Biologic valves can sometimes have a small closure or leakage backflow jet originating from the central coaptation point. This is physiologic regurgitation that usually only requires monitoring, and not treatment.Another non-central transvalvular leakage is occasionally seen in both porcine and pericardial valves and originates from the base of the stent post. Typically, it spontaneously decreases or even disappears by the end of the surgery, after administration of protamine. This leak, however, needs to be distinguished from abnormal paravalvular leakages, especially if the regurgitation is relatively large, as this may require an extra cardio-pulmonary bypass (CPB) run.In our case with stented bovine pericardial valves, detailed transesophageal echocardiography (TEE) examination immediately after CPB showed oblique and turbulent flow, which originated from the base of the stent post and flowed toward the anterior mitral leaflet. An extra CPB run, assessment of the cause of the leakage, and restoration if necessary, might have been required if the leakage did not improve or was exacerbated, because contact of the anterior mitral valve leaflet by the oblique flow is associated with the risks of infective endocarditis and hemolysis. Detailed TEE examination accurately delineated the site of the leak, which was subsequently found to originate from the site between the anterior stent post and the sewing ring. The leakage in this case was classified as non-paravalvular, non-central leakage within the sewing ring. Accurate diagnosis of the leakage by intra-operative TEE led to the decision to administer protamine and to adopt a wait-and-watch approach.

Gastrointestinal manifestations are a very rare complication of dermatomyositis (DM) and are much less frequent in adult cases than in juvenile cases. Only a few previous papers have reported adult patients who had DM with anti‐nuclear matrix protein 2 (anti‐NXP2) antibodies and who developed gastrointestinal ulcers. Herein, we report a similar case of a 50‐year‐old man who had DM with anti‐NXP2 antibodies followed by relapsing multiple gastrointestinal ulcers. Even after the administration of prednisolone, his muscle weakness and myalgia deteriorated and gastrointestinal ulcers relapsed. In contrast, intravenous immunoglobulin and azathioprine improved his muscle weakness and gastrointestinal ulcers. Based on the parallel disease activity of the muscular and gastrointestinal symptoms, we considered that his gastrointestinal ulcers were a complication of DM with anti‐NXP2 antibodies. We also propose that early intensive immunosuppressive therapy would be required for the muscular and gastrointestinal symptoms in DM with anti‐NXP2 antibodies.

Highlights We experienced successful treatment for large GIST with diaphragm invasion by a combination of preoperative imatinib treatment and laparoscopic resection. In the neoadjuvant imatinib, it is important to indicate cases and mediate the duration. The most important point for laparoscopic resection of large GIST is how to handle it.