Satisfaction with bispectral index monitoring of propofol-mediated sedation during endoscopic submucosal dissection: a prospective, randomized study

BACKGROUND AND STUDY AIMS

Endoscopic submucosal dissection (ESD) is one of the most complex and lengthy endoscopic procedures, so deep sedation during ESD is indispensable. Our study aims were to determine whether bispectral index (BIS) monitoring is useful in titrating and reducing the dose of the sedative propofol during ESD, and to measure the satisfaction of patients and endoscopists involved in this complex and lengthy endoscopic therapy.

PATIENTS AND METHODS

We performed a prospective, randomized clinical trial from July 2006 to February 2008. A total of 156 patients, with gastric neoplasm to be treated using ESD, were randomized to two groups. The BIS group (n = 78) was monitored for propofol sedation using BIS, and the no-BIS group (n = 78) was monitored by standard methods only. The two groups were compared by evaluating the doses of propofol administered to patients and the satisfaction scores (scale of 0 - 10) of patients and endoscopists.

RESULTS

Although there were no significant differences between the two groups in the mean dose of propofol used (BIS group vs. no-BIS group, 5.32 mg/kg/hour vs. 4.85 mg/kg/hour; P = 0.10), the satisfaction scores of the patients (9.15 vs. 7.94; P < 0.01) and endoscopists (8.53 vs. 6.42; P < 0.001) were significantly higher with BIS monitoring.

CONCLUSIONS

Monitoring with BIS during the ESD procedure did not lead to a reduction in the dose of propofol required, but did lead to higher satisfaction scores from the patients and endoscopists. A complicated and prolonged endoscopic treatment such as ESD can be carried out with optimal safety, control, and comfort by using BIS to monitor propofol sedation.

Three-dimensional splay fault geometry and implications for tsunami generation

Megasplay faults, very long thrust faults that rise from the subduction plate boundary megathrust and intersect the sea floor at the landward edge of the accretionary prism, are thought to play a role in tsunami genesis. We imaged a megasplay thrust system along the Nankai Trough in three dimensions, which allowed us to map the splay fault geometry and its lateral continuity. The megasplay is continuous from the main plate interface fault upwards to the sea floor, where it cuts older thrust slices of the frontal accretionary prism. The thrust geometry and evidence of large-scale slumping of surficial sediments show that the fault is active and that the activity has evolved toward the landward direction with time, contrary to the usual seaward progression of accretionary thrusts. The megasplay fault has progressively steepened, substantially increasing the potential for vertical uplift of the sea floor with slip. We conclude that slip on the megasplay fault most likely contributed to generating devastating historic tsunamis, such as the 1944 moment magnitude 8.1 Tonankai event, and it is this geometry that makes this margin and others like it particularly prone to tsunami genesis.

Herpes simplex virus pneumonia after cardiac surgery: report of a case

A rare case of a 61-year-old man who developed herpes simplex virus (HSV) pneumonia after cardiac surgery is presented. He was immunocompetent before the operation and had no history of a mucocutaneous herpesvirus infection. This potentially fatal complication was successfully managed with acyclovir treatment after establishing the diagnosis with bronchoalveolar lavage. A depression of the patient's cell-mediated immunity after cardiopulmonary bypass may have been a causative factor. An unusual type of pneumonia such the HSV pneumonia seen in the present case should therefore be considered in patients with severe hypoxemia accompanied with unexplained pulmonary infiltrates after cardiac surgery using cardiopulmonary bypass which does not improve with conventional treatment.

Obstructive jaundice caused by lymphatic remetastasis from the hepatic metastasis of rectosigmoid cancer

The significant benefit of performing hepatic resection for hepatic metastases from colorectal primary cancers is well established; however, the effectiveness of dissection of the lymph nodes draining the liver remains uncertain. Herein, we report the case of a 52-year-old man who was found to have obstructive jaundice caused by lymphatic remetastasis from the hepatic metastasis of primary rectosigmoid cancer. He had previously undergone a high anterior resection for the rectosigmoid cancer, in April 1990, and a hepatic resection for metastasis was done in March 1994. When the hepatic resection was carried out, dissection of the regional lymph nodes of the liver (i.e., the nodes in the hepatoduodenal ligament) was not performed because no obvious metastatic nodes were identified. Three years after the hepatic resection, enlarged lymph nodes compressing the extrahepatic bile duct from outside were identified by cholangiography and computed tomography (CT). Because radiological studies were unable to determine the lesion capable of metastasizing to these nodes, they were diagnosed as remetastasized lymph nodes from the hepatic metastasis that had been resected 3 years earlier. The lymphatic remetastases were intractable to treatment, and the patient finally died of hepatic failure and malignant cachexia. This case serves to demonstrate that lymphatic dissection of the regional lymph nodes may need to be taken into consideration when resection of hepatic metastases from colorectal cancers is performed.

Pulmonary carcinoid found in a patient who presented with initial symptoms of brain metastasis: report of a case

Although atypical pulmonary carcinoids frequently metastasize to regional lymph nodes, they rarely metastasize to the brain. We describe herein an extremely unusual case of a 52-year-old woman who presented with the symptoms of brain metastasis as the initial manifestation of an atypical pulmonary carcinoid. After control of the multiple metastatic brain lesions had been achieved by tumorectomy and stereotactic radiosurgery, a middle lobectomy of the right lung was performed to completely resect the primary pulmonary carcinoid. This aggressive surgical approach was successful in that it prolonged the survival of the patient and enhanced her quality of life.

Clinical experience with temporary vena cava filters

An experience with temporary filter placement, which seems to be safe and effective for temporarily preventing pulmonary embolism, is reported. Since October 1997, six patients had temporary filters. There were two men and four women, with a mean age of 37 years. Three filters were placed at the infrarenal inferior vena cava, two at the suprarenal inferior vena cava, and one at the superior vena cava. All filters were placed before various surgical interventions. During filter placement, anticoagulation therapy was routinely performed. There were no complications at and during filter placement. No pulmonary emboli occurred during surgical intervention. All filters were successfully removed, two of which were exchanged for permanent filters. All patients are alive and well without recurrent deep vein thrombosis and/or pulmonary emboli during a follow-up period of 11 to 25 months. Although this experience is small, temporary filter placement is safe and effective for short-term prevention of pulmonary emboli even in older patients or those with malignant disease. Veins of the upper part of the body may be more favorable than the femoral vein for insertion of a temporary filter. Temporary filters can be safely placed not only at the infrarenal inferior vena cava, but also at the suprarenal inferior vena cava or superior vena cava.

Contribution of serotonin to liver injury following canine small-intestinal ischemia and reperfusion

Intestinal ischemia and reperfusion (I/R) has been shown to be associated with multiple organ damages. Serotonin (5-hydroxytriptamine; 5-HT), which is synthesized in the enterochromaffin cells in the intestine and stored in platelets, is known to play an important role in platelet aggregation and vasoconstriction and may ultimately enhance such organ injuries. The purpose of this study was to investigate the association between liver damage and 5-HT levels in the liver after intestinal I/R. The entire canine small intestine, isolated on a vascular pedicle that consisted of the proximal superior mesenteric artery and superior mesenteric vein, was subjected to 4-h ischemia by clamping these vessels and the marginal arteries supplying the proximal and distal ends of the small intestine. Hepatic blood flow, liver tissue blood flow, bile flow rate, and hepatic venous ketone body ratio (HVKBR) were measured before and at the end of intestinal ischemia and at 5, 15, and 30 min, and 1 and 2 h after reperfusion. 5-HT levels in plasma of the portal vein and hepatic vein were assayed at the same intervals. Time-matched, sham-operated animals served as controls. Intestinal I/R significantly decreased the liver tissue flow, bile flow rate, and HVKBR. Compared to those in controls, 5-HT levels in the portal vein and hepatic vein were markedly increased after reperfusion. Furthermore, intravenous administration of 5-HT receptor antagonists attenuated the liver dysfunction after intestinal reperfusion. These results suggest that intestinal I/R induces continuous disturbance of hepatic microcirculation, leading to liver dysfunction, and that 5-HT may be implicated as one of the mediators of liver dysfunction after intestinal I/R.

A leukocyte depleting filter reduces endothelial cell dysfunction and improves transplanted canine heart function

BACKGROUND

To date leukocytes have been known to play a major role in reperfusion injury and have directed attention to leukocyte-endothelium interaction. This study was designed to investigate how much graft viability and the coronary microcirculatory function could be preserved by leukocyte depletion (LD) in a model of orthotopic cardiac transplantation.

METHODS

The heart in 10 beagle dogs was arrested by introducing a 4 degrees C St. Thomas' cardioplegic solution. They were harvested, immersed in the cold saline for 3 hours, and then orthotopically transplanted. Five recipients underwent LD (LD group) at reperfusion with the use of a Pall BC1B leukocyte depleting filter inserted into the cardiopulmonary bypass (CPB) circuit. The other 5 dogs without filtration served as a control group.

RESULTS

Leukocytes were about 80% filtrated and neutrophils were also 85% filtrated during the first 30 minutes of reperfusion in the LD group. A high level of adenosine triphosphate was maintained after transplantation in the LD group. The polymorphonuclear elastase level was significantly lower in the LD group. The cardiac function assessed by the slopes of the end-systolic pressure volume relation after transplantation was significantly higher in the LD group than in the control group (p < 0.05). The coronary vascular resistance responses to acetylcholine and nitroglycerin after transplantation were preserved significantly better in the LD group than in the control group (p < 0.05).

CONCLUSIONS

These results suggest that a leukocyte depleting filter placed in the CPB circuit would prevent leukocyte-mediated endothelial cell injury, improve microcirculation of the myocardium, and lead to excellent graft function.

Antinociceptive effect produced by intracerebroventricularly administered dynorphin A is potentiated by p-hydroxymercuribenzoate or phosphoramidon in the mouse formalin test

The antinociceptive effects of intracerebroventricularly (i.c.v.) administered dynorphin A, an endogenous agonist for kappa-opioid receptors, in combination with various protease inhibitors were examined using the mouse formalin test in order to clarify the nature of the proteases involved in the degradation of dynorphin A in the mouse brain. When administered i.c.v. 15 min before the injection of 2% formalin solution into the dorsal surface of a hindpaw, 1-4 nmol dynorphin A produced a dose-dependent reduction of the nociceptive behavioral response consisting of licking and biting of the injected paw during both the first (0-5 min) and second (10-30 min) phases. When co-administered with p-hydroxymercuribenzoate (PHMB), a cysteine protease inhibitor, dynorphin A at the subthreshold dose of 0.5 nmol significantly produced an antinociceptive effect during the second phase. This effect was significantly antagonized by nor-binaltorphimine, a selective kappa-opioid receptor antagonist, but not by naltrindole, a selective delta-opioid receptor antagonist. At the same dose of 0.5 nmol, dynorphin A in combination with phosphoramidon, an endopeptidase 24.11 inhibitor, produced a significant antinociceptive effect during both phases. The antinociceptive effect was significantly antagonized by naltrindole, but not by nor-binaltorphimine. Phenylmethanesulfonyl fluoride (PMSF), a serine protease inhibitor, bestatin, a general aminopeptidase inhibitor, and captopril, an angiotensin-converting enzyme inhibitor, were all inactive. The degradation of dynorphin A by mouse brain extracts in vitro was significantly inhibited only by the cysteine protease inhibitors PHMB and N-ethylmaleimide, but not by PMSF, phosphoramidon, bestatin or captopril. The present results indicate that cysteine proteases as well as endopeptidase 24.11 are involved in two steps in the degradation of dynorphin A in the mouse brain, and that phosphoramidon inhibits the degradation of intermediary delta-opioid receptor active fragments enkephalins which are formed from dynorphin A.

Superior vena caval placement of a temporary filter: a case report

Placement of permanent filters in the superior vena cava (SVC) for preventing pulmonary embolism (PE) arising from thrombi superior to the right atrium has rarely been performed. The authors report the first case of temporary filter insertion in the SVC because of upper extremity thrombosis accompanied with PE. After thrombectomy, the temporary filter was successfully removed. It is recommended to use a temporary filter, especially in young patients with upper extremity thrombosis requiring temporary prophylaxis against PE.

Abdominal multivisceral transplantation in pigs

We investigated the technical aspects of porcine abdominal multivisceral transplantation, in terms of pathophysiological features in animals given no immunosuppresant. The splanchnic organs of the donor animal were flushed in situ with University of Wisconsin solution via the abdominal aorta, using a pump. After a relatively short period of cold storage in saline, multivisceral grafts, including the liver, pancreas, and gastrointestinal tract, were transplanted orthotopically. Of the 18 recipient pigs that underwent the operation, 9 (50%) died within 24 h, mainly because of respiratory insufficiency (n = 5) and circulatory shock (n = 3). Three animals (17%) were lost to acute renal failure between the second and fifth postoperative days. Six pigs (33%) survived for more than 1 week, and the causes of death in these animals were bowel obstruction (n = 1), pneumonia (n = 2), rejection of the intestinal graft (n = 2), and deterioration (n = 1). Although the results of this study were not satisfactory, abdominal multivisceral transplantation using pigs is practical and may lead to the possible resolution of various problems, in regard to the immunologic aspects and the interrelationship of transplanted complex organs.

Preoperative autologous donation of blood for a simple cardiac anomaly: analysis of children weighing under twenty kilograms

OBJECTIVE

Preoperative autologous donation of blood has been expanded to cardiac operations in children. However, because of problems such as lack of cooperation and hemodilution during cardiopulmonary bypass, its efficacy in small children is unclear. This study clarifies the clinical significance of preoperative autologous donation of blood in small children.

METHODS

Thirty-seven patients weighing under 20 kg (age range, 3-9 years; weight range, 13-20 kg) underwent preoperative autologous donation and cardiac operations to treat a simple anomaly. Twenty-five age- and weight-matched patients who were not cooperative or refused preoperative autologous donation served as control subjects. Autologous blood was collected by the simple or leapfrog method and stored as blood components. Each collecting volume was 5 to 10 mL/kg.

RESULTS

The donation was performed 6+/-2 times during 50+/-16 days, and the whole storage volume was 48+/-17 mL/kg. There was no serious complication. The minimum hematocrit level negatively correlated with the priming volume of cardiopulmonary bypass (preoperative donation patients: P<.01, r(2) = 0.4; control subjects: P =.5, r (2) = 0.03). Blood loss did not significantly differ between preoperative donation patients and control subjects, and the transfused blood volumes were 43+/-13 mL/kg and 29+/-22 mL/kg, respectively. All of the autologous blood products but fresh frozen plasma were reinfused. Use of homologous blood was significantly less in preoperative donation patients than in control subjects (0% vs 80%, P <.01). In preoperative donation patients postoperative recovery in hemoglobin level was significantly better, which is concurrent with a higher reticulocyte level.

CONCLUSION

Preoperative autologous donation can be performed safely with clinical efficacy, even in children under 20 kg. This can be improved further through coupling with another procedure.

The influence of human T lymphotropic virus type I infection on the outcome of cardiovascular surgery

OBJECTIVE

Human T lymphotropic virus type I infects CD4(+) T cells and affects cell-mediated immunity. Cardiopulmonary bypass transiently alters lymphocyte subsets, resulting in a reduction in CD4(+) T cells and an increase in CD8(+) T cells. We proposed that cardiovascular operations and human T lymphotropic virus type I infection may act synergistically, resulting in serious damage to cell-mediated immunity.

METHODS

A total of 517 consecutive patients who were preoperatively screened for anti-human T lymphotropic virus type I antibody and underwent cardiovascular operations with cardiopulmonary bypass were enrolled in this study. Of the 517 patients, 82 (16%) had positive test results for anti-human T lymphotropic virus type I antibody. The surgical outcome of patients with positive and negative results for anti-human T lymphotropic virus type I antibody was analyzed retrospectively.

RESULTS

There was no difference between the 2 groups with respect to early mortality. Distribution of survival curve was also not significantly different (P =.5; mean follow-up duration, 2.4 +/- 1.8 years [range, 0-9.4 years] and 3.2 +/- 2.8 years [range, 0-9.8 years]) in the groups with positive and negative antibody results, respectively). In particular, long-term follow-up did not reveal adult T-cell leukemia or human T lymphotropic virus type I-associated myelopathy, and occurrence of neoplasm did not differ between groups. Early infectious complication was, however, significantly higher in the group with positive antibody results than in the group with negative results (P =.02). Logistic regression analysis revealed human T lymphotropic virus type I infection as a significant risk for this complication (P =.04; odds ratio, 2.5; 95% confidence interval, 1. 0-5.8).

CONCLUSION

A combination of human T lymphotropic virus type I infection and cardiovascular operation is believed to increase the potential risk of infectious complications shortly after the operation. However, this synergistic effect seems to be transient and has little influence on long-term prognosis.

Organ malperfusion in acute aortic dissection

OBJECTIVE

Organ malperfusion in aortic dissection can precipitate a serious condition. The strategy of treatment for it has been controversial. We have focused on the strategy and outcome of acute aortic dissection with organ malperfusion.

SUBJECTS AND METHODS

Between January 1995 and December 1998, 134 acute aortic dissection patients were admitted. There were 73 males (65.4 +/- 8.0 years old) and 61 females (66.7 +/- 7.4 years old). There were 83 patients of Stanford type A, and 51 patients of type B. Of them, 24 patients (17.9%) were complicated by organ malperfusion. The brain was affected in 4, the heart in 5, the spinal cord in 2, the liver in 1, the intestine in 1, the kidney in 4, and the lower extremities in 10 patients. Our management strategy for a patient with malperfusion in acute aortic dissection was that the antecedent operation was initially mandatory, and central grafting was secondarily considered.

RESULTS

Refusal of operation or lethal conditions excluded 8 of the 24 patients from operation. An antecedent operation was mandatory in eight of the remaining 16 patients. The overall mortality was 33.3% (8/24 patients), and operative mortality was 31.3% (5/16 patients) in the patients with malperfusion. The overall mortality was 11.8% (13/110 patients), and the operative mortality was 11.1% (9/81 patients) in the patients without malperfusion.

CONCLUSION

Organ malperfusion is a major component in the management and treatment of acute aortic dissection. Only an appropriate strategy and therapy could result in a satisfactory outcome.

Lysophosphatidic acid (LPA) receptors of the EDG family are differentially activated by LPA species. Structure-activity relationship of cloned LPA receptors

We examined the structure-activity relationship of cloned lysophosphatidic acid (LPA) receptors (endothelial cell differentiation gene (EDG) 2, EDG4, and EDG7) by measuring [Ca(2+)](i) in Sf9 insect cells expressing each receptor using LPA with various acyl chains bound at either the sn-1 or the sn-2 position of the glycerol backbone. For EDG7 the highest reactivity was observed with LPA with Delta9-unsaturated fatty acid (oleic (18:1), linoleic (18:2), and linolenic (18:3)) at sn-2 followed by 2-palmitoleoyl (16:1) and 2-arachidonoyl (20:4) LPA. In contrast, EDG2 and EDG4 showed broad ligand specificities, although EDG2 and EDG4 discriminated between 14:0 (myristoyl) and 16:0 (palmitoyl), and 12:0 (lauroyl) and 14:0 LPAs, respectively. EDG7 recognizes the cis double bond at the Delta9 position of octadecanoyl residues, since 2-elaidoyl (18:1, trans) and 2-petroselinoyl (18:1, cis-Delta12) LPA were poor ligands for EDG7. In conclusion, the present study demonstrates that each LPA receptor can be activated differentially by the LPA species.

The management of patients with dissection of the descending thoracic aorta: a comparison between closing and nonclosing dissections

This study was designed to clarify and compare the clinical characteristics and prognoses of patients with closing and nonclosing dissection of the descending thoracic aorta. Between January 1991 and December 1994, 19 patients with closing dissection (Group A) and 20 with nonclosing dissection (Group B) underwent surgical repair or medical treatment at our institution. There were 29 men and 10 women, aged between 37 and 74 years, with a mean age of 62 years. There was a significant difference in age between the two groups, being 67 +/- 7 and 58 +/- 12 years for Groups A and B, respectively (P = 0.009). The presence of a concurrent abdominal aortic aneurysm was confirmed in 32% and 10% of Groups A and B, respectively (P = 0.095). A total of 15 patients experienced a variety of complications related to the dissection, but there were no significant differences in the morbidity rate between the two groups. Visceral ischemic disorders such as renal failure, leg ischemia, and ileus were the most common complications. The overall survival rate 4 years after the development of dissection was 80%, with no significant difference between the two groups. These findings led to the establishment of our policy to place all patients with dissection of the descending thoracic aorta on careful antihypertensive therapy and frequent follow-up imaging studies to assess the aorta, regardless of the condition of the false lumen.

Surgical repair of a solitary deep femoral arterial aneurysm: report of two cases

We report herein two cases of a solitary deep femoral arterial aneurysm that were successfully treated by aneurysmectomy and ligation of the deep femoral artery. The patients were a 69-year-old man and a 73-year-old man, both of whom presented with localized pain and a pulsatile mass in the femoral area showing rapid enlargement. Ultrasonography and arteriography confirmed the diagnosis and revealed no evidence of aneurysm or occlusive disease in the other arteries. Aneurysmectomy and ligation of the deep femoral artery were performed, and no ischemic symptoms or thrombus developed postoperatively in either patient. Preoperative arteriography is essential to delineate not only the state of the aneurysm, but also that of the distal arterial tree. An emergency operation is also mandatory due to the rapid enlargement of this type of aneurysm, even if rupture occurs.

Involvement of the right atrium by malignant lymphoma as a cause of right cardiac failure: report of a case

We describe herein a rare case of malignant lymphoma occupying almost the entire space of the right atrial cavity and causing low cardiac output syndrome. A life-saving emergency operation was carried out after the establishment of a temporary bypass between the axillary and femoral veins to prevent exacerbation of the patient's condition during the induction of anesthesia. Cardiopulmonary bypass was commenced and the right atrium was opened. A large tumor in the right atrium could not be completely removed due to invasion of the atrial wall. A bypass from the left innominate vein to the pulmonary arterial trunk was constructed with a prosthetic graft to convert the blood flow directly from the systemic vein to the pulmonary artery. Postoperative radiation treatment was given, which resulted in reducing the size of the tumor considerably, and the patient is doing well 1 year after his operation.

Intrathecally administered spermine produces the scratching, biting and licking behaviour in mice

Intrathecal (i.t.) administration of spermine (0.1-10000 fmol), an endogenous polyamine, produced the behavioural response mainly consisting of biting and/or licking of the hindpaw along with a slight hindlimb scratching directed toward the flank in mice, which peaked at 5-15 min and almost disappeared at 30 min after an injection. The behaviour induced by spermine (10 pmol) was dose-dependently inhibited by intraperitoneal injection of morphine (0.125-0.5 mg/kg). The characteristic behaviour was also inhibited dose-dependently by i.t. co-administration of ifenprodil (62.5-4000 pmol), a competitive antagonist of the polyamine recognition site on N-methyl-D-aspartate (NMDA) receptor ion-channel complex, and D(-)-2-amino-5-phosphonovaleric acid (D-APV) (0.5-2 nmol) and 3-((+/-)-2-carboxypiperazin-4-yl)-propyl-1-phosphonic acid (CPP) (7. 8-500 pmol), the competitive NMDA receptor antagonists, and (5R, 10S)-(+)-5-methyl-10,11-dihydro-5H-dibenzo[a,b]cycloheptene-5, 10-imine hydrogen maleate (MK-801) (0.5-4 nmol), an NMDA ion-channel blocker, but not by 6-cyano-7-nitroquinoxaline-2,3-dione (CNQX), a non-NMDA receptor antagonist. Both (2S, 3S)-[cis-2-(diphenylmethyl)-N-[(2-methoxyphenyl)-methyl]-1-azabicy clo [2.2.2]octane-3-amine] (CP-96,345), a non-peptidic neurokinin-1 (NK-1) receptor antagonist, and CP-96,344, its inactive 2R,3R enantiomer, inhibited spermine-induced behavioural response in a dose-dependent manner. However, [Tyr(6), D-Phe(7), D-His(9)]-substance P(6-11) (sendide) and [D-Phe(7), D-His(9)]-substance P(6-11), the selective antagonists for NK-1 receptors, were without affecting spermine-induced behaviour. These results indicate that spermine-induced behaviour is mediated through the polyamine recognition site on NMDA receptor ion-channel complex without the involvement of substance P system in the mouse spinal cord.

[Simultaneous operation for lung tumor and cardiovascular disease]

Successful simultaneous operation for lung tumor and cardiovascular disease was performed in three cases. A 76-year-old man with stage I lung cancer and ischemic heart disease underwent a partial lobectomy following single coronary artery bypass grafting through a median sternotomy. A 62-year-old man with stage I suspected lung cancer and thoracic aortic aneurysm underwent a partial segmentectomy before aneurysmectomy and patch closure using vascular prosthesis through a left posterolateral thoracotomy. These two cases were performed under extracorporeal circulation. A 69-year-old man with bronchogenic carcinoma and abdominal aortic aneurysm underwent a left upper lobectomy with standard lympho node dissection following aneurysmectomy and grafting using vascular prosthesis. As a simultaneous procedure, limited operation for lung tumor, especially for stage I non-small cell lung cancer, is acceptable for cases in using extracorporeal circulation. On the other hand, except emergency ruptured cases of abdominal aortic aneurysm, standard radical operation for lung cancer as a simultaneous procedure is preferred for cases such as lung cancer accompanied with abdominal aortic aneurysm without extracorporeal circulation.

Watershed infarction after combined coronary and axillobifemoral bypass surgery

Watershed infarction sometimes causes a neurological disorder due to hypoperfusion of the brain during cardiac surgery. Here we report a case in which watershed infarction developed after combined coronary artery bypass and axillobifemoral bypass surgery.

Multiple duodeno-jejunal diverticula causing massive intestinal bleeding

A case of massive intestinal blood loss from multiple duodeno-jejunal diverticula is described. A 39-year-old man was referred to our hospital because of recurrent bloody stool and worsening anemia. Upper and lower endoscopy, selective abdominal angiography, and radionuclide scanning were performed to seek the cause of the intestinal bleeding, but none of these studies revealed the source of bleeding. Small-bowel barium follow-through examination showed numerous diverticula in the distal duodenum and proximal jejunum. Excision of the duodenal diverticulum and resection of the involved portion of the jejunum cured the patient. On histopathological examination, an ulcerative lesion with an exposed vessel suggestive of the source of bleeding was seen in the resected duodenal diverticulum. Although duodeno-jejunal diverticula are rare, the importance of a careful search for this malformation in a patient with intestinal blood loss is stressed.

Papillary fibroelastoma on the mitral valve

A 78-year-old woman was admitted with transient unknown fever and old cerebral infarction. An echocardiogram demonstrated mild mitral valve regurgitation and high echogenic mass on the mitral posterior leaflet. Surgery was performed with the diagnosis of a healed infective endocarditis. A sea anemone-like appearance tumor, 8 mm in diameter, was located on the mitral posterior leaflet. Annuloplasty was performed following removal of the tumor. A pathological examination confirmed the lesion was a papillary fibroelastoma. No evidence of infective endocarditis was seen. The cause of the fever remained unknown. The tumor was very fragile. Surgical removal was mandatory for preventing embolism despite the advanced age.

Effects of sarpogrelate hydrochloride on platelet aggregation, and its relation to the release of serotonin and P-selectin

Inhibitory effects of sarpogrelate hydrochloride (sarpogrelate), a 5-HT2 receptor antagonist, on platelet aggregation was examined as well as the relationship to serotonin and P-selectin, a platelet alpha-granule membrane glycoprotein. Platelet aggregation was induced by simultaneous addition of collagen (0.06-0.12 microg/ml), which did not induce aggregation alone, and serotonin (0.88 micromol/1) to platelet-rich plasma (PRP). The PRP was obtained from healthy volunteers and percentage maximum aggregation (MA) was measured. Serotonin levels and P-selectin levels in the supernatant of PRP after aggregation were determined. When vehicle-treated PRP was stimulated in the aforementioned manner, platelet aggregation dependent on collagen concentration was induced. Serotonin levels and P-selectin levels were also dependent on collagen concentration. Sarpogrelate (10(-6) to 10(-4) mol/l) inhibited such aggregation dose-dependently, and decreased serotonin levels and P-selectin levels in a dose-dependent manner. There were close correlations between MA and serotonin levels, MA and P-selectin levels, as well as serotonin and P-selectin levels. These results suggest that extracellular release of serotonin and P-selectin from platelets was caused by induction of aggregation, and these responses were suppressed by sarpogrelate.

Clinical experience of 473 patients with the omnicarbon prosthetic heart valve

BACKGROUND AND AIM OF THE STUDY

The long-term clinical experience of patients receiving Omnicarbon heart valve prostheses between January 1985 and December 1996 was investigated.

METHODS

In total, 473 patients (255 males, 218 females; mean age 57.5 +/- 10.1 years (range: 20n-73 years) received 523 prostheses. These included 253 mitral (MVR), 170 atrial (AVR) and 50 double (DVR) valve replacements.

RESULTS

The 30-day mortality rate was 4.7% (n = 22); in addition eight patients died more than 30 days after surgery, but during the same hospital stay. Mean follow up was 3.9 years (maximum 11 years and 7 months). Cumulative follow up was 1,750.1 patient-years (pt-yr); follow up was 97.5% complete. Among 39 late deaths, 20 were valve-related (seven cerebral infarction, seven cerebral bleeding, six endocarditis) and four cardiac-related. The overall five-year cumulative survival rate (excluding early mortality) was 90.2 +/- 11.7% (MVR 88.0 +/- 2.5%, AVR 93.1 +/- 2.3%, DVR 93.7 +/- 4.8%). At 10 years, the overall survival rate was 76.4 +/- 7.7%. Valve-related complications included thromboembolism (n = 13, 0.7%/pt-yr), anticoagulation-related hemorrhage (n = 12, 0.7%/pt-yr) and endocarditis (n = 7, 0.4%/pt-yr). Neither mechanical failure nor clinical hemolysis was observed. The overall valve-related event-free rate after five years was 89.3 +/- 2.0% (MVR 89.8 +/- 2.4%, AVR 93.5 +/- 2.6%, DVR 89.4 +/- 5.7%) and after 10 years it was 87.6 +/- 2.6% (MVR 85.4 +/- 3.7%, AVR 93.5 +/- 2.6%, DVR 82.5 +/-10.1%).

CONCLUSIONS

These long-term results with the Omnicarbon valve are excellent; especially satisfactory results were achieved in terms of the low rate of thromboembolic complication.

Ultrasonic evaluation of congestive liver after tricuspid annuloplasty

To assess the effect of tricuspid annuloplasty (TAP), the authors measured the size of the liver by using echography in the patients undergoing tricuspid annuloplasty. From April 1989 to August 1996, 18 patients underwent TAP. The authors measured preoperatively and postoperatively the hepatic index (HI) by echography, defined as follows: HI=L x D/BSA (L: the top-to-bottom length of the left hepatic lobe; D: the front-to-back length of the left hepatic lobe; BSA: body surface area). They also calculated the reducing rate (RR) of HI. The mean HI decreased after TAP; preoperative HI: 39.7+/-11.8 vs postoperative HI: 33.8+/-10.5 (p=0.0069). The RR of the patients with postoperatively residual tricuspid regurgitation (TR) over 2 degrees (n=4) was significantly lower than that of the other patients (n=14): -11.0+/-6.0% vs 20.2+/-3.2% (p=0.0003). They conclude that the use of echography to measure the HI is a good method of assessing congestion after TAP.

Influence of preoperative nutritional state on inflammatory response after surgery

To investigate whether the preoperative nutritional state influences the postoperative inflammatory reaction and immunity, we grouped patients whose postoperative nutritional support was performed by total parenteral nutrition into the good nutritional state group (group I) and the latent protein-calorie malnutrition suggested group (group II) based on the preoperative rapid turnover protein (RTP). Nutritional markers markedly decreased after surgery and recovered almost to preoperative levels on postoperative day (POD-) 7 in groups I and II. Nutritional markers on POD-7 in group II were significantly lower than those in group I (RTP, P < 0.001; albumin, P < 0.05). After surgery, levels of interleukin-6 (IL-6), C-reactive protein (CRP), and polymorphonuclear (PMN-) elastase were higher in group II than in group I (P < 0.01). In groups I and II, IL-6 and interleukin-8 (IL-8) rose before the remarkable elevation of CRP and PMN-elastase. In group I, all the nutritional markers showed a negative correlation with CRP and PMN-elastase. Further, a positive correlation was observed between IL-6 and CRP and between IL-8 and PMN-elastase. In conclusion, evaluation of the preoperative nutritional state appears to be very important for the prediction of postoperative complication.

Effectiveness of preoperatively obtained autologous platelet concentrates in open heart surgery

BACKGROUND

Autologous blood components have been widely introduced in open heart surgery. However, the effectiveness of autologous platelet products remains controversial.

METHODS

Autologous platelet concentrates (PC) were collected from patients (n = 35) scheduled for primary valvular heart surgery 1 to 3 days before the operation and were transfused immediately after cardiopulmonary bypass. Blood loss and platelet-related factors were compared with the control patients who had no PC (n=35).

RESULTS

There were no serious complications in harvesting, preservation, and transfusion of autologous PC. The maximal platelet aggregation response significantly improved after its transfusion and tended to be higher with autologous PC stored 1 day than with ones stored 2-3 days. Activation of coagulation and fibrinolytic factors did not significantly differ between the groups. Postoperative blood loss was significantly less in autologous PC group, and seemed to have a negative correlation with platelet aggregation response.

CONCLUSIONS

Autologous PC can be safely prepared and are clinically effective in reduction of postoperative blood loss in open heart surgery.

Application of a manifold system for temporary reperfusion during proximal anastomoses in conventional coronary bypass surgery

We report the application of a manifold system which is attached to saphenous vein grafts after the completion of distal coronary anastomosis. This technique permits not only the direct delivery of cardioplegic solution into the distal coronary artery, but also the reperfusion of revascularized coronary arteries via saphenous vein grafts by changing the connection to the arterial circuit during proximal anastomosis under a partial occlusion of the aorta in conventional coronary artery bypass surgery.

Inhibitory effects of H2-receptor antagonists on platelet function in vitro

To evaluate in vitro inhibitory effects of four types of histamine H2-receptor antagonist (H2-receptor antagonists), famotidine, roxatidine, cimetidine and ranitidine, on platelet function, we examined aggregating potency and P-selectin levels with agonist-induced aggregation. Ranitidine and cimetidine inhibited, in concentration of 0.35 mM, the secondary aggregation induced by 5 microM adenosine diphosphate (ADP), the aggregation induced by 1 microg/mL collagen and 3 microM arachidonic acid. All of H2-receptor antagonists inhibited, in concentration of 1.4 mM, the aggregation induced by ADP, collagen and arachidonic acid. Ranitidine and cimetidine reduced markedly, in same concentration, P-selectin levels after induction of aggregation by 5 microm ADP, 1 microg/mL collagen and 3 microM arachidonic acid. When classified by the strength of inhibitory action, ranitidine and cimetidine were strong, followed by famotidine and roxatidine. It is considered that inhibitory effects of H2-receptor antagonists on platelet function are weaker than those of acetylsalicylic acid (ASA), since ASA inhibited platelet aggregation in concentration of 100 microM. No relationship was observed between inhibitory effects of H2-receptor antagonists on platelet aggregation induced by above agonists and the presence or absence of imidazole ring in the chemical structure.

Coronary artery aneurysm after stent implantation

A coronary artery aneurysm that developed 6 months after coronary stent implantation in the left anterior descending artery, was treated by double coronary artery bypass grafting due to restenosis of the affected vessel and progression of right coronary artery stenosis. Although the poststenting aneurysm initially remained postoperative angiography showed that it had disappeared. In addition to thrombotic occlusion, another mechanism behind its disappearance may be that geometric changes of the implanted stent caused by heart retraction during surgery closed the entrance to the aneurysm.

Myxoma of mitral valve associated with infective endocarditis

A 20-year-old man was hospitalized for persistent fever, embolism, and syncopal attack. Echocardiography demonstrated a tumor on the mitral posterior leaflet. It was removed under extracorporeal circulation following extirpation of thrombus in the right common like artery. The tumor consisted of myxoma and vegetation with bacterial colony. Myxoma and/or vegetation had destroyed the mitral posterior leaflet. Accordingly, it was necessary to perform mitral valve replacement. The postoperative course was uneventful. This is the 14th surgical case of mitral valve myxoma, and the first case of that associated with infective endocarditis.

Repair of an acute type A dissection: fate of the remnant false lumen and preserved aortic valve

From January 1992 through March 1997, 75 patients (DeBakey type I/II = 56/19) underwent a surgical repair of a type A acute dissection. The patients included 37 men and 38 women ranging in age from 23 to 83 years with a mean of 65 years. All patients were admitted to our hospital with a mean interval of 2.2 days from the episode of onset. The overall hospital mortality rate was 25% (19/75). There were three late deaths among the 56 patients discharged from the hospital. The actuarial survival rate for the patients surviving the operation was 87% at 5 years after repair. A subsequent aortic operation was necessary in 6 patients, while 3 other patients who had late aortic complications were put on medical therapy alone. As a result, the aortic event-free survival rate was 54% at 5 years. For a type I dissection the false lumen was completely thrombosed after repair in 34%. The descending thoracic aorta with a patent false lumen was markedly enlarged in proportion to the follow-up time. After a conservative approach to the aortic valve, all but one patient demonstrated an adequate valve function throughout this study period. This experience with a midterm follow-up showed an acceptable durability of the preserved aortic valve and a progressive enlargement of the persistent false lumen with a high rate of aortic complications. Hence, all patients with a type A dissection need a close follow-up to assess the aorta for complications of either recurrent or residual aneurysms and dissections.

Experimental His-bundle pacing: histopathological and electrophysiological examination

His-bundle pacing gives a more physiological ventricular contraction in comparison to right ventricular apical pacing. However the problems of lead fixation and stability of long-term His-bundle pacing are yet unsolved. We used six adult beagles, in which a screw-in lead was anchored in the His-bundle region for observation of the pacing conditions and histopathologic changes of the conduction system over the course of 2 months. In the results, a satisfactory fixation was obtained using a conventional screw-in lead and no histological influence on the conduction system was observed. The pacing threshold at the time of implantation was 1.15 +/- 0.69 V (3.23 +/- 3.08 mA) in the pulse width of 0.5 ms. R wave amplitude, the impedance and slew rate were 7.28 +/- 2.04 mV, 409 +/- 102 Ohm, and 0.65 +/- 0.41 V/s, respectively. Two months later, these parameters changed to 2.83 +/- 1.06 V (10.4 +/- 5.71 mA), 5.63 +/- 1.62 mV, 310 +/- 71.3 Ohm, and 0.49 +/- 0.22 V/s, respectively. These results suggest the feasibility of clinical application of permanent His-bundle pacing.

Is direct closure dangerous for treatment of doubly committed subarterial ventricular septal defect?

BACKGROUND

We performed direct closure of doubly committed subarterial ventricular septal defects with aortic cusp prolapse. Postoperative echocardiographic studies showed that this method improved coaptation of the prolapsing aortic cusp, especially in patients with mild aortic regurgitation (AR).

METHODS

Twenty-one patients (mean age, 7.8+/-4.3 years; range, 2 to 18 years) with doubly committed subarterial ventricular septal defect underwent direct closure alone. Aortic valve prolapse was observed in all 21 patients, with mild AR found in 13 patients but not in the remaining 8. The site of the prolapsed aortic valve was in the right coronary cusp in all patients. We inserted an interrupted 4-0 or 5-0 polypropylene suture with a pledget from the lower margin of the ventricular septal defect to the pulmonary ring to increase protrusion of the prolapsed cusp by pushing it back and to improve coaptation of the aortic cusp.

RESULTS

The interval between surgical treatment and the last postoperative evaluation ranged from 3 to 24 months (median, 11 months). No residual ventricular septal defect was detected in any patient. In the 8 patients who had aortic valve prolapse without AR preoperatively, no AR was found at follow-up. Of the 13 patients who had mild AR associated with aortic valve prolapse preoperatively, AR diminished in 7 and did not progress in the remaining 6. Furthermore, no anatomic changes in either the aortic or pulmonary annulus were found on follow-up echocardiography. In the group of 13 patients with mild preoperative AR, AR significantly persisted in patients who were more than 10 years old at operation (p<0.05).

CONCLUSIONS

Our findings suggest that direct closure for this type of ventricular septal defect is safe and reliable in improving mild AR and that direct closure is more effective for younger patients in whom the prolapsing aortic cusp is mobile enough to be protruded. However, further long-term follow-up studies will be needed to ascertain the adequacy and usefulness of the method.

A long-term surviving patient with cancer of papilla of Vater after local resection

We report successful local resection for cancer of papilla of Vater in an 86-year-old woman. She was referred to our hospital because of right hypochondralgia. Abdominal ultrasonography and computed tomography showed marked dilatation of the common bile duct (CBD). Endoscopic retrograde cholangiography disclosed a small shadow defect in the terminal of the dilated CBD. Biopsy of the papilla revealed well-to-moderately differentiated adenocarcinoma. Considering her extreme old age and keeping in mind her quality of life after the operation, and the finding that the tumor was localized within the papilla and highly differentiated, we performed local resection. In addition, the intrapancreatic portion of the CBD and part of the main pancreatic duct (MPD) were further resected to secure a negative margin, confirmed by frozen section. The MPD was reapproximated to the duodenal mucosa and a choledocho-duodenostomy was performed for CBD reconstruction. Histopathological examination showed the tumor was papillary adenocarcinoma, 10 x 15 mm in size; there was no invasion beyond the sphincter of Oddi, it had partly infiltrated the CBD, but had not invaded to the pancreas or duodenum. The patient's postoperative course was not eventful and she has had good quality of life for the past 6 years since the operation, without any evidence of recurrence. Although radical pancreaticoduodenectomy is now the standard procedure in patients with malignant tumor of the papilla of Vater, local resection is a reasonable alternative for high-risk patients with highly differentiated, apparently localized carcinomas.

Allograft rejection of small bowel transplantation in pigs

Small bowel allograft rejection in large animals has yet to be well defined. There are no specific early signs of graft rejection. The present experiments were undertaken to compare acute small bowel allograft rejection in pigs with and without FK506 and also to examine the usefulness of mucosal biopsies. Thirty-six outbred Large-White pigs were divided into (1) group 1 (n = 9): nonimmunosuppressed recipients; (2) group 2 (n = 8): FK506-immunosuppressed recipients; (3) group 3 (n = 2): autotransplant controls; and (4) donors (n = 17). Orthotopic small bowel transplantations were performed with Thiry-Vella loops for daily biopsies. The survival rate of group 2 was significantly longer than that of group 1 (P < 0.05). One best survivor in group 2 was killed at postoperative day (POD) 365. Treatment by FK506 prevented rejection, but most of the pigs died of pneumonia. In group 1, rejection began on POD 3 and progressed to severe rejection rapidly within 7 days. In group 2, rejection began from POD 6 to POD 8, but either remained mild or spontaneously improved. The differences in the routine laboratory data and the tumor necrosis factor-alpha level were not evident between the groups. Histological studies of repeated graft biopsies are thus considered to be essential for detecting signs of graft rejection.

[Two cases of mitral restenosis occurring eight years after percutaneous balloon mitral commissurotomy (PTMC)]

A 63-year-old man and a 49-year-old man who underwent PTMC eight years before were admitted in our hospital because of regurgitation and restenosis of the mitral valve. Both of them had ulcer like lesion on the anterior leaflet near the commissure of the mitral valve. These changes were made by PTMC and likely caused thrombosis. Long-term follow up data of PTMC is essential to chose the correct operative method for treating mitral stenosis.