dissection (DeBakey type I). We performed emergency graft replacement of the ascending aorta and the aortic arch under extracorporeal circulation. Because of perioperative anuria, we used peritoneal dialysis (PD) just after the operation. Two days after the operation, we performed re-intubation nine hours after the extubation of the tracheal tube, and performed re-extubation three days later. For a while, his postoperative course was uneventful, but because of gradual worsening of APS, we administered more prednisolone, but 74 days after the operation, he died of multiple organ failure caused by an opportunistic infection, sepsis, and disseminated intravascular coagulation. This was very rare case of acute aortic dissection with MG and APS. After administration of more glucocorticoids, it is important to be wary of opportunistic infections.

The patient was a 63-year-old man with a history of multiple mononeuritis with hypergammaglobulinemia since 1980. The symptoms gradually worsened, and he had been bed-ridden since 1992. On February 28, 1997, he had sudden dyspnea after defecation. Echocardiography demonstrated a large thrombus in the right atrium and the right ventricle. Enhanced chest computed tomography revealed thrombi in the bilateral pulmonary arteries. The patient was considered to have acute pulmonary thromboembolism, and an emergency operation was indicated. Thrombectomy was performed under extracorporeal circulation through a median sternotomy. No thrombi were found in the right atrium or the right ventricle, and thrombi in the bilateral pulmonary arteries were removed completely. Four days after the operation, a Greenfield filter was implanted in the vena cava inferior because venography detected a thrombus in the right common iliac vein. The postoperative course was uneventful. No pulmonary rethromboembolisms were noticed after the operation. The long duration of being bed-ridden seemed to be the chief cause of thrombosis in the deep veins, and hyperviscosity due to hypergammaglobulinemia may have caused hyperthrombogenicity.

A 76-year-old man was admitted to our hospital because of sudden upper abdominal pain and shock status. The patient had undergone Miles' procedure with a colostomy on the left lower abdomen due to rectal cancer at the age of 70 years. CT scans revealed a thoracoabdominal aortic aneurysm. In view of the clinical findings, ruptured aneurysm requiring emergent operation was diagnosed. A left spiral skin incision was made, keeping away from the colostomy. An extraperitoneal approach was selected. The thoracoabdominal aorta was replaced with an artificial graft under partial extracorporeal circulation with femoral arterial and venous cannulation. The postoperative course was uneventful. No paraplegia occurred in spite of no reconstruction of the intercostal arteries due to severe atherosclerotic changes of the aortic wall. The fact that bleeding due to ruptured aneurysm was localized in the extrapleural and extrapritoneal spaces seemed to be an advantageous factor for the success in this case.

Direct coronary artery reimplantation to the aorta and mitral valve repair were successfully performed in a 29-year-old female with Bland-White-Garland syndrome (BWG syndrome). Under cardiopulmonary bypass, the main pulmonary artery was completely transected and the left coronary artery was excised with a cuff of pulmonary artery wall. Then the left coronary artery was directly anastomosed to the ascending aorta. Mitral regurgitation was repaired with valvulo-annuloplasty. The post operative course was excellent.