Cavernous hemangioma arising from the diaphragm.

A 51-year-old man was referred to our hospital with an abnormal nodule in the right lung field. Computed tomography revealed a homogeneous nodule adjacent to the diaphragm, which appeared to be an extrapulmonary lesion. No hilar or mediastinal lymph node swelling was detected, and positron-emission tomography showed no significant uptake. At surgery, 2 red papillary tumors were found, originating from the right diaphragm, and tumor extirpation was performed. The pathological diagnosis was cavernous hemangioma.

Outcome and survival analysis of pulmonary metastasectomy for hepatocellular carcinoma.

OBJECTIVE: The lung is the most common site for extrahepatic metastasis from hepatocellular carcinoma (HCC). We previously reported in a series of 20 patients that pulmonary metastasectomy for HCC is feasible in selected patients. The objective of this study was to re-evaluate the long-term outcomes and prognostic factors with an additional 25 patients. METHODS: We retrospectively analyzed the records of 45 consecutive patients who underwent pulmonary metastasectomy due to HCC at our institution between 1990 and 2010. RESULTS: Thirty-nine patients underwent hepatectomy or liver transplantation, whereas six patients underwent locoregional therapy for primary liver lesions. Twenty-seven patients died during a median 17.6-month follow-up period. The 2-year disease-free survival (DFS) was 19.5%. The 5-year overall survival (OS) was 40.9%. History of recurrence and serum des-gamma-carboxy prothrombin (DCP) level >40 mAU ml(-1) at initial pulmonary resection were unfavorably associated with OS in univariate analysis. CONCLUSIONS: Pulmonary metastasectomy for HCC in selected patients resulted in relatively good outcomes with regard to OS. History of recurrence and serum DCP levels were shown to be candidates of prognostic factors for OS.

[Delayed traumatic diaphragmatic hernia with strangulated stomach; report of a case].

A 30-year-old male who had suffered from the left hemopneumothorax due to the traffic accident 13 years before was admitted to our hospital suffering from abdominal pain. Computed tomography revealed the stomach was incarcerated through the left central tendon of the left diaphragm. He was diagnosed as delayed traumatic diaphragmatic hernia and emergency operation was performed via thoracic approach. Stomach and omentum, densely adhered to the lung and the chest wall, were strangulated in the left pleural cavity and hardly reducible. Stomach and omentum were reduced through the enlarged hernia and necrotized stomach was totally resected under the subsequent laparotomy. Hernia was closed directly via thoracic approach. A prompt diagnosis is necessary for a case highly suspicious of delayed traumatic diaphragmatic hernias presenting with strangulation.

Management of infected grafts and aneurysms of the aorta.

Seventeen patients treated for infected grafts (11/17) or aneurysms (6/17) of the aorta between 1998 and 2003 were reviewed to evaluate our experience with aortic infection. The causative organisms were identified in 12 patients (71%), with 5 (29%) having methicillin-resistant Staphylococcus aureus. A periaortic abscess occurred in eight patients, and all of them were associated with infected grafts. Surgical treatment included cryopreserved allograft replacement in eight patients, prosthetic graft replacement in four patients, and drainage with or without omental wrapping in five patients. One patient was still hospitalized at the end of the study period. Five patients with infected grafts died after the operation during the initial hospitalization. No early mortality occurred in the aneurysm group. The early mortality rate was 31% for all patients, 50% for the graft group, and 63% for patients with a periaortie abscess. Another patient with an infected aneurysm died of arrhythmia after discharge from the initial hospitalization, Ten patients are still alive without evidence of reinfection. The early mortality rate for patients with infected aortic grafts is higher than that for those with infected aneurysms, especially when a periaortic abscess accompanies them. However, the late outcome is favorable, with no reinfection or late treatment-related deaths.

[Post-myocardial infarction ventricular aneurysm and intractable ventricular tachycardia supported by left ventricular assist device: a case report].

A 57-year-old man was admitted under a diagnosis of myocardial infarction. Cardiac catheterization revealed total occlusions of the right coronary artery and the left anterior descending artery, and ventriculography showed aneurysmal change in the anterior and septal segments. Circulatory support was introduced with intraaortic balloon pumping, but intractable ventricular tachycardia developed. Electrophysiological mapping and cryoablation to the myocardium were performed intraoperatively, and then coronary artery bypass grafting with endoventricular circular patch plasty of the left ventricle was carried out. Weaning from the cardiopulmonary bypass was attempted, but a left ventricular assist device was subsequently implanted to support the deteriorated ventricular function. The hemodynamics of the ventricle improved several days after the circulatory support was introduced, and the left ventricular assist device was removed successfully. This case suggests that the left ventricular assist device is an effective method to support recovery from serious complications after myocardial infarction.

Multichannel monitoring of cerebral circulatory and oxygenation status using optical topography during deep hypothermic retrograde cerebral perfusion.

In this study, we evaluated changes in the cerebral circulatory and oxygenation status during deep hypothermic total circulatory arrest (TCA) and retrograde cerebral perfusion (RCP) using optical topography, a form of multichannel near-infrared spectrophotometry, to monitor the broad area perfused by the middle cerebral artery. Seven patients underwent thoracic aortic surgery with TCA and RCP via the superior vena cava. Pressure-regulated RCP was performed under pH-stat. No postoperative neurologic complications occurred. Using optical topography, the relative changes in oxy-, deoxy-, and total hemoglobin (oxy-Hb, deoxy-Hb, total Hb) were simultaneously measured from 24 points in both hemispheres. Deoxy-Hb was used for evaluating the regional oxygenation status under RCR The values of deoxy-Hb at the beginning of RCP were regarded as the basal values, and the rate of increase in deoxy-Hb per minute (deoxy-Hb/min) was calculated at each site. Deoxy-Hb/min during TCA was also calculated. In every case, both oxy-Hb and total Hb decreased and deoxy-Hb increased during TCA. When RCP was initiated, the decrease in oxy-Hb and the increase in deoxy-Hb were attenuated. Deoxy-Hb/min was significantly lower under RCP than during TCA in all portions. There was no significant difference of deoxy-Hb/min between any portions during RCP Our results showed that the status of circulation and oxygenation might be uniform in the brain during RCP and better than that under TCA.

[Fulminant myocarditis successfully treated with a left ventricular assist device: a case report].

A previously healthy 28-year-old woman was admitted under a diagnosis of acute myocarditis. Six hours after admission, circulatory support using intraaortic balloon pumping and percutaneous cardiopulmonary support were introduced, because uncontrollable ventricular arrhythmia appeared unexpectedly. Subsequently, decreased peripheral platelet count appeared, in spite of improved hemodynamics. Therefore, a left ventricular assist device was implanted and she was weaned from the percutaneous cardiopulmonary support. On the fifth postoperative day, she was successfully weaned from the left ventricular assist device with full recovery of myocardial function. Myocardial biopsy demonstrated the appearance of acute viral myocarditis. This case suggests that the left ventricular assist device might offer effective circulatory support for acute fulminant myocarditis.

Cerebral metabolism of nitric oxide during retrograde cerebral perfusion.

The aim of this study was to determine whether alpha- or pH-stat protects the brain during deep hypothermic retrograde cerebral perfusion. Fifteen anesthetized dogs on cardiopulmonary bypass were cooled to 18 degrees C under alpha-stat and underwent retrograde cerebral perfusion for 90 minutes under alpha-stat or pH-stat, or underwent antegrade cardiopulmonary bypass under alpha-stat as the control. Cerebral blood flow of the cortex was monitored and serial analyses of blood gases and total nitric oxide oxidation products made. Cerebral blood flow and cerebral metabolic rate for oxygen were significantly higher and plasma levels of nitric oxide oxidation products in the outflow from the brain were significantly lower in retrograde cerebral perfusion under pH-stat than under alpha-stat. This study shows that reduced levels of nitric oxide oxidation products may protect against neuronal damage induced by nitric oxide and that increased cerebral blood flow under pH-stat may lead to a reduction of nitric oxide oxidation products. Under retrograde cerebral perfusion, pH-stat is thus better than alpha-stat for protecting the brain.

Open stent-grafting for aortic arch aneurysm is associated with increased risk of paraplegia.

BACKGROUND: Open surgery using the endovascular stent-graft is a novel technique that lessens the invasiveness of surgery for the aortic arch. However, the outcome of this procedure remains uncertain. METHODS: Between November 1996 and July 2000, a total of 19 patients underwent open surgery using an endovascular stent-graft for thoracic aortic aneurysms. There were 15 men (78.9%) and 4 women (21.1%). Patient age ranged from 29 to 82 years (mean 69.3 years, median 74 years). Atherosclerotic thoracic aortic aneurysms were present in 17 patients (89.4%) and aortic dissection in 2 patients (10.5%). RESULTS: Two patients (10.5%) died in the hospital and 4 patients (21.1%) presented with paraplegia postoperatively. Among the 4 patients with postoperative paraplegia, 1 case was complicated with intraoperative aortic dissection. The other 3 patients with paraplegia had spinal cord ischemic time of more than 60 minutes and intraoperative body weight gain of more than 4 kg. Of these 3 patients, hemodynamic instability after cardiopulmonary bypass was observed in 1 patient and cholesterin embolus in the anterior spinal artery was found at autopsy in another. On univariate analysis, age greater than 75 years was the only risk factor associated with paraplegia (p < 0.05). Autopsy findings for the 2 patients showed that the Adamkiewicz arteries were not blocked by the stent-graft in either patient. CONCLUSIONS: Intraoperative aortic dissection, embolization of the intercostal arteries, long ischemic time of the spinal cord, and excessive weight gain during operation may have been associated with the high incidence of paraplegia after open surgery using the endovascular stent-graft.