Left ventricular function on exercise after surgical treatment of small aortic annuli

To evaluate left ventricular function during exercise after aortic annular enlargement 15 patients with either aortic (group I, n = 8) or aortomitral (group II, n = 7) annuloplasty for small aortic annuli and eight patients (group III) with standard valve replacement for aortic stenosis without small aortic annuli received gated cardiac pool imagining by technetium-99m-labelled red blood cells at rest and during exercise at a mean of 23 months after operation. Left ventricular ejection fraction, preload requitable stroke work and stroke power index (preload requitable stroke work/systolic ejection period) were measured. Compared with resting values, left ventricular performance and stroke work rate on exercise after aortic annular enlargements increased significantly, as did those after standard aortic valve replacement. These results suggest that aortic annular enlargement can be indicated for surgical treatment of valvular heart diseases associated with small aortic annuli.

Long-term results of aortic valve translocation for mycotic periannular abscess: comparative study of Danielson's original method and our threadless method

Between June, 1983, and October, 1992, we performed Danielson's original translocation method in four patients (group I) and our translocation method in seven patients (group II), for the treatment of active periannular abscess. There were no perioperative or hospital deaths in either group. The long-term results of these two groups are compared in this report. There were four late deaths (mortality rate 100%) in group I, and three late deaths (mortality rate 43%) in group II. The causes of death were cardiac in six patients and noncardiac in one patient. Vein graft failure occurred in one group I patient (25%) and in two group II patients (28%). Rupture or aortic pseudoaneurysm formation occurred in three group I patients (75%). These findings suggest that our threadless method may be superior to Danielson's original translocation method. Therefore, with close observation, especially of saphenons vein great (SVG) failure, arterial graft use could be acceptable for translocation.

[A case of primary pulmonary hemangiopericytoma recurred locally 10 years after the first surgery]

Hemangiopericytoma is a rare tumor of vascular origin. This tumor has a malignant potential and often recurs or metastasize. A case of primary pulmonary hemangiopericytoma which recurred locally 10 years after the first surgery is presented. The histological appearance of the tumor had some findings of malignant potential in both of the primary and recurrent lesions. We discussed on malignant potential of this tumor in the number of mitotic figures, cellular atipia, and DNA ploidy pattern.

[Surgical results of aortic stenosis with or without left ventricular dysfunction--postoperative change of left ventricular function]

Between January 1980 and December 1992, 82 patients with aortic stenosis underwent isolated aortic valve replacement at our institution. Age of the patients ranged from 26 to 72 (58 +/- 6.4) years, and 58 were men and 24 were women. The patients were divided into two groups according to preoperative left ventricular ejection fraction (LVEF): 23 patients (LVEF < 50%, mean 39.7%; Group D) and 59 patients (LVEF > or = 50%, mean 62.6%; Group N). By means of echocardiography, LV function were evaluated before and at one month after operation in terms of left ventricular fractional shortening (LVFS), left ventricular systolic internal diameter (LVIDs), left ventricular mass index (LVMI), and left ventricular end systolic wall stress (ESWS). Postoperative early mortality including hospital death was 8.7% in group D (2 cases; myocardial infarction 1, cerebral complication 1) and 3.3% in group N (2 cases; myocardial infarction 1, low output syndrome 1), and this difference was not significant (NS) between two groups. The 5- and 12-year actuarial survival rate were 87.8% and 87.8% in group D, 91.5% and 87.6% in group N, respectively (NS). LVFS (pre/post) was 0.25 %/- 0/08/0.24 +/- 0.10 in group D, 0.38 +/- 0.10/0.32 +/- 0.10 in group N. The difference were significant before (p < 0.0005) and after (p < 0.005) operation between two groups. LVIDs (mm; pre/post) were 39.0 +/- 7.9/35.0 +/- 9.6 in group D, 28.7 +/- 7.3/229.3 +/- 7.6 in group N. The difference were significant before (p < 0.0005) and after (p < 0.01) operation.(ABSTRACT TRUNCATED AT 250 WORDS)

Extensive spreading carcinoma of the esophagus with invasion restricted to the submucosa

OBJECTIVES

The aim of this study was to examine the clinicopathological features of extensive spreading type of squamous cell carcinoma (SCC) of the esophagus with invasion restricted to the submucosa.

METHODS

Thirty-eight submucosal SCC were studied histopathologically, and five of these 38 submucosal SCC, which demonstrated an extensive spreading-type SCC in which the size of the SCC was over 5 cm in longitudinal length while extending entirely across the esophageal lumen in a circumferential spread, are described in detail.

RESULTS

The extent of SCC depended mainly on the extent of intraepithelial carcinoma (IEC) and ranged from 50 to 135 mm in longitudinal length. IEC existed continuously in four cases, and multiple IEC existed separately in one case. An epithelium showing dysplasia was present in all cases, and the involvement of the glands and ducts by IEC was present in two cases. There was only one invasive part of SCC observed in one case, and three to 10 invasive parts of SCC were observed in the other four cases; various features of invasion, including an invasive SCC from the esophageal glands and ducts, were also present.

CONCLUSIONS

The extensive spreading-type SCC of the esophagus, which was considered to result from the widespread or multiple carcinomatous changes of the esophageal epithelium, was found to not be as rare as generally thought. The multiple and various features of the invasive parts of SCC suggested the simultaneous development of a downward invasion of SCC at different areas in extensive IEC.

[Changes in CT-scan findings of liver metastases from gastric carcinoma treated by hepatic arterial infusion chemotherapy, especially after chemo-embolization and induced hypertensive chemotherapy]

The purpose of this study was to clarify the effectiveness of hepatic arterial infusion chemotherapy (HAIC) from not only the reduction rate but also the characteristic findings in CT-scan. Subjects were nine responders of HAIC for liver metastases from gastric carcinoma (chemo-embolization, 4 cases; induced hypertensive chemotherapy, 5 cases). Low density (LD), enhancement and indentation of the metastatic lesions were the characteristic findings. As the result, LD was more frequent in chemo-embolization cases (100%) than in induced hypertensive chemotherapy cases (60%). LD change, which was appeared in four cases before partial response, was one of the findings indicating the effectiveness. On the other hand, autopsy revealed severe LD to be necrosis or abscess of metastatic lesion. Therefore, we should pay attention to avoid complications such as rupture, and discontinue HAIC when severe LD appears.

Major basic protein and topical administration of ketotifen in pollinosis under natural allergen provocation

In this study we investigated the potential relation among subjective symptoms, blood eosinophil counts and the levels of major basic protein (MBP) in serum throughout the pre- to postpollen season. In addition, we compared the effects of topical administration of ketotifen on these parameters between the prophylactic treatment group (n = 10) and the postsymptomatic treatment group (n = 10). We found that (1) the levels of MBP in serum during the season were significantly higher than those before the season and (2) the levels of the above three parameters in the prophylactic treatment group were significantly lower than those in the postsymptomatic treatment group during the season. It was concluded from these results that the action of MBP may be involved in the pathogenesis of allergic rhinitis. Furthermore, for the first time we provided evidence that topical ketotifen administration could suppress the systemic upregulation of the blood eosinophil count and MBP level in subjects with pollinosis.

[Analysis of tracheostomy for patients after thoracic esophageal cancer resection]

Tracheostomy is an available method for respiratory management, but a consensus has not been reached with regard to the significance of postoperative respiratory management. So, we analyzed postoperative tracheostomy patients of esophageal cancer and clarified its significance. We analyzed 26 patients from among 85 who underwent resection for thoracic esophageal cancer between April 1989 and December 1992. We divided them into 3 groups according to the indications of tracheostomy, group I: cases with postoperative pulmonary complications (n: 17), group II: cases of prophylaxis against pulmonary complications (n: 5) and group III: cases with dyspnea deriving from postoperative recurrent nerve palsy (n: 4). Tracheostomy was most often performed between 3 and 4 POD in group I, up to 1 POD in group II and from 5 POD to 7 POD in group III. Long-term respiratory support was needed in 13 cases in group I and 2 cases in group II. The rate of tracheostomy was higher in the case who had postoperative recurrent nerve palsy and received preoperative chemoradiotherapy. All cases excluding a case of MOF had a good clinical course after tracheostomy. We were able to clarify the significance of tracheostomy by dividing tracheostomy patients into 3 groups according to the indications for the procedure. It was concluded that tracheostomy is a very useful technique in the respiratory management of resected thoracic esophageal cancer patients.

[Intraperitoneal distribution of drug after gastric surgery]

To evaluate intraperitoneal distribution of drug after surgery, a radiographic study using peritoneography was performed. Five cases with positive intraoperative cytology of gastric carcinoma were studied. The tip of the subcutaneous injection catheter was located in the Douglas's fossa intraoperatively. As control group, 7 cases of inguinal hernia who underwent radical resection for gastrointestinal carcinoma and 2 cases who failed intraperitoneal chemotherapy through injection port, underwent peritoneography. The distribution of contrast medium in the peritoneal cavity was compared between groups. (Conclusion) The distribution of drug after gastric surgery was observed in all of the peritoneal cavity below the transverse colon. Distribution was not observed in the region where lymphadenectomy or bursectomy was done. The peritoneum has an important role in the distribution of drugs in the peritoneal cavity.

[Surgical results of aortitis syndrome (Takayasu disease) combined with annuloaortic ectasia]

From March 1973 to December 1994, 8 patients (2 males and 6 females) aged 34.4 +/- 7.8 years, underwent composite graft replacement (CGR) for aortitis syndrome combined with annuloaortic ectasia (AAE) in our institute. Five patients showed active aortitis syndrome and steroid therapy was administrated to 2 of them. The mean value of the C-reactive protein (CRP) was 1.6 +/- 1.8 before the operation. The maximum diameter of the ascending aorta was 67.1 +/- 10.3 mm (range 53 to 85 mm). Stenosis and/or ectasia of the neck vessels were recognized in 5 cases, as well as the coronary artery in 2 cases. Isolated CGR was performed in 6 cases, and combined with single CABG to LAD in 1 case and with total arch replacement in 1 case. The enlarged ascending aorta was replaced with main graft using the exclusion method and interposed grafts for coronary arteries were sutured with pledgetted mattress sutures all around the coronary ostia. In patients with stenosis of neck vessels, oxygen saturation of the jugular vein was monitored during extracorporeal circulation for surveillance of cerebral ischemia. There was 1 early death due to pulmonary failure. Seven cases survived without any complications during 4-132 months (mean 83.4 months) of the follow-up period. After the operation, 3 cases required steroid therapy during 4-50 months. We concluded that preoperative control of active inflammation, selection of operative procedures, timing for the operation, and the long-term precise management of the intractable disease were essential for successful treatment of aortitis syndrome with AAE.

Effect of methimazole on rat renal carcinogenesis induced by N-ethyl-N-hydroxyethylnitrosamine

The effect of methimazole on N-ethyl-N-hydroxyethylnitrosamine (EHEN)-induced renal lesions was investigated in a medium-term initiation/promotion bioassay in male Wistar rats. EHEN-initiated rats underwent unilateral nephrectomy of the left kidney and subsequent addition of the renal tumor promoters trisodium nitrilotriacetate (NTA), potassium dibasic phosphate (PDP), or hydroquinone (HQ), alone or in combination with methimazole, to the diet for 20 wk. The addition of methimazole reduced the severity of simple and adenomatous renal hyperplasias induced by NTA, PDP, and HQ, but had no effect on the number of renal cell tumors that arose in EHEN+NTA groups. Methimazole also decreased the bromodeoxyuridine (BrdU) labeling indices, but had little effect on the expression of alpha 2u-globulin in treated kidneys as compared to controls. It appears that methimazole exhibits antagonistic properties to nongenotoxic nephrotoxins, protecting against renal damage but not against tumorigenesis, probably arising from genotoxic insult.

[A case of intrahepatic infusion chemotherapy with angiotensin II human for liver metastasis from early gastric cancer]

A 71-year-old woman underwent subtotal distal gastrectomy for II a+ II c type early cancer of the gastric antrum. Histological type was poorly differentiated adenocarcinoma with medullary proliferation, and the lesion invaded the submucosal layer. Two years and 6 months after the operation, multiple liver tumors were found on the CT scan. A surgical resection of the liver tumor was performed. Microscopically, the liver tumors were compatible with gastric cancer. The remnant liver metastases were treated by intrahepatic infusion chemotherapy with Angiotensin II human (Delivert) using a subcutaneous implanted pump. The liver metastases disappeared on the CT scan after 3 courses of chemotherapy, but bone metastasis occurred after 2 months. This mode of chemotherapy was therefore considered a useful treatment for liver metastasis in gastric cancer. We concluded that not only intrahepatic infusion chemotherapy with Angiotensin II human but also another systemic chemotherapy was necessary to treat patients with liver metastasis in gastric cancer.

Long-term outcome of left ventricular dysfunction after surgery for severe aortic stenosis

Thirteen patients with severe aortic stenosis and left ventricular dysfunction (ejection fraction < 0.50, Group A) received echocardiographic evaluation before, and early and late after isolated aortic valve replacement. The results were compared with those of 11 aortic stenosis patients without left ventricular dysfunction (Group B). Using two-dimensional echocardiography, left ventricular diastolic internal diameter (LVIDd), left ventricular systolic internal diameter (LVIDs), left ventricular wall thickness (interventricular septum + posterior wall: LVWT), left ventricular fractional shortening (FS), left ventricular mass index (LVMI) and left ventricular end-systolic wall stress (ESWS) were assessed before (Pre), at one month (Early) and 4-7.6 (mean 5.5 +/- 1.0) years (Late) after operation. In the early postoperative period in Group A, significant decrease was observed in LVIDd (5.4 +/- 0.8 to 4.5 +/- 1.0 cm, p = 0.010), LVWT (3.3 +/- 0.7 to 2.9 +/- 0.7 cm, p = 0.027) and LVMI (336 +/- 149 to 222 +/- 112 g/M2, p = 0.013). From the early to late postoperative period FS showed significant improvement in both groups (0.23 +/- 0.12 to 0.32 +/- 0.12 in Group A, p = 0.025 and 0.27 +/- 0.07 to 0.36 +/- 0.07, p = 0.014). However, changes of other parameters were not significant and LVMI in Group A remained twice as high as the normal value. It is concluded from the above results, that LV contraction in aortic stenosis patients with preoperative left ventricular dysfunction improved during the late postoperative period. Although LVMI in the early postoperative period significantly decreased as compared with the preoperative value, it showed no further improvement and remained at an abnormally high level. Therefore, early surgical treatment of severe aortic stenosis before appearance of LV dysfunction should be recommended for postoperative recovery from LV hypertrophy.

[Evaluation of intraoperative peritoneal cytology and intraperitoneal chemotherapy using CDDP combined with MMC for gastric carcinomatous peritonitis]

A cytological examination in the lavaged peritoneal fluid during operation was performed in 462 patients with gastric cancer. The incidence of positive cytology was 36% in serosal invasion cases. The prognosis of positive cytology cases without peritoneal dissemination was slightly better than the P (+) cases. The incidence of the positive cytology was 48% in patients with serosal invasion more than 16 cm2. The prognosis of patients with serosal invasion below 32 cm2 was significantly better than in the patients with above 32 cm2. Intraperitoneal repeated administration of MMC 10 mg/body and CDDP 40-50 mg/body was continued one a month via the drug delivery system. Negative change of cytology was observed in 7 out of 14 patients, and the prognosis of these patients was better than that of the unchanged cytology group. Side effects such as severe gastrointestinal symptoms and bone marrow toxicities were not observed. Further studies should be done to confirm the efficacy of the intraperitoneal chemotherapy in terms of the prolongation of life.

Long-term results of coronary artery bypass grafting in elderly Japanese patients

BACKGROUND

This study was undertaken to examine long-term results of coronary artery bypass grafting in elderly Japanese patients.

METHODS

Of 1,425 coronary artery bypass grafting patients over the last 13 years, 137 patients were 70 or more years old and 1,288 were less than 70 years old. Mean number of distal anastomoses was similar in both groups. Postoperative survival and event-free proportion were estimated by the Kaplan-Meier actuarial method and compared among the groups by Cox-Mantel statistical analysis.

RESULTS

Operative mortality and the incidence of late cardiac death after coronary artery bypass grafting were equivalent between the elderly and younger groups, although the rates of left main trunk disease, acute myocardial infarction, and emergency operation in the elderly group were significantly higher than those in the younger group. Coronary artery bypass grafting in elderly patients had a relatively high hospital mortality and more late noncardiac deaths, but the incidence of postoperative cardiac intervention in elderly patients was lower than that in younger patients.

CONCLUSIONS

These results suggest that coronary artery bypass grafting for elderly patients is encouraged as well as is that for younger patients in a representative Japanese population.

[Retrospective study of sputum culture after esophagectomy]

We retrospectively investigated the sputum cultures of patients who underwent esophagectomy (n = 104) from just after operation to 11 postoperative days and evaluated the factors which influenced the cultures. We divided the 0-11 postoperative days into three periods (0-3 postoperative days (p.o.d.), 4-7 p.o.d., 8-11 p.o.d.). The sputum cultures were positive at a rate of 56.7% to 65.4% of patients during the period of observation (0-11 p.o.d.). Gram-negative bacillus was mostly detected. MRSA increased time-dependently. Diabetes mellitus, preoperative irradiation recurrent nerve palsy did not influence the positive rate of the sputum cultures. The positive rate of gram-negative bacillus and gram gram-positive coccus in the sputum of the patients who were given sefem-first generation antibiotics was lower than of patients who were given sefem-second generation antibiotics at 8-11 p.o.d. (p < 0.05). The positive rate of gram-negative bacillus in the sputum of patients who underwent esophagectomy with laryngectomy for cervical esophageal cancer was lower than that of patients who underwent esophagectomy without laryngectomy for thoracic or abdominal esophageal cancer at 4-7 p.o.d. (p < 0.05). The positive rate of gram-negative bacillus in the sputum of patients who underwent intraoperative tracheostomy was lower than that of patients who did not undergo intraoperative tracheostomy at 4-11 p.o.d. No patients had pneumonia during the period of observation except for the secondary lung complications. In conclusion, although we have done a good job of management, we should select the appropriate antibiotics with the patient's background in mind.

Resection margin for squamous cell carcinoma of the esophagus

OBJECTIVE

The safe resection margin in esophagectomy for esophageal squamous cell carcinoma (SCC) was determined based on the extent of epithelial and subepithelial accessory lesions from the main lesions of esophageal SCC.

BACKGROUND

There have been many reports on the high incidence of a positive resection margin for esophageal cancer. Although there were some studies on the relationships of the proximal clearance to postoperative local recurrence, no pathologic study on the resection margin has been reported.

METHODS

Four hundred twenty specimens of a whole resected esophagus were examined histopathologically and the longitudinal length from the main lesion to the five types of accessory lesions was measured on microscopic slides.

RESULTS

Contiguous intraepithelial carcinoma existed in 69 (46%) of 150 sites of main lesions restricted to the mucosa or submucosa and subepithelial lesions existed in 131 (54%) of 245 sites and 82 (55%) of 150 sites of main lesions invading an adventitia and into neighboring structures, respectively. The risk of a positive resection margin due to subepithelial lesions was below 5% at 10 mm in the main lesion, restricted to the submucosa or the muscularis propria, and at 30 mm in the main lesion, invading the adventitia in the potentially curative operation cases.

CONCLUSION

These clearances of the resection margin, in which the risk of a positive resection margin is below 5%, are acceptable, although these clearances should only be accepted after the extent of epithelial accessory lesions is accurately determined by the Lugol's stain method.

Soluble ICAM-1 as a regulator of nasal allergic reaction under natural allergen provocation

BACKGROUND

Intercellular adhesion molecule-1 (ICAM-1) plays a key role in the early stage of the signal cascade leading to cellular extravasation and development of an inflammatory response. Recently, it has been reported that the soluble form of this adhesion molecule is present in human sera, possibly mediating biological actions.

OBJECTIVE

The purpose of this study was to investigate levels of soluble ICAM-1 (sICAM-1) and its receptors in patients with allergic rhinitis, and to discuss sICAM-1's biological function.

METHODS

The levels of sICAM-1 in sera and nasal epithelial lining fluids (ELF), the percentage of CD11a-positive lymphocytes in the peripheral blood, and scores of subjective symptoms from 14 patients with pollinosis (allergic group) were measured from pre- to post-season, results were compared with those from 10 non-allergic subjects (control group).

RESULTS

The levels of sICAM-1 in sera and ELF were upregulated, and CD11a-positive lymphocytes were downregulated during the in-season in the allergic group. In addition, levels of sICAM-1 sera from the allergic group remained high during the post-season, when levels of other parameters (symptoms, blood eosinophil counts, sICAM-1 in ELF and CD11a-positive lymphocytes) had roughly returned to the initial pre-season levels.

CONCLUSIONS

We demonstrate systemic and local upregulation of sICAM-1 and systemic downregulation of LFA-1 positive lymphocytes in patients with seasonal allergic rhinitis under natural allergen provocation, suggesting that sICAM-1 plays a role in regulating seasonal allergic inflammation.

Detection of aberrations in androgen receptor gene by analysis of single-stranded conformation polymorphisms in polymerase chain reaction products

Analysis of single-stranded conformation polymorphisms in polymerase chain reaction (PCR) products (PCR-SSCP) is a sensitive method for detecting point mutations in genomic DNA. To investigate its utility in examining the androgen receptor gene, we analyzed data on a patient with the testicular feminization syndrome (TFS) with a known point mutation in exon C. We detected mobility shifts of fragments of the corresponding region. Since examination of the subject's brother (legally sister), who also has TFS, revealed an identical shift pattern, we sequenced the exon C of the sibling and detected a mutation identical to that in the former. We conclude that PCR-SSCP is available for screening mutations of the androgen receptor gene.

Development of an autoflow cruise control system for a centrifugal pump

To improve the ease of driving a centrifugal pump that is afterload dependent, we have developed an automatic flow control system for the Terumo Capiox centrifugal pump system. This system consists of an autoflow cruise control system with a safety cutoff. The Capiox Pump Console 3000 was controlled by a personal computer through a serial communication line. In the usual manual mode, the motor speed knob works as a pump speed control, and in the autoflow mode, the same knob works as a blood flow rate control. After selecting and obtaining the desired flow rate, the mode was changed from manual to autoflow mode. In the autoflow mode, the computer compares the desired flow rate with the actual flow measured by an ultrasonic Doppler flowmeter and adjusts the motor rotational speed accordingly. During both in vivo and in vitro testing, this autoflow mode was able to return the changed flow that was disrupted by either clamping and declamping of the tubing or by the bolus injection of a vasomotor drug to the selected flow rate within 10 s without any significant fluctuation. In conclusion, the newly developed computer controlled autoflow system was able to produce a reliable and effective flow regulation for a centrifugal pump.

[Resection of the posterior mediastinal gastric tube used in reconstruction after radical surgery for esophageal cancer--case reports]

Two patients are presented who underwent resection of a gastric tube placed in the posterior mediastinum during reconstruction following radical esophageal resection for esophageal cancer. The indications for gastric tube resection were bleeding from a peptic ulcer in one and gastric cancer in the other. Case 1: A 72-year-old man, who had undergone a thoracic esophagectomy 3.5 years prior to admission, presented with a chief complaint of hematemesis. The gastric tube was resected and replaced with an antethoracic, pedicled segment of left colon. Pathologic examination of the resected gastric tube revealed a penetrating peptic ulcer. Case 2: A 65-year-old man with esophageal cancer and early gastric cancer underwent thoracic esophagectomy with combined resection of the fundus and lesser curvature of the stomach. One year later, he was found to have a new early gastric cancer in the antrum. The distal portion of the gastric tube was resected and replaced with a pedicled jejunal graft. Of the 526 patients with esophageal cancer treated in our department from 1972 to 1993, peptic ulcers were evident in the gastric tube used to reconstruct the esophagus in only seven cases. The stomach was resected in only one of these patients. Similar patients requiring gastric tube resection have been reported. All six of these cases are reviewed. Cancer of the gastric tube developed in 3 of the 526 patients. Although 74 cases of gastric tube cancer have been reported in the Japanese literature, the patient presented here (case 2) is the first to undergo successful resection of the stomach from the posterior mediastinal position.