When performing aortic valve replacement in young patients, mechanical valves are recommended due to their durability. However, because mechanical valves require lifelong use of warfarin and carry risks such as easy bleeding, bioprosthetic valve replacement may be performed in some cases even in young patients. In this report, we describe a case of a patient who underwent bioprosthetic aortic valve replacement with aortic annular enlargement in anticipation of TAV in SAV and had a good postoperative course. The patient is a 51-year-old male. He was referred to our hospital for surgical treatment of severe aortic stenosis. The patient strongly preferred a bioprosthetic valve due to the disadvantage of taking warfarin. Therefore, we considered the possibility of TAV in SAV due to his young age, and decided to perform aortic annular enlargement if necessary. Intraoperatively, after resection and decalcification of the valve, a sizer was inserted, but the 19 mm sizer could not pass through, so we decided to perform aortic annular enlargement. Aortic annular enlargement was performed by suturing a Dacron patch and implantation of a 23 mm bioprosthetic valve. The patient had no major postoperative problems and was discharged home on the 14th day after surgery. In order to avoid PPM in the future when TAVI is performed, aortic annular enlargement should be considered in young patients undergoing aortic valve replacement using a bioprosthetic valve if TAV in SAV is considered to be difficult.

The patient was a 73-year-old man. We have performed an ascending aortic prosthesis replacement for a thoracic aortic aneurysm complicated by idiopathic thrombocytopenic purpura (ITP). The platelet count was not sufficiently increased neither by preoperative Helicobacter pylori (H. pylori) eradication nor corticosteroid therapy. After treatment with high-dose intravenous gammaglobulin (400 mg/kg/ day×5 days) and the use of thrombopoietin receptor agonists, the platelet count increased to 8.9×104/ μl and the operation was safely performed. With a steady increase in platelet count, the patient continued to do well post-operatively. We report a case in which a stable platelet count was achieved throughout the perioperative period by the effective combination of high-dose intravenous gammaglobulin and a thrombopoietin receptor agonist in a patient with ITP refractory to corticosteroid therapy.

Background/Aims: The optimal length of the uncovered portion of partially covered self-expandable metal stents (PCSEMSs) used in endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) remains unclear. This study investigated the safety and efficacy of PCSEMSs with different uncovered lengths, with a focus on stent migration and time to recurrent biliary obstruction (RBO). Methods: Outcomes of patients undergoing EUS-HGS using PCSEMSs with 5-mm and 20-mm uncovered portions at our institution from January 2016 to December 2021 were compared. Results: Sixty-two patients underwent EUS-HGS using PCSEMS (5/20-mm uncovered portions: 32/30). Stent migration occurred only in the 5-mm group. There were no differences in RBO rates (28.1% vs. 40.0%) or median time to RBO (6.8 vs. 7.1 months) between the two groups. Median overall survival (OS) was longer in the 20-mm group (3.1 vs. 4.9 months, p=0.037) due to the higher number of patients that resumed chemotherapy after EUS-HGS (56.7% vs. 28.1%, p=0.029). Good performance status, absence of hepatic metastases, and chemotherapy after EUS-HGS were independent predictors of longer OS. Conclusions No migration was observed in patients treated with PCSEMS with 20-mm uncovered portions. Patients treated with PCSEMS with 20-mm uncovered portions performed at least as well as those treated with 5-mm uncovered portions in all material respects.

Methods: This retrospective study includes 295 corrective surgery patients with ASD. Subjects were divided into two groups after propensity age matching analysis: cranial malalignment (McGS <−8 or >13) and normal cranial alignment (−8≤ McGS ≤13). Lumbar lordosis (LL), pelvic tilt (PT), TK, cervical lordosis (CL), and sagittal vertical axis (SVA) were evaluated between the two groups. Results: SVA (95–56 mm) and PT (34°–25°) decreased and LL (19°–41°) increased 2 years after surgery (p <0.05), but McGS (−1.1° to −0.5°) and CL (21°–19°) did not change. Conversely, in the group with cranial malalignment, SVA (120–64 mm), PT (35°–26°), and LL (12°–41°) showed similar results to the normal cranial parameter group 2 years after surgery, but in contrast, McGS (−13° to −2°) and CL (24°–18°) improved significantly. Conclusions Severe ASD adversely affects to maintain horizontal gaze but can be improved by spinal corrective surgery.

Methods: This study prospectively examined nine T-OPLL patients who underwent posterior thoracic decompression with kyphosis correction and instrumented fusion at Hamamatsu University School of Medicine between 2017 and 2019. All underwent preoperative selective angiography to detect and evaluate the Adamkiewicz artery and ASA. Intraoperative neuromonitoring and Doppler ultrasonography were performed to analyze neurological complications and spinal cord blood flow. Results: All nine patients showed ASA stenosis in the area of T-OPLL. In all patients, the Adamkiewicz artery was located between T7 and L2 and the area of ASA stenosis corresponded to the level of T-OPLL and greatest spinal cord compression; intraoperative Doppler ultrasonography confirmed the ASA defect at the same spinal level. The number of spinal levels from the Adamkiewicz artery to the most compressive OPLL lesion was greater in the two patients who developed postoperative neurological deficit compared to those who did not (5.5 vs. 2.3, p=0.014). Conclusions This is the first study to report detection of ASA stenosis in patients with T-OPLL. Maintaining spinal cord blood flow is important in these patients to avoid neurological deterioration.

Methods: As part of a 2016 health screening, 320 female volunteers underwent whole-spine radiographs. Age-matched healthy women were grouped according to the number of vaginal deliveries (0, 1–2, or ≥3). Demographic variables and spinopelvic parameters were compared among the three groups. Results: Of the 320 volunteers, 213 were enrolled (mean age, 71.1±7.2 years). The mean number of vaginal deliveries was 2.2. The average pelvic incidence (PI) was 55.6°±11.1° and was significantly higher in the 90 women with three or more vaginal deliveries than in the other two groups (p<0.001). The average sacral slope was 33.4°±11.1° and was significantly higher in the women with three or more vaginal deliveries than in the 18 who did not deliver vaginally (p<0.001). The 105 women with one or two vaginal deliveries had significantly higher PIs and sacral slopes than did those who did not deliver vaginally (p<0.001). Conclusions This is the first study documenting an association between vaginal delivery and pelvic parameters. Bony birth canal realignment during vaginal delivery can affect postnatal PI. Our study helps in understanding the PI changes over a woman’s life span.

Methods: We retrospectively reviewed the medical records of 404 patients who underwent corrective fusion surgery for ASD with a minimum 2-year follow-up. We studied cases of reoperation for postoperative rod fractures and investigated surgical procedure, intraoperative findings, clinical course, and rod refracture following revision surgery. Results: Rod fracture was observed in 88 patients (21.8%). Fifty-three patients (average age, 68.3 years; average blood loss, 502.2 mL [% estimated blood volume=16.4%]; and operation time, 203.3 minutes) who suffered from a rod fracture at an average of 28.3 months after the primary operation underwent reoperation. Surgical invasiveness had no significant differences in total or partial rod replacement; however, the procedures with and without an anterior bone graft significantly differed. The replaced rod refractured at an average of 35.3 months after the revision surgery of five patients. The rod also refractured at a level outside multiple rods in two patients and with traumatic episodes in three patients. Three patients had bone grafts in the anterior column. Conclusions Revision surgery involving a multirod with a posterior-only approach for a rod fracture that occurred after ASD was performed successfully. Bone grafting in the anterior column is unnecessary for patients without massive bone defects.

Combination of retrospective and prospective study.

Background/Aims: The Japan Gastroenterological Endoscopy Society (JGES) has published guidelines for gastroenterological endoscopy in patients undergoing antithrombotic treatment. These guidelines classify endoscopic ultrasound-guided biliary drainage (EUS-BD) as a high-risk procedure. Nevertheless, the bleeding risk of EUS-BD in patients undergoing antithrombotic therapy is uncertain. Therefore, this study aimed to assess the bleeding risk in patients undergoing antithrombotic therapy. Methods: This single-center retrospective study included 220 consecutive patients who underwent EUS-BD between January 2013 and December 2018. We managed the withdrawal and continuation of antithrombotic agents according to the JGES guidelines. We compared the bleeding event rates among patients who received and those who did not receive antithrombotic agents. Results: A total of 18 patients (8.1%) received antithrombotic agents and 202 patients (91.8%) did not. Three patients experienced bleeding events, with an overall bleeding event rate of 1.3% (3/220): one patient was in the antithrombotic group (5.5%) and two patients were in the non-antithrombotic group (0.9%) (p=0.10). All cases were moderate. The sole thromboembolic event (0.4%) was a cerebral infarction in a patient in the non-antithrombotic group. Conclusions The rate of EUS-BD-related bleeding events was low. Even in patients receiving antithrombotic therapy, the bleeding event rates were not significantly different from those in patients not receiving antithrombotic therapy.