The effectiveness of fascial closure with antimicrobial-coated sutures in preventing incisional surgical site infections in gastrointestinal surgery: a systematic review and meta-analysis

The aim of this study was to conduct a systematic review and meta-analysis of the efficacy of fascial closure using antimicrobial-sutures specifically for the prevention of surgical site infections (SSIs) in gastrointestinal surgery, as part of the revision of the SSI prevention guidelines of the Japanese Society of Surgical Infectious Diseases (JSSI). We searched CENTRAL, PubMed and ICHUSHI-Web in May 2023, and included randomized controlled trials (RCTs) comparing antimicrobial-coated and non-coated sutures for fascial closure in gastrointestinal surgery (PROSPERO No. CRD42023430377). Three authors independently screened the RCTs. We assessed the risk of bias and the GRADE criteria for the extracted data. The primary outcome was incisional SSI and the secondary outcomes were abdominal wall dehiscence and the length of postoperative hospital stay. This study was supported partially by the JSSI. A total of 10 RCTs and 5396 patients were included. The use of antimicrobial-coated sutures significantly lowered the risk of incisional SSIs compared with non-coated suture (risk ratio: 0.79, 95% confidence intervals: 0.64-0.98). In subgroup analyses, antimicrobial-coated sutures reduced the risk of SSIs for open surgeries, and when monofilament sutures were used. Antimicrobial-coated sutures did not reduce the incidence of abdominal wall dehiscence and the length of hospital stay compared with non-coated sutures. The certainty of the evidence was rated as moderate according to the GRADE criteria, because of risk of bias. In conclusion, the use of antimicrobial-coated sutures for fascial closure in gastrointestinal surgery is associated with a significantly lower risk of SSI than non-coated sutures.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Remimazolam anaphylaxis confirmed by serum tryptase elevation and skin test

Anaphylactic reactions during the induction of general anaesthesia are rare. Anaesthetists should determine the pathogenesis of anaphylaxis in order to establish appropriate treatment and prevent recurrence. Very little clinical information has been published to date about anaphylaxis induced by the recently launched drug remimazolam. A 78-year-old man, scheduled for elective surgery for colon cancer, became profoundly hypotensive and hypoxic shortly following the induction of general anaesthesia with remimazolam, remifentanil and rocuronium. His physiological derangement was successfully managed with adrenaline, vasopressors and intravenous fluid resuscitation. His serum tryptase level was significantly elevated and an intradermal test with diluted remimazolam revealed a positive reaction, confirming the diagnosis of anaphylaxis. We believe this is the first case report of remimazolam-induced anaphylactic shock diagnosed with a serum tryptase elevation and positive skin test.

Continued Chemotherapy After Concurrent Chemoradiotherapy Improves Treatment Outcomes for Unresectable Cutaneous Squamous Cell Carcinoma: An Analysis of 13 Cases

Background: There is no standard systemic therapy for unresectable cutaneous squamous cell carcinoma (ucSCC), although various chemotherapy regimens have been reported. In our department, concurrent chemoradiotherapy (CCRT) for ucSCC resulted in a 1-year survival rate similar to that of resectable cutaneous squamous cell carcinoma (cSCC). Treatment involves continued chemotherapy after CCRT. Here, we report the importance of continued chemotherapy after CCRT, based on treatment outcomes. Patients and Methods: We retrospectively evaluated 13 patients with ucSCC, assessing the overall survival, overall response rate (ORR), and disease control rate (DCR). Results: CCRT with continued chemotherapy resulted in an ORR of 84.6%, DCR of 92.3%, and 1-year survival rate of 75%. Of the 13 patients treated with CCRT with continued chemotherapy, 6 had no metastasis. The remaining 7 patients developed metastasis to other organs or lymph nodes beyond the regional lymph nodes, although most sites of metastasis were outside the irradiation area. Conclusion: We conclude that CCRT with continued chemotherapy was effective in treating the irradiation site (primary lesion and regional lymph nodes) and any organ metastasis, although, it is unclear for how long the treatment remains effective.

Dynamics of neutrophil and C-reactive protein reflect the clinical course of pyrexia during combination therapy with dabrafenib and trametinib

Pyrexia is the most common adverse event in patients with melanoma or other solid organ malignancies that are treated with the combination of dabrafenib and trametinib (combi-DT). Given the expanded indication for combi-DT, management of pyrexia is a high priority. No previous case series has revealed which blood markers reflect the course of pyrexia and there is no consensus on the management strategy for pyrexia. The current case series study describes the utility of neutrophil count (NC), neutrophil ratio (NR) and C-reactive protein (CRP) in 11 patients with metastatic melanoma and BRAF V600 mutations who experienced pyrexia during combi-DT in our department. We also described the clinical course of pyrexia episodes that were managed with the concomitant use of oral prednisolone and immediate withdrawal of combi-DT. Consequently, the analysis of 37 pyrexia episodes in 11 patients showed that the differences in NC, NR and CRP at the onset of pyrexia were significantly different from those at pyretolysis (P = 0.01, 0.006 and 0.03, respectively). Additionally, in the 24 pyrexia episodes treated with the concomitant use of oral prednisolone and the immediate withdrawal of combi-DT, the mean duration of pyrexia and the mean time to restart combi-DT were 3 and 6 days, respectively. Therefore, the blood markers that reflect the course of pyrexia during combi-DT may be helpful for the appropriate management of pyrexia; also, our management strategy for pyrexia successfully reduced the duration of pyrexia and did not require a long-term drug holiday. Further large-scale studies are required to verify our results.

Spatial and temporal patterns of bird species diversity in the Pantanal of Mato Grosso, Brazil: implications for conservation

Analysis of a three-year bird survey in the pantanal of Poconé revealed that most of the resident and seasonal birds are habitat generalists, using two or more habitats. In this study, previously sampled habitats were ranked in relation to species richness and stability (as measured by the ratio of seasonal to resident species). In all, nine habitats were grouped into three categories; results are as follows: 1) forests: more species-rich and more stable; 2) cerrado: intermediate levels; and 3) aquatic: less species-rich and less stable. The number of seasonal species remained relatively constant in forests throughout the year, while increasing in the other habitats during the dry season. The abundance of resident species seems to be related to species use of multiple habitats. Although many species were found to be habitat generalists, we discuss possible consequences of habitat loss and other human impacts on efforts to conserve this important bird community.

[Role of clinical data in NST: from the viewpoint of the clinical laboratory]

Serum albumin (Alb) sampling is used for patients who object to screening by NST. As Alb is decreased by malnutrition, it is available for nutritional assessment, reflecting the long-term nutritive condition. Recently, Alb was correlated with nutritional assessment proteins with RTP, like RBP, TTR and Tf. We recently set up a screening line of Alb < or =3.0g/dl; however, we will gradually elevate it to < or =3.5g/dl. The role of the medical technologist is to estimate the number of patients with < or =3.5g/dl, and investigate correlations between the Alb concentration and other markers, including ChE, TTR, TP and CRP.

IgG/IgA pemphigus with IgG and IgA antidesmoglein 1 antibodies detected by enzyme-linked immunosorbent assay

Pemphigus is an autoimmune mucocutaneous bullous disease characterized by autoantibodies against the cell surfaces of epidermal keratinocytes. Six cases with deposition of both IgG and IgA on keratinocyte cell surfaces have been reported in the recent literature. We provisionally termed these cases IgG/IgA pemphigus. We describe a 42-year-old Japanese woman with clinical and histopathological features resembling herpetiform pemphigus who demonstrated in vivo bound and circulating anticell surface autoantibodies of both IgG and IgA classes on immunofluorescence examination. Enzyme-linked immunosorbent assay using baculovirus-expressed recombinant desmoglein (Dsg) 1 and Dsg 3 showed that both IgG and IgA antibodies reacted with Dsg1. The reactivity was completely adsorbed with preincubation of serum with Dsg1 baculoprotein, further confirming the exclusive reactivity of both IgG and IgA antibodies with Dsg1. This is the second case of IgG/IgA pemphigus in which the human target antigens for both IgG and IgA antibodies have been unequivocally identified. This study provides further evidence that IgG/IgA pemphigus is a distinct disease entity.

Immune response to respiratory syncytial virus in young Brazilian children

We have evaluated the cellular and humoral immune response to primary respiratory syncytial virus (RSV) infection in young infants. Serum specimens from 65 patients <=12 months of age (39 males and 26 females, 28 cases <3 months and 37 cases > or = 3 months; median 3 3.9 months) were tested for anti-RSV IgG and IgG subclass antibodies by EIA. Flow cytometry was used to characterize cell surface markers expressed on peripheral blood mononuclear cells (PBMC) from 29 RSV-infected children. There was a low rate of seroconversion in children <3 months of age, whose acute-phase PBMC were mostly T lymphocytes (63.0 +/- 9.0%). In contrast, a higher rate of seroconversion was observed in children >3 months of age, with predominance of B lymphocytes (71.0 +/- 17.7%). Stimulation of PBMC with RSV (2 x 10(5) TCID50) for 48 h did not induce a detectable increase in intracellular cytokines and only a few showed a detectable increase in RSV-specific secreted cytokines. These data suggest that age is an important factor affecting the infants' ability to develop an immune response to RSV.

Gonadotropin-dependent expression of sterol 14-demethylase P450 (CYP51) in rat ovaries and its contribution to the production of a meiosis-activating steroid

Immunohistochemical analysis showed that sterol 14-demethylase P450 (CYP51) is expressed in mature follicles and corpus lutea of rat ovaries. In follicles, CYP51 is expressed in granulosa and theca cells but not in oocytes. The ovarian CYP51 activity of hypophysectomized rats is very low and induced by pregnant mares' serum gonadotropin (PMSG) treatment together with ovarian growth. The expression of CYP51 first increases in growing follicles and then appears in the corpus lutea after luteinization. The former event may be due to the follicular-stimulating hormone action of PMSG, and the latter may be caused by the luteinizing hormone effect of PMSG. Sterol analysis indicated that the product of the CYP51-mediated lanosterol 14-demethylation, 4,4-dimethylcholesta-8,14,24-trienol, which has been identified as a meiosis-activating steroid (MAS) in mammals [Byskov et al. (1995) Nature 374, 559-562], accumulates (about 10 pmol/mg of ovary) in mature rat ovaries, and the content is enough to activate the resumption of meiosis. These lines of evidence suggest that the expression of ovarian CYP51 is dependent on gonadotropins, and ovarian CYP51 activity is enough for accumulating MAS. Serum insulin does not affect the ovarian CYP51 level, although it is essential for hepatic CYP51 expression. These findings indicate that expression of CYP51 is regulated differently among organs.

Renal cell carcinoma with extension of tumor thrombus into the vena cava: surgical strategy and prognosis

PURPOSE

The outcome of patients who underwent radical resection of renal cell carcinoma extending into the vena cava was retrospectively analyzed, and risk factors for long-term survival were investigated.

METHODS

From 1983 to 1999, 33 patients who had renal cell carcinoma with inferior vena caval tumor extension underwent 34 surgical procedures. There were 27 men and six women with an average age of 60.1 years. Twenty-two cases (64.7%) were classified as stage III (T1-2 N1 M0 or T3 N0-1 M0), and 12 cases (35.3%) as stage IV (T4 or N2-3 or M1). Coexistent lung metastasis was found in seven cases (20.6%). The tumor thrombi invaded into the inferior vena cava below the hepatic hilum in 19 cases, below the orifice of hepatic veins in 12, and above the diaphragm in 3. Cardiopulmonary bypass graft was applied in 13 cases (38.2%). Inferior vena cava was reconstructed by direct suture (n = 19), polytetrafluoroethylene patch angioplasty (n = 13), or graft replacement (n = 2).

RESULTS

Two patients died during the early postoperative period because of retrohepatic caval injury and intraoperative pulmonary embolism. Late death occurred in 16 patients; the causes of death were tumor recurrence in 15 and acute pulmonary embolism as a result of graft thrombosis in 1. Overall 1-, 5-, and 10-year survival rates were 70%, 44%, and 26.4%, respectively. One- and 5-year survival rates were 81.3% and 52.9% for stage III and 50% and 31.2% for stage IV; a statistically significant correlation was found between surgical staging and survival (P =.049). Patients without lymph node metastasis had a significant survival advantage over those with lymph node metastasis (P =.022). There was no significant difference in survival on the basis of the presence or absence of synchronous lung metastasis (P =.291). The degree of local extension of the tumor or the level of tumor thrombus did not tend to influence survival.

CONCLUSIONS

Surgical prognosis in patients with renal cell carcinoma extending into the vena cava was determined by the staging of the tumor, especially lymph node status, and not by the level of tumor thrombus or the presence of concurrent lung metastasis. The use of cardiopulmonary bypass graft is recommended for the resection of tumor thrombus extending over the diaphragm.

Management of cholelithiasis in combination with cardiovascular surgery

A retrospective review of the perioperative management of patients with cardiovascular surgical disorders and cholelithiasis was conducted, and the surgical strategies employed are discussed. Between 1988 and 1998, 18 patients having cardiovascular surgical disorders underwent cholecystectomy. These patients were divided into three groups: group I, given a one-stage operation (n = 9); group II, given a two-stage operation (n = 3); and group III, given cholecystectomy during follow-up after cardiovascular surgery (n = 6). In group I, a median laparotomy was adopted for patients with an abdominal aortic aneurysm (AAA) to allow both disorders to be treated through the same incision, whereas a right subcostal approach was employed to separate the incisions for patients who underwent cardiac operations. In group II, one patient underwent cholecystectomy before cardiac surgery, and two patients underwent cholecystectomy for postoperative cholecystitis after cardiovascular operations. One patient from group II and all from group III were on preoperative anticoagulant therapy, two of whom underwent laparoscopic cholecystectomy. No fatal complications such as prosthetic infection, intraperitoneal hemorrhage, or cerebral attack were encountered. In conclusion, we consider that performing cholecystectomy during AAA repair may be safe and prevents the risk of postoperative cholecystitis; it is preferable to treat cholelithiasis coexisting with cardiac disorders concomitantly with or before cardiac operations; and laparoscopic cholecystectomy can be safely performed under anticoagulant therapy.

Tension hemothorax caused by a ruptured aneurysm of the descending thoracic aorta: report of a a case

The rupture of an aneurysm of the descending thoracic aorta into the right thoracic cavity is a comparatively rare event, and it is very difficult to establish a diagnosis immediately and rescue such patients. We describe herein the successful surgical treatment of a patient with this life-threatening emergency by initiating immediate cardiopulmonary bypass. It is mandatory to drain the right thoracic bleeding through a left thoracotomy without delay to release the tension hemothorax. Furthermore, it is necessary to evacuate the right thoracic hematoma through a right thoracotomy because complete removal o f a hugh hematoma through a left thoracotomy cannot be effectively achieved.

Design and synthesis of potential inhibitors of the ergosterol biosynthesis as antifungal agents

A series of azolylmethyloxolane derivatives with modified sterol side-chain structures, designed as potential dual functional inhibitors of cytochrome P450 14alpha-demethylase (14DM) and delta24-sterol methyltransferase (24-SMT) based on the common characteristic features of 24-aminosterols and azole antifungal agents, were synthesized and evaluated for their antifungal activities and inhibitory activities of 14DM and 24-SMT. Among these compounds, imidazolylmethyloxolane derivatives 28a and 28b showed potent in vitro antifungal activities comparable to those of itraconazole. However, the in vitro bioactivities have not been linearly translated into in vivo protection data for some unknown reasons.

Insulin is the essential factor maintaining the constitutive expression of hepatic sterol 14-demethylase P450 (CYP51)

The role of serum insulin in regulating the expression level of hepatic sterol 14-demethylase P450 (CYP51) was examined. Administration of streptozotocin, which destroys pancreatic beta-cells, caused reduction of CYP51 mRNA level in rats in parallel with the loss of serum insulin. Streptozotocin treatment also reduced the CYP51 activity. The decreased mRNA level and activity of the streptozotocin-treated rats were restored to the normal level within 24 h by repeated administration of insulin. CYP51 level of normal rats was insensitive to the circadian variation of serum insulin and insulin administration, and no significant difference was observed between the hepatic CYP51 activities of Sprague-Dawley and Wistar lean rats, although the serum insulin concentration of the latter was higher than the former. These facts indicate that the expression of hepatic CYP51 is maintained by serum insulin, and its lowest physiological level is sufficient for supporting the expression of CYP51. The responses of CYP51 expression to streptozotocin and insulin treatments were closely similar to those of the sterol regulatory element binding protein (SREBP)-1c expression [Shimomura et al. (1999) Proc. Nat. Acad. Sci. USA 96, 13656-13661]. Based on this fact, the possible contribution of SREBP-1c to the insulin-dependent expression of hepatic CYP51 gene was also discussed.

Intravenous leiomyomatosis extending into the right ventricular cavity: one-stage radical operation using cardiopulmonary bypass--a case report

The authors describe a 47-year-old woman with intravenous leiomyomatosis (IVL) extending into the right ventricular cavity. This rare entity is a neoplasm originating from smooth muscle of the uterus, with vermiform extensions into the inferior vena cava. The patient underwent a one-stage operation under simultaneous sternotomy and laparotomy, and radical excision of the tumor was successfully achieved with use of normothermic cardiopulmonary bypass. Although this tumor is histologically benign, it sometimes extends into the cardiac cavity and causes sudden death due to incarceration into the atrioventricular orifice. Moreover, recurrence or lung metastasis of IVL has been reported. The authors recommend a one stage-radical resection of the tumor or a two-staged operation within a short interval. In the literature, 24 surgical cases of the intravenous leiomyomatosis with intracardiac extension have been reported. The diagnosis and surgical treatment of this tumor are reviewed and discussed.

Perfusatory recovery of the grafted lung during convalescence from acute rejection

The aim of this study was to evaluate whether or not perfusatory recovery of the grafted lung occurs is the early stage of convalesce from acute rejection following a single lung transplantation. Eight adult mongrel dogs underwent an allotransplantation of the left lung with treatment of 10 mg/kg cyclosporine and 4 mg/kg azathioprine. Doppler flow probes were placed to the ascending aorta and the left pulmonary artery. Immunosuppressant therapy was discontinued to induce rejection after postoperative day 14. When the left pulmonary artery flow rate (l-PAFR) decreased to less than 20%, methylprednisolone (20 mg/kg) was administered for 3 days along with a resumption of cyclosporine and azathioprine. Pulmonary circulation and chest roentgenograms were evaluated every day through the rejection episode. An open lung biopsy was also performed in each dog to obtain specimens of the grafts and native lungs for histologic examination. When l-PAFR decreased to less than 20%, mild acute rejection was found in all dogs. l-PAFR increased significantly on the third day after methylprednisolone treatment. Thereafter, a histologic examination revealed minimal acute rejection in one dog and no abnormality in seven dogs. The perfusatory recovery of the grafted lung was thought to reflect the histological change in the course of convalescence.

[Transaortic video-assisted thrombectomy in the left ventricular cavity after acute myocardial infarction]

In recent years much attention has been paid to a minimal invasive surgery even in the field of cardiac surgery. We have successfully treated a 59 year-old male who underwent transaortic video-assisted thrombectomy in the left ventricular cavity following acute myocardial infarction due to occlusion (No. 7) of the left descending coronary artery (LAD). After the LAD was recanalized by percutaneous transluminal coronary angioplasty (PTCA) and then stenting, this thrombectomy was carried out. Following initiation of cardiopulmonary support, thrombus in the left ventricular apex was safely removed by transaortic endoscopic guidance. This technique was useful especially for the patient with poor ventricular function due to acute myocardial infarction because of no left ventriculotomy. Endoscopic guidance technique is reported in detail.

Insulin is a dominant suppressor of sterol 12 alpha-hydroxylase P450 (CYP8B) expression in rat liver: possible role of insulin in circadian rhythm of CYP8B

Sterol 12 alpha-hydroxylase (CYP8B) is a key enzyme for regulating the cholic acid/chenodeoxycholic acid ratio in bile acid biosynthesis. The hepatic CYP8B level was elevated in streptozotocin-induced diabetic rats, and the elevated CYP8B was suppressed by insulin administration [Ishida, H. et al. (1999) J. Biochem. 126, 19-25]. The streptozotocin-induced elevation of hepatic CYP8B mRNA concomitantly responded to the decrement of the serum insulin level. The CYP8B mRNA level in the cultivated rat hepatoma H4TG cells was strongly suppressed by insulin, although it was affected by dibutyryl cAMP or thyroxine to lesser extents. These observations demonstrate that CYP8B expression is dominantly regulated by the direct action of insulin on hepatocytes. A marked circadian rhythm (maximum at 13:00-16:00 and minimum at 1:00) was observed both on the mRNA level and the activity of CYP8B. This rhythm was shifted from that of cholesterol 7 alpha-hydroxylase, a rate-limiting enzyme of bile acid biosynthesis, showing a maximum at 22:00 and a minimum at 10:00, and this shift might oscillate the cholic acid/chenodeoxycholic acid ratio, which is increased in the late afternoon and decreased at midnight. The rhythm of CYP8B was the inverse of the circadian variation of serum insulin level and was similar to the circadian rhythm of glucose 6-phosphatase. These facts and the potent suppressive effect of insulin on CYP8B indicate that the oscillation of the serum insulin may be a factor in producing the circadian rhythm of CYP8B.

Surgical assessment of tricuspid valve replacement for severe tricuspid regurgitation without stenosis

Eight patients undergoing tricuspid valve replacement (TVR) for severe tricuspid regurgitation (TR) without stenosis were subjected to the study. Four patients had primary TR due to trauma, infective endocarditis, or Ebstein's anomaly, and the other 4 had secondary TR associated with mitral valve lesions. The right heart pressure as well as clinical manifestations due to right heart failure showed deteriorated values in both the primary and secondary TR groups, though pulmonary arterial pressure was higher in the latter group. In 2 patients, initial annuloplasty procedures could not reduce TR sufficiently and were instantly abandoned for TVR. These 2 patients, one with congenital and one with secondary TR, died of intractable right heart failure early postoperatively, while the remaining 6 patients are alive to date, in the New York Heart Association (NYHA) functional class I, during the follow-up period of 6-192 (mean, 104) months. The 2 patients who died had shown a longer morbid duration and a lower preoperative right ventricular systolic function indicated by stroke work to pulmonary artery resistance. This paper might suggest that an earlier surgical intervention in severe TR is recommended before the right ventricular function deteriorates.

Preventive influence of inhaled nitric oxide on lung ischemia-reperfusion injury

In lung transplantation, lung ischemia-reperfusion injury is a serious problem when using long-term preserved grafts. A warm ischemic lung model was prepared using rabbits. NO was administered by inhalation (group I, n = 9). The control group was not administered NO (group II, n = 8). Severe ischemia-reperfusion injury occurred as evidenced by hypoxia and lung edema. PaO2 at 120 min after reperfusion was 325 +/- 41 mmHg in group I and 40 +/- 6 mmHg in group II. The pulmonary blood flow of the left lung at 120 min after reperfusion was 51% +/- 3% in group I and 20% +/- 5% in group II. The wet-to-dry weight ratio was 5.5 +/- 0.2 for the right lungs, 5.8 +/- 0.8 for the left lung in group I, and 6.1 +/- 0.4 for the left lung in group II. Histopathologically, marked hemorrhage, hyaline membrane formation, and leukocyte infiltration were observed in group II but not in group I. These data suggested that inhaled NO reduced warm ischemia-reperfusion injury in the lung, and also contributed to a better preserved lung function.

Transaortic video-assisted removal of a left ventricular thrombus

A mobile and pedunculated left ventricular thrombus was developed after acute myocardial infarction in a 59-year-old man, and was successfully removed surgically through the aortic valve using a video-assisted thoracoscope. Transaortic video-assisted thoracoscopy greatly facilitated exposure of the interior of the left ventricle and preserved left ventricular function by avoiding ventriculotomy.

Valvular heart disease. A comparative study of results after primary operation, reoperation, and after multiple reoperation

Reoperation for valvular heart disease has been associated with a higher operative mortality than primary operations, especially in patients who had multiple prior operations. We have analyzed the 226 consecutive patients who underwent valve replacement. These involved 163 primary operations, 52 first reoperation, and 11 second/third reoperations. Preoperative left ventricular dysfunction was more severe, and operation time and cardiopulmonary bypass time were significantly greater according to the number of operations, associated with a greater amount of intraoperative blood loss. The operative mortality after a second/third reoperation was 27.3%, which was significantly higher than that after primary operation (6.7%) (p < 0.05), and that after first reoperation (5.8%) (p < 0.05). Seven (64%) patients who underwent a second/third reoperation had poor preoperative left ventricular function (%FS < 25%), and 5 (71%) of these required postoperative mechanical supports, and 3 (60%) of the 5 patients died of low output syndrome. We have found that poor preoperative left ventricular function and the duration on cardiopulmonary bypass, but not the number of reoperation were correlated with operative mortality. Continued efforts should be directed to decrease the mortality for multiple reoperative valve surgery.

Structure, evolution, and liver-specific expression of sterol 12alpha-hydroxylase P450 (CYP8B)

The rat CYP8B cDNA encoding sterol 12alpha-hydroxylase was cloned and sequenced. The amino acid sequence of the heme-binding region of CYP8B was close to those of CYP7A (cholesterol 7alpha-hydroxylase) and CYP7B (oxysterol 7alpha-hydroxylase). Molecular phylogenetic analysis suggests that CYP8B and the CYP7 family derive from a common ancestor. The P450s of the CYP7 and CYP8 families, except for CYP8A (prostacyclin synthase), catalyze the oxygenation of sterols from an alpha surface in the middle of the steroid skeleton. These facts suggest that CYP8B is a P450 closely linked to those of the CYP7 family. CYP8B was expressed specifically in liver. Hepatic CYP8B mRNA level and the 12alpha-hydroxylase activity were altered by cholestyramine feeding, starvation, streptozotocin-induced diabetes mellitus, and administration of clofibrate, dexamethasone or thyroxin, indicating the pretranslational regulation of CYP8B expression. The enhanced CYP8B mRNA expression in streptozotocin-induced diabetic rats was significantly decreased by insulin within 3 h of its administration. These facts demonstrate a regulatory role of insulin in CYP8B expression as a suppressor.

Aortic valve replacement after retrosternal gastric tube reconstruction for esophageal cancer

A 59-year-old man with a history of the thoraco-abdominal esophagus resection with retrosternal gastric tube reconstruction for esophageal cancer complicated by anastomosis leakage and purulent pericarditis was admitted for aortic regurgitation due to infective endocarditis. Floppy vegetation and worsening cardiac failure indicated aortic valve replacement. In a median sternotomy approach, the thickest adhesion between the cervical esophagus and posterior surface of the manubrium sternae was freed using an ultrasonic osteotome. Severe adhesions in the pericardium due to purulent pericarditis were found. Median sternotomy enabled minimal exposure of the aortic root, upper right atrium, and right superior pulmonary vein for instituting extracorporeal circulation and replacing the aortic valve. The patient's postoperative course was uneventful. For cardiac surgery in patients with a retrosternal gastric tube, left anterior or right thoracotomy may be considered to avoid gastric tube injury. Median sternotomy, however, is an alternative enabling safe heart exposure, and the ultrasonic osteotome was very useful in incising the sternum without injuring the cervical esophagus, which had no serosa.

Usefulness of postoperative percutaneous cardiopulmonary support using a centrifugal pump: retrospective analysis of complications

Between January 1992 and December 1997, we employed percutaneous cardiopulmonary support (PCPS) using a centrifugal pump in 25 patients. In 21 of them, PCPS was used postcardiotomy. These patients could not be weaned from cardiopulmonary bypass due to profound ventricular failure. As for the other 4 patients, PCPS was used preoperatively for profound cardiogenic shock, a thrombosed valve, a stuck valve, and pulmonary embolization. Nine patients (43%) were weaned from PCPS (Group 1), and 3 (14%) were discharged from the hospital. The other 12 patients (57%) had perioperative extensive myocardial infarction and could not be weaned (Group 2). The causes of death were bleeding and multiple organ failure (MOF) associated with ventricular failure. The reasons for MOF were perioperative massive transfusion and hepatic congestion caused by sustained ventricular failure. To increase the survival rate, complete hemostasis and prevention of increased central venous pressure by early use of PCPS are necessary.

Mild hypothermia for temporary brain ischemia during cardiopulmonary support systems: report of three cases

Recovery without residual neurological damage after cardiac arrest with temporary cerebral ischemia is rare. Therefore, it is most important that every effort is made to prevent brain damage occurring immediately after successful cardiopulmonary resuscitation. We report herein the cases of three patients who suffered either cardiogenic or hypovolemic shock and were resuscitated by a cardiopulmonary support system followed by mild hypothermia. All three patients recovered completely without any neurologic damage. The outcomes of these three patients demonstrated that mild hypothermia may be important for cerebral preservation after cardiopulmonary resuscitation.

The effect of direct lidocaine injection into the clamped aortic segment on the spinal evoked potential: early diagnosis for spinal cord ischemia

PURPOSE

The aim of this study was to identify a method to determine whether segmental artery reconstruction was indicated during aortic clamping.

METHOD

Spinal cord evoked potential (SCEP) and regional spinal blood flow were studied in 24 adult dogs. Using the left heart bypass technique, aortic clamping divided the aorta into thoracic, abdominal, and terminal segments. After the occlusion of the descending aorta and discontinuation of the perfusion to the abdominal segment, animals were assigned to four groups: no treatment with perfusion to the terminal aorta (group IA), no treatment with cessation of bypass (group IB), 5% lidocaine administration (5 mg/kg) into the abdominal segment with perfusion to the terminal aorta (group IIA), and lidocaine administration with cessation of bypass (group IIB).

RESULTS

Cessation of bypass reduced spinal blood flow and SCEP amplitude. Lidocaine injection allowed for a significant rapid decrease in SCEP amplitude in group IIB compared with group IB (24.2% +/- 13.4% versus 92.3% +/- 33.2%; p = 0.0039). The degree of spinal blood supply was reflected immediately in the magnitude of SCEP amplitude change by the direct lidocaine injection. (group IB versus group IIB; p = 0.023).

CONCLUSION

The direct injection of lidocaine into the clamped aorta results in a rapidly change in SCEP in the threat of ischemia and can be used to make an early detection of the segmental arteries perfusing to the spinal cord.

Efficacy of initial controlled perfusion pressure for ischemia-reperfusion injury in a 24-hour preserved lung

In lung transplantation, the safety period of the ischemic time of the graft is within 6 hours. Because of the problem of donor shortage, it is essential to extend the safety period of the preservation time of the donor lung. However, the longer the preservation time is, the more severe is the resulting ischemia-reperfusion injury. This study was designed to evaluate the efficacy of initial controlled perfusion pressure in the reduction of ischemia-reperfusion injury in a 24-hour preserved lung. Japanese white rabbit lungs were flushed with a low-potassium dextran solution (4C, 500 ml) after injection of prostaglandin E1 (20 microgram, bolus via PA) and submersed in the same solution for 24 hours at 4C. After preservation, the left lung was reperfused using an extracorporeal lung perfusion model which comprised of a closed circuit combined with a membrane deoxygenator. Assessment of lung function included gas analysis of influent and effluent blood and mean pulmonary artery perfusion pressure. Then the lung wet/dry weight ratio was calculated. In group I of the control group (n=6), the left lung was reperfused immediately following flushing (without preservation) at a flow rate of 50 ml/min for 60 minutes. In groups II and III, grafts were stored for 24 hours. In group II, grafts (n=6) were reperfused at a flow rate of 50 ml/min for 60 minutes. In group III (n =6), the flow rate was controlled by maintaining the perfusion pressure below 30 mmHg during the initial 5 minutes and was increased to 50 ml/min for the subsequent 60 minutes. In group II, the mean pulmonary artery pressure during perfusion increased rapidly, and oxygenation deteriorated. All grafts developed pulmonary edema within 12 minutes after reperfusion. Examination of the specimen revealed that the peripheral lung was not perfused. In group III, the mean pulmonary artery perfusion pressure was maintained below 30 mmHg, and oxygenation was preserved sufficiently throughout the experiment (delta PO2 > 100 mmHg) with no significant difference from control values. In conclusion, ischemia-reperfusion injury of the 24-hour preserved lung was attenuated prominently by controlling initial perfusion pressure for 5 minutes.

Usefulness of cardiopulmonary bypass in reconstruction of inferior vena cava occupied by renal cell carcinoma tumor thrombus

Aggressive surgical treatment in renal cell carcinoma is still controversial. The aim of this paper is to assess inferior vena caval (IVC) reconstruction for suprahepatic vena caval renal cell carcinoma (RCC) tumor thrombus. Twelve patients with suprahepatic vena caval thrombus from renal cell carcinoma who underwent surgical repair with cardiopulmonary bypass were evaluated. The vena caval defect was reconstructed by direct suture, patch repair, or graft replacement. Of 12 patients undergoing partial cardiopulmonary bypass, tumor thrombus extended to the junction of the hepatic vein in three patients and to the right atrium in one. Tumor thrombus was removed manually or with balloon catheter. Tumor thrombus in the right atrium was removed during electrical ventricular fibrillation. Repair of the IVC was performed by direct suture of the IVC wall in two patients, patch repair with expanded polytetrafluoroethylene (EPTFE) graft in seven, and graft replacement with an EPTFE graft in three. There were no operative deaths and the only postoperative complication was one patient death from pulmonary emboli. The four patients with nonlocalized disease died within 2 years, but four patients lived for more than 3 years postoperatively. Survival was 37.5% at 3 years and 18.8% at 5 years by the Kaplan-Meier's method.

CONCLUSIONS

(1) Partial cardiopulmonary bypass is useful for the control of bleeding when tumor thrombus in the IVC extends to the junction of the hepatic vein. (2) Nephrectomy with tumor thrombectomy of the IVC is valuable, and long-term survival is possible in patients without distant metastases or regional lymph node metastases.

Results of surgical treatment for thoracoabdominal aneurysm using cardiopulmonary bypass under moderate hypothermia and selective visceral artery perfusion

From 1994 to 1997, 11 consecutive patients with thoracoabdominal aneurysms underwent surgery using cardiopulmonary bypass under moderate hypothermia (33 degrees C) and selective visceralartery perfusion for spinal cord and visceral organ protection. Distal perfusion pressure was maintained above 60 mmHg (mean) during cardiopulmonary bypass. In the four patients, one or two pairs of large intercostal arteries between Th10 and L2 were reimplanted. In the four patients, visceral and renal arteries were reconstructed. Surgical mortality rate within 1 month was 18.2% (2/11). One patient died of bleeding from old empyema and another of multiple organ failure. No patients had paraplegia. In conclusion, cardiopulmonary bypass with selective visceral artery perfusion under moderate hypothermia may contribute to the prevention of the occurrence of paraplegia and acute renal failure.

Extra-anatomical bypass with EPTFE graft for residual pulmonary artery stenosis in Tetralogy of Fallot

We describe the case of 35-year old woman who had undergone radical surgery to correct Tetralogy of Fallot malformation at the age of nine admitted to our hospital because of palpitation and exertional dyspnea. Angiography revealed 90% re-stenosis of the right pulmonary artery and grade IV tricuspid regurgitation. Right lung was perfused only 16.7% as shown by pulmonary perfusion scintigraphy. Interposition between the pulmonary trunk and right pulmonary artery using an EPTFE graft and tricuspid annuloplasty using a Duran ring was performed. Blood flow to the right lung improved markedly from 16.7% to 37.0% and her symptom disappeared completely.

Reoperation after repair of type A and B dissecting aneurysm

BACKGROUND

In the late postoperative period after repair of an aortic dissection or dissecting aneurysm, reoperations may be required. The interval to reoperation, size and location of intimal tear, and results of reoperation were evaluated.

METHODS

Between January 1982 and April 1997, 138 patients underwent surgery for Stanford type A (90 patients) or type B (48 patients) dissections of the aorta. The entire aorta was evaluated in postoperative follow-up by computed tomography and magnetic resonance imaging for 6 months to 15 years. Reoperations were performed in 14 (10.1%) patients with changes in the aneurysms at the site of the initial repair or in the distal aorta. Selective cerebral perfusion or retrograde cerebral perfusion with deep hypothermia was used in the repair of the ascending, arch, and distal arch aneurysms. Reoperations included aortic root reconstruction (n=3), resection of a pseudoaneurysm (n=1), and replacement of the ascending aorta (n=1), arch (n=5), descending aorta (n=2), thoracoabdominal aorta (n=1), or abdominal aorta (n=1). Secondary reoperations were performed in four patients (replacement of the arch [n=2], thoracoabdominal aorta and abdominal aorta). Consequently two patients had subtotal aortic replacements. The aneurysms were caused by an anastomotic leak, a new intimal tear following aortic cross-clamping, a second intimal tear in the distal arch or abdominal aorta, and Marfan syndrome.

RESULTS

Two patients (2/18 11.1%) died of bleeding or low output syndrome. Two patients died of graft infection or prosthetic valve infection 3 months after surgery respectively.

CONCLUSIONS

1) The surgical results of reoperation for type A and B dissections were good. 2) Close postoperative follow-up of the patent false lumen in the entire aorta was necessary. 3) At the initial operation, total resection of the intimal tear in the aortic arch in low-risk patients reduced the risk of reoperation.