Teruo Ikezawa

Closure of the Distal Pancreatic Stump with a Seromuscular Flap

We describe herein our new method for transecting the pancreas and closing its stump in distal pancreatectomy, devised to decrease the risk of pancreatic fistula formation. With this technique, the pancreas is transected in such a way that a convex stump is left, whereby the pancreatic secretions from the parenchyma near the pancreatic stump are fully drained into the main pancreatic duct. A pedicled seromuscular flap of the stomach or jejunum is then used to cover the cut surface of the pancreas. This new technique provides tight closure of the pancreatic stump after distal pancreatectomy.

Tuberculous pseudoaneurysm of the descending thoracic aorta: a case report and literature review of surgically treated cases.

Tuberculous aneurysm of the aorta is an extremely rare disease with a high mortality rate. Only 32 patients treated surgically have been reported in the literature. These reports indicate an 84.4% operative survival rate. We present a case of a tuberculous false aneurysm in the descending thoracic aorta that was successfully treated surgically with an extracorporeal circulation. The hole in the aorta within the false aneurysm was closed with a Dacron patch because the aortic wall appeared to be free of active infection as a result of long-term preoperative antituberculous chemotherapy.

The inclusion of an omental flap in pancreatoduodenectomy

A technique for reducing the morbidity and mortality of pancreatoduodenectomy by using an omental flap to protect the anastomoses and splanchnic vessels exposed during dissection is described herein.

Pedicled jejunal seromuscular flap for bronchocutaneous fistula

We report the successful closure of a complicated bronchocutaneous fistula using a pedicled jejunal flap. The fistula, secondary to tuberculosis and irradiation, previously had been closed with a latissimus dorsi musculocutaneous flap. This initial repair failed. The recurrent fistulas were closed again using a jejunal seromuscular flap, and the chest wall defect was reconstructed with a rectus abdominis musculocutaneous flap.

Surgical experience of 13 infected infrarenal aortoiliac aneurysms: Preoperative control of septic condition determines early outcome

BACKGROUND The surgical management of infected aneurysms remains challenging and controversial. We aimed to assess the results of our retrospective series of patients surgically treated for infected infrarenal aortoiliac aneurysms and to verify our strategy. METHODS Retrospective case review of a single center. RESULTS Between January 1994 and December 2008, 545 patients with infrarenal aortoiliac aneurysms underwent surgery at our institution. Among these cases, 13 (2.4%) were classified as primary infected aneurysms. Seven were located in the infrarenal aorta and 6 were located in the iliac artery. The identified pathogens were Salmonella species (n = 2), methicillin-resistant Staphylococcus aureus (n = 2), and others. Systemic antibiotics were administered preoperatively to control septic conditions. At the time of surgery, 4 (31%) aneurysms had ruptured already. All but 2 cases, which were treated with extra-anatomic bypass, were repaired in situ using a Dacron graft. Although no in-hospital deaths occurred among the 3 patients who underwent planned surgery after successful control of septic conditions, 4 of 8 patients who underwent emergency surgery under septic conditions died during the early postoperative period. No signs of persistent or recurrent infection have been observed in our surviving patients with a mean follow-up of 40 months. CONCLUSION Timely surgical intervention after controlling sepsis provided excellent outcomes, whereas the mortality rate of patients with sepsis or rupture was still high. Debridement of periaortic-infected tissue and in situ prosthetic graft repair are feasible.

Solitary Profunda Femoris Artery Aneurysm

Solitary profunda femoris artery aneurysm (PFAA) is extremely rare but presents with symptoms related to rupture, distal embolization, or local compression of veins and nerves. We report two surgically treated cases of solitary PFAA. In case 1, a 69-year-old man presented with sudden onset of pain in the left groin. Computed tomography scan showed a large aneurysm with extravasation of the contrast medium in the left mid-thigh, indicating ruptured aneurysm of the profunda femoris artery. Case 2 involved a 70-year-old man whose computed tomography scan revealed a large, nonruptured PFAA. Both aneurysms were successfully resected with vascular reconstruction using the great saphenous vein.

Upper extremity ischemia in athletes : Embolism from the injured posterior circumflex humeral artery

Upper extremity ischemia in athletes is caused by embolism from the proximal arterial compromise at the thoracic outlet or under the pectoralis minor. The posterior circumflex humeral artery (PCHA), a branch of the third part of the axillary artery, can also be injured by repetitive overhead activity including the tennis or volleyball game, resulting in aneurysm formation or thrombotic occlusion, and this lesion could be a source of distal embolism. We report two patients with complaints of hand and forearm ischemia due to distal embolism from the aneurysm in one patient and thrombotic occlusion of the PCHA in the other. The former was a 20-year-old amateur tennis player. Angiography revealed an aneurysm of the PCHA and multiple distal embolism. He was treated by resection of the aneurysm and thromboendarterectomy with vein patchplasty of the occluded ulnar artery. Five years after surgery now, he can enjoy playing tennis without new embolic events, although he still has mild ischemic symptoms during playing tennis. The latter was a 17-year-old volleyball player. Angiography showed thrombotic occlusion of the PCHA and embolic occlusion of the digital arteries. Surgical intervention was not required because he decided not to play volleyball. Two years later now, he has had no new episodes of embolism, although he has ischemic symptoms only when cold.

Type I Endoleak-like Phenomenon Causing Rupture of the Replaced Aneurysm Sac 12 Years after Open Repair of Abdominal Aortic Aneurysm.

Only a few cases of endoleak following conventional abdominal aortic aneurysm repair have been reported. We treated a patient with a type I endoleak-like phenomenon occuring 12 years after conventional abdominal aortic aneurysm repair. Computed tomography demonstrated dilation of the surgically replaced, once-shrunken aneurysm sac to a diameter of 3.5 cm. Thrombus was identified between the graft and the sac. Four months later the sac ruptured, and emergency repair was performed. Dehiscence of the proximal anastomosis causing dilation and tearing of the sac was found. Dilation of a surgically replaced aneurysm sac after initial shrinkage may suggest an endoleak-like phenomenon requiring second repair.

Factors affecting the regression of surgically replaced abdominal aortic aneurysms.

PurposeAfter endovascular therapy for abdominal aortic aneurysms, aneurysm sac shrinkage is considered to be the best marker of successful treatment. Such shrinkage, however, is infrequent and the rate of shrinkage is variable because of endoleaks. To investigate the factors that influence such contraction, the aneurysm sac regression after a conventional surgical replacement of the abdominal aortic aneurysm in an inclusion fashion was studied.MethodsAbdominal aortic aneurysms that measured 5 cm in diameter or larger were studied in 35 patients who underwent surgical replacement. The aneurysm sac was closed anterior to the prosthesis. Of the 35 cases, 4 aneurysms were inflammatory and 10 had aneurysm wall circumferential calcification of greater than 40%. Computed tomography was performed preoperatively, and at 1 week, and then 3 months postoperatively.ResultsThe maximum major and minor diameters of the aneurysmal sac decreased significantly from 1 week to 3 months after surgery (major diameter: 49 ± 12 to 32 ± 8 mm and minor diameter: 39 ± 10 to 26 ± 7 mm). In inflammatory aneurysms, the maximum major and minor diameters were significantly larger at 3 months postoperatively, in comparison to nonspecific aneurysms. Among the 31 patients with nonspecific aneurysms, the maximum major diameter was significantly larger in those with aneurysmal calcification of greater than 40% of its circumference at 3 months postoperatively, in comparison to noncalcified aneurysms.ConclusionsThe surgically repaired abdominal aortic aneurysm contraction tends to develop over 3 months, and inflammation, thickening, and calcification of the aneurysm wall are all considered to influence the regression of the aneurysm.

Hepatocellular carcinoma invading the duodenum: combined resection of the lateral duodenum and repair with a pedicled gastric flap

A 57-year-old man presented with gastrointestinal bleeding from duodenal invasion by hepatocellular carcinoma. He underwent an extended right hepatic lobectomy with resection of the lateral duodenum.