Osamu Monta

A New Technique of Laparoscopic Obturator Hernia Repair:Report of a Case

An 84-year-old woman presented with ileus. Ultrasonography, a computed tomography scan, and small bowel contrast examination showed a Richter-type hernia in her left obturator orifice. Under general anesthesia, laparoscopic surgery with low-pressure (4mmHg) pneumoperitoneum was carried out using a peritoneal needle retractor, and a reduction of the strangulated intestinal loop was thus achieved. Because the hernial opening measured 5mm in diameter, it could be closed with four pieces of End-Universal stapler without polypropylene mesh. The ischemic ileum was resected, and the bowel was anastomosed extracorporeally with a minimal skin incision. She was ambulant on the first postoperative day, and her postoperative course was good. Obturator hernias are rare, but when a definitive diagnosis is made in such elderly patients, laparoscopic repair using the peritoneal needle retractor is recommended for minimally invasive surgery. We recommend doing the repair with an End-Universal stapler, since this procedure is more simple and useful for preventing infection than using polypropylene mesh in such a strangulated case.

Aortic Arch Repair With Antegrade Selective Cerebral Perfusion Using Mild to Moderate Hypothermia of More Than 28°C

BACKGROUND The temperature at circulatory arrest during open distal anastomosis is the most significant issue for aortic arch repair. In many institutions, there has been trend toward raising the temperature during circulatory arrest. METHODS Between 2004 and 2011, 164 consecutive patients underwent aortic arch repair with antegrade selective cerebral perfusion (ASCP) and moderate hypothermia. The patients were divided into two subsets (n = 84 each): group A (circulatory arrest at less than 27.9°C) and group B (at more than 28°C). RESULTS In group A compared with group B, mean temperature at circulatory arrest was 26° ± 1.0°C vs 29° ± 1.0°C, mean ASCP time was 72 ± 23 minutes vs 67 ± 17 minutes, and mean circulatory arrest time was 47 ± 21 minutes vs 44 ± 13 minutes. The 30-day mortality was 6.1% in both groups. Permanent neurologic deficit occurred in 8 patients (9.8%) in group A and in 5 (6.1%) in group B (p = 0.39). The incidence of renal failure requiring hemodialysis was 14.6% in group A and 3.6% in group B (p = 0.02). Postoperative respiratory failure requiring mechanical ventilation exceeding 3 days occurred in 12.2% of patients in group A and in 7.3% in group B (p = 0.04). CONCLUSIONS The temperature during ASCP can be safely increased to more than 28°C without increasing the rate of mortality and morbidity. ASCP with moderate hypothermia offered sufficient cerebral and distal organ protection.

Stent Grafting for Giant Bronchial Artery Aneurysm Disguised as an Aneurysm With Multiple Feeding Arteries

We report a case of a giant mediastinal bronchial artery aneurysm disguised as an aneurysm with multiple feeding arteries. A 74-year-old man with a history of bronchiectasis was admitted to our hospital for treatment of a bronchial artery aneurysm. Because the segment of feeding vessels between the thoracic aorta and the aneurysm was short, it was not possible to occlude the feeding artery simply by transarterial embolization. A combined procedure of stent-graft occlusion of the inflow artery and coil embolization of the outflow artery was successfully performed.

Thrombus formation due to flow competition after apico-aortic conduit.

We report a case of unusual thrombus formation and describe the risk of perioperative myocardial infarction or stroke in severe aortic stenosis after apico-aortic conduit. An 86-year-old woman was admitted with aggravation of dyspnoea on exertion and chest pain. She was complicated with severe aortic stenosis and liver cirrhosis. Echocardiography demonstrated a peak pressure gradient of 50 mmHg across the aortic valve with ejection fraction of 51%. Since she had porcelain aorta and severe liver dysfunction, we selected an apico-aortic conduit under left ventricular fibrillation as treatment. Postoperative computed tomography showed a large thrombus in the descending aorta. Using strict anticoagulation therapy, the thrombus almost disappeared and thrombo-embolic events did not occur after surgery.

Colonoscopic Diagnosis of Lymphoid Hyperplasia Causing Recurrent Intussusception: Report of a Case

This paper describes a 6-year-old boy with recurrent ileocecal intussusception due to lymphoid hyperplasia in the terminal ileum, which was diagnosed preoperatively by colonoscopy. At the age of 3 years, he developed diarrhea and a tender abdominal mass. He was diagnosed as having intussusception by ultrasound and was treated by hydrostatic barium enema. After resolution, he had three recurrent episodes of intussusception. A contrast barium enema revealed a small mass in the ileocecal region. Colonoscopy showed several exaggerated folds of the terminal ileum and a biopsy showed lymphoid hyperplasia. Because the repeated intussusception seemed to have been caused by the lymphoid hyperplasia in the terminal ileum, he underwent an ileocecal resection without any subsequent recurrence. Based on the above findings, we conclude that a colonoscopy may thus be useful both for diagnosing lymphoid hyperplasia in the terminal ileum as a cause of recurrent intussusception and for deciding how to manage it.

Severe tracheal compression due to cervical aortic arch aneurysm.

Abstract  We report a left‐sided cervical aortic arch (CAA) aneurysm that severely compressed the trachea resulting in respiratory insufficiency. A 59‐year‐old man was referred to our hospital because of a few years history of inspiratory obstruction without dysphagia. Enhanced computed tomography revealed severe tracheal stenosis caused by a large CAA aneurysm. As the location of the aneurysm was located between the left carotid artery and the left subclavian artery, we planned to approach the aneurysm resection via a median sternotomy extending to the bilateral supraclavicular region. Total arch replacement was performed and the tracheal compression was relieved. The postoperative course was uneventful and the tracheal stenosis was gradually decreased by 12 months after surgery. (J Card Surg 2011;26:400‐402)

Mid-long-term results after aortic arch repair using a four-branched graft with antegrade selective cerebral perfusion.

The purpose of this study is to evaluate mid‐long‐term results of aortic arch replacement.

Mycotic aneurysm of the descending thoracic aorta caused by Haemophilus influenzae.

Abstract  A 59‐year‐old man presented with a three‐month history of back pain, and enhanced computed tomography demonstrated an acutely expanding aneurysm of the descending thoracic aorta with slight erosion of the corresponding vertebrae. Because of suspected infectious or inflammatory etiology, he was managed with a combination of emergency aortic repair using prosthetic graft with omental flap and antibiotic chemotherapy. Haemophilus influenzae was identified from perioperative specimens and the postoperative course was uneventful. (J Card Surg 2010;25:218‐220)

Closure of the Left Main Trunk of the Coronary Artery and Total Arch Replacement in Acute Type A Dissection During Coronary Angiography

A 64-year-old woman was complicated with acute type A dissection arising from the left main trunk during percutaneous coronary angiography. As the extent of dissection was localized in the ascending aorta, a bare-metal stent was inserted into the left main trunk to cover the entry of dissection. Two days after an angiography, the patients hemodynamic status suddenly deteriorated. A computed tomographic scan showed expansion of a thrombosed false lumen severely compressing the true lumen. Emergency total arch replacement was performed, combined with ligation of the left main trunk and coronary artery bypass grafting. The patient recovered well without residual dissection in the sinus of Valsalva.

Mycotic aneurysm of the thoracic aorta caused by extended-spectrum beta-lactamase-producing Escherichia coli

We report a case of successful treatment of a mycotic aneurysm of the thoracic aorta. A 65-year-old man with a dissecting aneurysm presented with urinary tract infection. He had a history of severe liver cirrhosis. Two weeks after admission, he had a high-grade fever and enhanced computed tomography (CT) demonstrated acute expansion of the distal aortic arch aneurysm. Because of the acute aneurysm expansion and elevated inflammatory response, we suspected a mycotic aortic aneurysm with possible impending rupture. Since conventional open chest surgery was considered to carry a high operative risk, the patient was managed with a combination of emergency endovascular treatment and antibiotic chemotherapy. Extended-spectrum beta-lactamase-producing Escherichia coli were identified from blood culture before treatment. After strict antibiotic therapy, the postoperative course was uneventful and the patient remained well 12 months later.