A case of severe hemorrhagic shock caused by traumatic avulsion of uterine fibroid

Case presentation

A 40-year-old woman was injured in a motor vehicle accident. Physician-staffed helicopter emergency medical service (HEMS) was dispatched, and after the HEMS physician performed thoracostomy and tracheal intubation to relieve the tension pneumothorax and hemorrhagic shock, her carotid artery became unpalpable. The physician then decided to perform prehospital resuscitative thoracotomy. Immediately after arriving at the hospital, an emergency laparotomy was performed. Intraoperative findings showed that a huge uterine fibroid had been avulsed from the uterine wall, and we performed temporary hemostasis by extraction of the avulsed tumor and application of packing to the pelvic cavity. She was transferred to a rehabilitation hospital 42 days after the operation.

Conclusion

The injury mechanism in this case was considered a “submarine effect.” This was an extremely rare case in which the acute care surgeon and a gynecologist collaboratively employed a damage control strategy to deal with impending cardiac arrest.

Emergent surgery for cardiac herniation coexisting with complex blunt cardiac injury: A case report

A 38-year-old man was pressed on his trunk by a heavy object weighing about 100 kg. The patient was in shock status on arrival to the hospital. Circular collapse progressed rapidly during contrast computed tomography (CT) scanning. CT images revealed exacerbation of the right lateral deviation of the heart that was earlier seen on X-ray imaging. Considering cardiac herniation based on CT findings, we immediately performed resuscitative thoracotomy and clamshell thoracotomy at the emergency department. Intraoperative findings showed a pericardial defect, and the heart had deviated to the right thoracic cavity. Immediate repositioning revealed a marked improvement in circulation. Full-thickness cardiac injury was observed in the anterior wall of the left ventricle; no active bleeding was observed. We performed temporary thoracic wall closure after cardiorraphy for damage control. After admission to the intensive care unit, he presented with respiratory failure associated with pulmonary contusion. Therefore, veno-venous extracorporeal membrane oxygenation (V-V ECMO) was used from the 2nd to the 5th hospital day. After confirming no intra-thoracic events on the 6th hospital day, chest wall closure was performed. The patient subsequently developed heart failure and mitral regurgitation associated with papillary muscle rupture. On the 62nd hospital day, he underwent mitral annuloplasty at the cardiovascular surgery division; After rehabilitation till 152nd hospital day, he was discharged without any neurological abnormality. This was an extremely rare case with concomitant full-thickness myocardial injury, intracardiac injury, and cardiac herniation. Rapid resuscitative thoracotomy and damage control including V-V ECMO yielded good results. Retrospectively, cardiac herniation should have been suspected earlier basis this observation. Our report highlights that cardiac herniation should be considered in case of cardiac shadow aberrations in cases of blunt chest trauma, familiarity with condition and its characteristic imaging findings are critical for the doctor overseeing initial trauma treatment.

Planned Versus On-Demand Relaparotomy Strategy in Initial Surgery for Non-occlusive Mesenteric Ischemia

BACKGROUND

There has been insufficient evidence regarding a treatment strategy for patients with non-occlusive mesenteric ischemia (NOMI) due to the lack of large-scale studies. We aimed to evaluate the clinical benefit of strategic planned relaparotomy in patients with NOMI using detailed perioperative information.

METHODS

We conducted a multicenter retrospective cohort study that included NOMI patients who underwent laparotomy. In-hospital mortality, 28-day mortality, incidence of total adverse events, ventilator-free days, and intensive care unit (ICU)-free days were compared between groups experiencing the planned and on-demand relaparotomy strategies. Analyses were performed using a multivariate mixed effects model and a propensity score matching model after adjusting for pre-operative, intra-operative, and hospital-related confounders.

RESULTS

A total of 181 patients from 17 hospitals were included, of whom 107 (59.1%) were treated using the planned relaparotomy strategy. The multivariate mixed effects regression model indicated no significant differences for in-hospital mortality (61 patients [57.0%] in the planned relaparotomy group vs. 28 patients [37.8%] in the on-demand relaparotomy group; adjusted odds ratio [95% confidence interval] = 1.94 [0.78-4.80]), as well as in 28-day mortality, adverse events, and ICU-free days. Significant reduction in ventilator-free days was observed in the planned relaparotomy group. Propensity score matching analysis of 61 matched pairs with comparable patient severity did not show superiority of the planned relaparotomy strategy.

CONCLUSIONS

The planned relaparotomy strategy, compared with on-demand relaparotomy strategy, did not show clinical benefits after the initial surgery of patients with NOMI. Further studies estimating potential subpopulations who may benefit from this strategy are required.

Advanced cadaver-based educational seminar for trauma surgery using saturated salt solution-embalmed cadavers

Aim

Senior surgeons in Japan who participated in "cadaver-based educational seminar for trauma surgery (CESTS)" subsequently stated their interest in seminars for more difficult procedures. Therefore, we held a 1-day advanced-CESTS with saturated salt solution (SSS)-embalmed cadavers and assessed its effectiveness for surgical skills training (SST).

Methods

Data were collected from three seminars carried out from September 2015 to January 2018, including a 10-point self-assessment of confidence levels (SACL) questionnaire on nine advanced surgical skills, and evaluation of seminar content before, just after, and half a year after the seminar. Participants assessed the suitability of the two embalming methods (formalin solution [FAS] and SSS) for SST, just after the seminar. Statistical analysis resulted in P < 0.0167 comparing SACL results from seminar evaluations at the three time points and P < 0.05 comparing FAS to SSS.

Results

Forty-three participants carried out surgical procedures of the lung, liver, abdominal aorta, and pelvis and extremity. The SACL scores increased in all skills between before and just after the seminar, but were decreased by half a year after. However, SACL scores of each skill did not change significantly, except for external fixation for pelvic fracture at just after and half a year after. The SSS-embalmed cadavers were evaluated as being more suitable than FAS-embalmed cadavers for each procedure.

Conclusions

Advanced-CESTS using SSS-embalmed cadavers increased the participants' self-confidence just after the seminar, which was maintained after half a year in each skill, except external fixation for pelvic fracture. Therefore, SSS-embalmed cadavers are useful for SST, particularly for surgical repairs.

Delayed Expression of Circulating TGF-β1 and BMP-2 Levels in Human Nonunion Long Bone Fracture Healing

BACKGROUND

The healing process of bone fracture requires a well-controlled multistage and sequential order beginning immediately after the injury. However, complications leading to nonunion exist, creating serious problems and costs for patients. Transforming growth factor-beta 1 (TGF-β1) and bone morphogenic protein 2 (BMP-2) are two major growth factors involved in human bone fracture healing by promoting various stages of bone ossification. In this study, we aimed to determine the role of these factors during the fracture healing of human long bones and assess their impacts on nonunion condition.

MATERIALS AND METHODS

We performed a comprehensive analysis of plasma TGF-β1 and BMP-2 levels in blood samples from 10 patients with proved nonunion and 10 matched patients with normal union following a predetermined time schedule. The concentrations of TGF-β1 and BMP-2 were measured at each time point using a solid-phase ELISA.

RESULTS

TGF-β1 and BMP-2 levels were detectable in all patients. For all patients, a maximal peak for TGF-β1 was found at 3-week. In normal union group, TGF-β1 showed a maximal peak at 2-week while nonunion group had a delayed maximal peak at 3-week. Plasma levels of BMP-2 for all patients and for normal union group reached a maximal peak at 1-week, but nonunion group showed a delayed maximal peak at 2-week. In general, plasma TGF-β1 or BMP-2 level was not significantly different between normal union and nonunion groups.

CONCLUSION

The expression levels of TGF-β1 and BMP-2 appeared to be delayed in nonunion patients which could play an important role in developing an early marker of fracture union condition and facilitate improved patient's management.

The Pedicled Omental Flap Technique for Treating Extensive Defects or Soft-Tissue Infection of the Pelvic Area: A Report of 2 Cases

Severe trauma injuries, such as open pelvic fractures and degloving injuries, have recently become salvageable. However, extensive soft-tissue defects often remain and can lead to disuse atrophy of the extremities, prolonged hospital stays, and numerous other problems. Such injuries can be easily and effectively treated by a general trauma surgeon performing the pedicled omental flap technique. We report on 2 highly diverse and complicated cases of soft-tissue defect that were both successfully treated with this technique. One case was an extensive right-sided defect of the pelvic soft-tissue in a 20-year-old woman. The other case was in a 55-year-old man who underwent emergency artificial vessel replacement surgery for a femoral artery tear with severe damage to the surrounding muscle. Although the surgery was successful, a methicillin-resistant Staphylococcus aureus infection developed around the artificial vessel 10 days after surgery. In both cases, the pedicled omental flap technique was successfully performed and yielded epithelization without serious infection and with the infection subsiding with wound-area healing. To our knowledge, the pedicled omental flap technique has rarely been used to treat severe trauma, and our results suggest its usefulness for both preventing infection in large wounds and healing infected wounds.

Impact of urgent resuscitative surgery for life-threatening torso trauma

Purpose

This study investigated the advantages of performing urgent resuscitative surgery (URS) in the emergency department (ED); namely, our URS policy, to avoid a delay in hemorrhage control for patients with severe torso trauma and unstable vital signs.

Methods

We divided 264 eligible cases into a URS group (n = 97) and a non-URS group (n = 167) to compare, retrospectively, the observed survival rate with the predicted survival using the Trauma and Injury Severity Score (TRISS).

Results

While the revised trauma score and the injury severity score were significantly lower in the URS group than in the non-URS group, the observed survival rate was significantly higher than the predicted rate in the URS (48.5 vs. 40.2%; p = 0.038). URS group patients with a systolic blood pressure (SBP) <90 mmHg and a Glasgow coma scale (GCS) score of ≥9 had significantly higher observed survival rates than predicted survival rates (0.433 vs. 0.309, p = 0.008), (0.795 vs. 0.681, p = 0.004). The implementation of damage control surgery (DCS) was found to be a significant predictor of survival (OR 5.23, 95% CI 0.113–0.526, p < 0.010).

Conclusion

The best indications for the URS policy are an SBP <90 mmHg, a GCS ≥9 on ED arrival, and/or the need for DCS. By implementing our URS policy, satisfactory survival of patients requiring immediate hemostatic surgery was achieved.

Effectiveness of cadaver-based educational seminar for trauma surgery: skills retention after half-year follow-up

Aim

In Japan, trauma surgery training remains insufficient, and on-the-job training has become increasingly difficult because of the decreasing number of severe trauma patients and the development of non-operative management. Therefore, we assessed whether a 1-day cadaver-based seminar is effective for trauma surgery training.

Methods

Data were collected from 11 seminars carried out from January 2013 to March 2014, including a 10-point self-assessment of confidence levels (SACL) for 21 surgical skills and an evaluation of the contents before, just after, and a half-year after the seminar. Statistical analysis was undertaken using the paired t-test at P < 0.0167.

Results

A total of 135 participants were divided into three groups based on experience and clinical careers. The SACL improved in all skills between before and just after the seminar, however, they decreased between just after and a half-year after the seminar. The SACL did not change significantly in all skills between just after and a half-year after the seminar in highly experienced and experienced group members belonging to an emergency center.

Conclusions

A cadaver-based seminar provided more self-confidence just after the seminar for participants at all experience levels. This effect was not maintained after a half-year, except in participants who can practice the skills at an emergency center. Practicing and participating in the seminar repeatedly is suggested to be effective for skills retention in trauma surgery.

Dispatch of Helicopter Emergency Medical Services Via Advanced Automatic Collision Notification

BACKGROUND

Advanced automatic collision notification (AACN) is a system for predicting occupant injury from collision information. If the helicopter emergency medical services (HEMS) physician can be alerted by AACN, it may be possible to reduce the time to patient contact.

OBJECTIVE

The purpose of this study was to validate the feasibility of early HEMS dispatch via AACN.

METHODS

A full-scale validation study was conducted. A car equipped with AACN was made to collide with a wall. Immediately after the collision, the HEMS was alerted directly by the operation center, which received the information from AACN. Elapsed times were recorded and compared with those inferred from the normal, real-world HEMS emergency request process.

RESULTS

AACN information was sent to the operation center only 7 s after the collision; the HEMS was dispatched after 3 min. The helicopter landed at the temporary helipad 18 min later. Finally, medical intervention was started 21 min after the collision. Without AACN, it was estimated that the HEMS would be requested 14 min after the collision by fire department personnel. The start of treatment was estimated to be at 32 min, which was 11 min later than that associated with the use of AACN.

CONCLUSIONS

The dispatch of the HEMS using the AACN can shorten the start time of treatment for patients in motor vehicle collisions. This study demonstrated that it is feasible to automatically alert and activate the HEMS via AACN.

Saturated salt solution method: a useful cadaver embalming for surgical skills training

This article evaluates the suitability of cadavers embalmed by the saturated salt solution (SSS) method for surgical skills training (SST). SST courses using cadavers have been performed to advance a surgeon's techniques without any risk to patients. One important factor for improving SST is the suitability of specimens, which depends on the embalming method. In addition, the infectious risk and cost involved in using cadavers are problems that need to be solved. Six cadavers were embalmed by 3 methods: formalin solution, Thiel solution (TS), and SSS methods. Bacterial and fungal culture tests and measurement of ranges of motion were conducted for each cadaver. Fourteen surgeons evaluated the 3 embalming methods and 9 SST instructors (7 trauma surgeons and 2 orthopedists) operated the cadavers by 21 procedures. In addition, ultrasonography, central venous catheterization, and incision with cauterization followed by autosuture stapling were performed in some cadavers. The SSS method had a sufficient antibiotic effect and produced cadavers with flexible joints and a high tissue quality suitable for SST. The surgeons evaluated the cadavers embalmed by the SSS method to be highly equal to those embalmed by the TS method. Ultrasound images were clear in the cadavers embalmed by both the methods. Central venous catheterization could be performed in a cadaver embalmed by the SSS method and then be affirmed by x-ray. Lungs and intestines could be incised with cauterization and autosuture stapling in the cadavers embalmed by TS and SSS methods. Cadavers embalmed by the SSS method are sufficiently useful for SST. This method is simple, carries a low infectious risk, and is relatively of low cost, enabling a wider use of cadavers for SST.

[Reoperation due to failure of a Freestyle bioprosthesis]

We report re-do aortic valve and ascending aorta replacements by using the valve-on-valve technique for primary tissue failure of a Freestyle bioprosthesis. A 74-year-old male, who had had a 25 mm Freestyle bioprosthetic valve implanted by the sub-coronary method 5 years previously for aortic valve regurgitation due to congenital bicuspid valve, was referred to our hospital for dyspnea and palpitation. He presented with heart failure secondary to aortic regurgitation due to primary tissue failure, and computed tomography demonstrated an enlarged ascending aorta (5 cm in diameter). The operative findings revealed that the Freestyle bioprosthetic valve had a leaflet tear at the left coronary cusp. We replaced the degenerated Freestyle bioprosthesis with a 19 mm Mosaic aortic bioprosthesis by using the valve-on-valve technique, and ascending aorta replacement was performed simultaneously. This technique can be useful for re-do surgery for degenerated stentless valves to avoid potential risks of complete excision of the bioprosthesis.

[Multiple acute aortic dissection; report of a case]

A 60-year-old woman has been followed under the diagnosis of De Bakey type Illb acute aortic dissection. She developed sudden backache, and the diagnosis based on the emergent computed tomography (CT) was De Bakey type I dissection. At the operation, previous De Bakey type Illb dissection was far from the new dissection observed in the ascending aorta and arch aorta. We replaced the ascending aorta and aortic arch with woven Dacron graft (arch first technique) under retrograde cerebral perfusion. Since the residual dissection (De Bakey type III) in the multiple aortic dissection has tendency to dilate fast, intensive follow-up of the patient would be necessary.

[Successful repair of the left ventricular wall rupture after mitral valve replacement of an octogenarian; report of a case]

The left ventricular wall rupture is not only a rare complication after mitral valve replacement, but also a high mortality disease. We have encountered a case of this complication after removal of the extracorporeal circulation in an octogenarian female after mitral valve replacement with Carpentier-Edwards (25 mm). It could be successfully repaired from outside the heart on the cardiopulmonary bypass without second cardiac arrest. Repair from inside the heart using extracorporeal circulation and cardioplesia is generally recommended because of the accuracy. However, second cardiac arrest might be a risk of postoperative complications in octogenarians. Hence, prevention is the most important. And operative strategy for the repair is also important in these patients.

[Unstable angina pectoris associated with systemic lupus erythematosus and arterio-sclerotic obstruction in whom hemophagocytic syndrome appeared after emergent operation; report of a case]

A 45-year-patient who suffered from old myocardial infarction (OMI) associated with systemic lupus erythematosus (SLE) and arterio-sclerotic obstruction (ASO) had unstable angina. Emergent coronary artery bypass grafting (CABG) was performed using saphenous vein graft because the left inter mammary artery was possible to be the collateral source for ASO. A high grade fever occurred without return of SLE 9 days after the operation. Pancytopenia simultaneously occurred. Hemophagocytic syndrome was diagnosed by the bone marrow examination. Pulse therapy with steroids was given and it was remarkably effected. Hemophagocytic syndrome has high mortality. However, it is difficult to distinguish from the other disease with high fever and bone marrow suppression in early period. Therefore, bone marrow examination was required to diagnose and to start the appropriate therapy as soon as possible.

[Replacement of subtotal aorta in a 2-stage operation; report of a case]

A non-Marfan patient with a chronic type B dissecting aorta suffered acute retrograde dissection during his follow-up period so a subtotal aortic replacement was performed in a scheduled 2-stage operation. During the first operation, this patient underwent replacement of the ascending aorta and aortic arch under continuous retrograde cerebral perfusion (CRCP). In the second operation 3 weeks after the first surgery, replacement of the thoracoabdominal aorta was performed using spinal cord protection under hypothermia. The intercostal arteries were remodeled into a cobra head shape a few pairs at a time. The patient progressed well after the procedures with a mean artery pressure maintained at over 90 mmHg using norepinephrine. We recommended stage surgery, which is safer than current techniques, for entire aortic replacement in centers and hospitals with limited experience of grafting procedure.

[Ten cases of transverse aortic arch replacement using antlers graft technique]

Ten cases of total arch replacement were performed using the antlers graft technique. The patients consisted of 6 men and 4 women ranging in age from 34 to 76 years (mean: 62.1 years). These cases included 7 cases of Stanford type A acute aortic dissection and 3 cases of fusiform aneurysm of the aortic arch. During surgery we formed a composite graft (antlers graft) by attaching 10, 12 and 24 mm side branches to a 10 mm woven graft and under hypothermic circulatory arrest with retrograde cerebral perfusion (RCP), we first of all remodeled the neck vessels and re-established antegrade cerebral perfusion. We then remodeled the arch using another 24 mm graft and concluded surgery by anastmosing this graft to the antlers graft. Eighteen cases using the conventional technique, in which anastmosis is performed from the distal arch, needed 77 minutes on average for RCP. However, the antlers graft technique required only 46.2 minutes. Although 1 case each of cerebral complications was observed during both techniques, the antlers graft technique shortened the time required for emergence from the general anesthesia (4 hours vs 11.4 hours), the length of the stay in the ICU (6.0 days vs 7.3 days) and the total hospital stay (45.8 days vs 60.3 days), compared to the conventional technique.

Enterobacterial repetitive intergenic consensus sequence-based PCR (ERIC-PCR); its ability to differentiate Streptococcus pyogenes strains and applicability to the study of outbreaks of streptococcal infection

We evaluated the ability of enterobacterial repetitive intergenic consensus sequence-based PCR (ERIC-PCR) to differentiate 95 Streptococcus pyogenes strains with M or T serotypes isolated from sporadic streptococcal infections as compared with M or T serotypings and pulsed-field gel electrophoresis (PFGE). Although the ERIC-PCR had less discriminatory power, defined as the ability to divide the strains with the same serotypes into the different sub-types, than PFGE, it consistently classified the strains into 16 patterns with a high correlation with M or T serotyping. The PCR method further discriminated 4 M or T serotypes into sub-types. The application of ERIC-PCR to 5 outbreaks of streptococcal infection produced the results that agreed closely with those of T serotyping and PFGE. ERIC-PCR has sufficient discriminatory power and is a quick and relatively easy technique, making it useful for routine epidemiological investigations.

[Graft replacement of transverse aortic arch using the arch vessels first technique]

In surgical treatment of aortic arch aneurysm or aortic dissection, we have been employing retrograde cerebral perfusion (RCP). In the present study, we have developed "arch vessels first technique" to shorten perfusion time and achieved an excellent clinical outcome. The surgical procedure "arch vessels first technique" is outlined as follows. RCP is initiated following circulatory arrest, while a woven dacron graft (12 mm in diameter, the dacron graft must be prepared in advance) with two side arms (12 mm in diameter, i.e., with the same diameter) is anastomosed left subclavian artery, left common carotid artery and right brachiocepharic artery in a sequential manner. Then, brain circulation is initiated via one end of the dacron graft. Subsequently, in patients with aortic dissection, a 26 mm woven dacron tubular prosthesis is inserted, using an elephant trunk procedure, to perform "distal anastomose". A partial clamp is applied to the 12 mm woven dacron graft mentioned above, while this 26 mm graft is anastmosed to the 12 mm woven dacron graft side to side, thus reinitiating systemic circulation. While rewarming, the 26 mm woven dacron tubular prosthesis is proximal anastomosed. Mean RCP time was 79.4 minutes, using the conventional procedure "aortic arch distal anastomose", whereas the RCP time was shortened by this procedure "arch vessels first technique", as evidenced by mean RCP time of 57 minutes for patient with aortic dissection and of 39 minutes for patient with saccular aneurysm.

Patient access to medical records: problems and strategies for inpatient charts

Fasing the impending introduction of patient access to medical charts, we have attempted to include a more substantial description of medical activity in specific areas. Using the guidelines published jointly by the Ministry of Health and Welfare and the Tokyo Metropolitan Office in October 1998, the staff of the medical records division examined and evaluated the layout and description of items on individual hospital charts, with excellent results. To encourage the continued improvement of medical chart recording in the future, incentives should be implemented to avoid insufficient descriptions, encourage regular chart inspections, and promote education regarding the need for a systematic approach to charts and chart recording.

[Surgical repair of postinfarction ventricular septal defect: modified Komeda-David procedure]

Since Cooley first reported surgical repair of postinfarction ventricular septal defect in 1957, there have been technical improvements in this procedure. However, the outcome of surgery has not been gratifying thus far. In 1990, Komeda and associates reported a single patch of bovine pericardium sutured to the healthy myocardium around the infarcted area on the left side of the septum that excludes the infarcted myocardium from the left ventricular cavity; a procedure based on a completely different idea. Since the satisfactory outcome of the surgical treatment in this procedure was obtained in a series of 12 patients, this surgical procedure has been in widespread use in Japan. On the other hand, this procedure has a drawback that there is a difficulty in suturing the patch and may lead to a postoperative residual shunt. We investigated a modified surgical procedure that could overcome this difficulty and would like to report it in this paper. At first, the perforated area should be covered with a felt strip and closed with mattress sutures. Secondly, the infarcted myocardium from the left ventricular cavity should be obliterated using a two-patch method. The primary advantage of this procedure is that it achieves a broader range of vision than a single patch method and enables easy suturing. Additionally, the development of a residual shunt can be prevented owing to the closure of perforation even if sutures fail to hold and leakage occurs. The tow-patch method has the advantage of avoiding tension against sutures since the patch is not everted around the sutures. However, the question arises whether only the healthy myocardium can be picked out and sutured without fail. In order to make the two-patch method more reloable the perforation should be closed in advance.

[Estimation of left internal thoracic artery flow reserve after coronary artery bypass grafting using Doppler flow wire]

The usefulness of the left internal thoracic artery (LITA) for aortocoronary bypass grafting is now established. Reports of variation in LITA graft function are rare. Graft flow was measured using a Doppler flow wire to estimate graft function in 27 patients (24 males, 3 females) who underwent LITA grafting to the left anterior descending artery. Patients were classified into the following 3 groups: Group A consisted of 9 patients with normal left ventricular function and no native flow; Group B consisted of 11 patients with normal ventricular function and good native flow; Group C consisted of 7 patients with abnormal left ventricular function and no native flow. LITA graft function was also estimated 1 year after operation in 12 of these 27 patients (4 in each group). Diastolic/systolic velocity ratio (DSVR) and flow reserve were determined in the proximal, middle, and distal portions of the LITA graft and native left anterior descending artery before and after papaverine administration (8-10 mg). DSVR was significantly higher in the distal portion than in the proximal portion (p < 0.01), but this value did not change after papaverine administration. After 1 year, DSVR in the proximal portion was significantly higher in Group C than in Groups A or B (p < 0.05 for both). Four weeks after operation, the flow reserve of the distal portion was significantly higher in Group A than in Group C (p < 0.001). After 1 year, this value was significantly higher in Group A than in either Groups B or C (p < 0.01, p < 0.001, respectively). The rate of increase in flow reserve in the distal portion was significantly greater in Group A (23.4%) than in groups B (2.53%) or C (1.94%; p < 0.05 for both). The distal portion of the LITA was the best measurement site, since the flow pattern in the LITA graft varied throughout all portions. Diastolic flow velocity in the LITA graft was dominant in patients with myocardial damage. The results indicate that flow reserve of the LITA graft depends on antegrade native coronary flow and distal myocardial damage.

[Operation for left renal cell carcinoma complicated with acute pulmonary tumor embolism and cocurrent removal of tumor]

The prognosis of pulmonary tumor embolism is said to be poor and only a limited number of patients with this disease have survived. The patient was a 64-year-old male suffering from left renal cell carcinoma complicated with tumor extending from the left renal vein to the inferior vena cava. The patient underwent an operation for left renal cell carcinoma during which he developed tumor embolus to the pulmonary artery. The occurrence of the acute embolism was promptly detected and the removal of tumor was performed under cardiopulmonary bypass. The patient made good postoperative progress.

Trimethoprim-sulfamethoxazole for the prevention of methicillin-resistant Staphylococcus aureus pneumonia in severely burned patients

BACKGROUND

Patients with severe burns are at increased risk of developing methicillin-resistant Staphylococcus aureus (MRSA) ventilator-associated pneumonia. This study was designed to determine whether MRSA pneumonia can be prevented by prophylactic administration of trimethoprim-sulfamethoxazole (TMP-SMX).

METHODS

We conducted a prospective, randomized, placebo-controlled study in patients with severe burns (> or = 20%), who required ventilator support. Prophylaxis was done with oral TMP-SMX (80 mg/400 mg) three times daily for 10 days from 4 to 6 days after burn injury. The incidence of MRSA pneumonia and the side effects were evaluated during the administration period.

RESULTS

Twenty-one patients were assigned to receive TMP-SMX, and 19 patients to receive placebo. The incidence of MRSA pneumonia was 4.8% in the TMP-SMX group and 36.8% in the placebo group, showing a significant difference (p = 0.017). No major side effects of therapy were seen in the TMP-SMX group.

CONCLUSION

Prophylactic treatment with TMP-SMX can prevent MRSA pneumonia in severely burned patients.

[Thoracic aneurysm repair using circulatory arrest or retrograde cerebral perfusion]

Ascending aortic and transverse arch aneurysm repair requires some brain protection. At our hospital, profound hypothermia, circulatory arrest and retrograde cerebral perfusion have been used. Thirty patients for whom we used such brain protection techniques were studied with regard to incidence of stroke. Of these 30 patients, 7 underwent circulatory arrest with median arrest time was 31 minutes (range, 25 to 42 minutes), and 23 underwent retrograde cerebral perfusion with median perfusion time was 59 minutes (range, 24 to 123 minutes). The overall 30-day mortality rate was 16.6% (5 of 30 patients); these patients were all aortic dissection cases, and had exhibited signs of vital organs ischemia before the operation. Of the twenty-five patients who survived the operation, incidence of stroke was observed in 2 patients. One was a saccular transverse arch aneurysm, who underwent 71 minutes retrograde cerebral perfusion; debris was the cause of stroke in this case. The other was a Stanford type A aortic dissection, who underwent 32 minutes perfusion; malperfusion caused stroke in this case. Stroke did not occur in any of the 3 patients who underwent retrograde cerebral perfusion for more than 100 minutes. These results suggest that a uniform and constant cooling of the entire brain is important for brain protection. To this end, transapical aortic cannulation is effective to prevent malperfusion. It is also suggested that retrograde cerebral perfusion time can be up to 100 minutes, a longer duration hitherto accepted.

Biological monitoring of metabolites of sarin and its by-products in human urine samples

More than 20,000 passengers of Tokyo underground trains were intoxicated with warfare toxic chemicals. Most of the patients examined had marked miosis and decreased serum cholinesterase activity. Transient increase of serum CPK activity after 3 days of the exposure was the another sign. We intensively analyzed the metabolites in the urine of 4 patients. The following analytic results indicated the exposure to sarin as well as contaminated compounds such as diisopropyl methylphosphonate (DIMP), ethyl methylphosphonate fluoridate (EMPF, or ethylsarin), diethyl methylphosphonate (DEMP), and ethyl isopropyl methylphosphonate (EIMP). (1) Isopropanol (IPA) and ethanol (EtOH) were detected of large quantities in the urine samples, and were thought to be derived from sarin and the sarin counterpart, EMPF, DIMP, DEMP and EIMP. (2) Monoalkyl methylphosphonic acids (isopropyl methylphosphonic acid (IMPA) and ethyl methylphosphonic acid (EMPA) also were excreted in large amounts with taking the similar excretion pattern of IPA and EtOH. (3) The metabolite only derived from sarin and ethylsarin is F anions whose integral output in the urine was less than the equimolar level of the excreted (IMPA + EMPA + IPA + EtOH). (4) Other corroborative findings were low lethality: of more than 5,510 patients treated, 11 were acutely dead. (5) Nine exposed males had higher sister chromatid exchange (SCE) rate (5.00 +/- 1.48/cell) than the control (3.81 +/- 0.697/cell), because dialkyl methylphosphonates seemed to have alkylating activity and producing DNA adducts. The SCE rate also increased after the in vitro exposure of lymphocytes to dialkyl methylphosphonates.

New diagnostic peritoneal lavage criteria for diagnosis of intestinal injury

BACKGROUND

Although diagnostic peritoneal lavage (DPL) is a well-established, reliably objective method of diagnosis of intraperitoneal injury, it is too sensitive to be used as an indicator for emergency celiotomy. Therefore, since the development of ultrasonography and advanced computed tomographic scanners, the role of DPL has been markedly reduced. Despite such remarkable advances, however, radiologic diagnosis of intestinal injury cannot always provide definitive results, and DPL may still be valuable in such instances. We have developed a new DPL criteria specifically designed to aid in the diagnosis of intestinal injury and have evaluated its effectiveness.

METHODS

From August 1988 to December 1995, we performed DPL in 250 patients with blunt abdominal trauma and analyzed the diagnostic accuracy of our new criteria. We used the standard quantitative white blood cell (WBC) criterion for detection of intestinal injury supplemented by a positive-negative borderline adjusted to WBC > or = red blood cell (RBC)/150, where RBC > or = 10 x 10(4)/mm3.

RESULTS

Our criteria had a diagnostic sensitivity of 96.6% and a specificity of 99.4% for intestinal injury after exclusion of 57 patients in whom DPL was performed within 3 hours or after 18 hours from the time of injury. In 133 patients with hemoperitoneum, emergency celiotomy was performed in only 48; the remaining 85 patients with negative DPL based on the WBC criterion avoided surgery, and conservative management resulted in no complications.

CONCLUSION

With the proposed criteria, DPL can be used to diagnose or exclude intestinal injury even in the presence of hemoperitoneum.

[An experience with St. Jude medical prosthetic 19A-HP which resulted in restricted opening at an early stage after operation]

St. Jude medical hemodynamic plus series is positively used for aortic valve replacement (AVR) of small orifice because it can increase the orifice area by 26% compared with conventional prosthetic valves of the same size. We performed AVR with SJM 19A-HP on a patient having aortic stenosis with regurgitation using horizontal mattress suturing technique. The aortic orifice size was 18.9 mm at the preoperative measurement. The course after the operation was uneventful until 9 days after the operation when cinefluoroscopy revealed symmetrical restriction of opening of valve leaflets. We are now monitoring the clinical course at the patient has not developed any symptoms though the LV-Ao pressures gradient is 60 mmHg by Doppler echocardiography. As the restriction of valve leaflet opening was symmetrical, it is not likely that an excess of the ligature or remnant caused the restriction; structural problems of St. Jude medical prosthesis appear to be a more reasonable explanation. Since the orifice ring of this prosthesis is not reinforced, longitudinal forces applied to the hinge may alter the shape of the ring, thus restricting the movement of valve leaflets. In the present case, forced insertion of 19A-HP instead of more desirable 17-HP is considered to have caused longitudinal forces acting on the hinge.