Aortoesophageal fistula due to esophageal cancer: a case report of successful management.

BACKGROUND: Aortoesophageal fistula (AEF) is a rare but potentially life-threatening condition. The best treatment for the AEF due to esophageal carcinoma is still unresolved. Here, we report a rare case of AEF caused by esophageal cancer, that was successfully treated with emergency thoracic endovascular aortic repair (TEVAR), followed by esophagectomy and gastric tube reconstruction. CASE PRESENTATION: A 64-year-old man presented with loss of consciousness and hypotension during chemoradiotherapy for advanced esophageal cancer. Enhanced computed tomography showed extravasation from the descending aorta into the esophagus at the tumor site. We performed emergency TEVAR for the AEF, which stabilized the hemodynamics. We then performed thoracoscopic subtotal esophagectomy on day 4 after TEVAR to prevent graft infection, followed by gastric tube reconstruction on day 30 after TEVAR. At 9 months after the onset of AEF, the patient continues to receive outpatient chemotherapy and leads a normal daily life. CONCLUSION: TEVAR is a useful hemostatic procedure for AEF. If the patient is in good condition and can continue treatment for esophageal cancer, esophagectomy and reconstruction after TEVAR should be performed to prevent graft infection and maintain quality of life.

Trauma Care Systems in Urban Areas: Our Thoughts on the Contrasting Approaches in South Korea and Japan.

Trauma is a major global health issue, causing significant mortality, disability, and healthcare expenses. Since 2012, the Ajou Trauma Center in South Korea has been at the forefront, providing centralized severe trauma care for a population of 9.5 million. In 2022, the center managed 3,500 cases of severe trauma, including 500 helicopter transports, and conducted 2,800 surgeries, with 450 addressing torso trauma. Its exceptional performance has garnered global recognition, solidifying its position among the top advanced trauma centers. In Tokyo, critically ill and major trauma patients are currently transported to the nearest emergency and critical care centers, each serving a population of approximately 0.5 to 0.6 million people. Due to the low incidence of trauma per facility and an aging population, implementing a high level of trauma care and a comprehensive training framework within Japan's existing system poses significant challenges. A comparative analysis of South Korea's centralized system and Tokyo's decentralized approach indicates that the centralized system may lead to the establishment of a more advanced trauma center with ethical and equity considerations, compared to the decentralized approach. Therefore, consolidating major trauma cases in Tokyo shows promise for establishing exceptional trauma centers. This emphasizes the urgent need for Japan to take immediate steps towards a more robust future in trauma care. This assertion aligns with the global discourse on improving trauma care practices and could make a valuable contribution to the scholarly literature on trauma care systems.

Mitral valve repair using a semi-rigid posterior band: a 10-year Japanese single-center experience of 244 patients.

Background: Mitral valve repair (MVr) is an established procedure for patients who require surgery for primary mitral regurgitation (PMR). The Colvin-Galloway Future Band (CGFB) is a semi-rigid posterior band expected to improve the clinical outcomes of MVr. However, information on the hemodynamic and functional performance and long-term outcomes of CGFB is limited. We evaluated the quality, durability, and clinical performance after MVr using CGFB for PMR as the cohort study. Methods: A total of 244 patients who underwent MVr with CGFB were enrolled. Clinical and echocardiographic assessments were performed (mean follow-up period, 4.0±2.4 years). Results: Posterior mitral leaflet resection was the most common MVr procedure. CGFBs measuring 28 mm (35.2%) and 30 mm (36.5%) were used. The incidence of systolic anterior motion (SAM) was 1.6%. A total of 93.4% of the patients had no or trace MR at discharge. Over 90% of patients had no or mild MR at the last follow-up. The mean pressure gradient and mitral valve orifice area one year after MVr ranged between 2.6 and 3.6 mmHg and 2.3 and 3.4 cm2, respectively. At follow-up, 85.4% of the patients were New York Heart Association class I. Three patients underwent repeat mitral valve surgery. Conclusions: The CGFB demonstrates satisfactory quality and durability in MVr for PMR. Other advantages include a low occurrence of SAM and acceptable hemodynamic outcomes, particularly in patients requiring a smaller annuloplasty device.

Effects of Pemafibrate on Reducing Oxidative Stress and Augmenting Angiogenesis in Ischemic Limb Tissue.

OBJECTIVE: Oxidative damage is observed in the ischemic limbs of patients with arteriosclerosis obliterans. We investigated whether pemafibrate, a selective peroxisome proliferator-activated receptor alpha modulator, reduced oxidative stress in ischemic limbs and consequently rescued limb damage in model mice. MATERIALS AND METHODS: We surgically induced hind-limb ischemia in mice and orally administered pemafibrate solution (P-05 group, 0.5 mg/kg/day; P-10 group, 1.0 mg/kg/day) or control solution (control group). Seven days after the surgery, differences in reactive oxygen species (ROS) contents, antioxidative enzyme and transcription factor expression, blood flow, and capillary density in ischemic limbs were assessed. RESULTS: Tissue ROS levels were lower in the P-05 and P-10 groups compared with those in the control group. Although the tissue expression levels of nuclear factor-erythroid 2-related factor 2 increased in the P-10 group compared with that in the control group, no corresponding changes were observed in the tissue expression of four antioxidative enzymes. The limb salvage rates and capillary densities in ischemic limbs were higher in the P-05 and P-10 groups than that in the control group. CONCLUSION: Pemafibrate treatment reduced oxidative stress and augmented angiogenesis in ischemic limbs, contributing to prevention of limb damage in mice.

Prognostic factor in patient with recurrent pancreatic adenocarcinoma.

PURPOSE: To elucidate prognostic factors for post-recurrence survival in patients with pancreatic ductal adenocarcinoma (PDAC). METHODS: Patients who underwent curative-intent surgery for PDAC between January 2014 and May 2020 were identified. Among them, patients who had postoperative recurrences and received chemotherapy were retrospectively investigated. Independent prognostic factors for survival after recurrence were investigated using multivariate analyses. Eligible patients were divided into two groups according to the presence or absence of the identified prognostic factors, and survival times after recurrence were compared. RESULTS: Eighty-four patients with recurrent PDAC were included. Multivariate analysis showed that red blood cell (RBC) transfusion (HR, 2.80; p = 0.0051), low albumin level (HR, 1.84; p = 0.0402), and high carbohydrate antigen 19-9 (CA19-9) level at recurrence (HR, 2.11; p = 0.0258) were significant predictors of shorter survival after recurrence. The median survival times after recurrence in the transfusion and non-transfusion groups were 5.5 vs. 18.1 months (p < 0.0001), respectively; those in the low and normal albumin groups were 10.1 vs. 18.7 months (p = 0.0049), and those in the high and normal CA19-9 groups were 11.5 vs. 22.6 months (p = 0.0023), respectively. CONCLUSIONS: RBC transfusion, low albumin, and high CA19-9 levels at recurrence negatively affected survival after recurrence in patients with PDAC.

Surgical resection for liver recurrence after curative resection of pancreatic ductal adenocarcinoma.

PURPOSE: This study aimed to evaluate the clinical significance of surgical resection for liver recurrence in patients with curatively resected pancreatic ductal adenocarcinoma. METHODS: The medical records of patients with a liver recurrence after undergoing curative pancreatectomy for pancreatic ductal adenocarcinoma were retrospectively reviewed. Clinicopathological and prognostic factors were analyzed, as was the clinical impact of surgical resection for liver recurrence. RESULTS: Overall, 502 patients underwent curative pancreatic ductal adenocarcinoma resection. Of the 311 patients with recurrence after curative pancreatectomy, 71 (23%) had an initial recurrence in the liver, with 35 having solitary recurrence (11%). Patients with solitary, two or three, or more than four recurrences had median overall survival times of 28.5, 18.0, and 12.2 months, respectively (p < 0.001). Surgical indications for liver recurrence in our institution included solitary tumor, good disease control under chemotherapy after recurrence for > 6 months, and sufficient remnant liver function. Ten patients who met our institutional policy inclusion criteria underwent liver resection. Among 35 patients with initially solitary liver recurrence, those who underwent liver resection outlived those who did not (57.6 months vs. 20.1 months, p < 0.001). In multivariate analysis of overall survival, solitary liver recurrence and liver resection were independent favorable prognostic factors in patients with initial liver recurrence. CONCLUSION: In selected patients with solitary liver recurrence after curatively resected pancreatic ductal adenocarcinoma, liver resection may be a treatment option.

Endovascular Aortic Repair for Heavily Calcified Abdominal Aortic Stenosis Using the Gore Viabahn Vbx Balloon-Expandable Covered Stent.

Open surgery for the treatment of focal infrarenal aortic stenosis in high-risk patients may result in complications and mortality. Endovascular aortic repair may be used to treat these lesions. Here, we present the case of a 78-year-old woman with severe, highly calcified stenosis of the infrarenal abdominal aorta, which was successfully treated with the GORE VIABAHN VBX (Gore Medical; Flagstaff, AZ) balloon-expandable covered stent. Long-term and randomized controlled studies comparing open surgery with EVAR are necessary to evaluate the usefulness of this novel device.

Hepatic artery resection in distal cholangiocarcinoma.

PURPOSE: This study aimed to elucidate the safety and oncological outcomes of surgery with hepatic artery resection (HAR) for patients with distal cholangiocarcinoma. METHODS: The clinical data of patients with distal cholangiocarcinoma who underwent curative intent surgery at Hiroshima University between March 2009 and January 2021 were retrospectively analyzed. Eligible patients were classified according to the presence or absence of HAR (HAR and non-HAR group), and clinicopathological features and disease-free survival rates were compared between the two groups. RESULTS: Among the 60 patients analyzed, eight patients had received HAR, and the remaining 52 patients had not. The rate of portal vein resection, T stage, and the number of metastasized lymph nodes in the HAR group were significantly greater than those in the non-HAR group (p < 0.001, p = 0.00695, and p = 0.0480, respectively). Postoperative severe complication was confirmed in one patient, and there were no in-hospital deaths in the HAR group. Seven of 8 patients in the HAR group showed recurrence during follow-up, and of those, six patients showed early recurrence within 1 year postoperatively. The disease-free survival time in the HAR group was significantly shorter than that in the non-HAR group (median: 7.4 m vs. 34.2 m, respectively) (p < 0.001). Multivariate analysis revealed that lymph node metastasis and HAR were significant risk factors for predicting the adverse disease-free survival time (hazard ratio (HR), 3.21; p = 0.0142; HR, 4.47; p = 0.0346, respectively). CONCLUSIONS: Patients with distal cholangiocarcinoma who underwent surgery with HAR tended to show early recurrences, although HAR could be performed safely.

Pathologic complete response following FOLFIRINOX and olaparib treatment for hepatic metastasized pancreatic ductal adenocarcinoma with a germline BRCA mutation.

A 47-year-old female who was previously treated for BRCA1 germline mutant breast cancer presented with increasing back pain. Radiological and pathological investigations led to the diagnosis of pancreatic ductal adenocarcinoma with multiple hepatic metastases. Serum carbohydrate antigen 19-9 levels were highly elevated at 14,784 U/mL (normal, < 37 U/mL). After nine cycles of FOLFIRINOX treatment, radiological findings revealed remarkable shrinkage of the primary pancreatic tumor, disappearance of hepatic metastases, and normalized levels of carbohydrate antigen 19-9 levels. Because of increased neuropathy following FOLFIRINOX treatment, the patient was switched to maintenance olaparib treatment. Ten months later, her radiological response and normalized carbohydrate antigen 19-9 levels were stable. After staging laparoscopy, the patient underwent laparoscopic distal pancreatectomy as a conversion surgery. Histopathological examination revealed no signs of residual adenocarcinoma in the resected pancreatic specimens, which was diagnosed as a pathological complete response. The patient recovered without complications. Adjuvant olaparib treatment was administered with no signs of recurrence at 7 months after surgery. In conclusion, a pathologic complete response after FOLFIRINOX and olaparib maintenance treatment in hepatic metastasized pancreatic ductal adenocarcinoma is extremely rare. These bridging treatments may contribute to increased surgical resection rates and improved survival rates.

[Evaluation of oral medications in the geriatric medical care ward based on the Guidelines for Appropriate Use of Medications for the Elderly (2018), and an analysis of the number of oral medicines in relation to the nutritional route and activities of daily living (ADL) categories].

AIM: This study aimed to evaluate the use of potentially inappropriate medications (PIMs) and to examine the number of oral medicines based on the swallowing function and activities of daily living (ADL) categories in a geriatric medical care ward. METHODS: A prospective investigation of oral medication use of 124 consecutive patients (male, n=58; female, n=66) admitted to a geriatric medical care ward was conducted from November 2019 to October 2020. Nutritional routes and ADL categories were quantitatively assessed, and the respective medication quantities were subjected to a statistical analysis. RESULTS: The average number of oral medications was 5.8 at acute care admission, 4.4 upon transfer to the geriatric medical care ward and 4.8 at discharge. Approximately 30% of oral medications were classified as PIMs, including antithrombotic agents, diuretics, antidiabetic drugs, magnesium oxide, sleep and anxiolytic medications, and antipsychotic drugs. Magnesium oxide, antipsychotic drugs, sleep and anxiolytic medications were frequently discontinued during the patient's stay at the geriatric medical care ward. The proportion of PIMs significantly decreased from 35.1% at admission, to 28.8% at ward transfer, and 24.3% at discharge (P<0.01). The number of oral medicines at discharge varied based on the nutritional route, with averages of 5.5 for oral intake, 3.6 for enteral nutrition, and 0.7 for venous nutrition. It also varied based on ADL categories, with averages of 6.0 for ADL 1, 5.8 for ADL 2, and 3.8 for ADL 3. CONCLUSION: The use of PIMs decreased in the geriatric medical care ward. A reduced swallowing function and lower ADL were associated with a decrease in the quantity of oral medicines.

A case of unresectable locally advanced intrahepatic cholangiocarcinoma that achieved pathological complete response after gemcitabine and S1 chemotherapy.

The standard chemotherapy for patients with unresectable cholangiocarcinoma is gemcitabine plus cisplatin, and gemcitabine plus S-1 (GS) chemotherapy is also reported to have similar effectiveness in Japan. However, the response rates of these two chemotherapies were modest, and no patients with intrahepatic cholangiocarcinoma (ICC) have shown a pathological complete response (pCR) following these chemotherapies. We report here the first case of an initially unresectable locally advanced ICC that achieved pCR following GS chemotherapy.

Clinicopathological features of gastric cancer after pancreaticoduodenectomy: reporting of three institutional cases and review of the global literature.

PURPOSE: Gastric cancer after pancreaticoduodenectomy was firstly reported in 1995, and the number of reports about this topic has increased in the past years. This review aimed to elucidate the clinicopathological features of this disease. METHODS: Data for 32 cases were obtained using literature search, and three cases in our institution were added. RESULTS: Twenty cases were reported from Japan, and fifteen cases were from the Western countries (Germany: 1 case, France: 2 cases, USA: 12 cases). In Japanese and the Western cases, the most dominant indication for pancreaticoduodenectomy was distal bile duct cancer and pancreatic ductal adenocarcinoma, respectively. The most frequently applied procedure of pancreaticoduodenectomy was pylorus-preserving pancreatoduodenectomy with pancreaticogastrostomy and pancreaticoduodenectomy with pancreaticojejunostomy, respectively. The median length of time interval from pancreaticoduodenectomy to GC detection tended to be shorter in the Japanese cases (61.5 months vs. 115 months). Of all cases, thirteen (37.1%) patients with gastric cancer showed no abdominal symptoms, and eight were diagnosed at regular gastroscopy. Surgical gastrectomy was performed in 30 patients, and among them, concomitant pancreatectomy was performed in six patients. Four patients received reanastomosis of remnant pancreas using pancreaticojejunostomy. Twenty-two (73.3%) patients had undifferentiated carcinomas, and stage 1, 2, 3, and 4 cancer was identified in 14, six, six, and four patients, respectively. All eight patients who had received routine gastroscopy were T1N0M0 stage 1. CONCLUSION: Gastric cancers after pancreaticoduodenectomy including newly reported Japanese cases and our institutional cases were reviewed to make Japanese studies available to a broader scientific audience. Further investigation is necessary to elucidate the most important carcinogens among the various potential local and systemic factors.

Preoperative risk factors for positivity of peritoneal lavage cytology in patients with pancreatic ductal adenocarcinoma in the era of neoadjuvant therapy.

BACKGROUND: The preoperative risk factors for positive peritoneal lavage cytology (CY) are unknown, especially in patients who received neoadjuvant therapy. In addition, the optimal indications for staging laparoscopy (SL) are still unclear. The aim of this study was to investigate the preoperative risk factors of CY positivity in patients with pancreatic ductal adenocarcinoma (PDAC) treated with surgical resection and to determine the optimal indications for SL. METHODS: We retrospectively analyzed 493 patients with PDAC, including 356 treated with upfront surgery and 137 treated with neoadjuvant chemotherapy (NAC). The preoperative risk factor for CY positivity was investigated along with stratification according to NAC. RESULTS: Among the 493 patients, 36 (7.3%) were CY-positive. The CY-positive frequency in patients who received and did not receive NAC was 9 (6.6%) and 27 (7.6%), respectively. In the multivariate analyses, no independent preoperative predictive factor was found in patients who received NAC, whereas body and tail PDAC were identified as an independent risk factor for CY positivity in patients who did not receive NAC. CONCLUSIONS: The preoperative risk factors of CY-positive PDAC are body and tail PDAC in 356 patients who did not receive NAC. However, there is no useful predictive factor for CY positivity in patients treated with NAC. Based on these results, it was difficult to determine the optimal indication for SL especially in NAC cases.

Prognosis following an extended duration of adjuvant gemcitabine plus S-1 chemotherapy in patients with pancreatic ductal adenocarcinoma: Analysis using inverse probability of treatment weighting.

BACKGROUND/PURPOSE: The aim of this study was to assess whether the duration of adjuvant gemcitabine plus S-1 (GS) chemotherapy has any effect on survival in patients with pancreatic ductal adenocarcinoma (PDAC). METHODS: Of the 290 patients who received adjuvant GS chemotherapy, 100 (34%) received the standard duration (20-29 weeks) and 190 (66%) received an extended duration (≥30 weeks). To reduce selection bias, the prognostic impact (recurrence-free survival [RFS] and overall survival [OS]) based on the duration of adjuvant GS chemotherapy was analyzed using inverse probability of treatment weighting (IPTW). Moreover, to reduce immortal time bias, time-dependent multivariate analyses in which implementation of adjuvant GS chemotherapy was treated as time-varying covariate was also performed. RESULTS: Extended duration of adjuvant GS chemotherapy was significantly correlated with prolonged RFS (P < .001) and OS (P < .001) after IPTW adjustment. Time-dependent multivariate analyses revealed that extended duration of adjuvant GS chemotherapy was an independent prognostic factor for prolonged RFS (hazard ratio [HR], 0.58, P = .002) and OS (HR, 0.56, P = .005). CONCLUSION: Extended duration (≥30 weeks) of adjuvant GS chemotherapy in patients with PDAC was associated with an improved prognosis. These findings warrant a further prospective trial on PDAC to investigate the survival benefit of extended adjuvant chemotherapy.

Impact of disintegrin and metalloproteinase domain-containing protein 12 on pancreatic ductal adenocarcinoma treated with surgical resection and perioperative chemotherapy.

BACKGROUND/OBJECTIVES: A disintegrin and metalloproteinase domain-containing protein 12 (ADAM12) has been reported to influence tumor progression and chemosensitivity in human cancers. We assessed the prognostic impact of ADAM12 and its predictive value for neoadjuvant chemotherapy (NAC) in patients with pancreatic ductal adenocarcinoma (PDAC) treated with surgical resection. METHODS: ADAM12 expression was immunohistochemically examined in 428 patients with PDAC who underwent surgical resection. The association of ADAM12 expression with clinicopathological factors and survival was also analyzed. RESULTS: Patients with high ADAM12 expression exhibited significantly shorter median disease-free survival (DFS) (high ADAM12: 17.8 vs. low ADAM12: 37.9 months; P < 0.001) and overall survival (OS) (high ADAM12: 33.1 vs. low ADAM12: 65.0 months; P < 0.001). A multivariate analysis revealed that high ADAM12 expression was an independent risk factor for poor DFS (P < 0.001) and OS (P < 0.001) in all eligible patients. Of 100 patients who received neoadjuvant chemotherapy (NAC), high ADAM12 expression was significantly associated with poor DFS in a subset of patients treated with the nab-paclitaxel (PTX) neoadjuvant regimen (P = 0.03), whereas the prognostic value of ADAM12 was not evident in patients not treated with nab-PTX (P = 0.12). CONCLUSIONS: A negative prognostic value of high ADAM12 expression was observed in patients with PDAC treated with surgical resection, which was enhanced in patients treated with NAC, including nab-PTX. These results suggested that ADAM12 expression can predict nab-PTX chemosensitivity in PDAC and reflect PDAC progression.

Long-term survival after distal pancreatectomy with celiac axis resection and hepatic artery reconstruction in the setting of locally advanced unresectable pancreatic cancer.

The long-term survival of patients with locally advanced, unresectable pancreatic cancer is extremely poor. We present our experience with a 67-year-old woman who had a 40-mm mass in the body of the pancreas. Tumor infiltration reached the gastroduodenal artery, celiac artery, common hepatic artery, and splenic artery. After 10 courses of FOLFIRINOX, 2 courses of gemcitabine plus nab-paclitaxel, and 6 courses of gemcitabine alone, we performed distal pancreatectomy with celiac axis resection and hepatic artery reconstruction. The bifurcation of the gastroduodenal artery and the proper hepatic artery had to be resected, after which we created 2 anastomoses: proper hepatic-to-middle colic artery, and second jejunal-to-right gastroepiploic artery. Histopathologic examination revealed an Evans grade IIb histologic response to prior treatment and verified the R0 resection status. The patient was discharged on postoperative day 30 after treatment of a grade B pancreatic fistula and is still alive, without recurrence, more than 5 years after initiation of treatment. This patient with locally advanced, unresectable pancreatic cancer achieved long-term survival through perioperative multidisciplinary treatment, including distal pancreatectomy with celiac axis resection and hepatic artery reconstruction. This aggressive procedure could be a treatment option for patients with locally advanced, unresectable pancreatic cancer.

Intimo-Intimal Intussusception due to Stanford Type A Acute Aortic Dissection Presenting as Cerebral Infarction.

Complete circumferential dissection is a rare clinical presentation of aortic dissection, wherein the dissected flap has the potential to cause intimo-intimal intussusception, which can lead to several catastrophic complications. We report a case of Stanford type A acute aortic dissection with intimo-intimal intussusception causing unstable cerebral ischemic symptoms. An 82-year-old man was taken to another hospital with severe intermittent dizziness. Head magnetic resonance imaging revealed multiple right-hemispheric cerebral infarctions. Computed tomography also showed a "missing flap," indicating that the intimal flap was observed in the aortic root and arch but not in the ascending aorta. The patient was referred to our hospital for emergent surgery. Intraoperatively, the intimal tear was found to be circumferential, and the transected intima was folded and superimposed from the origin of the brachiocephalic artery to the aortic arch. Ascending aortic replacement and aortic valve replacement were performed; the postoperative course was good.

Optimal lymph-node dissection for pancreatic tail cancer.

PURPOSE: The optimal range of lymph-node dissection for pancreatic tail cancer remains unclear. We investigated the location and frequency of lymph-node metastases to identify the correct range of lymph-node dissection for pancreatic tail cancer. METHODS: We analyzed clinical data retrospectively, on patients who underwent distal pancreatectomy for resectable left-sided pancreatic cancer, between February, 2006 and March, 2021. Eligible patients were divided into two groups according to the tumor location: those with pancreatic tail cancer (Pt group) and those with pancreatic body or body and tail cancer (non-Pt group). RESULTS: Of the 96 patients analyzed, 61 (64%) were assigned to the Pt group and 35 (36%) were assigned to the non-Pt group. Metastases to stations 7, 8, 9, 10, 11, 14, and 18 were found in 0 (0%), 0 (0%), 0 (0%), 4 (7%), 18 (30%), 2 (4%), and 10 (17%) patients in the Pt group, and in 1 (3%), 4 (12%), 2 (6%), 1 (3%), 18 (51%), 3 (9%), and 6 (17%) patients in the non-Pt group, respectively. CONCLUSION: Lymph-node dissection at stations 7, 8, and 9 might not be necessary in patients with resectable pancreatic cancer confined to the pancreatic tail.

Increased clostridium difficile infection in the era of preoperative chemotherapy for pancreatic cancer.

BACKGROUND: In recent trend of preoperative chemotherapy, postoperative clostridium difficile infection (CDI) might be increasing in pancreatic ductal adenocarcinoma (PDAC) patients. This study aimed to elucidate the inducement of postoperative CDI in the new era of preoperative chemotherapy. METHODS: Eligible patients were those who received pancreaticoduodenectomy for PDAC. Patients were classified into two groups according to the presence or absence of postoperative CDI, and the independently associated factors for postoperative CDI were investigated. Additionally, eligible patients were classified using the identified associated factors, and the duration of preoperative antimicrobial administration and incidence of CDI were compared between the groups. RESULTS: Two hundred PDAC patients were eligible for this study, and postoperative CDI was detected in 15 (7.5%) patients. Multivariate analysis revealed that preoperative biliary tract infection (BTI) and chemotherapy (Chemo) were independently associated with postoperative CDI (OR, 4.05; 95% CI, 1.25-13.1; p = 0.0200 and OR, 3.64; 95% CI, 1.14-11.6; p = 0.0209, respectively). The patients were classified into four groups according to the presence or absence of preoperative BTI and Chemo (BTI-/Chemo-, BTI-/Chemo+, BTI+/Chemo- and BTI+/Chemo + group). The median durations of preoperative antimicrobial administration were 0, 2, 8 and 15 days in each group, respectively. Postoperative CDI was detected in 3.7%, 10.0%, 10.5% and 31.3% in each group, respectively, and patients in BTI+/Chemo + group suffered CDI more frequently compared to those in BTI-/Chemo-group (p = 0.00778). CONCLUSIONS: Preoperative BTI and chemotherapy might induce postoperative CDI for PDAC patients.

Hemodynamic and clinical performance of the 25-mm Medtronic Mosaic porcine bioprosthesis in the mitral position.

The 25-mm Medtronic Mosaic porcine bioprosthesis (MB25) is the smallest bioprosthesis that has been approved for use in the mitral position in Japan. Various studies have reported satisfactory hemodynamic performance and good long-term outcomes of the Medtronic Mosaic porcine bioprosthesis. However, the hemodynamic and clinical performances of the MB25 in the mitral position remain unknown. This study aimed to evaluate the hemodynamic and clinical performance of the MB25 in mitral valve replacement (MVR). Twenty patients who underwent MVR using the MB25 between February 2013 and April 2018 were studied. We evaluated the hemodynamic performance of the MB25, cardiac chamber size, cardiac function, and systolic pulmonary artery pressure (PAP) using echocardiography during follow-up. The study outcomes were major adverse cardiac events (MACEs) and all-cause mortality. Sixteen patients (80%) had a patient prosthesis mismatch defined as an index effective orifice area of ≤ 1.2 cm2/m2. The left atrial dimension was significantly reduced after surgery (p = 0.0282). The mean pressure gradients (MPG) in the mitral position were 5.5 ± 1.7 mmHg at discharge and 4.2 ± 1.3 mmHg at 1 year postoperatively. The MPG in the mitral position significantly decreased during the follow-up period (p = 0.0489). Systolic PAP significantly improved postoperatively. The 1-, 3-, and 5-year survival rates were 87, 79, and 70%, respectively. No cardiac death occurred. There were no MACEs or reports of structural valve degeneration during the follow-up period. The hemodynamic and clinical performances of the MB25 in the mitral position were satisfactory as the smallest biological mitral valve. The MB25 is a reasonable option for MVR to reduce the surgical difficulty in high-risk patients with an advanced age, a small body size or MAC and when recurrent MVR or complex procedures are performed.