Usefulness of Transesophageal Echocardiography in Diagnosing the Cause of Circulatory Collapse During Reoperation for an Inferior Vena Cava-Left Atrium Shunt After Atrial Septal Defect Closure: A Case Report.

Iatrogenic inferior vena cava (IVC)-left atrium (LA) shunt is a rare complication in atrial septal defect (ASD) surgery, caused by mistaking the Eustachian valve for the lower margin of the ASD. In this report, we describe the case of a 45-year-old woman who experienced circulatory collapse at termination of cardiopulmonary bypass during surgical IVC-LA shunt repair. Transesophageal echocardiography helped identify stenosis between the IVC and the right atrium, caused by a residual original incorrectly placed ASD patch. Removal of most of the patch led to improvement in circulatory failure.

[Metastatic Right Atrial Tumor of Renal Cell Carcinoma:Report of a Case].

Metastatic cardiac tumors are known to be more common than primary cardiac tumors, and most patients are asymptomatic. In patients with renal cell carcinoma (RCC) with cardiac metastases, total tumor resection is known to improve the prognosis. We report a case of a successfully resected RCC with right atrial metastasis under cardiopulmonary bypass. A 71-year-old female with abdominal distention was diagnosed with right RCC and extension to the right atrium. After neoadjuvant chemotherapy, she underwent right nephrectomy and neiection of intraocular tumor extention with partial right atrium under cardiopulmonary bypass, because the tumor tightly adhered to the right atrium. She had a good postoperative course and was discharged home on the 22nd postoperative day. Nine months after surgery, she shows no sign of recurrence.

Anesthetic management for withdrawal from a right ventricular assist device and Fontan procedure in a patient with an implantable left ventricular assist device for fulminant cardiomyopathy.

BACKGROUND: We herein report the anesthetic management for extracardiac conduit-total cavopulmonary connection (EC-TCPC) for weaning from an extracorporeal right ventricular assist device (RVAD) in a patient with an implantable left ventricular assist device (LVAD) for fulminant cardiomyopathy. CASE PRESENTATION: A 24-year-old man developed fulminant cardiomyopathy and was placed on a biventricular assist device (BiVAD) comprising an implantable LVAD and an extracorporeal RVAD. The Fontan procedure was performed to wean the patient from the RVAD and allow him to be discharged home. Atrial septal defect creation, right ventricular suture, and tricuspid valve closure were then simultaneously performed to ensure sufficient left ventricular preload to drive the LVAD. Furthermore, to keep the central venous pressure lower, the inflow cannula of the LVAD was oriented in the correct direction. CONCLUSION: This is the first report of anesthetic management of the Fontan procedure in a patient with a BiVAD.

[Stanford Type A Acute Aortic Dissection Complicated with Intestinal Ischemia Preceded by Superior Mesenteric Artery Bypass:Report of a Case].

A 78-year-old male with sudden onset of chest and back pain was transported to our institution by ambulance. Upon arrival at our hospital, he also complained of abdominal pain. Contrast-enhanced computed tomography (CT) revealed the presence of Stanford type A acute aortic dissection complicated with intestinal ischemia;because of the effects of aortic dissection, the superior mesenteric artery 378 Vol.76 No.5(2023-5) (SMA) was obstructed, leading to the complication of intestinal ischemia. An arterial blood gas test showed elevated lactate and metabolic acidosis. We immediately performed resection of the necrotic portion of the intestine and bypass of the common iliac artery to the SMA. Subsequently, after confirmation of the improvement of acidosis, ascending aortic replacement was performed on the same day. Although the patient's condition was complicated by acute kidney injury and pneumonia, he was discharged home on the 55th postoperative day. Acute aortic dissection complicated by intestinal ischemia has a poor prognosis;however, here we reported a life-saving surgical procedure in a patient with this presentation.

Outcomes after Rivaroxaban Treatment of Extensive Deep Vein Thrombosis.

BACKGROUND: Regression of thrombus in response to treatment with direct oral anticoagulants (DOACs) in patients with extensive deep vein thrombosis (DVT) has not been fully evaluated. This study aimed to determine the therapeutic efficacy of rivaroxaban in the treatment of extensive DVT. METHODS: We retrospectively evaluated 76 patients treated with rivaroxaban among 728 new DVT patients, at our hospital from January 2018 to March 2021. Extensive DVT was defined as thrombus connecting to 2 or more segments of the inferior vena cava (IVC), iliac vein, femoral vein, or popliteal vein. Localized DVT was defined as a thrombus confined to 1 segment of the inferior vena cava (IVC), iliac vein, femoral vein, or popliteal vein. We compared the changes in thrombus between the extensive DVT group (36 patients) and the localized DVT group (40 patients). RESULTS: In the localized DVT group, 14 (37%) had total recanalization within 3 weeks after DOAC initiation, and 30 (79%) had total recanalization within 3 months. In the extensive DVT group, only 3 (9%) had total recanalization within 3 weeks after starting DOAC, and even after 3 months, only 5 (15%) had total recanalization. Symptoms (P = 0.01) and extensive DVT (P < 0.01) were significantly associated with the risk for failure of total recanalization. CONCLUSIONS: Rivaroxaban was highly effective for total recanalization of localized DVT but not for symptomatic or extensive DVT. In patients with symptomatic extensive DVT, catheter-based thrombolysis may be considered in selected cases.

Long-term and short-term outcomes of laparoscopic versus open resection following tube decompression for obstructive colorectal cancer: a single-center retrospective study.

PURPOSE: The benefits of laparoscopic surgery over open surgery are well documented; however, the suitability of laparoscopic surgery for obstructive colorectal cancer is still controversial. The aim of this retrospective study was to compare the clinical benefits of laparoscopic surgery vs. open surgery for obstructive colorectal cancer after tube decompression. METHODS: We analyzed the outcomes of patients who underwent laparoscopic surgery vs. open surgery for curative resection after tube decompression for obstructive colorectal cancer at our hospital between January, 2007 and March, 2018. RESULTS: This study comprised 67 patients: 29 patients who underwent open surgery and 38 patients who underwent laparoscopic surgery. The morbidity within 30 days after surgery was comparable between the groups. The 3-year overall survival rates of the open and laparoscopic groups were 83.3 and 79.4%, respectively (p = 0.6244), and the 3-year disease-free survival rates were 59.3 and 71.2%, respectively (p = 0.3200). Multivariate analysis showed that nodal stage (p = 0.021) was an independent prognostic factor for OS and sex (p = 0.010) and side-ness (p = 0.048) were independent prognostic factors for DFS. CONCLUSION: If adequate decompression is achieved, laparoscopic resection following tube decompression for obstructive colorectal cancer can be a safe alternative to open surgery.

Cost-effectiveness of TAS-102 plus bevacizumab versus TAS-102 monotherapy in patients with metastatic colorectal cancer.

BACKGROUND: TAS-102 plus bevacizumab is an anticipated combination regimen for patients who have metastatic colorectal cancer. However, evidence supporting its use for this indication is limited. We compared the cost-effectiveness of TAS-102 plus bevacizumab combination therapy with TAS-102 monotherapy for patients with chemorefractory metastatic colorectal cancer. METHOD: Markov decision modeling using treatment costs, disease-free survival, and overall survival was performed to examine the cost-effectiveness of TAS-102 plus bevacizumab combination therapy and TAS-102 monotherapy. The Japanese health care payer's perspective was adopted. The outcomes were modeled on the basis of published literature. The incremental cost-effectiveness ratio (ICER) between the two treatment regimens was the primary outcome. Sensitivity analysis was performed and the effect of uncertainty on the model parameters were investigated. RESULTS: TAS-102 plus bevacizumab had an ICER of $21,534 per quality-adjusted life-year (QALY) gained compared with TAS-102 monotherapy. Sensitivity analysis demonstrated that TAS-102 monotherapy was more cost-effective than TAS-102 and bevacizumab combination therapy at a willingness-to-pay of under $50,000 per QALY gained. CONCLUSIONS: TAS-102 and bevacizumab combination therapy is a cost-effective option for patients who have metastatic colorectal cancer in the Japanese health care system.

Bridge to Surgery for Obstructing Colonic Cancer: A Comparison between Right- and Left-sided Lesions.

OBJECTIVES: Few studies have compared management and outcomes of bridge to surgery (BTS) for obstructive colonic cancer according to the location of the tumor. Additional information is needed about this procedure's characteristics and short-term and long-term outcomes. We aimed to compare patient and tumor characteristics, and outcomes of BTS for obstructive right-sided versus left-sided colonic cancers. METHODS: This was a retrospective, single center, cohort study. The study cohort comprised 149 patients, including 48 with right-sided and 101 with left-sided obstructive colonic cancers, who were treated with BTS between January 2007 and December 2017. Data on medical history, investigations, treatments, and prognosis were collected from an electronic database of a single hospital. The primary end points were overall (OS) and disease-free (DFS) survival and short-term surgical outcomes. RESULTS: Significantly more patients with right-sided cancers had postoperative complications (29.2% vs. 14.9%, p = 0.039). Additionally, postoperative chemotherapy was administered to a marginally significantly greater proportion of patients with left-sided cancers (29.2% vs 45.5%, p = 0.057). The long-term outcomes were comparable between the two groups (the 5-year OS rates were 67.6% and 80.9% [p = 0.117] and the 5-year DFS rates were 62.2% and 58.6% [p = 0.671]). Multivariate analyses using all studied variables showed that lymphovascular invasion, advanced T stage, and adjuvant chemotherapy were independent poor prognostic factors. CONCLUSIONS: The long-term outcome was not different between the right- and left-sided groups. In a BTS setting, postoperative complications may reduce the compliance of adjuvant chemotherapy in right-sided cancers and affect long-term outcomes.

Risk Factors for Progression of Distal Deep Vein Thrombosis.

BACKGROUND: There is insufficient evidence regarding the optimal treatment method for distal deep vein thrombosis (DVT), including indications for anticoagulation therapy. Treatment results of patients with distal DVT were evaluated to clarify the risk factors that result in extension of distal DVT to the proximal vein and indications for anticoagulation therapy.Methods and Results:Among 430 patients with DVT between January 2018 and December 2019, 253 were diagnosed with distal DVT; 41 patients who had already started anticoagulation therapy were excluded, and the remaining 212 were included as study subjects. Anticoagulation therapy was not started immediately; conservative treatment with compression stockings was performed. Ultrasonography after 2 weeks revealed thrombus disappearance in 39 patients (21%), and thrombus reduction in 38 patients (20%). In contrast, extension of thrombus to the proximal vein was noted in 12 patients (6.3%) and anticoagulation therapy was commenced. After 3 months, the thrombus had disappeared in 75 patients (52%). No patient developed pulmonary thromboembolism during follow-up. With respect to the risk factors for extension to proximal vein during conservative treatment, active cancer (P=0.03), prolonged bed rest (P<0.01), and D-dimer level >8µg/mL (P=0.01) were identified. CONCLUSIONS: It is reasonable to consider anticoagulation therapy in distal DVT patients with active cancer, prolonged bed rest or high D-dimer level.

Watch-and-wait strategy for type A intramural haematoma and acute aortic dissection with thrombosed false lumen of the ascending aorta: a Japanese single-centre experience.

OBJECTIVES: In this study, we investigated the early and midterm outcomes of initial watch-and-wait strategy for Stanford type A intramural haematoma and acute aortic dissection with thrombosed false lumen of the ascending aorta in patients with a maximum aortic diameter of ≤50 mm, pain score of ≤3/10 and no ulcer-like projection in the ascending aorta. METHODS: Inpatient and outpatient records were retrospectively reviewed. RESULTS: Of the 81 patients with type A intramural haematoma and acute aortic dissection with the thrombosed false lumen of the ascending aorta between April 2011 and April 2019, a watch-and-wait strategy was selected in 46 patients. The mean age of the patients was 68 years, and 22 (48%) patients were female. Ten patients underwent emergency pericardial drainage for cardiac tamponade at the time of presentation and 8 patients underwent aortic repair during hospitalization for new ulcer-like projection, re-dissection or rupture. In-hospital mortality occurred in 2 (4%) patients. During follow-up, survival at 1 and 2 years was 95% and 92%, respectively. There was no significant difference in survival or aortic events between patients in whom the watch-and-wait strategy and emergency surgical treatment were indicated. CONCLUSIONS: The early and midterm outcomes of the initial watch-and-wait strategy were favourable for type A intramural haematoma and acute aortic dissection with the thrombosed false lumen of the ascending aorta in Japanese patients with a maximum aortic diameter of ≤50 mm, pain score of ≤3/10 and no ulcer-like projection. Further study is required to show the safety of this strategy.

Association Between Motor-Evoked Potentials and Spinal Cord Damage Diagnosed With Magnetic Resonance Imaging After Thoracoabdominal and Descending Aortic Aneurysm Repair.

OBJECTIVES: The authors investigated the association between intraoperative motor-evoked potential (MEP) changes and the severity of spinal cord infarction diagnosed with magnetic resonance imaging (MRI) to clarify the discrepancy between them, which was observed in patients with postoperative motor deficits after thoracic and thoracoabdominal aortic surgery. DESIGN: A multicenter retrospective study. SETTING: Motor-evoked potential <25% of control values was deemed positive for spinal cord ischemia. The severity of spinal cord infarction was categorized into grades A to D based on previous studies using the most severe axial MRI slices. The associations between MRI grade, MEP changes, and motor deficits were examined using logistic regression. PARTICIPANTS: Twenty-three of 1,245 patients (from 1999 to 2013, at 12 hospitals in Japan) were extracted from medical records of patients who underwent thoracic and thoracoabdominal aortic repair, with intraoperative MEP examinations and postoperative spinal MRI. INTERVENTIONS: No intervention (observational study). MEASUREMENTS AND MAIN RESULTS: Motor-evoked potential <25% of control value was associated significantly with motor deficits at discharge (adjusted odds ratio [OR], 130.0; p = 0.041), but not with severity of spinal cord infarction (adjusted OR, 0.917; p = 0.931). Motor deficit at discharge was associated with severe spinal cord infarction (adjusted OR, 4.83; p = 0.043), MEP <25% (adjusted OR, 13.95; p = 0.031), and combined deficits (motor and sensory, motor and bowel or bladder, or sensory and bowel or bladder deficits; adjusted OR, 31.03; p = 0.072) in stepwise logistic regression analysis. CONCLUSION: Motor-evoked potential <25% was associated significantly with motor deficits at discharge, but not with the severity of spinal cord infarction.

Initial experience using Excimer laser for the extraction of chronically implanted pacemaker and implantable cardioverter defibrillator leads in Japanese patients.

BACKGROUND: Given the exponential growth in cardiac device implantations, the need for less invasive lead extraction is increasing. The Excimer laser was approved for lead removal in Japan in 2010. The present study reports the initial experience using this novel technique to extract chronically implanted pacemaker and implantable cardioverter defibrillator (ICD) leads from Japanese patients. METHODS AND RESULTS: We performed a retrospective study of consecutive patients undergoing lead extraction using the laser sheath at a single Japanese center. Patient and lead characteristics, indications, and outcomes were analyzed. From August 2010 to September 2012, a total of 70 leads, including 14 ICD leads, were removed using the laser sheath from 40 patients (26 male, 14 female; age 65.5±18.3 [mean±SD] years; body mass index 21.8±3.5 kg/m2). The median implant duration was 87 months (range 13-328 months). Indications were infection (n=35), venous occlusion (n=4), and pain (n=1). The femoral approach was used in combination with the laser technique in five cases. Complete procedural success was achieved with 68 leads (97.1%). Although the electrode tip was left behind in the remaining two leads, the desired clinical outcomes could be achieved; which were defined as clinical success. No cases resulted in failure. There were no major complications, including death and bleeding requiring open-chest surgery. CONCLUSIONS: Laser sheaths appear to provide a feasible and effective means of extracting chronically implanted pacemaker and ICD leads in Japanese patients.

[Effectiveness of underbody type forced-air warming blanket during endovascular aneurysm repair].

BACKGROUND: Intraoperative hypothermia is frequently observed during endovascular aneurysm repair (EVAR), leading to postoperative serious sequelae. We evaluated the effectiveness of underbody type forced-air warming blanket against hypothermia during EVAR. METHODS: Medical records of 144 patients who had undergone EVAR, were reviewed to investigate the body temperature and whether patients had been extubated in operating rooms. RESULTS: Seventy nine patients used underbody type forced-air warming blanket (blanket group) and 64 patients no warming system (NW group). The intraoperative lowest core temperature and core temperature at the end of the operation were higher in the blanket group (36.0 degrees C vs 35.6 degrees C, P < 0.001, 36.4 degrees C vs 35.6 degrees C, P < 0.001). In the blanket group extubation was performed in all patients, although five patients could not be extubated in the NW group. CONCLUSIONS: Underbody type forced-air warming blanket is effective to prevent intraoperative hypothermia during EVAR.

[Bladder temperature versus tympanic temperature in patients undergoing abdominal aortic aneurysm surgery].

BACKGROUND: Inaccurate measurements of body temperature might be associated with complications during the perioperative period. We conducted a retrospective cohort study to compare the bladder temperature and the tympanic membrane temperature in patients undergoing open repair of abdominal aortic aneurysm. METHODS: Fifteen adult patients who had undergone general anesthesia with/without epidural anesthesia were included in the present cohort. The bladder and the tympanic temperatures were simultaneously recorded at 6 points during surgery. One-way repeated measures ANOVA and Bland-Altman analysis were performed to assess statistical significance. The two-tailed P values less than 0.05 were considered statistically significant. RESULTS: No difference was found between the bladder and the tympanic temperatures before abdominal aortic cross-clamping. However, during and after cross-clamping, the bladder temperature values were likely to be lower compared with the tympanic values. The average temperature difference (+/- 2 SD) was 0.4 degrees C (+/- 1.1 degrees C) (95% CI: -1.21-0.78). CONCLUSIONS: The tympanic membrane might be a reliable site for core body temperature measurement in abdominal aortic aneurysm surgery patients.

[Undiagnosed hereditary angioedema in a patient undergoing emergency caesarean section].

Hereditary angioedema (HAE) is characterized by acute, recurrent attacks of localized edema. Surgical procedures, trauma, and infections have been considered as potential triggers of HAE. Although HAE is a rare genetic disorder, approximately 50-60% of all HAE patients are involved with at least one occurrence of upper airway obstruction. The airway trouble is the most life-threating complication in HAE patients because HAE-related edema does not respond to typical treatment, such as administration of epinephrine, antihistamines, or glucocorticoids. Indeed, mortality rates of laryngeal attack are estimated around 25% to 40%. Here we describe a case of undiagnosed HAE patient undergoing emergency caesarean section under neuraxial blockade. A 31-year-old woman showed multiple regions at her lip margin during surgery and rapidly developed lip swelling after admission to the ward. Neither respiratory nor hemodynamic instability was found during and after surgery. Immediately, in order to assess whether HAE caused these dermatological manifestations, we measured values of both complement component 4 (C4) and functional activity of C1-esterase inhibitor (C1-inh), a protein of the complement system. These laboratory data showed low levels, which were compatible with HAE definition. After commencement of C1-inhibitor replacement therapy, her lip swelling and erythema gradually disappeared without adverse drug reactions. The patient was finally discharged from our institution 10 days after surgery.

Sclerosing encapsulating peritonitis: regional changes of peritoneum.

Sclerosing encapsulating peritonitis (SEP) is characterized by the diffuse appearance of marked sclerotic thickening of the peritoneal membrane. We experienced a case with SEP accompanied by regional changes of peritoneum. A 37-year-old woman with end-stage renal failure was started on continuous ambulatory peritoneal dialysis in 1985 and was transferred to hemodialysis in 1997. She was admitted because of ileus in 1998 with SEP and died of septicemia. The diagnosis of SEP was confirmed via the autopsy. The root of the mesentery was retracted and shortened. Since the peritoneal change was marked in the regions with free margin of mesentery and was less apparent in the regions not adhered to mesentery, it is indicated that mechanical stress also contributes to the occurrence of SEP. Since calcification and ossification were only seen in a free margin of small bowel from mesentery, it is suggested that there is a close relationship between calcification and ossification. Since fibrosis invaded into the muscle layer, dysfunction of bowel movement as well as bowel obstruction contributed to the appearance of ileus. It is suggested that mechanical stress by the root of mesentery which is retracted and shortened also contributes to the appearance of SEP.