The treatment of carotid stenosis complicated by severe vessel tortuosity can present challenges in distal vessel selection and device delivery. This article reports the use of a steerable microcatheter (SM) for carotid artery stenting (CAS) in such cases. A 67-year-old male with transient lower extremity weakness and bilateral cerebral infarctions was found to have bilateral carotid stenosis. CAS was planned for both carotid arteries due to coronary artery disease. The left carotid artery exhibited severe stenosis with a 90-degree angle between the common and internal carotid artery (ICA). Anticipating difficulty in navigating the device, we used a 2.4 Fr SM. By adjusting the catheter tip to align with the ICA, we successfully guided the wire distally. Following the catheter exchange, a distal protection device was deployed, and CAS was completed successfully. SMs provide exceptional vascular selectivity and support, improving success in complex cases.

The treatment of carotid stenosis complicated by severe vessel tortuosity can present challenges in distal vessel selection and device delivery. This article reports the use of a steerable microcatheter (SM) for carotid artery stenting (CAS) in such cases. A 67-year-old male with transient lower extremity weakness and bilateral cerebral infarctions was found to have bilateral carotid stenosis. CAS was planned for both carotid arteries due to coronary artery disease. The left carotid artery exhibited severe stenosis with a 90-degree angle between the common and internal carotid artery (ICA). Anticipating difficulty in navigating the device, we used a 2.4 Fr SM. By adjusting the catheter tip to align with the ICA, we successfully guided the wire distally. Following the catheter exchange, a distal protection device was deployed, and CAS was completed successfully. SMs provide exceptional vascular selectivity and support, improving success in complex cases.

The treatment of carotid stenosis complicated by severe vessel tortuosity can present challenges in distal vessel selection and device delivery. This article reports the use of a steerable microcatheter (SM) for carotid artery stenting (CAS) in such cases. A 67-year-old male with transient lower extremity weakness and bilateral cerebral infarctions was found to have bilateral carotid stenosis. CAS was planned for both carotid arteries due to coronary artery disease. The left carotid artery exhibited severe stenosis with a 90-degree angle between the common and internal carotid artery (ICA). Anticipating difficulty in navigating the device, we used a 2.4 Fr SM. By adjusting the catheter tip to align with the ICA, we successfully guided the wire distally. Following the catheter exchange, a distal protection device was deployed, and CAS was completed successfully. SMs provide exceptional vascular selectivity and support, improving success in complex cases.

The treatment of carotid stenosis complicated by severe vessel tortuosity can present challenges in distal vessel selection and device delivery. This article reports the use of a steerable microcatheter (SM) for carotid artery stenting (CAS) in such cases. A 67-year-old male with transient lower extremity weakness and bilateral cerebral infarctions was found to have bilateral carotid stenosis. CAS was planned for both carotid arteries due to coronary artery disease. The left carotid artery exhibited severe stenosis with a 90-degree angle between the common and internal carotid artery (ICA). Anticipating difficulty in navigating the device, we used a 2.4 Fr SM. By adjusting the catheter tip to align with the ICA, we successfully guided the wire distally. Following the catheter exchange, a distal protection device was deployed, and CAS was completed successfully. SMs provide exceptional vascular selectivity and support, improving success in complex cases.

The treatment of carotid stenosis complicated by severe vessel tortuosity can present challenges in distal vessel selection and device delivery. This article reports the use of a steerable microcatheter (SM) for carotid artery stenting (CAS) in such cases. A 67-year-old male with transient lower extremity weakness and bilateral cerebral infarctions was found to have bilateral carotid stenosis. CAS was planned for both carotid arteries due to coronary artery disease. The left carotid artery exhibited severe stenosis with a 90-degree angle between the common and internal carotid artery (ICA). Anticipating difficulty in navigating the device, we used a 2.4 Fr SM. By adjusting the catheter tip to align with the ICA, we successfully guided the wire distally. Following the catheter exchange, a distal protection device was deployed, and CAS was completed successfully. SMs provide exceptional vascular selectivity and support, improving success in complex cases.

We use transumbilical laparoscopic-assisted appendectomy (TULAA) with a lifting retractor as the surgical technique of first choice for acute appendicitis. Although this technique provides excellent cosmetic results and contributes to reducing medical costs, it is less advantageous in difficult-to-complete cases that require conversion to pneumoperitoneum or additional ports. We retrospectively reviewed the records of 76 patients who underwent laparoscopic appendectomy between June 2020 and March 2023 (43 in a TULAA group and 33 in a pneumoperitoneal conversion group) to identify preoperative factors associated with pneumoperitoneal conversion. Univariate analysis showed significant differences for preoperative C-reactive protein (CRP) level, age, and body mass index. Logistic regression analysis identified preoperative CRP level and age as significant risk factors for pneumoperitoneal conversion. The pneumoperitoneal conversion rate was 12.5%, 48.2%, and 68% for patients with 0, 1, and 2 preoperative risk factors, respectively, indicating patients with 2 risk factors were more likely to undergo pneumoperitoneal conversion. These data may inform the selection of the surgical technique and the decision to convert to pneumoperitoneum.

We recorded a case of a 58-year-old man who presented with swelling of the right neck after sudden chest pain. He was diagnosed with Stanford type A aortic dissection. Computed tomography revealed an aneurysm in the innominate artery surrounded by a hematoma. We therefore suspected a rupture of the innominate artery. In addition, the right common carotid artery was almost completely obstructed due to dissection. An emergency partial arch replacement was performed. Cardiopulmonary bypass (CPB) was established with two blood supplies : the right axillary and left common femoral arteries. When CPB was started, the innominate artery ruptured and could no longer be used for cerebral perfusion or as an anastomotic site. The right side of the neck was opened, and a synthetic graft was anastomosed to the right common carotid artery for cerebral perfusion. Finally, the graft was anastomosed with a branch of the main trunk. The right subclavian artery was also reconstructed using a graft that was anastomosed to the axillary artery for blood supply. The postoperative course was favorable, and no cerebral complications were observed.

Laparoscopy is useful for minimally invasive detailed examination of patients with suspected gastrointestinal perforation. Here we report a case of gastrointestinal perforation of unknown cause that was diagnosed laparoscopically as perforation of the sigmoid colon by a toothpick. The patient was a 41-year-old woman. She presented with a chief complaint of left lower abdominal pain and CT showed a small amount of free air in the peritoneal cavity, so emergency surgery was performed. Laparoscopy revealed a foreign body penetrating the sigmoid colon. After mobilization of the sigmoid colon, the surgical technique was switched to minilaparotomy and partial sigmoid colectomy was performed. The foreign body that had penetrated the intestine was identified as a toothpick. We later learned that the patient had become intoxicated while eating at a yakiniku barbecue restaurant 7 days prior to the operation, and she guessed that she had accidentally consumed a toothpick stuck in an onion. Gastrointestinal perforation by a toothpick is rare and is difficult to diagnose preoperatively because toothpicks appear transparent on X-ray imaging. In this case, laparoscopy was useful for identifying the site and cause of perforation as well as the extent of leakage into the peritoneal cavity.

A 70-year-old woman who was bedridden because of right hemiplegia attributable to a history of cerebral hemorrhage underwent surgical thrombectomy for pulmonary embolism four years previously. Symptoms of heart failure appeared one year previously, and she was diagnosed with constrictive pericarditis and had been treated with medication by a previous doctor. In the current situation, she visited the previous doctor with the chief complaint of fever, and pericardial effusion was observed on echocardiography. Cardiac tamponade was suspected and she was transferred to our hospital. She was then diagnosed with purulent pericarditis because purulent fluid was observed during pericardiocentesis drainage. Bacteroides fragilis was isolated from the culture of the abscess. The abscess was resistant to conservative antibiotic therapy ; therefore, we performed a pericardiotomy with a left small thoracotomy. The pleural effusion was found to be negative for culture and the patient exhibited a good postoperative course. Purulent pericarditis is refractory with poor prognosis. An appropriate surgical procedure must be chosen considering the patient's activities of daily living. Here, we report a surgical case wherein we chose the left thoracotomy approach and achieved positive results.

We treated a total of 67 patients for mamushi viper (Gloydius blomhoffii) bite during a 10-year period between 2007 and 2016. The mean age of the patients was 68 years, with those aged ≥ 60 years accounting for about 80％ of all patients. Most injuries occurred between July and September in rice fields and other cropland, or in the patients’ homes. Except for 1 severe case who developed a marked thrombocytopenia immediately after the incident, the remaining 66 patients were included in the analysis. All patients received inpatient care, with a mean hospital stay of 6.8 days. There was a significant positive correlation between the size of the swelling at the bite site and the length of hospital stay. Kidney dysfunction occurred in 3 patients, 1 of whom died. The mean time to the largest swelling was 21.8 h while the mean time to the highest creatine phosphokinase level was 2.6 days. The more severe cases were more likely to be have been treated with mamushi antitoxin while 2 of the 3 patients with kidney dysfunction, including the 1 fatality, were not, suggesting that the use of mamushi antitoxin is essential in severe cases. We also report a very rare case of mamushi viper bite complicated by thrombocytopenia.