[Coronary artery bypass grafting for simultaneous subacute stent thrombosis after sirolimus-eluting stent implantation].

An 82-year-old man developed simultaneous stent thrombosis 11 days after the implantation of a sirolimus-eluting stent (SES) in the proximal left anterior descending artery (LAD) and the proximal right coronary artery (RCA). The patient immediately underwent percutaneous coronary intervention; however, his condition became critical due to the development of recurrent stent thrombosis, and emergent coronary artery bypass grafting with saphenous vein grafts was performed. Postoperative angiography showed good patency of both grafts; thrombus formation in the LAD and RCA was negative. Since the patient had a history of liver dysfunction due to ticlopidine administration, the thienopyridine derivative was not administered; this was believed to be the main cause of subacute stent thrombosis. He was administered aspirin, cilostazol, and sarpogrelate instead. A good postoperative course was achieved only using aspirin. This case demonstrates that simultaneous SES thrombosis in multivessel lesions poses a life-threatening situation.

Acute hydrocephalus in posterior fossa injury.

This is the first known report of the use of computerized tomography (CT) scanning to examine acute hydrocephalus in posterior fossa injury. Of the 1802 patients with acute head trauma treated at Funabashi Municipal Medical Center, 53 (2.9%) had suffered injury to the posterior fossa. Of these, 12 patients (22.6%) had associated acute hydrocephalus: nine patients with acute epidural hematoma (AEH) and three with intracerebellar hematoma and contusion (IH/C). There was a significant relationship between cases of AEH with hydrocephalus and supratentorial extension, hematoma thickness of 15 mm or more, and abnormal mesencephalic cisterns. In cases of IH/C, bilateral lesions and no visible fourth ventricle were significant causes of hydrocephalus. According to these results, possible mechanisms of acute hydrocephalus in posterior fossa injury may be as follow: in cases of AEH, hematoma that extends to the supratentorial area compresses the aqueduct posteriorly and causes hydrocephalus; in cases of IH/C, hematoma and contusional lesions may directly occlude the fourth ventricle and cause acute hydrocephalus. Seven patients suffering from AEH with acute hydrocephalus underwent evacuation of their hematoma without external ventricular drainage. In these cases, CT scanning showed that the hydrocephalus improved immediately after evacuation of the hematoma. Two patients suffering from IH/C with hydrocephalus underwent a procedure for evacuation of the hematoma and external ventricular drainage. The authors do not believe that ventricular drainage is necessary in treating posterior fossa AEH. However, both evacuation of the hematoma and ventricular drainage are necessary in cases of IH/C with hydrocephalus to provide the patient with every chance for survival. There was no significant difference in mortality rates when cases of AEH with acute hydrocephalus (0%) were compared with cases of AEH without hydrocephalus (7.7%). The observed mortality rates in cases of IH/C with hydrocephalus and those without hydrocephalus were 100% and 15.4%, respectively; this is statistically significant.

[Transition of patients with chronic neurological diseases from hospital to home].

The following steps are essential in promoting a successful transition. (1) General condition of the patient must be stable. (2) Both parents must give consent to home care. (3) One parent at least must be thoroughly trained in all aspects of care. (4) Medical supplies must be kept in the home, and home modification to provide easy access and movement should be done as much as possible. (5) A medical support system must be established; home visiting nurses must be provided; medical doctors in the neighborhood and the local ambulance dispatch center must be notified of the patient's condition in case of an emergency.

[Off-pump coronary artery bypass grafting for patients with cardiogenic shock due to acute myocardial infarction].

UNLABELLED: Off-pump coronary artery bypass (OPCAB) is less invasive, so we have recently been expanding the indication. We performed OPCAB for 3 patients with cardiogenic shock due to acute myocardial infarction (AMI). PATIENTS: All patients were supported hemodynamically by intra-aortic balloon pumping (IABP) prior to surgery. RESULTS: We performed the revascularization of territories for the left anterior descending artery (LAD) and right coronary artery (RCA) in these high risk patients using OPCAB technique to improve the hemodynamic state. In all patients, IABP was removed within 48 hours after surgery and the postoperative course was uneventful. CONCLUSIONS: It seems that OPCAB is a useful and effective procedure for a selected patient even with cardiogenic shock due to AMI.

[Re-coronary artery bypass grafting using a MIDCAB technique in a patient with a patent RITA-LAD graft].

In a patient with a patent RITA-LAD (right internal thoracic artery-left anterior descending artery) graft, re-CABG (re-coronary artery bypass grafting) with re-median sternotomy has been a high risk procedure. A 56-year-old male underwent 4-CABG (RITA-LAD, LITA-Dx, SVG-PL, and SVG-RCA) nine years ago. Coronary angiography showed that the RITA-LAD graft was well patent, but there was 95% stenosis distal to RITA-LAD anastomosis site. We performed re-CABG (right gastroepiploic artery-LAD; RGEA-LAD), using MIDCAB (minimally invasive direct coronary artery bypass) technique with neither re-median sternotomy nor cardiopulmonary bypass. The right gastroepiploic artery was harvested through a small upper median laparotomy and anastomosed to LAD through a small left anterior thoracotomy. The postoperative course was uneventful. This technique seems to be useful for re-revascularization of the LAD in a patient with a patent RITA-LAD graft.

[Antiemetic efficacy of the repeated use of granisetron in multiple cycles of anti-cancer chemotherapy].

Twenty-three patients with gynecological cancer who were treated with 85 cycles of cytotoxic chemotherapy containing platinum received intravenous granisetron repeatedly. Granisetron (3 mg/body) was drip-infused twice for each cycle at a 24-hour interval. The antiemetic efficacy was evaluated and compared for each day and each cycle, and analysed using the chi-square and H tests. There were no significant differences between the first cycle and the subsequent second through fifth cycles in the severity of nausea and the frequency of vomiting. The latter tended to increase in the second day of each cycle. These results indicated that granisetron does not decrease in antiemetic efficacy by repeated administration during multiple cycles of anti-cancer chemotherapy.

Laparascope-assisted versus conventional restorative proctocolectomy with rectal mucosectomy.

To assess the advantages of a laparoscope-assisted proctocolectomy with ileal J-pouch anal anastomosis compared with conventional procedures, we retrospectively analyzed the results of the two procedures as follows: Eleven patients including five patients with familial adenomatous polyposis (FAP) and six with ulcerative colitis (UC) underwent a laparoscope-assisted proctocolectomy and hand-sewn ileal J-pouch anal anastomosis at our department from June 1997 to November 1999. This laparoscope-assisted colectomy (LAC) group was then compared with a group of 13 patients who had undergone conventional ileal pouch anal anastomosis using a standard laparotomy from 1986 to 1997. The median operative time of the LAC group was 8h 23min, which was 81 min longer than that of the standard colectomy (SC) group. The number of days during which eating was prohibited were similar in the two groups but the median postoperative hospital stay was significantly shorter in the LAC group (24.1 days). In the LAC group, the small incisions showed better cosmetic results and there was also a remarkable reduction in the degree of postoperative pain. In conclusion, a laparoscope-assisted proctocolectomy with ileal J-pouch anal anastomosis can be employed widely in patients with FAP and also in selected patients with UC.