Feasibility and Safety of Sac Embolization Using N-Butyl Cyanoacrylate in Emergency Endovascular Aneurysm Repair for Ruptured Abdominal Aortic Aneurysms or Isolated Iliac Artery Aneurysms.

PURPOSE: To evaluate the feasibility and safety of sac embolization with N-butyl cyanoacrylate (NBCA) in emergency endovascular aneurysm repair (EVAR) for ruptured abdominal aortic aneurysm (AAA) and iliac artery aneurysm (IAA) in comparison to EVAR without sac embolization. MATERIALS AND METHODS: Between February 2012 and December 2019, among 44 consecutive patients with ruptured AAA or IAA, 29 underwent EVAR. Of these, 22 patients (median age 77.5 years; 18 men) had concomitant sac embolization using NBCA; the remaining 7 patients (median age 88 years; 6 men) underwent EVAR without sac embolization and form the control group. The technical success, clinical success (hemodynamic stabilization), procedure-related complications, and mortality were compared between the groups. RESULTS: All EVAR procedures and embolizations were successful. The clinical success rates in the NBCA and control groups were 95% (21/22) and 71% (5/7), respectively (p=0.14). There was no complication related to the procedure. Type II endoleak occurred in 4 of 21 patients (19%) in the NBCA group vs none of the control patients. One patient (5%) died in the NBCA group vs 3 (43%) in the controls (p=0.034). CONCLUSION: Sac embolization using NBCA in emergency EVAR appears to be feasible and safe for ruptured AAA and IAA.

Aortic Arch Enlargement and Coarctation Repair of Preserving the Lesser Curvature of the Aortic Arch Through a Left Thoracotomy in Neonates.

The aim of this study was to analyze the aortic arch repair technique for preserving the lesser curvature without cardiopulmonary bypass through a left thoracotomy in neonates with coarctation of the aorta (CoA) and a hypoplastic distal aortic arch (HDAA). HDAA was defined as z-score of the aortic arch < - 2.5. Twenty-four neonates with CoA and HDAA were retrospectively studied. Patients underwent enlargement of the HDAA associated with CoA repair when their z-scores were < - 4. They were divided into 2 groups on the basis of the preoperative z-score of the distal aortic arch: group 1 (n = 14), z-score ≥ - 4; group 2 (n = 10), z-score < - 4. Twenty-two patients had intracardiac defects. Follow-up ranged from 0.9 to 20.1 years (median 11.6 years). The z-scores of the distal aortic arch were significantly smaller in group 2 than group 1 (- 5.09 ± 1.05 vs - 3.19 ± 0.36, p < 0.001). There were no hospital deaths and no hypertension. All dimensions of the aortic arch in both groups revealed significant catch-up growth (p < 0.02). All patients showed a pressure gradient ≤ 5 mmHg across the aortic arch and between the arms and legs at the latest follow-up. Two patients showed an angulated arch deformity over 10 years later. This technique provided good catch-up growth and a low incidence of reobstruction and deformity of reconstructed aortic arch in both groups. These results suggest that this modification might be considered as one choice of technique for CoA and HDAA.

Bacterial peritonitis in a patient with malignant ascites caused by pancreatic carcinoma: Case report and review of literature.

Bacterial peritonitis, an infection of the ascitic fluid, can be classified etiologically as spontaneous or secondary bacterial peritonitis. The former is mainly caused by portal hypertension and its subsequent effects, whereas the latter is caused by the direct dissemination of bacteria into the peritoneal cavity. Previous reports have described some distinguishing features of these two entities. Here, we report the first known case of bacterial peritonitis with Aeromonas hydrophilia and Escherichia coli in a patient with malignant ascites associated with pancreatic carcinoma who exhibited features of both spontaneous and secondary peritonitis. Our report suggests that clinicians should also consider bacterial peritonitis in patients with malignant ascites who present with ostensibly cancer-related symptoms.

Effectiveness of cardiac surgery in patients with trisomy 18: a single-institutional experience.

BACKGROUND: Surgical repair for cardiac lesions has rarely been offered to patients with trisomy 18 because of their very short lifespans. We investigated the effectiveness of cardiac surgery in patients with trisomy 18. Patients and methods We performed a retrospective analysis of 20 consecutive patients with trisomy 18 and congenital cardiac anomalies who were evaluated between August, 2003 and July, 2013. All patients developed respiratory or cardiac failure due to excessive pulmonary blood flow. Patients were divided into two subgroups: one treated surgically (surgical group, n=10) and one treated without surgery (conservative group, n=10), primarily to compare the duration of survival between the groups. RESULTS: All the patients in the surgical group underwent cardiac surgery with pulmonary artery banding, including patent ductus arteriosus ligation in nine patients and coarctation repair in one. The duration of survival was significantly longer in the surgical group than in the conservative group (495.4±512.6 versus 93.1±76.2 days, respectively; p=0.03). A Cox proportional hazard model found cardiac surgery to be a significant predictor of survival time (risk ratio of 0.12, 95% confidence interval 0.016-0.63; p=0.01). CONCLUSIONS: Cardiac surgery was effective in prolonging survival by managing high pulmonary blood flow; however, the indication for surgery should be carefully considered on a case-by-case basis, because the risk of sudden death remains even after surgery. Patients' families should be provided with sufficient information to make decisions that will optimise the quality of life for both patients and their families.

Replacement of the extracardiac conduit for infective endocarditis after a fontan operation.

We report the management of infective endocarditis after an extracardiac Fontan operation. Obstruction of the infected conduit and the associated pulmonary arterial embolism led to failure of the Fontan circulation. This was managed by completely removing both the infected conduit and emboli and replacing the conduit.

A Shaped Pectoralis Major Muscle Flap under Indocyanine Green Fluorescence Angiography for Sternal Wound Infection.

The treatment of a sternal wound infection is challenging because it requires radical debridement and reconstruction with a well-vascularized flap. The defects after debridement are three-dimensionally complex, especially if synthetic grafts are involved. Although the pectoralis major muscle (PMM) flap is useful for reconstruction, it is difficult to fill up the complex dead space surrounding the vascular prosthesis when using a conventional PMM flap. Herein, we describe a new technique of splitting and shaping the PMM flap to fit the complex defect. Intraoperative indocyanine green fluorescence angiography was used to assess dynamic blood flow of the PMM supplied by internal mammary artery perforators. This technique allows the PMM flap to be split and shaped to securely fit the dead space, which may improve the healing rate.

Single-stage repair for ascending aortic aneurysm, artery stenosis and occlusion of neck vessels caused by Takayasu arteritis.

Takayasu arteritis results in a variety of vascular symptoms, and there are some cases in which progressive vascular lesions require surgical intervention. We present a case with ascending aortic aneurysm, right common carotid artery stenosis, left common carotid artery occlusion and left subclavian artery stenosis caused by Takayasu arteritis that was successfully treated with total arch replacement and ascending aorta to right internal carotid artery bypass.

Surgical outcomes of acute type A aortic dissection in septuagenarians and octogenarians.

BACKGROUND: We studied surgical outcomes of acute type A aortic dissection and compared early and late outcomes between septuagenarians and octogenarians. METHODS: From 2010 to 2019, we evaluated 254 consecutive patients with acute type A aortic dissection. We performed emergent operations within 48 h of symptom onset for 188 patients, including 59 septuagenarians and 32 octogenarians. RESULTS: The overall 30-day mortality rate was 8.5% in septuagenarians and 9.4% in octogenarians (p = 1.0). The hospital mortality rate was 10.2% in septuagenarians and 12.5% in octogenarians (p = 0.74). Multivariate analysis identified prolonged ventilation (≥ 72 h) as a significant risk factor for hospital mortality. Being an octogenarian was not significantly associated with hospital mortality. The actuarial survival rate at 5 years was 80.1% in septuagenarians and 58.5% in octogenarians (log-rank p = 0.09). The freedom from aortic event rate at 5 years was 91.0% in septuagenarians and 100% in octogenarians (log-rank p = 0.23). CONCLUSION: The two groups showed no significant differences in hospital mortality or morbidity. Our tear-oriented strategies might be appropriate for both septuagenarians and octogenarians. Prolonged ventilation (≥ 72 h) was a significant risk predictor for hospital mortality.

A safe sequential treatment approach for patients who have acute cholecystitis with severe inflammation: Transmural gallbladder drainage followed by laparoscopic cholecystectomy under the guidance of fluorescence imaging.

INTRODUCTION: For patients who have acute severe cholecystitis, urgent/early biliary drainage followed by delayed/elective laparoscopic cholecystectomy is recommended according to the Tokyo Guidelines 2018. Percutaneous transhepatic gallbladder drainage is an established technique. Recently, transmural gallbladder drainage under the guidance of endoscopic ultrasonography (EUS-GBD) was reported as a safe alternative. During surgery, fluorescence imaging using indocyanine green (ICG) has been increasingly used for visualizing the bile ducts. Herein, we report a sequential treatment approach which ensures safety without impairing normal activities before cholecystectomy: EUS-GBD followed by laparoscopic cholecystectomy using ICG fluorescence imaging. MATERIALS AND SURGICAL TECHNIQUE: A 66-year-old man with acute cholecystitis underwent urgent EUS-GBD and had the drainage tube placement through the duodenum into the gallbladder. During 2.5 months of the waiting period, he had no clinical troubles. After insertion of a laparoscope, we found a structure between the gallbladder and the duodenum. We injected 0.025 mg/mL of ICG into the nasobiliary drainage tube (placed in the gallbladder through the duodenum) and confirmed that the structure was a fistula. After removing the tube, the fistula was divided using a surgical stapler under the guidance of fluorescence imaging. The cystic and common bile ducts were also clearly visualized as fluorescence. DISCUSSION: We reported a safe sequential treatment approach for the patient who required biliary drainage: EUS-GBD followed by laparoscopic cholecystectomy under the guidance of ICG fluorescence imaging. This sequential approach may improve patients' satisfaction with respect to quality of life during the waiting period and may ensure the safety of laparoscopic cholecystectomy.

The new red-emitting phosphor of oxyfluoride Ca2RF4PO4:Eu3+ (R=Gd, Y) for solid state lighting applications.

The novel red-emitting phosphors of Eu3+-activated Ca2RF4PO4:Eu3+ (R=Gd, Y) prepared by a solid-state reaction have been evaluated as a candidate for white solid state lighting. The detailed luminescence properties, e.g., the excitation spectra, the luminescence spectra and quantum efficiency under the excitation of near-UV, and decay lifetimes were reported. The phosphors can be efficiently excited by near UV light and exhibit a dominant emission peaked at 611 nm (5D0-7F2) with CIE coordinates of (x=0.661, y=0.333). The thermal stabilities were investigated from the luminescence intensities, color purity and the decay curves by increasing temperature. The luminescence parameters related to white LEDs applications were compared to some red phosphors and discussed in details. The red-emitting Ca2RF4PO4:Eu3+ (R=Gd, Y) may be potentially useful in the fabrication of white LEDs.

The thermal stabilities of luminescence and microstructures of Eu2+-doped KBaPO4 and NaSrPO4 with ß-K2SO4 type structure.

Eu(2+)-doped monophosphates NaSrPO(4) and KBaPO(4) with the ß-K(2)SO(4) structure were synthesized using the conventional high temperature solid state reaction. The X-ray powder diffraction, photoluminescence excitation, and emission spectra and decay curves were measured. The phosphors can be efficiently excited by UV-visible light from 220 to 430 nm to realize emission in the visible range. The natures of the Eu(2+) emission, e.g., the chromaticity coordinates, the Stokes shifts, and the luminescence absolute quantum efficiencies, were reported. The luminescence quenching temperatures and the thermal activation energies for NaSrPO(4):Eu(2+) and KBaPO(4):Eu(2+) were obtained from the temperature dependent (10-435 K) luminescence intensities and decay curves. KBaPO(4):Eu(2+) presents only one emission center; however, Eu(2+) ions have a "disordered environment" in NaSrPO(4) lattices. The relationship between the luminescence thermal stabilities and the crystal structures was discussed. The crystallographic occupations of rare earth ions doped in these hosts were analyzed by the site-selective emission spectra and the excitation spectra of Eu(3+) ions in the (7)F(0)→(5)D(0) transitions using a pulsed, tunable, and narrow-band dye laser. In KBaPO(4), the Eu(3+) ions could be distributed in the host with a high "ordered state" in only one site in the lattices. However, the multiple site structure of Eu(3+) ions with highly disordered distributions in NaSrPO(4) lattices was suggested.

Intraoperative Findings of an Atypical Type II Endoleak from an Artery within the Aneurysmal Wall after Endovascular Aneurysm Repair.

A 75-year-old man underwent emergent endovascular aortic repair for a ruptured abdominal aortic aneurysm. Two years later, computed tomography revealed aneurysm enlargement with endoleaks. Next, late open conversion was performed. Intraoperatively, we detected a spurting type II endoleak from an artery within the aneurysmal wall, which was unconnected to any branch vessels outside the aneurysm, and surgical ligation and sacotomy was performed uneventfully. To our knowledge, this is the first report to intraoperatively identify a type II endoleak from an artery within the aneurysm wall. Even for atypical type II endoleak, such as this case, open surgical repair should be effective.

Novel fine gauge electrocautery dilator for endoscopic ultrasound-guided hepaticogastrostomy (with video).

Highlight Ogura and colleagues present a novel electrocautery dilation device for endoscopic ultrasound-guided procedures. The distal end of the outer dilator contains a 3-Fr metal tip, allowing a smaller burning effect than with conventional devices. This novel device may have clinical impact for endoscopic ultrasound-guided procedures as tract dilation device.

Mutant IDH1 confers resistance to energy stress in normal biliary cells through PFKP-induced aerobic glycolysis and AMPK activation.

Metabolism is a critical regulator of cell fate determination. Recently, the significance of metabolic reprogramming in environmental adaptation during tumorigenesis has attracted much attention in cancer research. Recurrent mutations in the isocitrate dehydrogenase (IDH) 1 or 2 genes have been identified in several cancers, including intrahepatic cholangiocarcinoma (ICC). Mutant IDHs convert α-ketoglutarate (α-KG) to 2-hydroxyglutarate (2-HG), which affects the activity of multiple α-KG-dependent dioxygenases including histone lysine demethylases. Although mutant IDH can be detected even in the early stages of neoplasia, how IDH mutations function as oncogenic drivers remains unclear. In this study, we aimed to address the biological effects of IDH1 mutation using intrahepatic biliary organoids (IBOs). We demonstrated that mutant IDH1 increased the formation of IBOs as well as accelerated glucose metabolism. Gene expression analysis and ChIP results revealed the upregulation of platelet isoform of phosphofructokinase-1 (PFKP), which is a rate-limiting glycolytic enzyme, through the alteration of histone modification. Knockdown of the Pfkp gene alleviated the mutant IDH1-induced increase in IBO formation. Notably, the high expression of PFKP was observed more frequently in patients with IDH-mutant ICC compared to in those with wild-type IDH (p < 0.01, 80.9% vs. 42.5%, respectively). Furthermore, IBOs expressing mutant IDH1 survived the suppression of ATP production caused by growth factor depletion and matrix detachment by retaining high ATP levels through 5' adenosine monophosphate-activated protein kinase (AMPK) activation. Our findings provide a systematic understanding as to how mutant IDH induces tumorigenic preconditioning by metabolic rewiring in intrahepatic cholangiocytes.

The Impact of MDCT and Endoscopic Transpapillary Mapping Biopsy to Predict Longitudinal Spread of Extrahepatic Cholangiocarcinoma.

BACKGROUNDS: We aimed to investigate the diagnostic accuracy of multidetector-row computed tomography (MDCT), mapping biopsy, and other imaging modalities to predict the longitudinal extension and depth of invasion of extrahepatic cholangiocarcinoma at possible surgical ductal margins. METHODS: Of 102 patients with surgical resection of extrahepatic cholangiocarcinoma between January 2010 and October 2015, 32 evaluated by multidetector-row computed tomography (MDCT) performed before biliary drainage and mapping biopsy were enrolled. Mapping biopsies were performed at 74 sites to determine the resection point of the bile duct (at 74 possible surgical ductal margins). Diagnostic accuracy was evaluated by histopathology. RESULTS: The diagnostic accuracy of MDCT for longitudinal cancer spread was 79.7%, that of biopsy was 73.0%, and combining the two modalities showed highest accuracy (83.8%). The depth of tumor invasion could be predicted by combination of the ductal wall thickness and contrast enhancement on MDCT, that is, at 11 of 13 sites (84.6%) with submucosal invasion, ductal wall thickness was > 2.5 mm with high contrast enhancement. CONCLUSIONS: MDCT demonstrated highest accuracy of diagnosing longitudinal extension at possible surgical ductal margins in patients with extrahepatic cholangiocarcinoma. The depth of tumor invasion could be predicted by ductal wall thickness and contrast enhancement of MDCT.

Detection of common bile duct stones: comparison between endoscopic ultrasonography, magnetic resonance cholangiography, and helical-computed-tomographic cholangiography.

OBJECTIVES: New modalities, namely, endoscopic ultrasonography (EUS), magnetic resonance cholangiopancreatography (MRCP), and helical computed-tomographic cholangiography (HCT-C), have been introduced recently for the detection of common bile duct (CBD) stones and shown improved detectability compared to conventional ultrasound or computed tomography. We conducted this study to compare the diagnostic ability of EUS, MRCP, and HCT-C in patients with suspected choledocholithiasis. METHODS: Twenty-eight patients clinically suspected of having CBD stones were enrolled, excluding those with cholangitis or a definite history of choledocholithiasis. Each patient underwent EUS, MRCP, and HCT-C prior to endoscopic retrograde cholangio-pancreatography (ERCP), the result of which served as the diagnostic gold standard. RESULTS: CBD stones were detected in 24 (86%) of 28 patients by ERCP/IDUS. The sensitivity of EUS, MRCP, and HCT-C was 100%, 88%, and 88%, respectively. False negative cases for MRCP and HCT-C had a CBD stone smaller than 5mm in diameter. No serious complications occurred while one patient complained of itching in the eyelids after the infusion of contrast agent on HCT-C. CONCLUSIONS: When examination can be scheduled, MRCP or HCT-C will be the first choice because they were less invasive than EUS. MRCP and HCT-C had similar detectability but the former may be preferable considering the possibility of allergic reaction in the latter. When MRCP is negative, EUS is recommended to check for small CBD stones.

In vivo identification of pancreatic cystic neoplasms with needle-based confocal laser endomicroscopy.

Pancreatic cystic lesions (PCLs) are increasingly identified with the widespread use of imaging modalities. The precise diagnosis of PCLs remains a challenge despite the use of CT, MRI, and EUS-FNA. Confocal laser endomicroscopy (CLE) is a new endoscopic imaging modality that provides real-time, very high magnification images. A smaller CLE probe, which can be passed through a 19-gauge FNA needle, is now available. Needle-based CLE during EUS has recently been examined to evaluate PLCs, and the specific criteria of nCLE for the diagnosis of PLCs have been proposed.

Infected pseudoaneurysm following a modified Blalock-Taussig shunt procedure.

A 3-year-old boy with pulmonary atresia with ventricular septal defect, who had undergone placement of a modified Blalock-Taussig shunt, presented with a 1-week history of high fever. Computed tomography showed a pseudoaneurysm at the anastomosis between the right brachiocephalic artery and the graft. After intravenous antibiotic therapy, the pseudoaneurysm and infected graft were resected through a median sternotomy. This report describes successful management of a potentially fatal complication following placement of a modified Blalock-Taussig shunt.