Obturator foramen bypass for infective groin caused by closure device.

A 69-year-old man underwent carotid artery stenting through the right femoral artery with a percutaneous vascular closure device for hemostasis. Eleven days later, an infective femoral artery pseudoaneurysm was diagnosed by computed tomography. At surgery, a defect in the femoral artery was observed, corresponding to the remnants of the closure device. Removal of the foreign material, debridement, wound irrigation, and arterial patch plasty were performed, but the infection and leg ischemia did not improve. After several failed attempts to revascularize and control the infection, obturator foramen bypass was performed. The postoperative course was uneventful, indicating the usefulness of this procedure.

Endovascular Total Arch Repair Using In Situ Fenestration for Arch Aneurysm and Chronic Type A Dissection.

BACKGROUND: Total arch replacement and ascending aorta and arch replacement are the gold standard treatments for aortic arch aneurysm and are possible treatment strategies for chronic type A dissection, with good reported outcomes. However, because total arch replacement is extremely invasive, it can be difficult to perform in some patients. We designed an endovascular total arch repair procedure with the use of in situ fenestration and commercially available devices, and we present our initial experience. METHODS: Seven patients (chronic type A aortic dissection, n = 3; thoracic arch aneurysm, n = 4) who underwent endovascular total arch repair with the use of in situ fenestration thoracic endovascular aortic repair from a zone 0 landing were retrospectively analyzed. All the procedures were performed under general anesthesia and cardiopulmonary bypass. The triple branches were manually punctured in a retrograde manner with the use of an 18-gauge/30-cm needle or a 21-gauge aspiration needle, and all the branches were reconstructed with the use of stent grafts; balloon touch-up was performed if appropriate. RESULTS: The procedure was successful in 6 of the 7 patients; the remaining 1 patient additionally underwent an axillary-axillary artery bypass during the operation because the left subclavian artery was difficult to puncture. All the patients had an acceptable postoperative course, with no 30-day and in-hospital deaths. None of the patients had endoleaks, and all the patients exhibited a reduction in aneurysm diameter or thrombosed false lumen during a mean follow-up period of 17.6 months. CONCLUSIONS: Endovascular total arch repair with the use of in situ fenestration can be performed with commercially available devices with acceptable interim results.

[Surgical Treatment of Prosthetic Valve Endocarditis; Tips of Complete Resection of Infective Tissue and Valve Replacement].

Fifteen consecutive prosthetic valve endocarditis (PVE) patients were operated from March 2009 to September 2014. The average age of patients was 68 years ( range 49 to 82) and 7 patients were male. The interval between initial surgery and reoperation was 62.4 months(range 2.6 to 340.9). Seven of these cases(47%) developed PVE within the 1st year after surgery were defined as early PVE. All microorganisms isolated from blood cultures in early PVE were Staphylococcus species. Generally, the infective prosthetic valve was removed 1st, then all infective tissues were excised from the periannular cavity. A new prosthetic valve was replaced in supra-annular fashion. One patient who had a severe discontinuity between the most part of left ventricle and aorta necessitated a root replacement. One patient in aortic PVE, needed an additional patch-plasty of anterior mitral leaflet. The mean cardiopulmonary bypass and aortic clamping times were 250 minutes( range 132 to 426) and 165 minutes( range 117 to 309), respectively. Four patients needed permanent pacemaker implanted for complete A-V block. Five patients had transient acute renal failure, and 1 required dialysis could be weaned at 40 post operative day. Average postoperative hospital stay was 39 days (range 21 to 108), and the operative mortality was 0%. The postoperative follow up was 3.1 years( range 0.6 to 6.0), all patients were doing well without re-infection and heart failure except 1 patient died by non-cardiac disease.

[Effectiveness of Mitral Natural Folding Plasty for Minimally Invasive Cardiac Surgery Mitral Valve Plasty (MICS MVP)].

We performed 45 cases of Natural folding plasty without leaflet resection for degenerative mitral regurgitation (MR) between September 2005 and July 2014. Twenty cases of 45 were operated by right small intercostal approach (MICS). There was no operative mortality. No patient had greater than mild MR intraoperative transesophageal echocardiography. The median follow-up was 847 (19~1,747) days. One case needed a second pump run performed without complication. One patient had a reoperation performed for recurrent MR 20 months later. Natural folding plasty for degenerative MR with favorable long term out come in our results. This technique is simple and reproducible for most surgeons. Furthermore, with its simplicity and reversibility, we considered it to be suitable for MICS approach.

[Thoracic Endovascular Aortic Repair (TEVAR) Combined with Embolization Technique for Saccular Aortic Arch Aneurysm].

Many of saccular aortic arch aneurysms exist near left subclabian artery(LSA). The thoracic endovascular aneurysm repair( TEVAR) landing on zone 2 is a less invasive and suitable procedure for this type of aneurysm. However, there are several cases with the aneurysm located close to LSA necessitate landing TEVAR on zone 1 or zone 0, otherwise the aneurysm could not be sealed completely. And this procedure seems to increase the invasiveness. In order to complete the sealing of the aneurysm and also keep the less invasiveness, we performed TEVAR using an axillo-axillary bypass or simple occlusion of LSA followed by an embolization using metal coil and NBCA through the catheter which detained in the saccular aneurysm beforehand. We report our experience of seven cases have been successfully treated by this procedure with good results.

Type IA endoleak embolization after TEVAR via direct transthoracic puncture.

We report the case of a 74-year-old man who developed type IA endoleak after endovascular thoracic aortic repair. The patient was admitted with expansion of the aneurysm after TEVAR, for additional therapy. Fluoroscopy and cone-beam computed tomography-guided direct transthoracic sac puncture and complete embolization of the endoleak channels with metal coils and glue were performed, and resulted in complete exclusion of the endoleak. One month after the coil embolization, the type IA endoleak was completely excluded, and the thoracic aneurysm had decreased in size.

[Diffuse descending necrotizing mediastinitis with cardiac tamponade;report of a case].

Descending necrotizing mediastinitis( DNM) is often a lethal condition resulting from odontogenic or cervical infection, with a previously reported mortality rate of 25 to 40%, which is known to accompany occasional pericardial effusion. Here, we report a case of diffuse DNM with cardiac tamponade.

Direct percutaneous puncture embolization of type II endoleaks using a coaxial technique.

PURPOSE: To demonstrate a coaxial needle technique for direct percutaneous puncture embolization of type II endoleaks. TECHNIQUE: The technique is demonstrated in a 79-year-old woman and an 80-year-old man who developed type II endoleaks after endovascular repair of thoracic and internal iliac artery aneurysms, respectively. Expansion of the aneurysms required additional therapy. Fluoroscopy and cone-beam computed tomography-guided direct percutaneous endoleak sac embolization with n-butyl-2-cyanoacrylate (NBCA)-lipiodol was performed using the coaxial technique, which resulted in complete embolization of the endoleak sac. At 6 and 3 months after embolotherapy, respectively, the NBCA-lipiodol filled the endoleak sacs and the communicating channels up to the respective feeding arteries; no enlargement of the aneurysms was observed. CONCLUSION: Direct percutaneous sac embolization using a coaxial technique for type II endoleaks is a feasible treatment and yields good short-term results. More experience with this technique and longer follow-up of these patients is needed.

[Prevention of cerebral infarction in thoracic endovascular aneurysm repair(TEVAR) of distal aortic arch aneurysms; left subclavian artery balloon technique].

Thoracic endovascular aneurysm repair(TEVAR) has been applied more and more frequently to an atherosclerotic distal aortic arch aneurysm. Even if the procedure is successful, extensive cerebral infarction might occur, especially in the left vertebral artery area. We therefore devised a new method to prevent embolic events using a thrombectomy catheter with an end hole, which was placed at the origin of the letf subclavian artery via the radial artery. This simple left subclavian artery balloon technique not only prevents cerebral embolism in the left vertebral artery system, but also provides a position marker under X-ray, and enables tight compaction of the embolization coils.

Pulmonary artery sarcoma successfully treated by right pneumonectomy after definitive diagnosis.

Pulmonary artery sarcoma (PAS) is a rare and lethal neoplasm that is usually diagnosed during surgery or autopsy. Early diagnosis and radical surgical resection offer the only chance for survival. However, making a preoperative histopathological diagnosis is quite difficult. We encountered a 57-year-old woman presenting a PAS that mimicked a pulmonary thromboembolism. After confirming a definitive diagnosis using a catheter suction biopsy, we successfully performed a right pneumonectomy via a median sternotomy without cardiopulmonary bypass. Eighteen months after surgery, no recurrence was observed.

Castleman's disease along the left tracheobronchial tree with a difficult preoperative diagnosis.

A 39-year-old man was referred to our hospital because of an asymptomatic middle mediastinal tumor. A preliminary histological diagnosis of the tumor by bronchoscopy was difficult to obtain because the tumor was located along the left tracheobronchial tree, which is difficult to approach. The tumor was resected through a right anteroaxillary thoracotomy without any major complications, and histopathological examination revealed that the lesion was Castleman's disease, hyaline-vascular type. Radiological findings of the lesion were typical; however, the rarity of the tumor made the imaging diagnosis difficult. If a lesion is located along the tracheobronchial tree, Castleman's disease should be considered in the differential diagnosis.

Estimated glomerular filtration rate is superior to measured creatinine clearance for predicting postoperative renal dysfunction in patients undergoing pancreatoduodenectomy.

OBJECTIVE: A retrospective study was conducted to compare measured creatinine clearance (Ccr) with estimated glomerular filtration rate (eGFR) as a preoperative renal function test in patients undergoing pancreatoduodenectomy. METHODS: The records of 139 patients undergoing pancreatoduodenectomy were enrolled, and preoperative Ccr, a 3-variable equation for eGFR (eGFR3) and a 5-variable equation for eGFR (eGFR5) were estimated. The maximum increases in the postoperative serum creatinine and urea nitrogen levels were compared between the groups with normal and abnormal levels relative to Ccr, eGFR3, and eGFR5. RESULTS: There were 30 patients with abnormal Ccr levels, 17 with abnormal eGFR3 levels, and 16 with abnormal eGFR5 levels. Postoperative serum creatinine and urea nitrogen levels were significantly higher in patients with eGFR3 and eGFR5 abnormal levels than in patients with eGFR3 and eGFR5 normal levels. Postoperative serum creatinine and urea nitrogen levels tended to be higher in patients with Ccr abnormal level. The sensitivity and specificity of eGFR3 and eGFR5 for postoperative renal dysfunction were better than those of Ccr, and multivariate analysis showed that eGFR5 was the only independent predictive factor for postoperative renal dysfunction. CONCLUSIONS: The eGFR5 and eGFR3, rather than the Ccr, are recommended as preoperative renal function test in patients undergoing pancreatoduodenectomy.

Estimating glomerular filtration rate preoperatively for patients undergoing hepatectomy.

AIM: To compare creatinine clearance (Ccr) with estimated glomerular filtration rate (eGFR) in preoperative renal function tests in patients undergoing hepatectomy. METHODS: The records of 197 patients undergoing hepatectomy between August 2006 and August 2008 were studied, and preoperative Ccr, a three-variable equation for eGFR (eGFR3) and a five-variable equation for eGFR (eGFR5) were calculated. Abnormal values were defined as Ccr < 50 mL/min, eGFR3 and eGFR5 < 60 mL/min per 1.73 m(2). The maximum increases in the postoperative serum creatinine (post Cr) level and postoperative rate of increase in the serum Cr level (post Cr rate) were compared. RESULTS: There were 37 patients (18.8%) with abnormal Ccr, 31 (15.7%) with abnormal eGFR3, and 40 (20.3%) with abnormal eGFR5. Although there were no significant differences in the post Cr rate between patients with normal and abnormal Ccr, eGFR3 and eGFR5 values, the post Cr level was significantly higher in patients with eGFR3 and eGFR5 abnormality than in normal patients (P < 0.0001). Post Cr level tended to be higher in patients with Ccr abnormality (P = 0.0936 and P = 0.0875, respectively). CONCLUSION: eGFR5 and the simpler eGFR3, rather than Ccr, are recommended as a preoperative renal function test in patients undergoing hepatectomy.

Systemic inflammatory response predicts postoperative outcome in patients with liver metastases from colorectal cancer.

BACKGROUND: Few studies have investigated the Glasgow Prognostic Score (GPS) in patients with liver metastases from colorectal cancer (LM-CRC). METHODS: The GPS was calculated as follows: patients with both an elevated level of CRP (>10 mg/L) and hypoalbuminemia (Alb <35 g/L) were allocated a score of 2, and patients showing one or neither of these blood chemistry abnormalities were allocated a score of 1 or 0, respectively. RESULTS: Ninety-three patients were evaluated retrospectively. Kaplan-Meier analysis and log rank test revealed that a higher GPS predicted a higher postoperative death (P < 0.0001). Univariate analysis revealed that sex, number of hepatectomy, number of tumors, synchronous lung metastasis and CRP were associated with postoperative death. Multivariate analysis revealed that number of hepatectomy (odds ratio, 3.193; 95% CI, 1.093-9.330; P = 0.0338), number of tumors (odds ratio, 2.946; 95% CI, 1.094-7.931; P = 0.0325), synchronous lung metastasis (odds ratio, 3.424; 95% CI, 1.055-11.11; P = 0.0404) and CRP (odds ratio, 4.509; 95% CI, 1.313-15.49; P = 0.0167) were associated with postoperative death. CONCLUSIONS: GPS is able to classify patients with LM-CRC into three independent groups. Among the selected factors, CRP is considered an important and high sensitive predictor of postoperative death in such patients.

Pancreatic juice leakage is a risk factor for deep mycosis after pancreatic surgery.

PURPOSE: Deep mycosis (DM) is an opportunistic infection that can be fatal in immunocompromised hosts. Pancreatic surgery is associated with a high degree of stress and patients who undergo pancreatic surgery are considered to be immunocompromised. This study retrospectively evaluated whether DM affects the clinical course after pancreatic surgery. METHODS: Between January 2005 and April 2007, 67 patients underwent pancreatic surgery. There were 42 males (62.7%) and 25 females (37.3%) with a mean age of 66.7 years. Their diagnoses consisted of cancer of the papilla of Vater (n = 9), pancreatic head cancer (n = 20), pancreatic tail cancer (n = 3), bile duct cancer (n = 17), duodenal cancer (n = 3), and others (n = 15). Surgical procedures included pancreatoduodenectomies (PD; n = 52), hepato-pancreatoduodenectomies (HPD; n = 4), distal pancreatectomies (DP; n = 7), total pancreatectomies (TP; n = 2), and the modified Puestow procedure (m-Pp; n = 2). Patients who were positive for any of CAND-TEC (C-T), beta-D-glucan (beta-D), or culture for mycosis were classified into group 1 (G1; n = 12) and those who were negative for all these examinations were classified into group 2 (G2; n = 55). The preoperative, perioperative, and postoperative data were compared between G1 and G2. An antifungal drug (Micafungin; 75 mg per day) was given to G1 patients. RESULTS: The preoperative data included the neutrophil and lymphocyte counts, total protein, blood urea nitrogen, and amylase, and there were no significant differences in these parameters between the two groups. However, the incidences of diabetes mellitus and total bilirubin at maximum in G1 and G2 were 41.7% and 7.3% (P = 0.04), 4.6 +/- 1.5 and 1.4 +/- 0.9 (P = 0.007), respectively. The mean operation time in G1 and G2 was 548.5 +/- 138.1 and 510.0 +/- 133.7 min (P = 0.39) and intraoperative blood loss was 762.2 +/- 369.5 and 782.5 +/- 599.1 ml (P = 0.88), respectively. The postoperative complications included pneumonia (G1: G2 = 7: 20; P = 0.14), pleural effusion (7: 24; P = 0.27) and ascites (10: 33; P = 0.11), with no significant intergroup differences. However, the respective durations of pancreatic juice leakage in G1 and G2 were 12 and 12, respectively, with a statistically significant difference (P < 0.01). All the G1 patients were treated with the antifungal drug for 7.8 days. Postoperative hospital stays in G1 and G2 were 47.3 days and 38.7 days, respectively (P = 0.15) and the survival rates at 19 months after surgery were 46.7% and 79.4%, respectively (P = 0.04). CONCLUSIONS: Deep mycosis was observed in patients with pancreatic juice leakage, thus contributing to a poor outcome. Therefore, an early diagnosis of DM and the initiation of antifungal treatment are necessary for the improving prognosis.

Serum alpha-fetoprotein level per tumor volume reflects prognosis in patients with hepatocellular carcinoma after curative hepatectomy.

BACKGROUND/AIMS: The clinical usefulness of alpha-fetoprotein (AFP) in the management of hepatocellular carcinoma (HCC) remains controversial. This study aimed to assess the prognostic reliability of serum AFP levels per tumor volume (AFP/volume) after curative resection. METHODOLOGY: A total of 196 patients with HCC were analyzed with reference to serum AFP levels at diagnosis. Clinicopathological data included presence of cirrhosis, indocyanine green retention rate (ICGR15), tumor size and number of HCCs. Tumor volume for HCCs was calculated preoperatively by Computed tomography volumetry, and AFP/volume was calculated by dividing serum AFP level by tumor volume. RESULTS: No significant correlation between serum AFP levels and presence of cirrhosis or ICGR15 was observed. A significant correlation existed between serum AFP levels and both size (P=0.001, r=0.276) and number (P=0.023, r=0.186) of HCCs. The 5-year survival rates in patients with low (< 200 ng/mL) and high (> or = 200 ng/mL) serum AFP level were 85.0% and 36.0%, respectively. AFP/volume tended to be negatively associated with survival period (p=0.084, r = -0.346), and a significant negative correlation existed between AFP/volume and disease-free survival period (p=0.001, r = -0.347). Median values of AFP/ volume in patients who displayed recurrence by 1 year and 6 months were 11.51 and 20.05, respectively. CONCLUSIONS: AFP/volume represents a better prognostic indicator for patients with HCC than serum AFP value alone. In particular, patients with AFP/volume > 20.0 are likely to experience recurrence within 6 months after curative hepatectomy.

Ball-valve gastric tumor associated with anomalous junction of the pancreatico-biliary ductal system and a right-sided round ligament: report of a case.

We report the case of a ball-valve gastric tumor associated with anomalous junction of the pancreatico-biliary ductal system (AJPBDS) and a right-sided round ligament, misdiagnosed preoperatively as advanced gastric cancer with pancreatic head invasion. A 72-year-old woman presented with chest pain, but laboratory data showed only anemia. Gastroscopy revealed a bleeding polypoid gastric tumor in the anterior wall of the stomach, herniating into the duodenum (ball-valve syndrome), and a Bormann type-2 tumor in the posterior wall. Ultrasonography showed gallbladder stones, dilatation of the intrahepatic bile duct and pancreatic duct, and a left-sided gallbladder (attributed to a right-sided round ligament with anomalous branches of the portal veins). Laparotomy revealed that the gastric tumors were not advanced cancer invading the pancreatic head. Intraoperative cholangiography showed an AJPBDS, causing dilatation of the intrahepatic bile duct and pancreatic duct. We performed distal gastrectomy and cholecystectomy without biliary diversion. Microscopy revealed that the polypoid tumor was a hyperplastic polyp.

Effect of infra-hepatic inferior vena cava clamping on bleeding during hepatic dissection: a prospective, randomized, controlled study.

BACKGROUND: The success of hepatectomy can be associated with intraoperative blood loss because massive blood loss causes a poor prognosis. This study was designed to evaluate the effect of infrahepatic inferior vena cava (IVC) clamping on the bleeding amount during hepatectomy. METHODS: Eighty-five patients scheduled to undergo hepatic resection were randomly assigned to the IVC clamping or an IVC nonclamping group according to age, indocyanine green retention rate at 15 minutes, operative procedure, and number of tumors by prospective, randomized method. All analyses were compared by Mann-Whitney U test. RESULTS: Forty-three patients were assigned to the IVC clamping group and 42 to the nonclamping group (IVC clamping group vs. non-clamping): total blood loss (499 vs. 584 ml; p = 0.567), amount of bleeding during hepatectomy (233 vs. 285 ml; p = 0.474), amount of bleeding during hepatectomy/area of dissection (4.9 vs. 6.6 ml/cm(2); p = 0.63), CVP difference (-3 cmH(2)O vs. -1 cmH(2)O; p < 0.01), and diameter of the right hepatic vein (-2.2 cm vs. 0; p < 0.01). CONCLUSIONS: Although we had speculated that infrahepatic IVC clamping would reduce blood loss during hepatectomy, we failed to demonstrate any beneficial effects in this clinical setting with low CVP.

Outcome of surgical resection for hilar cholangiocarcinoma in elderly patients.

BACKGROUND/AIMS: The aim of the present study was to assess the safety and outcome of surgical resection for hilar cholangiocarcinoma in the elderly. METHODOLOGY: Thirty-one patients with hilar cholangiocarcinoma were divided into two groups: Group 1 (n=8), less than 65, and; Group 2 (n=23), 65 years of age and older. Patient characteristics, peri-operative data, 5-year survival rates and 5-year disease-free survival rates were compared between the two groups. RESULTS: There were no differences in patient characteristics except that the AST level at admission was higher in Group 2 than in Group 1. There were no differences in peri-operative data. Postoperative morbidity rates in Groups 1 and 2 were 12.5% and 33.3%, respectively (p=0.23). Median periods of postoperative hospitalization in Groups 1 and 2 were 32.5 days and 66 days, respectively (p=0.03). Overall 5-year survival rates in Groups 1 and 2 were 37.5% and 44.7%, respectively (p=0.57), and the respective 5-year disease-free survival rates were 25.0% and 28.6% (p= 0.37). CONCLUSIONS: Although surgical resection for hilar cholangiocarcinoma in the elderly is associated with relatively high morbidity rate and longer hospital stay, it can be performed safely as in the younger, by employing accurate peri-operative management.

Needlescopic Cholecystectomy Versus Needlescope-assisted Laparoscopic Cholecystectomy.

This clinical study was performed to compare the feasibility, safety, and best use of the needlescope and needlescopic instruments. Needlescopic cholecystectomy (NC) or needlescope-assisted cholecystectomy (NAC) was performed in 40 cases of gallbladder (GB) stone or polyp. There were 12 men and 28 women, with a mean age of 51.8 years (range, 27 to 79 y). The port sites consisted of three 2-mm ports at the right upper quadrant and one 12-mm port at the umbilicus. To evaluate the feasibility and safety of the needlescope, the time taken to perform each operative step was compared for NC and NAC. Operation time was divided into: (1) skin incision to insertion of the 4 ports; (2) insertion of the 4 ports to cannulation into the cystic duct; (3) time of intraoperative cholangiography (IOC); (4) skin incision to cutting of the cystic duct without IOC; (5) cutting the cystic duct to dissection of the GB; (6) dissection of the GB to removal of the GB; (7) removal of the GB to skin closure; and (8) total operation time. IOC was performed successfully in 10 cases of NC and 10 cases of NAC. Respective mean times of the 8 steps were 5.4 versus 5.3 minutes, 34.2 versus 32.2 minutes, 20.1 versus 18.4 minutes, 33.9 versus 31.3 minutes, 19.6 versus 18.9 minutes, 3.1 versus 2.9 minutes, 10.0 versus 10.2 minutes and 82.5 versus 77.8 minutes for NC versus NAC, respectively. There were no significant differences in any of the factors related to surgical procedures between the 2 groups, and there were no perioperative complications. The use of a needlescope and needlescopic instruments was feasible and safe for laparoscopic cholecystectomy in both surgical laparoscopic procedures for highly selected patients.