Background/Aims: Immune checkpoint blockade has recently been reported to be effective in treating microsatellite instability (MSI)-high tumors. Therefore, sufficient sampling of histological specimens is necessary in cases of unresectable pancreatic cancer (UR-PC). This multicenter study investigated the efficacy of endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) using a Franseen needle for MSI evaluation in patients with UR-PC. Methods: A total of 89 patients with UR-PC who underwent endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) or EUS-FNB using 22-G needles at three hospitals in Japan (2018–2021) were enrolled. Fifty-six of these patients (FNB 23 and FNA 33) were followed up or evaluated for MSI. Patient characteristics, UR-PC data, and procedural outcomes were compared between patients who underwent EUS-FNB and those who underwent EUS-FNA. Results: No significant difference in terms of sufficient tissue acquisition for histology was observed between patients who underwent EUS-FNB and those who underwent EUS-FNA. MSI evaluation was possible significantly more with tissue samples obtained using EUS-FNB than with tissue samples obtained using EUS-FNA (82.6% [19/23] vs. 45.5% [15/33], respectively; p<0.01). In the multivariate analysis, EUS-FNB was the only significant factor influencing the possibility of MSI evaluation. Conclusions EUS-FNB using a Franseen needle is desirable for ensuring sufficient tissue acquisition for MSI evaluation.

Here, we report a rare case in which the inlet pressure of the oxygenator increased three times in two operations, even though two different types of oxygenators were used. A 45-year-old man underwent mitral valve repair owing to posterior cusp (P2) prolapse. Immediately after median sternotomy, the patient went into anaphylactic shock. We immediately started cardio-pulmonary bypass. The inlet pressure in company A's oxygenator increased, and the oxygenator was immediately replaced with the same type of oxygenator. However, the same occurred, and the oxygenator was exchanged for one made by company B. Thereafter, the operation was completed without further oxygenator problems.Fifty-five days after the initial surgery, a second operation was performed to repair a pseudoaneurysm at the root vent cannulation site. After induction of general anesthesia, the patient went into anaphylactic shock, as before, but circulation was maintained. Cardio-pulmonary bypass was started using company B's oxygenator, as it gave no problems at the previous surgery. However, it had to be exchanged owing to inlet pressure elevation. Thereafter, cardio-pulmonary bypass was maintained without pressure elevation, and the operation was completed. The reasons for the inlet pressure elevations are unclear.

Calcified amorphous tumor (CAT) is a non-neoplastic mass characterized by calcified nodules that was first reported in 1997. It is often associated with dialysis or mitral annular calcification (MAC). CAT is considered a risk factor for systemic embolism, but there has been no report of CAT damaging the native valve tissue and leading to valvular disease. An 81-year-old woman had shortness of breath on exertion starting 1 year previously, and was referred to our hospital with cardiac murmur detected on physical examination. Echocardiography showed evidence of severe mitral valve regurgitation with ruptured chordae tendineae of the posterior leaflet and a poorly mobile club-shaped structure protruding into the left ventricle and appearing to be continuous with MAC. She underwent elective mitral valve repair. A club-shaped calcification originating from MAC was found under the P2 segment, with ruptured P2 chordae tendineae immediately above it and mitral perforation in the contralateral A2 segment, which were likely to have resulted from direct damage by the hard structure. Mitral valve repair was successful with mass resection, triangular resection of the posterior leaflet P2 segment, and closure of the perforation. Histopathological findings of the mass were consistent with CAT, with no evidence of infection or malignancy. CAT may not only cause embolism but also grow while damaging the native valve tissue. It is important to closely follow-up and perform surgery in proper timing.

Objective : To investigate the surgical outcomes of left ventricular free wall rupture (LVFWR) and ventricular septal perforation (VSP) in terms of mechanical complications following acute myocardial infarction (AMI). Methods : Subjects comprised 26 patients (male : 12, female : 14, mean age : 74 years) who underwent surgery between 2001 and 2012. The LVFWR type was blowout in 2 cases and oozing in 5 cases. Immediately after diagnosis, 4 cases underwent intra-aortic balloon pumping (IABP) and 2 cases received extracorporeal membrane oxygenation (ECMO). LVFWR was repaired by suture and patch closure in 5 patients and by TachoComb in 2 patients. VSP was caused by anterior infarction in 15 cases and inferior infarction in 5 cases. IABP was inserted in 16 cases. VSP was repaired by the infarct exclusion technique in 17 patients, while 2 patients underwent suture or patch closure. Results : The operative mortality rate was 14.3% for LVFWR and 15.8% for VSP. The cause of operative death in 1 patient with blowout type LVFWR who was in a state of cardiopulmonary arrest on arrival, was low cardiac output syndrome (LOS). The causes of operative death in VSP included 2 patients with LOS and 1 patient who died suddenly 8 days postoperatively due to ventricular fibrillation. Two VSP patients underwent repeat surgery for residual shunt. The five-year Kaplan-Meier survival rates were 85% for LVFWR and 62% for VSP. Of 20 patients who received IABP preoperatively, the time from confirming LVFWR or VSP diagnosis after admission to IABP initiation was 103±45 (48-120) min in the survival group (n=17) and 259±174 (122-455) min in the operative mortality group (n=3). A significant difference was observed between the two groups (p=0.04). Conclusion : Therapeutic strategies including rapid diagnosis after admission, early insertion of IABP, and prompt surgery could improve the prognosis for patients with LVFWR and VSP following AMI.

A 24-year-old woman, under the treatment for atypical depression, visited our emergency room on foot with a chief complaint that she stabbed herself in the chest with a sewing needle. Chest X-ray and plain CT showed the needle penetrating the chest into the heart. There was no sign of pneumothorax or cardiac tamponade. She was hemodynamically stable. Echocardiography revealed atrial septal defect (ASD) by chance. We performed urgent surgery for needle removal and ASD closure through median sternotomy. The needle was easily recognized near the right ventricle apex. The right atrium was opened, but the needle was not seen through the tricuspid valve because of trabecular formation. After the needle was removed, ASD was closed using the direct suture method. The needle was 35 mm long. She was transferred to the psychiatry department on postoperative day 4 and had a good postoperative course.

Diffusion-weighted imaging (DWI) reflects changes in proton mobility caused by pathological alterations of tissue cellularity, cellular membrane integrity, extracellular space perfusion, and fluid viscosity. Functional imaging is becoming increasingly important in the evaluation of cancer patients because of the limitations of morphologic imaging. DWI is being applied to the detection and characterization of tumors and the evaluation of treatment response in patients with cancer. The advantages of DWI include its cost-effectiveness and brevity of execution, its complete noninvasiveness, its lack of ionizing radiation, and the fact that it does not require injection of contrast material, thus enabling its use in patients with renal dysfunction. In this article, we describe the clinical application of DWI to gynecological disorders and its diagnostic efficacy therein.
Diffusion Magnetic Resonance Imaging ; Extracellular Space ; Gynecology ; Humans ; Magnetic Resonance Imaging ; Membranes ; Perfusion ; Protons ; Radiation, Ionizing ; Viscosity

A 76-year-old woman with abdominal aortic aneurysm coexisting horseshoe kidney and pelvic arteriovenous malformation (AVM) is reported. Operation was performed by a transperitoneal approach via typical median laparotomy. The aneurysm was successfully replaced by a bifurcated prosthetic graft without division of the renal isthmus. Cold lactated Ringer solution was injected into an aberrant renal artery at the time of aortic cross-clamping. This was useful not only to protect the kidney against ischemic injury, but also to know the perfusion area of the vessel. The aberrant renal artery was attached to the prosthetic graft following the aortic proximal anastomosis. Though a part of the asymptomatic AVM, which involved the left ureter, ovary, and uterus, was located anterior to the left iliac arteries, distal anastomoses at the internal and external iliac arteries were done smoothly. No surgical intervention was applied to the AVM in the operation. The post-operative course was uneventful.

In Japan, few surveys have evaluated the structure and clinical process of cardiovascular surgery programs. We mailed a questionnaire to all 149 facilities participating in the Japan Adult Cardiovascular Database as of April 1st 2007. We received responses from 129 facilities (response rate 86.6%). For CABG surgery, many facilities regard “IMA use (95.3%) ” and “off-pump surgery” is the first choice as a facility and recommend “discharge antiplatelets (89.9%) ” and “discharge antilipid (47.3%) ”. On the other hand most facilities did not made any recommendation regarding “preoperative beta blockers (72.9%) ” and “discharge beta blockers (60.5%) ”. The usage rates of preoperative beta blockers and discharge beta blockers were very low in Japan though their usage rates were relatively high in the United States.

The purpose of this study was to clarify physical characteristics related to low back pain (LBP) in collegiate track and field athletes. We particularly focused on the nature of the track and field. The subjects were 21 male collegiate track and field athletes including only sprinters, hurdlers, long jumpers and triple jumpers. The examined parameters were physical characteristics, isokinetic flexor and extensor strength in the knee and trunk regions. The evaluation of LBP was estimated by a questionnaire test and orthopedic surgeons' diagnosis. According to these evaluations, we divided all track and field athletes into two groups ; LBP group (n＝11, 52.4%) and no LBP group (n＝10, 47.6%). As a result, a take-off leg of knee flexor/extensor strength ratio in the LBP group was significantly lower than that in the no LBP group (P＜0.05). The LBP group showed a significant difference between a take-off leg and a lead leg in knee flexor strength compared with the no LBP group (P＜0.05). The LBP group has been short engaged in the track and field than the no LBP group (P＜0.05). In the trunk flexor and extensor strength, there was no significant difference between the LBP and the no LBP group in this study. These results suggest that the imbalanced knee muscle strength may be one of some factors related to chronic low back pain in collegiate track and field athletes.

To investigate the relationship between adolescent sport activity and abnormalities of the lumbar spine on radiography and magnetic resonance imaging (MRI), 237 collegiate athletes (mean age 19.4), representing judo, wrestling, and track, were analyzed from the point of contact or noncontact sports. Radiologic and/or MRI abnormalities of the lumbar spine were found in 68.7% of contact sports athletes (judo and wrestling, n=147), 53.3% of noncontact sports athletes (track, n=90), 69.9% of athletes who have played contact sports over 9 years (C9 athletes, n=83), and 47.1% of atheletes who have done noncontact sports over 9 years (N9 athletes, n=17). Discopathy related abnormalities on radiologic examination were found in 25.3% and 11.8% of C9 and N9 athletes. Disc degeneration on MRI was found in 45.8% and 29.4% of C9 and N9 athletes. Spondylolysis was found in 31.3% of C9, 5.9% of N9, 31.3% of elementary-C (athletes who played contact sports during elementary school, n=96), 32.8% of elementary-L/I (limited contact/impact sports, n=58), and 8.6% of elementary-N athletes (noncontact sports, n=35), respectively. From these results, we concluded that contact sports activity during adolescence induces lumbar spine abnormalities at a higher rate compared to noncontact sports and that spondylolysis is related to contact or limited contact/impact sport activity during elementary school.