Abdominal aortic aneurysm in a patient presenting with ischemic colitis

A 76-year-old man with an abdominal aortic aneurysm (AAA) initially presented with ischemic colitis, which was improved by conservative treatment. Preoperative assessment by computerized axial tomography scanning and aortography revealed an infrarenal type AAA with mural thrombus, stenoses of the right common iliac artery and the left internal iliac artery. The patient underwent aortoiliac bypass surgery with resection of the stenoses, and reconstruction of the left internal iliac artery. No complications including bowel ischemia, were noted postoperatively. This case emphasized the potential benefits of the extraperitoneal approach to the aorta, reconstruction of both internal iliac arteries, and use of prostaglandin E1.

Unusual Remnant Thymic Tissue in an Adult Mimicking Malignant Neoplasm: Escape From Age-Related Involution

Here we report on a 55-year-old man with an abnormal anterior mediastinal shadow and multiple nodules in the thymus, which increased in size over a period of 15 months. He was diagnosed with early prostatic cancer, and treated with chemotherapy. Although no definite preoperative diagnosis was obtained, surgery was performed because of the possibility of malignant neoplasm or metastasis. Extended thymectomy was performed and pathological examination revealed that the nodules were remnant thymic tissue and not malignant lesions. Although the cause of this unusual remnant thymic tissue remains unclear, it may have been related to autoimmune or endocrinological disease.

[Prosthetic valve endocarditis complicated with cardiogenic shock and disseminated intravascular coagulation; report of a case]

A 67-year-old man, who had been performed aortic and mitral valve replacement 3 years before, was admitted because of appetite loss, general fatigue and anemia. Although transthoracic echocadiogram showed no evidence of prosthetic valves failure, the patient fell in profound shock. He needed endotracheal intubation and inotropic support. Transesophageal echocadiogram revealed vegetation formation on the prosthetic mitral valve and massive periprosthetic valve leakage. The diagnosis of prosthetic valve endocarditis was established. Blood examination showed severe disseminated intravascular coagulation (DIC). The patient underwent re-mitral valve replacement and recovered well from shock and DIC.

Penetrating brain injury with nasal entry by a plastic stick. Case report

A case of a 52-year-old male presented with an unusual penetrating brain injury with nasal entry. At admission he had erythema of periorbital soft tissue in the left eye and epistaxis. His neurological condition was lethargic (Glasgow Coma Scale of 13) with nonfluent aphasia. Computed tomography scan revealed intracranial contusion hematoma in the left frontal lobe and fracture of the left frontal base, which were treated surgically. At the 6-month follow-up he still showed nonfluent aphasia. Disturbances, mostly cognitive, were noted on his psychological tests. A survey of the literature reveals a few cases of this nature in penetrating brain injury with nasal entry. A penetrating brain injury with nasal entry which causes nonfluent aphasia is discussing.

Simultaneous mitral valve replacement and bypass grafting for mycotic aneurysm of the femoral artery during the active phase of infective endocarditis: a case report

A 52-year-old woman with a 3-week history of fever and cough was diagnosed as having bacterial endocarditis with vegetation and severe mitral valve insufficiency by echocardiography. Blood culture revealed Streptococcus mitis. After antibiotic treatment for 3 weeks, the patient noticed swelling with pain in her left groin. Computed tomography revealed an occluded aneurysm in the left common femoral artery. Simultaneous surgical treatments of mitral valve replacement and bypass grafting using a saphenous vein following resection of the mycotic femoral arterial aneurysm were performed. Pathohistological examination of surgical specimens revealed acute inflammatory findings, but no microorganisms were found, probably because of the preoperative antibiotic therapy. Her postoperative course was uneventful, and there was no recurrence of mycotic aneurysms in a period of 10 months after the operation. Prompt recognition and urgent simultaneous surgical treatments for mycotic aneurysms complicated with infective endocarditis were effective.

[Total arch replacement following partial replacement of the descending aorta for acute type A aortic dissection: report of a case]

A 42-year-old man was admitted to our hospital due to severe back pain. A computed tomographic scan revealed aortic dissection from the ascending aorta to the left common iliac artery. His blood pressure was well controlled untill he went into shock 21 hours after the onset. He was given a diagnosis of aortic rupture to the left pleural cavity by echocardiography and chest X-ray. He underwent emergent left thoracotomy under femoro-femoral bypass. We found a rupture of the descending aorta 3 cm above the diaphragma and replaced the ruptured segment with a woven Dacron graft. On postoperative day 9, we performed total arch replacement utilizing deep hypothermia and selective cerebral perfusion. We located the entrance tear in the aortic arch. His postoperative course was uneventful and he showed no neurological deficit. He was discharged from the hospital on postoperative day 36.

Magnetic resonance imaging for surgical consideration of acute head injury

The authors studied the extravasation of contrast enhancement on magnetic resonance (MR) imaging within 6 hours after head injury in 10 patients with 12 intracranial haemorrhagic lesions. The decision for surgical intervention was made by neurological examination, computed tomographic scan, and contrast extravasation on MR imaging. Nine of 10 patients showed extravasation of contrast agent and one patient showed equivocal findings of contrast extravasation. All intracranial lesions with contrast extrav asation led to enlargement in size. With the exception of 1 patient who showed equivocal findings of contrast extravasation, 9 patients needed surgical evacuation of the haemorrhagic lesions. The results of the current study imply that extravasation of contrast medium indicates persistence of post-traumatic bleeding. MR imaging with gadolinium enhancement in acutely head injured patients may be used to predict the development of haemorrhagic lesions and could be helpful in decision making for surgical intervention.

[Relationship between hyperglycemia following head injury and neurological outcome]

Severe head injury is associated with a stress response that includes hyperglycemia, which has been shown in both experimental and clinical studies to exacerbate the severity of brain injury during ischemic conditions. To define the relationship between serum glucose levels and the outcome of patients suffering from closed head injury, we retrospectively reviewed the clinical courses of 88 consecutive head-injured patients. The patients were divided into two groups according to their GCS score on admission: severely head-injured group (GCS score of 8 or less) in 36 patients; moderately head-injured group (GCS score of 9 to 12) in 52 patients. Severely head-injured group had significantly higher serum glucose levels than moderately head-injured group (mean +/- standard error of the mean; 201 +/- 4.6 mg/dl vs. 171.4 +/- 3.8 mg/dl) (p < 0.01). Patients who subsequently resulted in severe disability, vegetative state, or death had significantly higher serum glucose levels than patients who had good recovery or moderate disability (204.9 +/- 5.9 mg/dl vs. 162.9 +/- 5.1 mg/dl) (p < 0.01). Cases with a fatal clinical course were mostly associated with high glucose levels. All patients who showed a serum glucose level greater than 240 mg/dl on admission were dead. These data suggest that the hyperglycemia on admission is a frequent component of the stress response to head injury, a significant indicator of severity of injury and a potent predictor of the outcome from head injury.

Spinal cord stimulation for cerebral vasospasm as prophylaxis

Cervical spinal cord stimulation (SCS) was used to increase cerebral blood flow (CBF) in 10 patients with secured cerebral aneurysms in Hunt and Hess grade 3 or 4 and with Fisher group 3 subarachnoid hemorrhage (SAH). The patients underwent preemptive electrical stimulation through a percutaneous lead following aneurysm surgery. All patients also received hypervolemic therapy and nicardipine. Efficacy of the treatment was evaluated using xenon computed tomography and cerebral angiography. The CBF in the distribution of the middle cerebral artery significantly increased following SCS (p < 0.05). Four of 10 patients showed angiographic vasospasm, but none developed severe sequelae of cerebral vasospasm. The overall outcome was good or excellent in seven of the 10 patients. No serious adverse effects due to SCS were observed. Fluid management and calcium antagonist have a beneficial effect on cerebral vasospasm following SAH, but is not tolerated or is ineffective in some patients. SCS as an adjunctive therapy for cerebral vasospasm following SAH may have a favorable effect on outcome.

Magnetic resonance imaging with gadolinium DTPA enhancement in patients with acute head injury

Gadolinium-enhanced magnetic resonance (MR) imaging in patients with acute head injury was conducted to study if contrast extravasation was associated with development of hemorrhagic lesions. A series of 60 head-injured patients were admitted to our emergency unit. Computerized tomography (CT) scans and skull x-ray films were taken as rapidly as possible after hospitalization. Injury severity on admission was evaluated using the Glasgow Coma Scale (GCS) score, motor score, and pupillary examination, while overall outcome was assessed with the Glasgow Outcome Scale (GOS) 3 months after injury. Of all patients admitted, MR imaging with gadolinium enhancement was performed in 18 patients who were at high risk of developing hemorrhagic lesion within 6 h after injury. In these patients we investigated whether contrast extravasation was associated with development of hemorrhagic lesions. All 18 patients presented abnormal findings on their admission CT scans. Admission GCS score in those patients who underwent MR imaging with gadolinium enhancement was 13 or more in 12 patients, 9-12 in four patients, and 8 or less in two patients. Fourteen of 18 patients showed contrast extravasation, corresponding with an evolution of lesion size. Nine of 14 patients who demonstrated extravasation of the contrast medium required surgical treatment. The results of the current study suggest that extravasation of contrast medium indicates a continuance of posttraumatic bleeding. Thus, MR imaging with gadolinium enhancement in acutely head-injured patients may constitute a reasonable strategy for predicting the development of hemorrhagic lesions.

Development of an endocardioscope for repair of an atrial septal defect in the beating heart

The purpose of this study was to evaluate the possibility of surgical treatment of an atrial septal defect in the beating heart without cardiopulmonary bypass. The first step was to develop an endocardioscope that permitted observation of the inside of the beating heart. To visualize the inside of the beating heart, the tip of the endoscope was covered with a glass adapter. The endocardioscope was inserted through the right atrial appendage in eight beagles. The atrial septum, foramen ovale, coronary sinus, tricuspid valve, and chordae tendineae were identified without hemodynamic derangement. The second step was to attempt to close the foramen ovale with clips or staplers. We were able to close the foramen ovale with these devices, but a safer, easier device is needed. The endocardioscope we developed should prove to be a useful tool for minimally invasive surgical treatment of heart diseases, such as atrial septal defect.

VATS-stepwise resection of a giant bulla in an oxygen-dependent patient

We report a case of a giant bulla in a 16-year-old boy who was oxygen and wheelchair dependent. He had been diagnosed with Marfan's syndrome and had severe kyphoscoliosis. The giant bulla occupying his entire left thoracic cavity compressed the contralateral lung. Until referral to our hospital, a bullectomy had been deferred during the preceding 5 years because of his poor pulmonary function and severe chest wall deformity. The patient was considered a candidate for thoracoscopic bullectomy. A stepwise resection technique was used. First, the bulla should be emptied by aspiration or wall perforation. Second, the redundant wall of the bulla should be resected by a looped ligation without opening the cavity. Third, a stapled resection of the downsized bulla should be performed. After a successful bullectomy, his subjective symptoms and pulmonary function improved. The reduction of the bulla makes bullectomy easily and decreases the number of staplers, and reduces operating time compared with opening the bulla and suturing it. Therefore, when treating a giant bulla, we recommend a stepwise resection technique.

The long-term survival rates of patients after repair of abdominal aortic aneurysms

This study was undertaken to examine the long-term survival rates of patients following abdominal aortic aneurysm (AAA) repair in comparison with an age-matched normal population, and to determine by multivariate analysis the factors influencing long-term survival. Of 125 patients who underwent AAA repair prior to July 1986, 13 died during hospitalization. Of these 13 patients, 6 who suffered aneurysmal rupture all died within 30 days. The survival rate of patients with ruptured aortic aneurysms was significantly lower than that of those with nonruptured aneurysms. Of the 112 patients surviving hospitalization, 85 died within 0.48 to 24 years after their operation. The long-term survival rate of patients who had suffered a preoperative cardiovascular event was significantly lower than that of those who had not suffered a preoperative cardiovascular event. The actual survival rate was significantly lower than the expected survival rate. According to a multivariate analysis, the significant predictors of late survival were age, aneurysmal rupture, and chronic renal failure in all the patients, and age, chronic renal failure, and pre- and postoperative cardiovascular events in patients who did not die in hospital. These findings indicate the importance of improving immediate perioperative management of ruptured AAA and that cardiovascular events should be prevented, or treated during long-term follow-up.

[Usefulness of aspiration surgery for elderly patients with hypertensive cerebellar hemorrhage]

We report two cases with hypertensive cerebellar hemorrhage who were successfully treated with frameless stereotaxic aspiration. First case, an 85-year-old man with hypertension had a large-sized hematoma in left cerebellar hemisphere. Emergency aspiration for cerebellar hemorrhage was carried out through a suboccipital burr hole. He had a good recovery at discharge. Second case, an 84-year-old female with hypertension showed right cerebellar hemorrhage. She had been in somnolence state for one month with conservative treatment. Then, aspiration surgery for the hematoma was carried out through a suboccipital burr hole. Her neurological condition was ameliorated. Frameless stereotaxic aspiration for cerebellar hemorrhage through suboccipital burr hole is less invasive and useful procedure, especially for elderly patients.

[Development of a blood cardioplegia delivery system for children]

We have developed a blood cardioplegia delivery system for children. Essential points of a delivery system in pediatric cardiac surgery are (1) a small amount of priming volume of a delivery system, and (2) slow, steady infusion of a cardioplegic solution. We changed a heat exchanger to a smaller one for reduction of priming volume, and changed a roller pump tube to a smaller one for slow, steady infusion. Thus, priming volume of a delivery system has reduced from 180 to 100 ml, and we can infuse a cardioplegic solution at a steady rate less than 10 ml/min. Our clinical experience with this system suggests that this blood cardioplegia delivery system is useful for pediatric cardiac surgery.

Somatic mutations of the von Hippel-Lindau tumor suppressor gene and loss of heterozygosity on chromosome 3p in human glial tumors

Molecular genetic analysis of von Hippel-Lindau tumor suppressor gene (VHL gene) was performed on 38 tissues of human glial tumors (ependymoma, 1; astrocytoma, 6; oligodendroglioma, 1; oligoastrocytoma, 2; anaplastic oligoastrocytoma, 3; anaplastic astrocytoma, 14; glioblastoma multiforme, 11). Somatic DNAs extracted from frozen tumor specimens were examined by single-strand conformational polymorphism analysis and direct sequencing. In addition, loss of heterozygosity (LOH) on chromosome 3p in 15 glial tumor cases, lymphocyte DNAs of which were available, was examined by use of 10 microsatellite probes and two polymorphism markers for the VHL gene. Two cases of low-grade gliomas showed somatic sense mutations in exon 3 of the VHL gene, and 6 of 15 cases (40.0%) showed LOH of chromosome 3p. The VHL gene-mutated cases also showed LOH. The retention of heterozygosity and high pathological grade of glial tumors were correlated significantly. In addition, Kaplan-Meier survival analysis for patients with glial tumors showed that patients with LOH had a significantly longer survival time than those without LOH. These results suggest that somatic mutations on 3p, including the VHL gene, may be involved in tumorigenesis of some low-grade glial tumors.

[Coagulation disorders as early predictor of brain injury]

To identify early prognostic value of brain injury, a comparison was made between computerized tomography (CT) findings, coagulation abnormalities, and clinical features in 51 patients with closed head injury. The patients were divided into three groups according to their plasma level of fibrin-fibrinogen degradation product (FDP): normal group (FDP 10 micrograms/ml or less) in 20 patients; moderately abnormal group (FDP 10-40 micrograms/ml) in 15 patients; and highly abnormal group (FDP 40 micrograms/ ml or more) in 16 patients. Cases with a fatal clinical course were mostly associated with very high FDP level. Mortality rate in the highly abnormal group was 44% and 7% in the moderately abnormal group were dead cases, while no cases in the normal group turned out poor outcome. Injury severity, as assessed by Glasgow Coma Scale (GCS) score, correlated with the increase of plasma FDP level. Although severe head injury (GCS 8 or less) was found in 44% of the highly abnormal group and 13% of the moderately abnormal group, normal group only had one case (5%). Very high FDP concentrations were found to be associated with combined hemorrhagic lesions and mass effect on CT scan, but not with a specific localization of brain damage. In summary, the evaluation of coagulation and fibrinolytic function in patients following closed head injury might have both diagnostic and prognostic value.

Video-assisted thoracic surgery for thorascopic resection of giant bulla

This report outlines our experience of 6 patients who underwent video-assisted thoracic surgery (VATS) using a linear endoscopic stapler to remove a giant bulla from the lung. Successful treatment with VATS was carried out in 4 patients, but the procedure needed to be changed to a thoracotomy in 2 patients - in one because of difficulty in single-lung ventilation, and in the other, due to a persistent air leak. Thus, we conclude that giant bulla without any associated severe respiratory failure can be an indication for VATS.

Suppression of fluid accumulation following pericardial inflammation in a patient with primary chylopericardium

The patient was a 50-year-old woman with primary chylopericardium. Triglyceride rich chyloid fluid was continuously drained from the pericardial space through an indwelling catheter. A surgical procedure was scheduled since a medium chain triglyceride diet was insufficient to control the fluid accumulation. Before the operation, inflammatory signs were apparent around the indwelling catheter and the catheter was removed immediately. The inflammation was easily treated with antibiotics, and the pericardial effusion no longer accumulated during a follow-up period of 10 months. The inflammatory process may have caused fibrin production and tissue adhesion in the pericardial cavity, and these might have prevented an accumulation of chyloid fluid and occluded the connection between the thoracic duct and the pericardial cavity.

Congenital coronary artery fistula--surgical results and late changes in coronary artery aneurysm

Four pediatric cases of congenital coronary artery fistula were surgically treated and followed for 8 years. In the 3 cases of right coronary artery to right ventricle fistula, regression of coronary artery dilatation was observed postoperatively. In the 1 case of circumflex artery to right atrium fistula, aneurysmal dilatation of the abnormal vessel persisted for 8 years. A reduction in vessel size is expected if the fistula-related coronary artery has a normal course and normal branchings. When the aneurysmal vessel takes an abnormal course without branches, it should be removed surgically along with fistula closure.

[Venovenous extracorporeal membrane oxygenation in an elderly patient with severe respiratory failure--report of a case]

A 69-year-old woman, who developed acute respiratory distress syndrome (ARDS) after coronary artery bypass grafting, underwent venovenous extracorporeal membrane oxygenation (V-V ECMO) because conventional ventilatory support was ineffective. We used a covalently bonded heparin surface ECMO system, including an artificial lung, a centrifugal pump, cannulas, tubing and connectors, that was maintained with low-dose systemic heparinization, the patient was weaned from ECMO after 186 hours. During ECMO, her platelet count was about half of the initial level and markedly elevated thrombin-antithrombin complex (TAT), plasmin-alpha 2 plasmin inhibitor complex (PIC) and D-dimer were decreased by the use of heparin and protease inhibitors. V-V ECMO seems to be useful even in patients with severe adult respiratory failure and can be performed safely if a heparin covalent circuit is applied.

[Changes in hematological indices, iron levels and marrow erythroids through autologous blood donation before cardiac surgery--predonation with versus without recombinant human erythropoietin]

Preoperative autologous blood donation is widely used in cardiac surgery. However, some patients are unable to store adequate amounts of blood before surgery, and some develop anemia after the operation. We attempted to clarify the limitations of blood donation alone and its influence on erythropoiesis in comparison with those associated with adding recombinant human erythropoietin (rEPO). Subjects were twenty-five patients who were scheduled to undergo elective cardiac surgery. A unit of autologous blood (200 ml) was to be donated every 3 or 4 days for 2 weeks. 200mg of ferrous sulfate was given orally every day in 10 patients (the simple donation group), while 200 U/kg of rEPO was given intravenously 3 times a week in combination with oral ferrous sulfate supplementation in 15 patients (the rEPO-treatment group). After donation, reticulocyte counts increased significantly in both groups. In the simple donation group, hematocrit levels decreased significantly (p < 0.02), while serum iron levels did not change significantly. In the rEPO-treatment group, hematocrit levels remained unchanged and serum ferritin levels decreased significantly (p < 0.02) after the donation; in addition, serum iron levels in the rEPO-treatment group decreased significantly (p < 0.05) than those in the simple donation group during donation. The erythroid/nucleated cell ratio remained almost normal in the simple donation group. This ratio was significantly higher in the rEPO-treatment group than in the simple donation group (36.4 +/- 8.3% versus 26.2 +/- 6.8%, p < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

[A new operative technique for pulmonary artery banding: adjustment of pulmonary artery bands by mitral valve flow velocity]

We developed a new technique to adjust the pulmonary artery band at surgery by monitoring the mitral valve flow velocity, which is indirectly indicative of the pulmonary flow. We employed this technique for 10 consecutive patients aged from 5 days to 5 months (mean, 1 months) weighing from 2.7 to 4.4 kg (mean, 3.3 kg). Underlying disease was aortic coarctation or interrupted+ventricular septal defect in 7 patients, single ventricule in 1 patients and miscellaneous defects in 2 patients. The pulmonary artery was exposed through a left lateral thoracotomy and a 3 mm wide Teflon tape was placed around the main pulmonary artery. The transducer of the Doppler echocardiography was placed along the left sternal border. The band was tightened gradually until the maximum velocity of the mitral valve flow decreased to around 70% of the previous level. During banding procedure, arterial oxygen saturation, heart rate and left ventricular contractility were monitored continuously. If bradycardia, unacceptable hypoxemia or ventricular dysfunction occurred, the band was released. The mitral valve flow velocity decreased rapidly by just a little additional tightness of the band between the range of 50% to 80% of the previous level. This technique enabled a very fine adjustment (less than 0.5 mm plication) and postoperative management has become very easy. Although there is a limitation of this technique that monitoring of the mitral valve flow velocity cannot be applied to the patients with significant interatrial shunt or mitral regurgitation, we conclude that this technique is simple and useful to obtain the optimum constriction of the pulmonary artery with excessive pulmonary blood flow.

[Tetralogy of Fallot with a restrictive ventricular septal defect caused by a membranous flap]

A 5-year-old boy who had typical tetralogy of Fallot (TOF) with mild cyanosis was referred to us. Preoperative echocardiogram revealed that in addition to the TOF morphology, an abnormal piece of tissue attached to the right side of the ventricular septum was floating and obstructing flow through the ventricular septal defect (VSD) in systole. Preoperative cardiac catheterization showed suprasystemic right ventricular pressure with a gradient of 60 mmHg between the right ventricle and the aorta, and a right ventriculogram demonstrated a narrow radiolucent structure beneath the aortic valve in the right ventricle. During surgery a fibrous membranous tissue, with no relation to the tricuspid valve, was found to extend from the edge of the VSD to the aortic valve and to partially occlude the defect. This tissue was used as a suture anchorage for patch closure of the defect. Preoperative echocardiography is useful to detect such flaps and early surgical correction should be done to prevent right ventricular failure resulting from right ventricular pressure overload.

[Successful primary correction for tetralogy of Fallot associated with total anomalous pulmonary venous drainage (type Ia)]

The surgical correction was performed successfully in a 3-year-old girl with tetralogy of Fallot associated with total anomalous pulmonary venous drainage (type Ia). The preoperative cardiac catheterization and angiography showed high systolic pulmonary artery pressure (58 mmHg) and small left ventricular volume (54% of normal). The early postoperative course was stormy because of the unstable circulatory state. During the early postoperative period, we estimated the volume of left ventricle by 2 D echocardiography. A significant increase of the volume was observed on the 8th postoperative day, when her circulatory state became stable. The cardiac catheterization before discharge revealed Pp/Ps of 0.38 and normal LV volume. We conclude that primary repair should be done for this combined cardiac anomaly, even if small left ventricle and pulmonary hypertension is present.

Total circular annuloplasty with absorbable suture for the repair of left atrioventricular valve regurgitation in atrioventricular septal defect

To obtain a better control of left atrioventricular valve regurgitation, we applied total circular annuloplasty with the use of absorbable sutures to 14 children with atrioventricular septal defect (six complete forms and eight incomplete forms). In the intraoperative period, a good coaptation of the leaflets was achieved and the regurgitation was minimized or disappeared. Follow-up studies with echocardiography for 13 survivors showed a gradual increase of annular size during the postoperative period. Ten patients of the survivor group (77%) maintained good valvular competency in a long-term period. Total circular annuloplasty is a simple and effective procedure to reduce the regurgitation and prevent the annular dilatation during the immediate postoperative period.

Thoracoscopic stapled bullectomy supported by suturing

In 1985, a thoracoscopic technique for closing bullae with hemostatic clips was developed. However, the method was limited, and therefore clinical application was small. A linear endoscopic stapler (Endo-GIA) was developed in 1990. The advent of the Endo-GIA nearly made thoracoscopic treatment of spontaneous pneumothorax practicable, and ended the use of clipping. In addition, a new operative technique was developed, the 3-cm minithoracotomy bullectomy for the treatment of spontaneous pneumothorax. This technique has now become obsolete. The current method is that of a thoracoscopic stapled bullectomy using the Endo-GIA, supported by suturing. The recurrence rate was 2.7% (1/37) using this method. The one recurrence occurred in a case where no bullae were observed during the operation. Our findings suggest that thoracoscopic stapled bullectomy supported by suturing is a practicable treatment of spontaneous pneumothorax. An economical use of the endoscopic stapler and complementary suturing may be less expensive than using a laser. Pleurodesis should be performed in the patients in whom no distinct bullae are discovered thoracoscopically.

[A successful insertion of the prosthetic valve in supraannular position concomitant with pericardial enlargement of the aortic root in a child: a case report]

A 4-year-old boy admitted to our hospital due to congestive heart failure one year after the intracardiac repair of tetralogy of Fallot. Echocardiography and cineangiography revealed severe aortic regurgitation. The aortic valve replacement was performed with a prosthesis larger than the aortic annulus. Operative findings showed that the cause of aortic regurgitation was infective endocarditis. The aortic root was enlarged with pericardial patch and a 21 mm St. Jude Medical valve prosthesis was inserted in supraannular position. This technique was very useful for insertion of a prosthetic valve one or two sizes larger than the aortic annulus without risk of distorting the mitral valve or left ventricular function.

Does recombinant human erythropoietin accelerate erythropoiesis for predonation before cardiac surgery?

This study was performed to determine the effect of recombinant human erythropoietin (rEPO) on preoperative autologous blood donation in patients undergoing elective coronary bypass or valvular operations. Nineteen patients received 200 u/kg of rEPO intravenously 3 times a week, and 210 mg/day of iron sulfate orally, for 2 weeks before surgery (EPO group). Seven matched patients only took the same dose of iron sulfate (control group). Bone marrow was aspirated from the sternum during surgery, and the Myeloids/Erythroids ratio was calculated in 13 patients of the EPO group. The total donated blood mass was 853 +/- 231 g in the EPO group, and 657 +/- 140 g in the control group (p < 0.05). The average increase in hemoglobin (Hb) mass from admission to the day before surgery was 87 +/- 33 g in the EPO group, and 24 +/- 13 g in the control group (p < 0.001). Furthermore, the logarithm of the ratio of "increased Hb mass/Hb mass at admission" was significantly correlated to the Myeloids/Erythroids ratio (r = -0.9130, p < 0.01). These results strongly indicate that rEPO is a very useful agent for predonation of autologous blood for cardiac operations.

[Excellent late results of total circulatory annuloplasty with absorbable suture for the repair of mitral regurgitation of atrioventricular septal defects in children]

We treated 15 children with atrioventricular septal defects (6 complete type and 9 incomplete type) using total circulatory annuloplasty for mitral regurgitation. In 14 patients, total circulatory annuloplasty was performed with absorbable suture and in one patient with polypropylene suture. Operative death was one patient associated with tetralogy of Fallot and another 14 patients survived. Preoperative mitral regurgitation was grade 1 in one patient, grade 2 in 6 patients and grade 3 in 7 patients. After operation mitral regurgitation reduced to grade 1 in 13 patients and grade 2 in one patient. In the late results, only one patient underwent reoperation for exacerbation of mitral regurgitation. The present data suggested that total circulatory annuloplasty with absorbable suture was very useful technique for the repair of mitral regurgitation of atrioventricular septal defects in children.

[An operative case of aortic valve regurgitation due to blunt trauma to the chest]

While a 70-year-old man was riding a motorcycle, he was hit by car on his chest on October 19, 1990. Medical check-up at the emergency room of another hospital was negative. However, he fell in to dyspnea on the night of next day which progressed to develop signs of orthopnea. He revisited the hospital where he was found to have aortic regurgitation and subsequent congestive heart failure after medical examination including echocardiography and was referred to our hospital 7 days after the accident. He was operated upon the following day. On opening the pericardium, about 100 ml of reddish black fluid was accumulated. The appearance of the heart was normal except for black discoloration of the epicardial fat pad at the base of the aorta. Opening the ascending aorta transversely, the right coronary cusp was found to be perforated. The aortic valve was considered preferable to replace than to repair. The aortic valve was replaced with a St. Jude Medical valve. His recovery was uneventful and he has been well thereafter.

[A case of carcinoid tumor of the right truncus intermedius resected by the bronchoplasty without lobectomy]

A case report of endobronchial carcinoid was presented. A 20-year-old male complaining of hemoptosis was bronchoscopically proved to have a carcinoid tumor located in the membraneous portion of the right truncus intermedius. Right thoracotomy was done on February 26, 1990, and bronchoplasty was performed without losing lung parenchyma. We cut right upper bronchus, truncus intermedius, and main bronchus, and performed double-barreled anastomosis between a double end of right upper bronchus and truncus intermedius and right main bronchus. Histological diagnosis was typical carcinoid. Postoperative course was uneventful, and one year after the operation anastomosis line was proved clear with no evidence of carcinoid recurrence of granular stenosis.

[Surgery of vascular rings associated with complex intracardiac anomaly]

Two rare cases with surgically treated vascular ring associated with complex congenital cardiac anomaly are reported. Each case showed vascular ring due to right aortic arch, right descending aorta, aberrant left subclavian artery and left ductus arteriosus. Case 1 was a 2-year-old boy associated with ligamentum arteriosum and total anomalous pulmonary venous connection (TAPVC), and presented dyspnea and dysphagia. Case 2 was a 3-year-old girl associated with patent ductus arteriosus (PDA) and tetralogy of Fallot (TOF). In case 1, the two-staged operation was performed because of the necessity of mechanical ventilation and of recurrent respiratory infection. Division of the ligamentum, dissection of bronchus and esophagus was performed at the first operation through left thoracotomy, and the intracardiac repair of TAPVC was done three months later. In case 2, PDA division and the intracardiac repair of TOF was done simultaneously through median sternotomy because of the mild symptom of vascular ring and technical feasibility. Each case was successfully treated and became completely asymptomatic.

[Surgical management of valve replacement in children]

From 1965 to 1990, 49 valve replacements were performed on 43 patients under the age of 15. Mitral valve replacements were performed on 21 patients, and re-replacements were done on 4 of them afterwards. In the first 9 mitral valve replacements before 1974, Starr-Edwards (S-E) ball valves were used. Five of these patients died in the hospital (early mortality rate was 56%). Since 1975, bioprosthetic valves were used in three cases, but all of these valves ceased to function due to primary tissue failure (PTF) within 3 years. Consequently, SJM valves are now used as a first choice. Ten aortic valve replacements were performed on 9 patients with the results of one early death, two late deaths, and one late re-operation. Tricuspid valve replacements were performed on 11 patients, 5 of whom utilized S-E ball valves. Three of the five patients died in the hospital. One patient was re-operated on, swapping the S-E ball valve for the SJM valve. SJM valves were used primarily in 2 patients, and bioprosthetic valves in 4. Two patients died, one with a SJM valve, and the other with a bioprosthetic valve. Two pulmonary valve replacements were performed, one employing a SJM valve, the other a bioprosthetic valve. Two adult patients with SJM valve in the right side of the heart had thrombotic complications, though the patients with bioprosthetic valves had none. Atrioventricular valve replacements were performed on 5 patients under the age of 3, but all of them died.(ABSTRACT TRUNCATED AT 250 WORDS)

[Surgical management of congenital aortic valve stenosis in neonates and infants]

From 1985 to 1989, 4 neonates or infants (3 males and 1 female) underwent open valvotomy for severe aortic valve stenosis. In all patients, preoperative echocardiograms showed abnormal findings of endocardial fibroelastosis and/or poor performance of left ventricle. All patients underwent valvotomy using cardiopulmonary bypass. There was one early death from left ventricular failure. All other patients survived and the pressure gradient through aortic valve was reduced from 50-100 mmHg to 25-50 mmHg postoperatively. We conclude that infants with severe aortic valve stenosis should undergo open valvotomy before the manifestation of endocardial fibroelastosis and/or left ventricular muscle damage, and that open aortic valvotomy using cardiopulmonary bypass is most suitable method for severe aortic valve stenosis in infants.

Hypothalamic obesity due to hydrocephalus caused by aqueductal stenosis

A case is presented of 14 year old female with hypothalamic obesity due to hydrocephalus caused by aqueductal stenosis. Evidence of hypothalamic obesity included 1) acute hyperphagia and weight gain, 2) neuroradiology showed hydrocephalus with focal enlargement of the third ventricle, 3) endocrinological studies revealed hyperinsulinaemia and impaired growth hormone (GH) response to arginine, but normal GH response to growth hormone-releasing factor (GRF) and 4) Torkildsen's ventriculo-cisternal shunting resulted in improvement in hyperphagia and obesity.

[Management results of primary intracranial malignant lymphoma]

Nineteen cases of primary malignant lymphoma of the central nervous system were reported. The clinical characteristics, diagnostic procedure and therapeutic method, especially concerning chemotherapy, were analysed. The following conclusions were obtained: 1) histological classifications and surgical procedures were not factors involved in prognosis. 2) radiotherapy was regarded as an effective but a palliative treatment. 3) combined chemotherapy for systemic malignant lymphoma, such as VEMP, VEP, COPP, seemed to be of little use for intracranial malignant lymphoma. 4) intra-arterial administration of high-dose methotrexate, ACNU and intravenous administration of high-dose cytosine arabinoside can be expected to be a useful chemotherapeutic approach.

[Effect of recombinant human erythropoietin on reduce of homologous blood transfusion in open heart surgery]

We have used recombinant human erythropoietin (rEPO) in order to prevent patients from developing anemia following preoperative autologous blood preservation. Thereby, we have been able to reduce intraoperative homologous blood transfusion during cardiac operations. In June and July, 1989, six middle-aged selective patients received rEPO (200 IU/kg) intravenously every other day starting from fifteen days before the day of their operations. One unit (200 ml) of autologous blood was drawn and preserved every few days. However, no significant differences were observed in red cell counts, hematocrit, hemoglobin and serum protein levels between before and after preservation. Not only preoperative autologous blood preservation with provision of rEPO, but also using the intraoperative autotransfusion system enabled us to perform cardiac operations on 5 out of 6 patients without any homologous blood transfusion. None of the six patients exhibited any undesirable effects due to rEPO administration. Their postoperative courses were excellent.

Effect of recombinant human lipocortin I on brain oedema in a rat glioma model

Glucocorticoids have been extensively used to treat brain oedema, but little is known on the mechanisms of steroids in the prevention and resolution of tumour-induced brain oedema. Recently, the mechanism of steroid action is thought to involve synthesis of proteins with antiphospholipase activity called lipocortins. In a previous study, we have demonstrated the efficacy of dexamethasone (DEX) in resolving peritumoural oedema in a rat glioma model. Using the same model, we studied the effect of recombinant human lipocortin I on the resolution of peritumoural oedema. Intracerebral tumours were produced in 6-week-old Wistar rats by implantation of rat glioma C6 cells. In comparison with sham-operated controls, the tumour-implanted animals showed significant increase in the cortical water content, which was reduced by DEX administration to the level in the sham-operated controls. The water content within the tumour was also significantly decreased by DEX treatment. On the other hand, there was no difference in water content between lipocortin-treated and non-treated animals. These findings suggest that tumour-induced brain oedema can be reduced by DEX treatment but not by lipocortin. In conclusion, it is doubtful whether glucocorticoids exert their action in resolving brain oedema by inducing PLA2 inhibitory proteins named lipocortins.

Establishment of a human glioma cell line bearing a homogeneously staining chromosomal region and releasing alpha- and beta-type transforming growth factors

A human glioma cell line (YKG1), which was positively identified for glial fibrillary acidic (GFA) and S-100 proteins, was established from a surgical specimen of a patient with glioblastoma. Chromosome analysis of the cells revealed a homogeneously staining region (HSR) on a marker chromosome. The assay for transforming growth factors (TGFs) in the conditioned medium of the cell line revealed that it contained high levels of alpha- and beta-type TGFs, which might regulate the growth of glioblastoma and influence on the peritumoral tissues.

[Growth factors produced by rat glioma cells: activities of transforming growth factors]

Growth factors contained in cultured medium of rat glioma C6 cells (C6 cells) were examined mainly for the activity of transforming growth factors (TGFs). Cultured medium of C6 cells was dialyzed against acetic acid, lyophilized and chromatographed by gel-permeation method, the fractions were assayed by soft agar colony formation, iodine 125 (125I)-epidermal growth factor (EGF)-binding competition and incorporation of tritium-thymidine. Two nontransformed cell lines, clonal NRK49F and BALB/3T3 A 31-1-1 (3T3) cells, were used as indicator cells for the soft agar colony assay. 3T3 cells were also used for the incorporation of tritium-thymidine. EGF receptor-rich A 431 cells were used for 125I-EGF-binding competition assay. The activity of alpha-type TGFs was examined by soft agar colony formation of NRK49F cells and inhibition of EGF-binding to A 431 cells since TGF alpha has sequence homology with EGF and binds to EGF receptors on the cell membrane, while the activity of beta-type TGFs was examined by soft agar colony formation of 3T3 cells and NRK 49 F cells with the addition of EGF. High level of activities of both TGF alpha and TGF beta were detected in 14,000 to 45,000 daltons, and also high level of the activity of DNA synthesis was detected at the same molecular weight. These results suggest that C6 cells produce TGF alpha and TGF beta as well as platelet-derived growth factors (PDGFs)-analogue. Since amplification of EGF receptor gene has been demonstrated in glioma, TGF alpha released by glioma may provide autocrine stimulation through the binding to the amplified EGF receptors. TGF beta is known to increase EGF receptors on the cell membrane. TGF beta has been demonstrated not only to stimulate but also inhibit cell proliferation under certain circumstances.(ABSTRACT TRUNCATED AT 250 WORDS)

Immunohistological evaluation of macrophage infiltrates in brain tumors. Correlation with peritumoral edema

Peritumoral edema is one of the most serious complications of intracranial neoplasms; however, the exact pathogenesis of this condition is still unknown. To explore the effect of macrophages in brain tumors on the pathogenesis of peritumoral edema, 42 specimens of primary or metastatic brain tumors were studied. Frozen sections were examined by an immunoperoxidase staining technique with anti-Leu-M3 monoclonal antibody. Eight of 14 gliomas demonstrated Leu-M3-positive cell (macrophage) infiltration. The two glioblastomas showed a moderate or marked degree of macrophage infiltration. Twelve of 16 meningiomas demonstrated varying degrees of macrophage infiltration. All six metastatic brain tumors exhibited prominent macrophages in intra- and peritumoral tissues. Four acoustic neurinomas and two hemangioblastomas showed a slight to moderate degree of macrophage infiltration. Excellent correlation was found between the degree of macrophage infiltration seen on immunoperoxidase staining and the peritumoral edema detected on computerized tomography brain scans of patients with supratentorial tumors, especially meningiomas. Macrophages are known to secrete various substances (including arachidonate metabolites) that may interfere with vascular permeability. These data suggest that macrophages infiltrating brain tumors may play an important role in the pathogenesis of peritumoral edema.

[Chemotherapy for experimental subarachnoid dissemination model of brain tumor]

Chemotherapy was applied for experimental subarachnoid dissemination model of brain tumor which was established in male Wister-SPF (SLC) rats inoculated intracisternally with 2 X 10(5) C6 rat glioma cells. Nontreated animals died about 24 days after inoculation. Autopsy findings of the animals showed localized or multifocal invasion of the tumor on leptomeninges in cisterna magna, and partially infiltration into the parenchyma of the cerebellum and medulla oblongata. Three days after inoculation, the tumor deposition and proliferation already occurred. Several tumor cell layers were found in the subarachnoid space over the cerebellomedullary surface. Tumor bearing animals were at first treated by single agent. These are ACNU administered intraperitoneally, methotrexate administered intracisternally, and OK-432 administered intraperitoneally. In the next stage, combination of these drugs was applied. ACNU, 3 mg/kg i. p., on Day 3, was effective in elongation of median survival time by 23.6%, statistically significant (P less than 0.02). Methotrexate, 0.25 mg/kg i.th., on Day 3, was also effective in elongation of median survival time by 8.4%, statistically significant (P less than 0.05). OK-432, 0.1 KE/kg i. p., daily, 14 times, from Day 3 to Day 16, was ineffective in elongation of median survival time. Combination of ACNU, methotrexate and OK-432, in the same schedule as described above, produced the longest median survival time of 42.4%, statistically significant (P less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

[Unilateral exophthalmos caused by organized hematoma of the orbit--report of a case (author's transl)]

The authors reported a case with unilateral proptosis of over ten years' duration due to organized hematoma of the orbit. It has generally been accepted that any given hemorrhage within the orbit can be resolved in a relatively short period of time. Persistent intraorbital hematoma, therefore, in the form of organized hematoma is very unusual in incidence and has been reported very few in the literature. Our patient presented himself with a ten-and-several-year history of unilateral exophthalmos, limited ocular movement and decreased visual acuity on the involved side. There was no specific symptom when compared with the other intraorbital tumors. Total resection of the tumor was performed through transcranial frontozygomatic approach. Histopathologic examination revealed evidence of organized hematoma without definite sources of bleeding such as microangioma, microaneurysm or arteriovenous malformation. Retrospective review of history failed to uncover episodes of hemorrhagic tendency or direct trauma to the head or the orbit. Subsequently a diagnosis of spontaneous organized hematoma was made. Great emphasis was laid on the fact that CT-scan was one of the most useful diagnostic tools. Our surgical approach was introduced and discussed.