The ideal intercostal space for internal mammary vessel exposure during total rib-sparing microvascular breast reconstruction: A critical evaluation.

BACKGROUND: Total rib-preserving free flap breast reconstruction (RP-FFBR) using internal mammary vessel (IMV) recipients usually involves vessel exposure in the second or third intercostal spaces (ICS). Although the third one is more commonly used, no direct comparisons between the two have hitherto been performed. OBJECTIVES: To compare the in-vivo topography and vascular anatomy of second and third ICSs in patients undergoing FFBR using the rib-preservation technique of IMV exposure. METHODS: An analysis of prospectively collected data on intercostal space distance (ISD), number and arrangement of IMVs, location of venous confluence, and vessel exposure time was conducted on a single surgeon's consecutive RP-FFBRs. RESULTS: A total of 296 RP-FFBRs were performed in 246 consecutive patients. The second, third, or both second and third spaces were utilized in 282, 28, and 22 cases, respectively. The ISDs were 20.6 mm ±â€¯3.52 for the second ICS and 14.0 mm ± 4.35 for the third ICS (p<0.0001, CI = 5.17-7.97, t-test). The second versus third ICS vein content was as follows: single 81.4% vs. 74%, dual 18.6% vs. 26%, and confluence 3.7% vs. 13%. The second ICS single vein was medial to the artery in 92.6%. The third ICS single vein was medial to the artery in 88.2% Vessel exposure times for second (47.2 mins ±â€¯26.7) and third (46.5 mins ±â€¯31.4) spaces were similar (p = 0.93). The overall intraoperative anastomotic revision rate was 9.1%, and the postoperative flap re-exploration rate was 4.0%, with 99.7% overall flap success. DISCUSSION AND CONCLUSION: Preferential use of the second ICS is supported by its more predictable vascular anatomy, a broader space for performing the microanastomoses and a higher frequency of a single postconfluence (and thus larger) vein facilitating the microsurgery.

Phase I study of CPT-11 and etoposide in patients with refractory solid tumors.

PURPOSE: To determine the maximum-tolerated dose (MTD) and acceptable dose level of a cytotoxic regimen of CPT-11, a new camptothecin derivative, in combination with etoposide (VP-16) and to describe the principal toxicities associated with it. PATIENTS AND METHODS: Patients with refractory solid tumors received VP-16 and CPT-11 daily for 3 consecutive days (days 1 through 3) every 3 or 4 weeks. Groups entered the trial at escalating CPT-11/VP-16 dose levels of 40/60, 60/60, 60/80, and 80/60 mg/m2. Thirty-four patients entered this study, of whom 33 were assessable for toxicity and 22 for therapeutic efficacy. RESULTS: Granulocytopenia was so severe that this regimen required supportive therapy with recombinant human granulocyte colony-stimulating factor (G-CSF). The majority of the patients experienced a 5% weight loss and diarrhea was the dose-limiting toxicity. The MTDs were 60/80 and 80/60 mg/m2 administered on days 1 through 3. Five of seven previously untreated patients with non-small-cell lung cancer (NSCLC) achieved partial responses (PRs) to this therapy, as did two with NSCLC who had received prior chemotherapy, two with head and neck cancer, and one with an adenocarcinoma (primary tumor unknown). CONCLUSION: The recommended dose of CPT-11/VP-16 for this regimen with G-CSF is 60/60 mg/m2 on days 1 through 3 every 3 to 4 weeks. We suggest that the combination of topoisomerase I and II inhibitors is likely to be an effective treatment strategy. The activity of this regimen against NSCLC is particularly encouraging and should be evaluated in a phase II trial.

Laparoscopic partial or cortical-sparing adrenalectomy by dividing the adrenal central vein.

BACKGROUND: We perform laparoscopic partial adrenalectomy without sectioning the adrenal central vein has been described because it is important to preserve this vein in the remnant adrenal gland in order to maintain its function. In this article, we describe our technique for laparoscopic partial or cortical-sparing adrenalectomy by dividing the adrenal central vein. METHODS: The procedures were performed in four patients with aldosterone-producing adenomas (APA) and two patients with pheochromocytomas. RESULTS: There were no postoperative complications. At follow-up, adrenal 131I-adosterol scintigrams showed that remnant adrenal function had been preserved in all cases. CONCLUSION: Since the vascular bed adjacent to the remnant adrenal gland is integral to the preservation of its function, it is important to perform procedures that do not separate the remnant adrenal gland from the retroperitonium space. Because the operative field is clearly visualized on the high-magnification video monitor, this delicate procedure can be performed with a high degree of accuracy via the laparoscopic approach. We consider this operative technique to be useful for selected cases.

Endoscopic thyroidectomy by the axillary approach.

Neck surgery has recently become one of the newest fields for the application of endoscopic surgery because the resultant scar is small and inconspicuous. Still, some patients feel even a small scar on the neck is not cosmetically acceptable. We therefore have developed a new technique of endoscopic thyroidectomy by the axillary approach that leaves no scar on the neck at all. When this method is used, the small scar in the axilla is completely covered by the patient's arm in a natural manner. The cosmetic result is excellent, and sensory loss in the neck is negligible because the area of surgical dissection is small. We believe that endoscopic thyroid surgery by the axillary approach will find a role in the treatment of thyroid disease.

[Prospective randomized study on effect of duration of antimicrobial prophylaxis for mastectomy].

A prospective randomized trial was done to study effects of the duration of ofloxacin (OFLX) administration for prophylaxis against mastectomy wound infections. One hundred and seventeen women who were hospitalized, during periods between June 1990 and September 1992 were considered for enrollment in this study. Selected patients were treated with 600 mg of OFLX daily in 3 divided doses starting the day before surgery. One group was treated for 5 days and the other was treated for 10 days. A hundred and ten patients were found eligible to complete the study and 58 patients were assigned to the 5-day group and 52 patients were assigned to the 10-day group by the random-envelope method. Nine episodes of infections occurred among the patients in the 5-day group and 12 episodes of infections occurred among those in the 10-day group. The mean time until onset of infection was not significantly different between the 2 groups (12 versus 8 days). The number of strains isolated from the drainage tube when removed was highly correlated with occurrences of infections, and the number of strains isolated from infected wounds was also highly correlated with the need to use a different antibiotic. By multiple regression analysis, age was the only significant factor identified for wound infection. The duration of OFLX administration had no significant effect on the development of wound infections. Prolonged prophylactic use of this drug for mastectomy did not reduce the incidence of postoperative infections in this study.

[Asymptomatic multiple intracranial tuberculous nodules detected in a case of miliary tuberculosis].

A case of multiple intracranial tuberculous nodule following miliary tuberculosis was reported. The case was a 19-year-old woman visited a general practitioner, because of fever. Chest x-ray film on the first visit showed diffuse granular shadows in her both lungs with pleural effusion in the left side. The case was diagnosed as bacterial pneumonia, and was treated with antibiotics. She had been getting worse, and the doctor finally examined her sputum, and tubercle bacilli were seen in her sputum (Gaffky 4) by the Ziehl Neelsen's staining. She was introduced to our hospital. Chest x-ray film on admission showed diffuse granular shadows in her both lungs and she was diagnosed her as miliary tuberculosis, and anti-tuberculous therapy was quickly started. She didn't complain of any neurological disorders, but her brain CT showed several nodules in the left cerebral cortex enhanced with contrast medium. T1 weighted MRI enhanced by Gd-DTPA revealed abnormal enhancements in the cerebrum, the cerebellum, and the midbrain. She was treated with anti-epileptic drugs, but after 65 days, she started to suffer from epileptic stroke. Six months later, her brain lesions have improved by the use of anti-tuberculosis drugs and anti-epileptic drugs. The incidence of tuberculosis has decreased in Japan, and, many doctors did not show concern on, thus, a doctor's delay is a serious problem in Japan. Advocary should be made to doctors to detect tuberculous patients as early as possible.

[Mental health topics presented at annual meetings of Japanese Society of Public Health: 1969-1988--from a perspective of community mental health].

This study was conducted to clarify the trends in the presentations on mental health at annual meetings from the standpoint of community mental health (C.M.H.). A review of all of the 428 mental health topics of proceedings, "Shoroku-shu", presented from 1969 to 1988 including background data was performed. The results were as follows; 1. Fifty four percent of the 428 topics were contributed by staff of public health centers, the "frontier" of C.M.H. 2. As for content, in the early 1960's, a high rate of 'ad hoc' research was observed. Around 1970, the number of presentations based on research decreased, and case studies of daily activities increased. Another finding was that around 1970 there was an increase in preliminary reports based on the model of C.M.H. In 1980's, topics on rehabilitation (e.g. Day Care) increased. 3. Finally, close attention should be paid to the increase in topics on alcohol related disability in recent years.

[An analysis of community mental health services at public health centers in the Tokyo metropolitan area--services for 727 new cases during 5 years in Bunkyo-Ward].

For an overview of the community mental health services at Public Health Centers (PHCs), cases were statistically analyzed from the aspect of 3 points: the situation of psychiatric treatment at initial contact (psychiatric treatment), the person who had been living with the case at first contact (living style) and the person who contacted the PHC first (first contact person). During approximately 5 years, 463 new cases contacted the 2 PHCs in Bunkyo-Ward for consultation. Among them, 132 were under psychiatric treatment, 324 under no treatment and 7 unknown. Additionally, 264 were found to be registered on official documents, some of whom received PHC services after being listed. The percentage of schizophrenic cases in the psychiatric treatment group at first contact were higher than in the non-treatment group. More cases with psychiatric treatment were visited by PHN than without treatment. There were great differences in the first contact person among the groups classified according to living style. Especially, in the non psychiatric group, the percentage of the first contact person being other than family and relative was higher in the group who had been living alone than any other groups. Percentages of personal interview of a case, consultation by a psychiatrist in PHCs, and visiting the home of a case were different among the groups classified by psychiatric treatment, living style and first contact person. However, no difference in services outcome (total number of contacts made by a cases, relatives of cases, and other related persons), or present service utilization (continuing, discontinued, completed) among the groups classified by psychiatric treatment, living style, and first contact person was seen.

[Patterns of utilization of external employee assistance program--analysis of employees who have their psychiatrists].

The purpose of this paper is to clarify some patterns of utilization of an external employee assistance program (EAP) we have conducted for other public and private facilities in the Tokyo Kenbikyoin Foundation between April, 1986 and December, 1996. The subjects were 26 men and 12 women in 7 facilities under the following conditions: (1) Employees who have already had their own psychiatrists at the first interview of the external EAP; (2) Facilities utilize the EAP for two or more employees who met the first criterion. As a result, utilization patterns differed depending on medical staff's attitude toward the external EAP. There was a significant difference according to sex. The rate for men was 54% in worksites where medical staff understood this external program (worksite A1) and 93% in worksites where they did not (worksite A2-3, B). As to expectations for the program, there were more consultations for organizational measurements (63%) in worksite A1, while less organizational matters (27%) and more personal complains about their psychiatrists in the worksite A2-3, and B. These results suggest that the involvement of medical staff is the key to utilizing the external EAP effectively.

[Two cases of epidural neulolysis using ethyl alcohol and histopathologic changes in the spinal cord].

We report two cases of cancer pain treated with transcatheter thoracic epidural neurolysis using ethyl alcohol, and epidural histopathologic changes in the spinal cord observed in one of the patients. Case 1: A 59-year-old woman complained of intractable right thoracic back pain due to mediastinal osteo-sarcoma. After obtaining pain relief by epidural block using local anesthetics, we did transcatheter thoracic epidural alcohol block using 2-4 ml of 75-100% ethyl alcohol for three times. Her VAS score decreased from 8/10 to 2/10 and the good pain control was obtained until her death 24 days after the third block. After obtaining permission from her family, necropsy was performed. Spinal nerve roots and the spinal cord showed no abnormality. But the laminar structure of the dura had been destroyed at the outer one third of the dura. Case 2: A 49-year old woman suffered from right upper abdominal pain due to giant metastatic liver tumor. We performed twice transcatheter thoracic epidural neurolysis using 2-3 ml of 75% ethyl alcohol. Her VAS score decreased from 7/10 to 3/10 and the pain relief was maintained until her death 2.5 months after the neurolysis. Motor palalysis was not observed in both cases.

[Operative results of composite aortic root replacement by a Svensson's method].

The results of reconstruction of the aortic root performed on 9 patients by Svensson's method were examined. Nine subjects comprised 6 men and 3 women aged 23-69 years. In the preoperative diagnosis, annulo-aortic ectasia (AAE) was found in 7 cases, acute Type A aortic dissection in 1 case and AAE accompanied by chronic dissection after AVR in 1 case. Every patient underwent reconstruction by direct implantation of the right coronary artery button and interposition grafting for the left coronary artery, using a composite valve graft made of SJM valve and collagen coating artificial graft. Although one patient was lost due to multiple cerebral infarction, no marked changes were observed in other 8 patients. Angiography at short-term after operation showed no problems in the composite valve graft, and revealed good coronary arterial flow. Now, 2-62 months after operation (41 months on average), no late death occurred. On angiography of 2 cases performed after a long-term period, patency of the interposition graft was excellent. The early and late results of aortic root reconstruction by Svensson's method appeared favorable.

[A case of tricuspid infective endocarditis in a drug addict].

This report describes a successful operative case of tricuspid infective endocarditis in a drug addict. A 24-year-old man with a history of drug addiction (6 months) complained of general fatigue and high fever. Echocardiography showed a large vegetation attached to the tricuspid valve and severe tricuspid regurgitation. Blood cultures revealed septicemia due to methicillin sensitive Staphylococcus aureus. He was treated for about 1 week with intravenous antibiotics. However, subsequent severe heart failure necessitated emergency operation. The tricuspid valve was replaced with Carpentier-Edwards bioprosthesis because of severe destruction of the tricuspid valve. The postoperative course was uneventful and he has remained free from endocarditis for 15 months after surgery.

[A surgical case of papillary muscle reconstruction and double-CABGs for mitral regurgitation due to ruptured papillary muscle after myocardial infarction].

A 76-year-old female patient underwent papillary muscle reconstruction, and d-CABGs a month after the onset of myocardial infarction. Posterior papillary muscle (PPM) was recognized to be ruptured partially, its stump was sewn to original PPM. An ePTFE suture (CV 5) was placed from anterior mitral leaflet to anterior papillary muscle in attempt to reinforce PPM-repair. Carpentier-Edwards ring was inserted and d-CABGs (LITA to LAD and GEA to RCA) were performed, simultaneously. Postoperative examination revealed no regurgitation and no stenosis of bypass grafts during follow-up period of 5 months after the procedure. Papillary muscle reconstruction was effective procedure for MR due to the ruptured papillary muscle.

[Preventive effects of intra-arterial infusion chemotherapy of liver metastasis in non-resectable pancreatic cancer].

This is a study which evaluates intra-arterial chemotherapy for non-resectable carcinoma of the pancreas without liver metastasis (locally advanced). Twenty-one patients received ia-chemotherapy (MA-CP: Methotrexate + Angiotensin II----Citrovorum factor + Prostaglandin E1). They showed a 39% 1-year survival rate and 92% of 1-year cumulative rate of survival without liver metastasis. These incidences were significantly higher than those of (13%, 50%) 52 patients who underwent systemic chemotherapy (control). As the reason for such significant differences, we suspected that a high dose of chemotherapeutic view after MTX had been infused into the pancreatic-supplying arteries. This speculation was confirmed by the serial determination of the MTX concentration in the portal blood.

[Late phase II clinical study of RP56976 (docetaxel) in patients with advanced/recurrent breast cancer].

A late phase II clinical study of RP56976 (Docetaxel), a new semisynthetic anticancer agent, was conducted in patients with advanced/recurrent breast cancer. RP56976 (Docetaxel) was in general administered at an intravenous dose of 60 mg/m2 with dose-free intervals of 3-4 weeks. Of the 74 patients enrolled, 64 patients completed the scheduled course of treatment. Three patients showed complete response (CR), 32 patients partial response (PR), 3 patients minor response (MR), 18 patients no change (NC), and 8 patients had progressive disease (PD). The overall response rate was 54.7%. The response rate in patients who previously had received chemotherapy was 55.7%, and the response rate in patients who had resistance to anthracycline agents or who did not respond to previous treatment was 58.7%. Adverse reactions included nausea/vomiting in 38 patients (57.6%), fatigue in 46 patients (69.7%), anorexia in 46 patients (69.7%), fever in 26 patients (39.4%), and alopecia in 60 patients (90.9%), all of which were tolerable. Abnormal laboratory findings included leukopenia (Grade III or more) in 57 patients (86.4%) and neutropenia (Grade III or more) in 56 patients (86.2%). The results show that RP56976 (Docetaxel) is an excellent agent with high antitumor effect for the treatment of advanced/recurrent breast cancer.

[Adjuvant intra-arterial chemotherapy with gastrin receptor antagonist after hepatic resection in colorectal cancer metastasis].

The aim of this study was to determine whether chemo-endocrine therapy after the resection of liver metastasis from colorectal cancer would prevent recurrence in the remnant liver and prolong survival. Eleven colorectal cancer patients underwent hepatic resection for liver metastasis. Subsequently, they were administered Proglumide gastrin antagonist 1,200 mg/day + 5'-DFUR 800 mg/day for 2 years. In seven of them, MMC 6-10 mg and ADM 20 mg were infused intra-arterially every two weeks alternately for one year. In four of them, 5-FU 250 mg/day was infused for seven days continuously intra-arterially every two weeks for one year. Recurrence in the remnant liver occurred in four of 11 patients. All of these patients underwent repeated hepatectomy. The mean disease-free survival in the remnant liver was 37 months and the five-year survival rate was 91%. These results indicate that intra-arterial chemotherapy with gastrin receptor antagonist might be effective for adjuvant therapy in patients with resectable liver metastasis from colorectal cancer.

[Adjuvant chemo-endocrine chemotherapy with gastrin antagonist after resection of liver metastasis in colorectal cancer].

This study was designed to determine whether or not chemo-endocrine therapy after the resection of liver metastasis from colorectal cancer would prevent re-recurrence in the liver. Postoperatively, seven patients received proglumide gastrin antagonist (1,200 mg/day) +5'-DFUR (800 mg/day) orally for 2 years. MMC 6-10 mg and ADR 20 mg were infused every two weeks alternately for 1 year via catheter in the common hepatic artery. After median follow-up of 39 months, re-recurrence rate in the remnant liver after hepatic resection was 14% (1/7) for patients with chemo-endocrine therapy and 52% (24/46) for the controls. These results suggest the possibility that chemo-endocrine therapy is effective to prevent re-recurrence of liver metastasis in patients with colorectal cancer.

[Effect of careful tooth-brushing instruction by teachers on incipient gingivitis in school children].

At the Hiraizumi Primary School in Iwate Prefecture, 84 children with incipient gingivitis were selected at the annual dental examination in May. And the teachers instructed these children individually how to remove the remaining dental plaque. Moreover, the children were checked for the cleanliness of the teeth and inflammation of the gingiva by the teacher or their parents three times a day during the one week just before the second examination. In July the second examination was held and it was revealed that in sixty-three of eighty-four selected children the incipient inflammation of gingiva had improved.