Quality of epicardial adipose tissue predicts major adverse cerebral and cardiovascular events following transcatheter aortic valve implantation.

Epicardial adipose tissue (EAT) have been shown to be associated with several heart disease, including coronary artery disease (CAD), atrial fibrillation (AF), and heart failure (HF). It is reported that the quality of EAT, represented by fat attenuation determined using computed tomography (CT) imaging, can detect the histologically-assessed remodeled EAT. We tested the hypothesis that quality of EAT would predict major adverse cerebral and cardiovascular events (MACCE) following transcatheter aortic valve implantation (TAVI) in patients with aortic stenosis (AS). A total of 125 consecutive severe AS patients who underwent TAVI were enrolled (39 male, mean 85.4 ± 4.0 years). Using CT imaging before TAVI, we measured the average CT fat attenuation of EAT (EAT attenuation) and investigated the association with MACCE. During the mean follow up period of 567 ± 371 days, 21 cases of MACCE were observed. Patients with MACCE had greater levels of EAT attenuation compared to those without (- 74 ± 3.7 Hounsfield Units (HU) vs - 77 ± 5.5 HU, p = 0.010). Based on the ROC curves, the high EAT attenuation was defined as > - 74.3 HU. According to this cut-off index, 44 patients were classified into the high EAT attenuation group (28 female, mean age 87 ± 3.6 years), whereas 81 patients were classified into the low EAT attenuation group (13 female, 85 ± 4.1 years). Kaplan-Meier survival curve demonstrated that the patients in the high EAT attenuation group showed greater prevalence of MACCE (log-rank 6.64, p = 0.010). Cox proportional hazards regression analysis revealed that EAT attenuation and Logistic EuroSCORE were independently associated with the incidence of MACCE. Our results suggest that quality of EAT, assessed by EAT attenuation detected by CT imaging, can predict the cerebral and cardiovascular events after TAVI in patients with AS.

Surgical and radiosurgical outcomes for Koos grade 3 vestibular schwannomas.

This study aimed to reveal the preferred initial treatment for Koos grade 3 vestibular schwannomas (VS). We performed a two-institutional retrospective study on 21 patients with Koos grade 3 VS undergoing resection at Yokohama Medical Center and 37 patients undergoing radiosurgery at Yokohama Rosai Hospital from 2010 to 2021. Tumor control, complications, and functional preservation were compared. The median pre-treatment volume and follow-up duration were 2845 mm3 and 57.0 months, respectively, in the resection group and 2127 mm3 and 81.7 months, respectively, in the radiosurgery group. In the resection group, 16 (76.2%) underwent gross total resection, and three patients (14.3%) experienced regrowth; however, no one required additional treatment. In the radiosurgery group, the tumor control rate was 86.5%, and three cases (8.1%) required surgical resection because of symptomatic brainstem compression. Kaplan-Meier analyses revealed that tumors with delayed continuous enlargement and large thin-walled cysts were significantly associated with poor prognostic factors (p = 0.0027, p < 0.001). The pre-radiosurgery growth rate was also associated with the volume increase (p = 0.013). Two cases (9.5%) required additional operation due to complications such as post-operative hematoma and cerebrospinal fluid leaks in the resection group, whereas temporary cranial neuropathies were observed in the radiosurgery group. Two patients (9.5%) had poor facial nerve function (House-Brackmann grading grade 3) in the resection group, while no one developed facial paresis in the radiosurgery group. Trigeminal neuropathy improved only in the resection group.Radiosurgery can be considered for the treatment of Koos grade 3 VS for functional preservation. However, resection may also be considered for patients with severe trigeminal neuropathy or a high risk of volume increments, such as large thin-walled cysts and rapid pre-treatment growth.

Primary central nervous system other iatrogenic immunodeficiency-associated lymphoproliferative disorders presenting as extraosseous plasmacytoma with a progressive clinical course: A case report and literature review.

Other iatrogenic immunosuppressive-associated lymphoproliferative disorders (OIIA-LPDs) rarely occur in the central nervous system (CNS). Additionally, they almost always present as lymphoma and withdrawal by cessation of immunosuppressive treatment. We report a case of primary CNS OIIA-LPD that presented as extraosseous plasmacytoma (EP) with a progressive clinical course in spite of immunosuppressive treatment cessation. A 78-year-old man with a history of rheumatoid arthritis (RA) presented with a month-long headache. Magnetic resonance imaging showed mass lesions in the left temporal lobe, left middle fossa, and intradural cervical spine. The left temporal lesion was resected and diagnosed as EP histologically, and OIIA-LPD presented as plasmacytoma integrally due to his history of immunosuppressive treatment using tacrolimus for RA. Despite immunosuppressive treatment cessation, OIIA-LPD lesions did not regress but, on the contrary, showed a progressive clinical course. Considering his advanced age and renal dysfunction, postoperative treatment with radiation and moderate chemotherapy using prednisolone were administrated. Subsequently, the disease state stabilized, and the patient had a Karnofsky performance status score of 90 for 6 months; however, the tumor recurred with meningeal dissemination, and he died 8 months after treatment. Types of OIIA-LPD onset as EP and its progressive clinical course resistant to cessation of immunosuppressive treatment are rare. Moreover, this OIIA-LPD disease state worsened despite its radiosensitivity. We believe the progressive clinical course of this OIIA-LPD case with its high cell proliferation is similar to Epstein-Barr virus negative plasmablastic lymphoma, which could lead to a poor outcome.

Proposal criteria of paradoxical low-flow low-gradient aortic stenosis for predicting prognosis in patients undergoing transcatheter aortic valve implantation.

BACKGROUND: Paradoxical low-flow, low-gradient (PLF-LG) aortic stenosis (AS) is associated with poor prognosis in patients undergoing transcatheter aortic valve implantation (TAVI). This study aimed to verify the conventional criteria of PLF-LG AS (left ventricular ejection fraction [LVEF] > 50%, mean aortic valve pressure gradient [AVPG] < 40 mm Hg and stroke volume index [SVI] < 35 ml/m2 by measuring Doppler method) compatible for predicting prognosis in patients undergoing TAVI. MATERIALS AND METHODS: A total of 128 consecutive patients who underwent TAVI for AS with LVEF > 50% were enrolled. The primary endpoint was the hospital readmission due to heart failure (HRHF) and the secondary endpoint was all-cause mortality after hospital discharge. The patients were classified by both the conventional criteria of PLF-LG AS and the proposal criteria of PLF-LG AS if mean aortic valve pressure gradient (AVPG) < 40 mmHg and SVI by measuring Simpson's method < cut off value based on the ROC curve for predicting HRHF. RESULTS: According to the conventional criteria, only 6 patients were diagnosed with PLF-LG AS. However, according to the proposal criteria, 16 patients were diagnosed with PLF-LG AS. Fourteen patients developed HRHF during the follow-up period after TAVI. Based on the ROC curves, SVI by measuring Simpson's method (cut off value = 25 ml/m2) had higher sensitivity and specificity for predicting HRHF (AUC = 0.74, p = 0.0013) than SVI by measuring Doppler method (AUC = 0.63, p = 0.045). The multivariate analysis revealed that PLF-LG AS defined by the proposal criteria (HR: 5.25; 95% CI: 1.60-17.16; p = 0.0073) but not by the conventional criteria was independently associated with HRHF. PLF-LG AS defined by the conventional criteria and the proposal criteria were not associated with all-cause mortality in the univariate analysis. CONCLUSIONS: Our results demonstrated that new criteria of PLF-LG AS defined as SVI < 25 ml/m2 measured by Simpson's method could predict HRHF in patients with severe AS who underwent TAVI.

Extensive Aortic Stent Graft Coverage for Thoracoabdominal Aortic Aneurysm is Associated With Hemorrhagic Complications Induced by Disseminated Intravascular Coagulation.

BACKGROUND: Hybrid endovascular repair for thoracoabdominal aortic aneurysm (TAAA) is a less invasive alternative treatment than conventional open repair. However, disseminated intravascular coagulation (DIC) and hemorrhagic complications can occur postoperatively. We investigated risk factors for hemorrhagic complications after hybrid endovascular TAAA repair. METHODS: Sixty-one patients who underwent elective hybrid endovascular TAAA repair between 2007 and 2020 were included. Laboratory data before and after placing stent graft were collected, and DIC was diagnosed using a scoring system established by the Japanese Association for Acute Medicine. The length of the stent graft used to cover the aorta was defined as the aortic coverage length, which was measured using the first postoperative computed tomography image. Predictors of unexpected hemorrhagic complications were evaluated. RESULTS: Postoperative thrombocytopenia was observed in 57 (93%) patients, and their platelet count decreased significantly after stent graft placement (14.3 [9.5-18.0] vs. 8.2 [5.4-10.9] × 104/µL, P < 0.001). Fifteen (25%) and 45 patients (74%) were diagnosed with DIC before and after stent graft placement, respectively. Hemorrhagic complications were observed in 21 patients (34%). Multivariate logistic regression analysis revealed that aortic coverage length was an independent risk factor for hemorrhagic complications (odds ratio 1.441/50 mm increase; 95% confidence interval, 1.041-1.994, P = 0.027). The cutoff value for aortic coverage length obtained from the receiver operating characteristic curve (area under the curve = 0.72) was 304.4 mm (sensitivity 0.76, specificity 0.70). CONCLUSION: Aortic coverage length is a risk factor for hemorrhagic complications. Patients undergoing extensive aortic coverage greater than 304 mm should be closely monitored.

Three-month outcomes of aortic valve reconstruction using collagenous membranes (biosheets) produced by in-body tissue architecture in a goat model: a preliminary study.

BACKGROUND: Autologous pericardium is widely used as a plastic material in intracardiac structures, in the pulmonary artery, and in aortic valve leaflets. For aortic valve reconstruction (AVRec) using the Ozaki procedure, it has produced excellent clinical results over a 10-year period. In-body tissue architecture (iBTA), which is based on the phenomenon of tissue encapsulation of foreign materials, can be used to prepare autologous prosthetic tissues. In this preliminary study, we examined whether biosheets can be used as valve leaflet material for glutaraldehyde-free AVRec by subchronic implantation experiments in goats and evaluated its performance compared with glutaraldehyde-treated autologous pericardium for AVRec. METHODS: Biosheets were prepared by embedding molds for two months into the dorsal subcutaneous spaces of goats. Autogenic biosheets (n = 4) cut into the shape of the valve were then implanted to the aortic valve annulus of four goats for three months without glutaraldehyde treatment. Autologous pericardium (n = 4) was used in four goats as a control. Valve function was observed using echocardiography. RESULTS: All goats survived the three-month study period. With biosheets, the leaflet surfaces were very smooth and, on histology, partially covered with a thin neointima (including endothelial cells). Biosheets were more thoroughly assimilated into the aortic root compared with autologous pericardium. CONCLUSIONS: For the first time, biosheets were used for large animal AVRec. Biosheets could function as leaflets in the aortic position and may have the ability to assimilate into native valves.

Impact of breast cancer subtype on clinical outcomes after Gamma Knife radiosurgery for brain metastases from breast cancer: a multi-institutional retrospective study (JLGK1702).

INTRODUCTION: Brain metastasis (BM) is one of the most important issues in the management of breast cancer (BC), since BMs are associated with neurological deficits. However, the importance of BC subtypes remains unclear for BM treated with Gamma Knife radiosurgery (GKS). Thus, we conducted a multicenter retrospective study to compare clinical outcomes based on BC subtypes, with the aim of developing an optimal treatment strategy. METHODS: We studied 439 patients with breast cancer and 1-10 BM from 16 GKS facilities in Japan. Overall survival (OS) was analyzed by the Kaplan-Meier method, and cumulative incidences of systemic death (SD), neurologic death (ND), and tumor progression were estimated by competing risk analysis. RESULTS: OS differed among subtypes. The median OS time (months) after GKS was 10.4 in triple-negative (TN), 13.7 in Luminal, 31.4 in HER2, and 35.8 in Luminal-HER2 subtype BC (p < 0.0001). On multivariate analysis, poor control of the primary disease (hazard ratio [HR] = 1.84, p < 0.0001), active extracranial disease (HR = 2.76, p < 0.0001), neurological symptoms (HR 1.44, p = 0.01), and HER2 negativity (HR = 2.66, p < 0.0001) were significantly associated with worse OS. HER2 positivity was an independent risk factor for local recurrence (p = 0.03) but associated with lower rates of ND (p = 0.03). TN histology was associated with higher rates of distant brain failure (p = 0.03). CONCLUSIONS: HER2 positivity is related to the longer OS after SRS; however, we should pay attention to preventing recurrence in Luminal-HER2 patients. Also, TN patients require meticulous follow-up observation to detect distant metastases and/or LMD.

Gorget-like Cuddling Suture: An Anastomosis Reinforcement Technique to Reduce Suture Bleeding for Aortic Surgery.

We developed a new reinforcement technique, the Gorget-like Cuddling (GOCU) suture, to prevent suture line bleeding during aortic surgery. After continuous aortic anastomosis with thick outer felt, an additional 2-0 Ticron (Medtronic, Minneapolis, MN) suture is placed distal from the first suture line. This GOCU suture directly holds the needle holes. Wall tension on the anastomosis can also be reduced to prevent longitudinal dilatation of the aorta. This technique can contribute to hemostasis for a fragile aortic wall in cases like acute aortic dissection.

[Combined Valvular Disease with Suspected Acquired von Willebrand Syndrome].

A 73-year-old female was referred to our department for surgical treatment of combined rheumatic valvular disease. She had undergone percutaneous transluminal mitral commissurotomy 29 years before. She underwent double valve replacement with bioprosthetic valves and tricuspid annuloplasty combined with left atrial appendectomy for chronic atrial fibrillation. Because of remarkable bleeding following surgery, rapid blood transfusion and re-thoracotomy were immediately performed. However, the bleeding persisted even after re-thoracotomy, and acquired von Willebrand syndrome due to valvular disease was suspected. Von Willebrand factor/factor Ⅷ preparation was administered, and bleeding promptly became under control. Recently, acquired von Willebrand syndrome due to valvular disease has attracted attention. We need to keep it in mind during perioperative management for patients with valvular disease.

The impact of EGFR-TKI use on clinical outcomes of lung adenocarcinoma patients with brain metastases after Gamma Knife radiosurgery: a propensity score-matched analysis based on extended JLGK0901 dataset (JLGK0901-EGFR-TKI).

PURPOSE: Recent advances in targeted therapy have prolonged overall survival (OS) for patients with lung cancer. The impact of epidermal growth factor receptor-tyrosine kinase inhibitors (EGFR-TKI) on brain metastases (BM) treated with stereotactic radiosurgery (SRS) has not, however, been fully elucidated. We investigated the influence of post-SRS EGFR-TKI use on the efficacy and toxicity of SRS for BM from lung adenocarcinoma. METHODS: We used the updated dataset of the Japanese Leksell Gamma Knife (JLGK) 0901 study, which proved the efficacy of Gamma Knife SRS in patients with BM. Propensity score matching (PSM) analysis was employed to determine the impact of concurrent or post-SRS EGFR-TKI use on OS, neurological death, intracranial disease recurrence and SRS-related adverse events. RESULTS: Among 1194 patients registered in the JLGK0901 study, 608 eligible lung adenocarcinoma patients were identified and 238 (39%) had received EGFR-TKI concurrently or during the post-SRS clinical course. After PSM, there were 200 patient pairs with/without post-SRS EGFR-TKI use. EGFR-TKI use was associated with longer OS (median 25.5 vs. 11.0 months, HR 0.60, 95% CI 0.48-0.75, p < 0.001), although the long-term OS curves eventually crossed. Distant intracranial recurrence was more likely in patients receiving EGFR-TKI (HR 1.45, 95% CI 1.12-1.89, p = 0.005). Neurological death, local recurrence and SRS-related adverse event rates did not differ significantly between the two groups. CONCLUSIONS: Although patients receiving EGFR-TKI concurrently or after SRS had significantly longer OS, the local treatment efficacy and toxicity of SRS did not differ between patients with/without EGFR-TKI use.

Stereotactic radiosurgery in elderly patients with brain metastases: comparison with non-elderly patients using database of a multi-institutional prospective observational study (JLGK0901-Elderly).

PURPOSE: Stereotactic radiosurgery (SRS) has been increasingly used for elderly patients with brain metastases (BMs). However, no studies based on a large sample size have been reported. To compare SRS treatment results between elderly and non-elderly patients, we performed a subset study of elderly patients using our prospectively-accumulated multi-institution study database (JLGK0901 Study, Lancet Oncol 15:387-395, 2014). METHODS: During the 2009-2011 period, 1194 eligible patients undergoing gamma knife SRS alone for newly diagnosed BMs were enrolled in this study from 23 gamma knife facilities in Japan. Observation was discontinued at the end of 2013. The 1194 patients were divided into the two age groups, 693 elderly ( ≥ 65 years) and 501 non-elderly ( < 65 years) patients. Our study protocol neither set an upper age limit nor required dose de-escalation. RESULTS: Median post-SRS survival time was significantly shorter in the elderly than in the non-elderly patient group (10.3 vs 14.3 months, HR 1.380, 95% CI 1.218-1.563, p < 0.0001). However, regarding all secondary endpoints including neurological death, neurological deterioration, SRS-related complications, leukoencephalopathy, local recurrence, newly-developed tumors, meningeal dissemination, salvage SRS, whole brain radiotherapy and surgery and decreased mini-mental state examination scores, the elderly patient group was not inferior to the non-elderly patient group. In the 693 elderly patients, there was no post-SRS median survival time difference between those with 5-10 versus 2-4 tumors (10.8 vs 8.9 months, HR 0.936, 95% CI 0.744-1.167, p = 0.5601). CONCLUSIONS: We conclude that elderly BM patients are not unfavorable candidates for SRS alone treatment.

Rupture of the Remaining Renal Artery Aneurysm While Waiting for Stage 2 Surgery for a Patient with Bilateral Renal Artery Aneurysms and Multiple Aneurysms.

A 21-year-old man was referred to our department for treatment of multiple aneurysms, including bilateral renal artery aneurysms. He was clinically diagnosed with Loeys-Dietz syndrome. So, we developed a 2-stage surgical strategy. The first surgery involved reconstructing the right renal artery and replacing part of the abdominal aorta, bilateral common iliac artery, and bilateral internal and external iliac arteries with a synthetic graft. Although stent grafting of the left renal artery aneurysm had been scheduled for the second surgery, sudden rupture of the left renal artery aneurysm forced us to perform emergency renal artery reconstruction.

Gamma Knife Radiosurgery for Metastatic Brain Tumors from Malignant Melanomas: A Japanese Multi-Institutional Cooperative and Retrospective Cohort Study (JLGK1501).

BACKGROUND: The incidences of metastatic brain tumors from malignant melanomas have increased and survival has been prolonged by novel molecular targeted agents and immunotherapy. However, malignant melanomas are uncommon in Asian populations. OBJECTIVES: We retrospectively analyzed treatment efficacy and identified prognostic factors impacting tumor control and survival in Japanese melanoma patients with brain metastases treated with gamma knife radiosurgery (GKRS). METHODS: We retrospectively reviewed the medical records of 177 patients with 1,500 tumors who underwent GKRS for brain metastases from malignant melanomas. This study was conducted by the Japanese Leksell Gamma Knife Society (JLGK1501). RESULTS: Six and 12 months after GKRS, the cumulative incidences of local tumor recurrence were 9.2 and 13.8%. Intratumoral hemorrhage (p < 0.0001) and larger tumor volume (p = 0.001) in GKRS were associated with significantly poorer local control outcomes. The use of immune checkpoint inhibitors before GKRS was significantly associated with symptomatic adverse events (p = 0.037). The median overall survival time after the initial GKRS was 7.3 months. Lower Karnofsky performance status scores (p = 0.016), uncontrolled primary cancer (p < 0.0001), and multiple brain metastases (p = 0.014) significantly influenced unfavorable overall survival outcomes. The cumulative incidences of neurological death 6 and 12 months after GKRS were 9.7 and 17.4%, those of neurological deterioration were 14.2 and 19.6%, and those of new tumor appearance were 34.5 and 40.5%. CONCLUSIONS: The results of the present multicenter study suggest that GKRS is a relatively effective and safe modality for control of tumor progression in Japanese patients with brain metastases from malignant melanomas.

[Transcatheter Aortic Valve Implantation for Sever Aortic Valve Stenosis].

Since reimbursements for transcatheter aortic valve implantation(TAVI) for severe aortic valve stenosis began in 2013, TAVI has spread rapidly in Japan. TAVI is currently performed in nearly 100,000 cases a year worldwide, and more than 4,000 procedures performed annually in Japan. The TAVI valves available in Japan are Edwards' "SAPIEN" and the Medtronic "Evolut R". The "SAPIEN" is a balloon-expanding valve and can be placed via a transfemoral or transapical approach. In contrast, the "Evolut R" is a self-expanding valve and can be placed via the transfemoral, transsubclavian or direct aortic approach. The surgical indications for TAVI are high-risk patients in whom surgical aortic valve replacement (SAVR) cannot be performed by conventional thoracotomy, and dialysis patients are excluded. With the evolution of the associated devices, the performance of TAVI has become comparable to that of SAVR. The outcomes of TAVI in Japan are particularly good compared with the results of the world. Globally, TAVI treatment is being adopted in intermediate- to low-risk patients as well as in high-risk patients. TAVI treatment is expected to continue to spread in the future.

[Two Cases of Hepatic Encephalopathy after Chemotherapy for Metastatic Colorectal Cancer].

We reported 2 cases of hepatic encephalopathy after chemotherapy for advanced colorectal cancer. Case 1: A 49-year-old male was diagnosed advanced sigmoid colon cancer with peritoneal dissemination, multiple liver metastasis and multiple osseous metastasis. After resection of primary lesion, we administered mFOLFOX6 plus bevacizumab combination therapy. He was in comatose(Japan coma scale 200)3 days after 2 courses of administration of this regimen. Case 2: A 57-year-old female was diagnosed advanced rectal cancer with multiple huge liver metastasis and multiple osseous metastasis. We administered mFOLFOX6 plus panitumumab combination therapy. She was in comatose(Japan coma scale 100)3 days after 10 courses of administration of this regimen. In both cases, radiographic imaging showed no abnormal sign and blood examination revealed a high level of serum ammonia. We diagnosed their disturbance of consciousness as a symptom of hepatic encephalopathy. Branched-chain amino acid infusion rapidly improved disturbance of consciousness. We must consider the symptom, hepatic encephalopathy in patients receiving chemotherapy for advanced colorectal cancer.

[Challenge of Treating Thoracoabdominal Aortic Aneurysms with Hybrid Thoracic Endovascular Aortic Repair].

The treatment of thoracoabdominal aortic aneurysms in great vessels is still challenging, as the early results of the operation are not very promising compared with other aortic operations, and the incidence of spinal cord ischemia is relatively high. In Japan, which is becoming a super-aging society, the method of performing minimally invasive operations remains a major issue. At our facility, we have been performing abdominal debranching thoracic endovascular aortic repair (TEVAR) to resolve these issues. Hybrid TEVAR was performed in 51 cases of aortic aneurysm and chronic dissection of the thoracoabdominal field between 2007 and 2015. The standard operative procedure of abdominal debranching involves replacing the abdominal aorta with a bifurcated graft and making an anastomosis between the left leg of the bifurcated graft and a quadrifurcated graft;the visceral arteries are then reconstructed using the quadrifurcated graft. Abdominal debranching and TEVAR were performed as a 2-stage procedure. Hybrid repair of a thoracoabdominal aortic aneurysm is a good option for elderly, high-risk patients because the early and late results are acceptable.

[Anorectal Malignant Melanoma Is a Very Rare Disease and Has a Poor Prognosis].

We performed abdomino-perineal-resection(APR)on 2 cases of anorectal malignant melanoma. The first case was a 70- year-old woman suffering from bloody stool. Colonoscopy showed a black tumor in the rectum. Biopsy revealed a malignant melanoma. A CT scan showed multiple lung metastases and liver metastasis. She underwent surgery for the purpose of bleeding control, but died shortly thereafter because her liver and lung metastases had worsened. The second case was a 43- years-old man suffering from bloody stool. He had a black type 3 tumor in the rectum. A biopsy revealed malignant melanoma. A CT scan showed lateral lymph node swelling. He underwent APR with right side-lateral dissection. An established treatment for anorectal malignant melanoma has not been agreed upon and it is controversial. We experienced 2 cases that underwent surgery and we report them along with relevant information from the literature.

[Transaortic Thoracic Endovascular Aortic Repair Via Right Anterior Mini-thoracotomy;Report of a Case].

An 81-year-old man presented with ruptured thoracic aortic aneurysm under stable condition. He had been suffering from chronic obstructive pulmonary disease, chronic renal failure and rheumatoid arthritis. We performed hybrid thoracic endovascular aortic repair via right anterior mini-thoracotomy inserting a device through a conduit on the ascending aorta. The patient was discharged without aorta-related complications.

[Clinical Experience with Nutrition and Anticoagulation Therapy for a Patient with a 30 cm Residual Jejunum].

Patients with short bowel syndrome experience malabsorption and digestive disorders. They are unable to maintain adequate nutrition by the oral or enteral route alone, and their requirements for liquids, electrolytes, nutrients, microelements, vitamins, etc., are not completely met. Managing the nutritional needs of these patients is important. Another concern is these patients' inability to absorb medication, because the small intestine that is shortened in short bowel syndrome is the principal site of drug absorption. Here, we report a case of a 74-year-old woman with a 30 cm residual jejunum after surgery for acute occlusion of the superior mesenteric artery and the clinical management of nutrition and anticoagulant medication in this patient.

[Treatment Experience with Sorafenib for Lung Metastases of Hepatocellular Carcinoma Complicated with Interstitial Pneumonia].

A 74-year-old man was diagnosed with hepatocellular carcinoma(HCC; S4/8)and underwent anterior segment resection of the liver in 2015. He was hospitalized with a wound infection 2 months after surgery. On the 8th hospital day he complained of respiratory discomfort. A CT showed multiple lung metastases and a ground-glass appearance in both lungs. We diagnosed interstitial pneumonia with metastatic lung tumors. Steroid therapy was performed for the interstitial pneumo- nia(prednisolone 1,000mg/day×3 days), and sorafenib therapy was initiated for the metastatic lung cancer(starting from 200mg/day to 800mg/day). The prednisolone improved his symptoms. The lung metastatic tumors shrunk by the 36th hospital day after the CT. However, he developed difficulty in breathing again on the 58th hospital day, and again showed a ground-glass appearance in both lungs by CT. We thought it was drug-induced interstitial pneumonia and we discontinued oral sorafenib. He underwent steroid pulse therapy, but his symptoms did not improve and he died.