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.

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.

Objective: Sitosterolemia is a rare autosomal recessive disease caused by the deleterious variants of adenosine 5'-triphosphate (ATP)-binding cassette sub-family G member 5 (ABCG5) or ATP-binding cassette sub-family G member 8 (ABCG8). There are only few data on the pathogenicity of ABCG5 and ABCG8. This study aimed to propose a scheme for determining variant pathogenicity and to catalog the putative pathogenic variants in sitosterolemia. Methods: This study enrolled 377 consecutive Japanese patients with hyper-low-density lipoprotein cholesterolemia (mean age: 46.5±19.8 years, with 192 men) who have targetedsequenced data on ABCG5 or ABCG8 (among 21 Mendelian lipid genes for any dyslipidemias) and serum sitosterol levels at Kanazawa University Hospital from 2016 to 2021. Serum sitosterol levels were divided by 0.79 in patients treated with ezetimibe, accounting for the average reduction with this drug. ABCG5 or ABCG8 variants were defined as putative pathogenic if associated with serum sitosterol levels ≥5 µg/mL or homozygous if associated with serum sitosterol levels ≥10 µg/mL. Results: Twenty-three ABCG5 or ABCG8 variants (16 missense, 2 nonsense, 2 frameshift, 2 deletion, and 1 splice mutation) were identified. Based on our definition, 11 putative pathogenic variants (median sitosterol level: 10.1 [6.5–17.1] µg/mL) were found in 36 individuals and 12 benign variants (median sitosterol: 3.5 [2.5–4.1] µg/mL) in 14 individuals. Conclusion The scheme proposed for assessing the pathogenicity of genetic variations (ABCG5 and ABCG8) is useful. Using this scheme, 11 putative pathogenic, and 12 benign variants in ABCG5 or ABCG were classified.

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.

Leriche syndrome is often complicated with ischemic heart disease (IHD). In such cases, as the internal mammary artery (IMA) supplies blood to the lower-limbs through a collateral network, coronary artery bypass grafting (CABG) using IMA is considered to worsen the lower-limb ischemia and use of intra-aortic balloon pumping prior to lower limb revascularization is not possible. Recent advances in endovascular technology enable us to perform endovascular treatment (EVT) even in Leriche syndrome. In 3 patients diagnosed with Leriche syndrome associated with IHD, tailor-made treatments were performed as one-stage or two-stage surgeries. Various techniques such as percutaneous coronary intervention (PCI), CABG, and open surgical revascularization or EVT of lower limbs were employed. EVT is a less invasive and more attractive alternative to open surgical revascularization, it led to new treatment options in patients with this particular circumstance. Considering the severity of pathophysiology, treatment strategy should be determined on a case-by-case basis.

An 18-year-old man with hypoxic encephalopathy was admitted because of recurrent minor bleeding a tracheal stoma, which was suspected as a tracheo-innominate artery fistula (TIF). He had undergone tracheostomy and gastrostomy 2 years prior and had mild opisthotonos and scoliosis. Although tracheal endoscopy showed no tracheal mucosal erosion, necrosis, or granulation tissue formation, contrast-enhanced computed tomography (CT) revealed a close contact between the innominate artery and the anterior wall of the trachea, and an equal height between the innominate artery and the tip of the tracheal cannula. Magnetic resonance angiography of the head showed dominant intracranial blood flow from the left internal carotid and vertebral arteries. Preventive innominate artery transection through the supra-sternal approach without sternotomy or reconstruction of the innominate artery was performed for this high-risk case of TIF. The patient's postoperative course was uneventful. Postoperative CT revealed that the innominate artery was transected and isolated from the site of tracheostomy. The preserved connection between the right common carotid and subclavian artery at the distal sutured stump helped maintain blood flow in the right internal and middle cerebral arteries. The patient was discharged on postoperative day 9 without any new neurological complications or bleeding from a tracheal stoma. TIF is a rare but fatal complication after laryngotracheal separation or tracheostomy. It is important to prevent the onset of TIF, however, there are no criteria for preventive innominate artery transection. Our preventive innominate artery transection through the supra-sternal approach is considered as one of the useful surgical treatment for high-risk cases of TIF accompanied by severe neuromuscular disorders.

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.

Secondary abdominal fascial closure by abdominal vacuum-assisted closure (VAC) therapy is required for abdominal organ protection and prevention of infection due to abdominal compartment syndrome (ACS) developing after the surgery. In this paper, we present our experience with abdominal VAC therapy for two cases that required open abdominal management after surgical repair for ruptured abdominal aortic aneurysm, with favorable outcomes. Case 1 involved a 72-year-old man who underwent endovascular aortic repair for ruptured abdominal aortic aneurysm. Abdominal VAC therapy was started after decompression laparotomy because he developed ACS immediately after surgery. Secondary abdominal fascial closure was performed on day 4 postoperatively, and he had no complications. Case 2 involved a 71-year-old man who underwent emergency Y-graft replacement for ruptured abdominal aortic aneurysm. We considered secondary abdominal fascial closure necessary because of prominent intestinal edema and massive retroperitoneal hematoma, and performed abdominal VAC therapy. We changed the VAC system on day 4, postoperatively and performed secondary abdominal fascial closure on day 7, postoperatively. Abdominal VAC therapy is considered effective and safe for patients requiring secondary abdominal fascial closure after abdominal surgery.

A 14-year-old women who had a history of aortic root replacement at 7 years old admitted our hospital due to dilatation of aortic arch aneurysm. Loeys-Dietz syndrome was diagnosed when she was 10 years old. Computed tomography showed 70 mm proximal arch aneurysm. Operative findings revealed brachiocephalic artery and left common carotid artery branched from aneurysm. Partial arch replacement was performed and distal anastomosis was made between left common carotid artery and left subclavian artery. Close observation by CT regularly is necessary and undergo aortic repair not to miss the timing of surgery.

After vascular surgical procedures, complications of the wounds in the groin region may sometimes lead to prosthetic graft infections or prolonged hospital stays. While some wounds heal completely during re-suture and VAC therapy, healing of other wounds that involve refractory graft infection, lymphorrhea, or a dead space, is extremely difficult. We performed tissue coverage using a Sartorius muscle flap for such difficult cases. The muscle is twisted onto itself to fill the dead space with some blood supply. Tissue coverage using a Sartorius muscle flap with adequate blood flow was effective in improving lymphorrhea and infection. We report four such cases where complications in the groin region were managed using a Sartorius muscle flap for wounded coverage.