Usefulness of PETRA-MRA for Postoperative Follow-Up of Stent-Assisted Coil Embolization of Cerebral Aneurysms.

Objective: Image evaluation after stent-assisted coil embolization (SAC) for a cerebral aneurysm is difficult with conventional MRA or CTA because of metal artifacts. Pointwise encoding time reduction with radial acquisition (PETRA)-MRA is a noninvasive imaging examination that can reduce metal artifacts. This study aimed to examine whether PETRA-MRA can be used as a follow-up imaging after SAC. Methods: Twelve patients (eight women and four men; mean age, 66.9 ± 13.2 years) underwent SAC for unruptured aneurysms and were retrospectively evaluated using time-of-flight (TOF)- and PETRA-MRA data from the same follow-up session. Two neurosurgeons independently compared the aneurysm occlusion status and flow visualization score in the stented parent artery (4-point scale, where 4 points represented excellent visualization) between TOF- and PETRA-MRA images. If DSA was performed within 3 months before or after PETRA-MRA, the aneurysm assessment was compared between MRA and DSA. The interobserver agreement for each MRA was evaluated. Results: Nine of the 12 patients underwent DSA within 3 months before and after TOF- and PETRA-MRA. The aneurysm occlusion status on DSA was more consistent with PETRA-MRA (eight of nine cases) than with TOF-MRA (one of nine cases; P = 0.023). The median visualization score of the stented parent artery was significantly higher for PETRA-MRA (4 [interquartile range {IQR} 3-4]) than for TOF-MRA (1 [IQR 1-1], P = 0.003). The interobserver agreement for evaluation of the aneurysm occlusion status and visualization score of the parent artery for PETRA-MRA were excellent (κ = 0.98 and 0.93, respectively). In one case, PETRA-MRA was able to detect aneurysm recurrence, leading to subsequent retreatment. Conclusion: PETRA-MRA is a noninvasive examination that can be used to evaluate the occlusion status of aneurysms after SAC and visualize the stented parent artery. PETRA-MRA is useful for repeated follow-up examinations after SAC.

Prognostic Impact of the Early Use of Tolvaptan in Elderly Patients with Acute Decompensated Heart Failure.

The number of elderly patients with acute decompensated heart failure (ADHF) is increasing, and it is often difficult to treat. This study aimed to evaluate the efficacy and safety of using tolvaptan early after hospitalization in elderly patients with ADHF and the prognosis one year after hospitalization. This study enrolled 185 patients with ADHF who were admitted for the first time. Tolvaptan was administered within 24 h after admission. These patients were assigned to two groups: over 80 years old (n = 109) and under 80 years old (n = 76). There were no significant differences between the two groups in the occurrence of MACCE within one year (25% vs. 20%, p = 0.59). All-cause mortality was significantly higher in the over-80 group (12% vs. 2%, p = 0.01). There were no significant differences in the incidence of worsening renal failure (11% vs. 7%, p = 0.46) and hypernatremia (5% vs. 9%, p = 1.0), and in the duration of hospitalization (19.2 days vs. 18.8 days, p = 0.8). Tolvaptan might be effective and safe in elderly patients with ADHF, and there was no difference in the incidence of MACCE within one year.

Timing of real-time indocyanine green fluorescence visualization for lymph node dissection during laparoscopic colon cancer surgery.

PURPOSE: Although numerous studies have highlighted the potential value of indocyanine green (ICG) imaging in lymph node dissection of cancer surgery, its efficacy and optimal method remain to be clarified. This study aimed to investigate how lymphatic flow observation via ICG fluorescence could contribute to colon cancer surgery. METHODS: From October 2018 to March 2021, a total of 56 patients with colon cancer who underwent laparoscopic complete mesocolic excision with intraoperative ICG imaging were analyzed. Lymphatic flow was examined at the following time points following ICG injection: within 5 min, 30-60 min, and over 60 min. We also evaluated the distribution of ICG fluorescence per each vascular pedicle. RESULTS: Lymphatic flow was observed within 5 min following ICG injection in 6 cases (10.7%), and at 30-60 min following ICG injection in 43 cases (76.8%). ICG-stained vascular pedicles were variable especially in hepatic flexural, transverse, and splenic flexural colon cancer. Lymph node metastases were observed in 14 cases. Although metastatic lymph nodes were present only in the area along the ICG-stained vascular pedicles in 12 of the 14 cases, two patients exhibited lymph node metastasis in areas along the ICG-unstained vascular pedicles. ICG fluorescence was observed outside the standard range of lymph node dissection in 9 cases (20.9%: 9/43). Although addition of the proposed resection areas was made in 8 of these 9 cases, there was no pathologically positive lymph node. CONCLUSION: Real-time ICG fluorescence imaging of lymph nodes may improve the performance of laparoscopic colon cancer surgery, although its oncological benefit is not yet clear.

Single-incision laparoscopic partial cecectomy for appendiceal mucocele in a patient with porphyria photosensitivity.

Erythropoietic protoporphyria (EPP) is a rare hereditary subtype of cutaneous porphyria characterized by photosensitivity. Increased exposure to light irradiation may precipitate acute liver failure, and surgical light-induced intestinal burns and perforations are known to occur. We report a case of EPP in a patient who underwent laparoscopic partial cecectomy for appendiceal mucocele. A 55-year-old man with EPP was presented for treatment of appendiceal mucocele. A light test using two types of laparoscopes (Companies O and S) was performed preoperatively. Light from the laparoscope manufactured by Company O caused photosensitivity; this effect was not observed with light from the laparoscope manufactured by Company S. Therefore, we performed laparoscopic partial cecectomy through a single umbilical incision using the laparoscope from Company S. Except for the incision site, the patient's skin was completely covered using surgical drapes. No intra- or postoperative complications were observed. Histopathological examination of the resected specimen revealed a low-grade appendiceal mucinous neoplasm.

Lotus root-like appearance in the left anterior descending artery treated with a drug-coated balloon angioplasty.

A lotus root-like appearance of the coronary artery diagnosed by optical coherence tomography (OCT) is characterized by old coronary thrombi that form small lumen channels. Herein, serial OCT images of a left anterior descending artery with a lotus root-like appearance, treated with drug-coated balloon angioplasty are described.

Effect of Early Initiation of Evolocumab on Lipoprotein(a) in Patients with Acute Myocardial Infarction: Sub-Analysis of a Randomized Controlled Trial.

Elevated circulating lipoprotein(a) levels are associated with an increased risk of cardiovascular events. We reported that early initiation of evolocumab, a proprotein convertase subtilisin/kexin type 9 inhibitor, in addition to a statin substantially reduced the lipoprotein(a) levels in patients with acute myocardial infarction (AMI) after primary percutaneous coronary intervention (PCI). This sub-analysis sought to investigate the effect of evolocumab on lipoprotein(a) based on baseline lipoprotein(a) levels and characteristics. This study was a prespecified analysis of a randomized controlled trial that enrolled 102 patients who underwent primary PCI for AMI. Patients received pitavastatin (2 mg/day) alone or pitavastatin and evolocumab 140 mg subcutaneously within 24 h and 2 weeks after the index PCI. The evolocumab group showed significantly suppressed lipoprotein(a) levels in patients with baseline lipoprotein(a) levels of ≤10 mg/dL, 10 < lipoprotein(a) ≤ 20 mg/dL, and >20 mg/dL compared with the control group, as well as similar reductions in lipoprotein(a) levels in all patient subgroups. Among these subgroups, evolocumab tended to show more favorable effects in patients with diabetes mellitus. In AMI patients, early initiation of evolocumab therapy within 24 h of primary PCI suppressed the increase in lipoprotein(a) levels within 4 weeks, regardless of baseline levels and characteristics.

Fulminant myocarditis after the second dose of COVID-19 mRNA vaccination.

Myocarditis is an adverse event associated with coronavirus disease 2019 (COVID-19) mRNA vaccination. A 50-year-old man presented with dyspnea and resting chest pain after receiving the second dose of the COVID-19 mRNA vaccine and developed cardiogenic shock. Fulminant myocarditis was diagnosed by endomyocardial biopsy and treated with intravenous corticosteroids.

Laparoscopic posterior pelvic exenteration for clear cell adenocarcinoma arising in an episiotomy scar.

Malignant degeneration of endometriosis is a very rare event, especially when it develops in an episiotomy scar. A 53-year-old woman with an enlarged perineal mass presented to the hospital. She had undergone vaginal delivery with episiotomy twice. Imaging analyses showed a mass involving the levator ani muscle apart from the rectum, with lymph node metastases to the right inguinal and internal iliac regions. A biopsy specimen of the right inguinal lymph node revealed poorly differentiated adenocarcinoma. She underwent neoadjuvant chemotherapy according to the treatment strategy of anal fistula cancer. Laparoscopic posterior pelvic exenteration and pelvic lymph node dissection with anterior inguinal node dissection was performed, along with perineal reconstruction. Pathological examination revealed clear cell adenocarcinoma with lymph node metastases, derived from extrapelvic endometriosis in the episiotomy scar. She was treated with adjuvant chemotherapy according to the treatment strategy of vulvar cancer, and showed no evidence of recurrence after 15 months of surgery.

Laparoscopic surgery for median arcuate ligament syndrome using real-time stereotactic navigation.

INTRODUCTION: In median arcuate ligament syndrome (MALS), a hyperplastic MAL causes compression and stenosis of the celiac artery (CA). The treatment involves releasing the external pressure on this artery by dissecting the ligament. However, it is difficult to identify the artery because of its deep anatomical location. Stereotactic navigation provides real-time information regarding the surgical instrument's location on computed tomography (CT) images. We utilized this system to overcome the difficulty of anatomical identification. MATERIALS AND SURGICAL TECHNIQUE: We present a case of aneurysm rupture caused by MALS, which was treated with laparoscopic MAL dissection with real-time stereotactic navigation. Surgery was performed in a hybrid operating room with three-dimensional C-arm CT (Artis Zeego, Siemens) and an installed Curve navigation system (BrainLab). Preoperative CT images were aligned with intraoperative C-arm CT-like images and the surgical instrument position was projected onto preoperative CT images. After the left gastric artery isolation, the fibrous tissue surrounding the left gastric artery was dissected toward the CA while confirming the location of the CA and aortic wall using the navigation system. The CA's diameter was dilated from 1.8 to 2.6 mm with intraoperative angiography. DISCUSSION: This is the first report of laparoscopic MAL dissection using real-time stereotactic navigation. Although navigation setting was time-intensive, this system helped us understand the anatomical structures and in safely and precisely dissecting the MAL.

Secular Decreasing Trend in Plasma Eicosapentaenoic and Docosahexaenoic Acids among Patients with Acute Coronary Syndrome from 2011 to 2019: A Single Center Descriptive Study.

Despite intensive lipid-lowering interventions, patients treated with statins develop atherosclerotic cardiovascular disease (ASCVD), and these patients have an increased risk of developing recurrent cardiovascular events during follow-up. Therefore, there is a need to focus on the residual risks in patients in statin therapy to further reduce ASCVD. The aim of this study was to retrospectively investigate the 10-year trend (2011-2019) regarding changes in polyunsaturated fatty acids (PUFAs) in patients with acute coronary syndrome (ACS) in a single center. We included 686 men and 203 women with ACS admitted to Kagawa Prefectural Central Hospital. Plasma PUFAs, including eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA), arachidonic acid (AA), and dihomo-γ-linolenic acid (DGLA), were measured at admission for suspected ACS. A secular decreasing trend in the levels of EPA and DHA and the EPA/AA ratio, but not of AA and DGLA, was observed. The analyses based on age (>70 or <70 years) and sex showed that the decreasing trend in the levels of EPA and DHA did not depend on age and remained significant only in men. Further studies are needed to obtain robust evidence to justify that the administration of n-3 PUFA contributes to the secondary prevention of ACS.

Utility of ICG fluorescence imaging with vessel clamp for ileocecal resection while preserving ileal conduit constructed after previous total cystectomy.

BACKGROUND: Indocyanine green (ICG) is useful for evaluating the intestinal perfusion of anastomosis. Especially for patients with prior surgeries, ICG imaging enables surgeons in visualizing the anatomical field. Here, we reported the positive and negative staining techniques of ICG fluorescence with vessel clamp for determining the optimal resection area of vessels and mesentery. CASE PRESENTATION: An 80-year-old man, who had an ileal conduit constructed after a prior total cystectomy, was diagnosed with ascending colon cancer. Although the tumor-feeding vessel was primarily the ileocecal artery, there was no detailed information about the blood running through the ileal conduit. At first, the ascending colon and the marginal vessels were transected at distal side of the tumor. Next, both, the ileocecal artery and the marginal artery of oral side of the ileal anastomotic site were clamped. Finally, we injected ICG intravenously to assess the blood flow. As a result, the blood flow between the ileal anastomotic site and transected ascending colon was not identified (negative staining). Therefore, we cut the root of the ileocecal artery, and dissected the peripheral mesocolon including the ileal anastomotic site. After the ileo-ascending colon anastomosis, we injected ICG intravenously again. The blood flow to the ileal conduit was preserved (positive staining). CONCLUSION: ICG fluorescence imaging with vessel clamp can clearly visualize the demarcation line between ischemic and non-ischemic intestinal tract. In colorectal surgeries, this technique is useful to assess the anastomotic perfusion and determine optimal dissection area of vessels and mesentery in secondary intestinal surgery.

Laparoscopic left hemicolectomy with regional lymph node navigation and intracorporeal anastomosis for splenic flexure colon cancer.

Laparoscopic approaches have become a standard strategy for colon cancer patients who undergo surgical treatment. Complete mesocolic excision (CME) with central vascular ligation (CVL) is the fundamental principle of radical resection of colon cancers. Splenic flexure colon cancer (SFCC) is rare, accounting for less than 4% of all colorectal cancer cases. Moreover, a laparoscopic approach for SFCC following the CME/CVL concept can be challenging because the blood supply of the splenic flexure is derived from either the middle colic artery (MCA) branching from the superior mesenteric artery, the left colic artery (LCA) branching from the inferior mesenteric artery. In addition, approximately one third of SFCC patients have an accessory MCA that can originate from the celiac trunk. Herein, we describe the technical procedure of a laparoscopic left hemicolectomy for SFCC using indocyanine green (ICG) for necessary and sufficient lymphadenectomy followed by intracorporeal anastomosis. Two injections of ICG (0.5 mg/0.2 ml × 2) into the subserosa of the proximal and distal sides of the tumor preceded the surgical procedure after pneumoperitoneum. Near infrared images obtained throughout the laparoscopic procedure helped visualize lymphatic drainage vessels and inform decision making for determining vessels requiring ligation according to the CVL concept: MCA, LCA or accessory MCA. Complete intracorporeal anastomosis following necessary and sufficient lymphadenectomy with ICG can minimize the dissecting area of the laparoscopic left hemicolectomy for SFCC patients. Intravenous ICG injection (2.5 mg) after anastomosis helps confirm blood perfusion at the anastomosis site. Four patients with SFCC underwent a laparoscopic colectomy under ICG navigation in 2019 at our institute. The median operative time was 237 min, the median estimated blood loss was 0 ml, and the median number of dissected lymph nodes was 13. No patients experienced postoperative complications. In conclusion, laparoscopic left hemicolectomy with ICG navigation and intracorporeal anastomosis for SFCC patients may be a feasible option for the radical resection of colon cancer.

Changes in the sexual function of male patients with rectal cancer over a 2-year period from diagnosis to 24-month follow-up: A prospective, multicenter, cohort study.

BACKGROUND AND OBJECTIVES: This prospective study aimed to identify long-term changes in sexual function of men with rectal cancer from point of diagnosis to 24 months postoperatively. METHODS: Male patients undergoing laparoscopic rectal cancer surgery were prospectively enrolled. International Index of Erectile Function (IIEF) Questionnaire scores were collected at diagnosis; first follow-up; and 6, 12, and 24 months postoperatively. Missing values were managed via multiple imputations using the propensity score method. Paired t tests were applied to examine changes in IIEF scores over time. RESULTS: This study analyzed 115 patients. For erectile function, there were no significant changes in scores from the point of diagnosis to first treatment (9.4 vs. 9.8 as mean scores; p = .227). Scores deteriorated postoperatively and recovered until 12 months post-surgery, but did not improve significantly from 12 months to 24 months post-surgery (8.7 vs. 8.2 as mean scores; p = .440). This pattern of change was observed in all other domains: orgasmic function, sexual desire, orgasmic satisfaction, and overall satisfaction. CONCLUSIONS: Sexual function was not influenced by a rectal cancer diagnosis. Sexual function deteriorated following surgery and recovered until 12 months post-surgery; however, it did not significantly improve from 12 months to 24 months postoperatively.

Stereotactic Navigation for Rectal Surgery: Comparison of 3-Dimensional C-Arm-Based Registration to Paired-Point Registration.

BACKGROUND: Stereotactic navigation enables surgeons to use the preoperative CT or MRI images as a real-time "navigation map." Although stereotactic navigation has been established in neurosurgery and orthopedic surgery, whether this technology is applicable to GI tract surgery remains challenging because of tissue deformation and organ motion. A critical component of this technology is the registration that links the patient's actual body to the preoperative imaging data. OBJECTIVE: The objective was to assess the applicability of stereotactic navigation in rectal surgery, focusing on the registration method. DESIGN: This study was based on a prospective case series. SETTING: The study was conducted in a single university hospital. PATIENTS: Four patients who underwent laparoscopic rectal surgery were included. INTERVENTIONS: Paired-point registration was performed for 2 cases, whereas 3-dimensional C-arm-based registration was performed for the other 2 cases. In addition, 3-dimensional C-arm-based registration was performed twice during the operation. MAIN OUTCOME MEASURE: Navigation accuracy was evaluated by measuring target registration error at 8 anatomical landmarks. RESULTS: Target registration error of the 3-dimensional C-arm-based registration group was significantly smaller than that of the paired-point registration group (median, 19.5 mm vs 54.1 mm; p < 0.001). In particular, the error of Z-axis (cranial-to-caudal direction) was significantly smaller in 3-dimensional C-arm-based registration (median, 12.4 mm vs 48.8 mm; p < 0.001). In one case in the 3-dimensional C-arm-based registration group, target registration error of the second registration became significantly smaller than that of the first registration (p = 0.008). LIMITATIONS: This was an observational study with small sample size. CONCLUSION: Three-dimensional C-arm-based registration could be performed with the patient in a lithotomy position with head down and lateral tilt without being affected by positional changes. Three-dimensional C-arm-based registration resulted in significantly higher navigation accuracy than paired-point registration, and its accuracy could be further improved by intraoperative re-registration.

Robot-assisted low anterior resection after aluminum potassium sulfate and tannic acid sclerosing therapy for internal hemorrhoids.

BACKGROUND: Internal hemorrhoids are the most common anal diseases. Aluminum potassium sulfate and tannic acid (ALTA) injection is a new sclerosing therapy for the treatment of internal hemorrhoids. Although ALTA injection has been widely used, there are no previous reports of rectal cancer patients who underwent robot-assisted low anterior resection (Rob-LAR) after ALTA injection to treat internal hemorrhoids. CASE PRESENTATION: A 70-year-old man with rectal cancer was presented to our hospital. He had an ALTA injection 2 months before presentation at a clinic due to hematochezia with internal hemorrhoids. The rectal tumor was located 7 cm above the anal verge, and Rob-LAR with the da Vinci Xi system was performed. The patient had sclerosis on the stump of the anal side, which made it difficult to transect the rectum with linear staplers. This required multiple repeats of compression through the SmartClamp feedback. After anastomosis with the double-stapling technique, we constructed a diverting ileostomy. CONCLUSION: Although ALTA injection is a promising strategy for internal hemorrhoids, rectal cancer should be excluded before the sclerosing therapy.