[Initial Clinical Experience of the Herbal Medicine Inchinkoto for Refractory Hyperbilirubinemia Following Open-heart Surgery].

We retrospectively assessed our initial clinical experience of the herbal medicine Inchinkoto for refractory hyperbilirubinemia following open-heart surgery. Six patients developed hyperbilirubinemia in an acute phase after surgery and their maximum total bilirubin levels were 6.4~26.4 mg/dl( mean:13.1± 8.2 mg/dl). They were initially treated with ursodeoxycholic acid and/or Stronger Neo-Minophagen C containing monoammonium glycyrrhizinate, glycine, aminoacetic acid, and L-cysteine hydrochloride hydrate. These treatments, however, were ineffective, and Inchinkoto was introduced at 5~34 day (mean:13.3±11.3 days) after surgery. Hyperbilirubinemia improved in all patients after the introduction of Inchinkoto:1 day after in 1 case, 2 days after in 2 cases, 3 days after in 2 cases, and 4 days after in 1 case. These results indicate the potential of Inchinkoto to attenuate refractory hyperbilirubinemia following cardiac surgery with cardiopulmonary bypass.

[SUBFASCIAL ENDOSCOPIC PERFORATOR VEIN SURGERY IN THE TREATMENT OF SEVERE VARICOSE VEINS].

Surgical treatment of severe varicose veins (CEAP classification : C4b-C6) should involve not only interruption of incompetent superficial veins to prevent venous regurgitation due to valve incompetence but also interruption of incompetent perforator veins. Subfascial endoscopic perforator vein surgery (SEPS) is performed via a small skin incision and involves interruption of perforator veins by the insertion of an endoscope into the subfascial space. SEPS produces good surgical outcomes: it is accurate in detecting and transecting perforator veins; has a low frequency of surgical wound complications; prevents lipodermatosclerosis and formation of pigmented skin lesions; and is minimally invasive compared with Linton's operation. Thus, SEPS is an excellent procedure for patients with incompetent perforator veins. SEPS has been covered by the Japanese national health insurance system since April 2014, and it is expected that SEPS will be further developed and become more widespread in use.

Relationship between body figure and stump length in cyanoacrylate closure of varicose veins.

BACKGROUND: Recurrence of incompetent saphenous veins after treatment is associated with remnant reflux to the branches close to the saphenofemoral or saphenopopliteal junctions, which originate from the residual patent stump after saphenous vein treatment. This study aimed to determine the factors affecting residual stump length after cyanoacrylate closure. METHODS: This retrospective study used prospectively collected data of patients who underwent cyanoacrylate closure. Postoperative Duplex scanning was performed to evaluate occlusion of the target vein, stump length, and the presence of endovenous glue-induced thrombosis. The clinical outcomes and patient characteristics were also evaluated. RESULTS: Seventy procedures for incompetent saphenous veins were performed in 67 limbs of 47 patients. The average patient age was 43 (range, 43-89) years; 34 (72%) were female patients. Target vein occlusion was achieved in all patients and endovenous glue-induced thrombosis occurred in 1.5 % of patients. The mean stump length was 18.3 mm. Total occlusion from the junction was observed in 13 vessels (19%). Particularly, higher total occlusion rate was found in treatments of the small saphenous vein compared with those of the great saphenous vein (GSV). In 6 GSV treatments, longer stumps (>45 mm) remained. Those with a stump >45 mm were all female patients, with significantly shorter height and higher Body Mass Index compared with those with stump lengths <45 mm. CONCLUSIONS: Body figure should be considered when performing cyanoacrylate closure to treat insufficient saphenous varicose veins. However, further investigations are to be warranted.

Intraoperative collection of autologous platelet-rich plasma from the cardiopulmonary bypass circuit upon initiation of extracorporeal circulation.

OBJECTIVES: The aim of this study is to evaluate the possibility of the autologous platelet-rich plasma (PRP) collection from the cardiopulmonary bypass (CPB) circuit and to evaluate its effect on the aggregative function. METHODS: For seventy-two patients undergoing cardiac surgery with CPB, an autologous PRP was prepared using the Haemonetics Component Collection System® by drawing blood from the CPB circuit immediately after CPB was established. The blood samples were taken at three points for examination, A: beginning of surgery, B: immediately after heparin reversal with protamine following discontinuation of CPB, C: after the collected autologous PRP was returned to the patient. Platelet count and platelet aggregation ability were analyzed. RESULTS: The mean platelet count in autologous PRP was 5.5 (range: 3-14) units. Platelet count decreased by 115.0 (±27.3) × 1000/µl from A to B and increased by 27.3 ± 17.2 (× 1000/µl) from B to C. When platelet aggregation was measured by Adenosine Diphosphate (ADP) 3.0 µM, it decreased by 42.6% ± 12.1% from A to B and increased by 8.7% ± 7.4% from B to C. CONCLUSIONS: Autologous PRP can be safely collected by drawing blood from the CPB circuit, platelet count and aggregation ability significantly decreased after CPB including autologous PRP collection. Some improvement was detected in the number of the platelets count and platelet aggregation ability by administrating an autologous PRP even if autologous PRP is collected from CPB circuit. TRIAL REGISTRATION: UMI-CTR, UMIN000023776 . Registered 1 October 2016.

Treatment of ventricular septal perforation caused by blunt trauma using the right ventricle approach: A case report.

Traumatic ventricular septal perforation (VSP) is a rare condition that can occur following chest trauma and can lead to heart failure. Herein, a case of VSP caused by blunt chest trauma successfully closed using the double-patch technique via the right ventricle after medial sternotomy is presented. This case report highlights the necessity of emergency surgery in the acute phase of traumatic VSP if heart failure is difficult to control. This technique was useful for acute surgery. .

Surgical methods and clinical results of subfascial endoscopic perforator surgery in Japan.

OBJECTIVES: To clarify the surgical methods and the clinical results of subfascial endoscopic perforator surgery in Japan. METHODS: This study included 1287 limbs of 1091 patients who underwent subfascial endoscopic perforator surgery in 14 hospitals. Simultaneous saphenous vein treatment was performed in 1079 limbs (83.8%), and 118 limbs (9.2%) had deep venous lesions. The venous clinical severity score was calculated before and 6 to 12 months after surgery. The ulcer healing rate and ulcer recurrence rate were calculated cumulatively. RESULTS: Preoperative venous clinical severity score was significantly decreased from 10.0 ± 6.6 to 3.1 ± 3.4 ( P < .0001) postoperatively. The primary ulcer healing rate was 96.2% (332/345 C6 limbs) at an average follow-up of 47.7 months, and the ulcer recurrence rate was 12.0% (49/393 C5, C6 limbs) at the average follow-up of 46.0 months after the ulcer healed. CONCLUSION: These results indicate that subfascial endoscopic perforator surgery is an alternative to improve the long-lasting disease severity and/or clinical outcome.

Long-Term Results of Obturator Bypass.

OBJECTIVE: We evaluated the long-term outcomes of obturator bypass. MATERIAL AND METHODS: A total of 16 patients (13 males and 3 females; 17 limbs) who underwent obturator bypass surgery at our department between April 1995 and March 2008 were included. RESULTS: Their ages ranged from 50 to 90 with a mean of 74 years. Inguinal infections observed in the 16 patients consisted of vascular graft infections in 13 patients, hemostatic device infections following endovascular therapy in two patients, and femoral artery infections following coronary angiography in one patient. The cumulative patency rate was 69% for 3 years and 43% for 5 years. The cumulative survival rate was 64% for 3 years and 55% for 5 years. CONCLUSION: Obturator bypass surgery was successfully performed with favorable results for arterial infections and vascular graft infections in the inguinal region.

Positioning for Endovenous Laser Ablation: Comparative Study with Thigh Stripping.

We performed a comparative study of surgical outcomes and venous functions between endovenous laser ablation with a 980-nm diode laser (EV group) and thigh stripping (ST group). There were no severe complications and initial success rates were 100% in both groups. In the EV group, preoperative symptoms improved in 94.3% of cases, the venous occlusion rate was 98%, and endovenous heat induced thrombosis had occurred in 11.9% (Class 3: 0.7%) at 12 months after the operation. Although comparative study of postoperative venous function by air plethysmography showed significant improvement in both groups, there was less recovery of postoperative venous function in the EV than in the ST group. (This article is a translation of J Jpn Coll Angiol 2015; 55: 13-20.).

Bypass vs. Endovascular Therapy of Infrapopliteal Lesions for Critical Limb Ischemia.

OBJECTIVE: This study was conducted to determine whether to perform endovascular intervention or bypass surgery as a treatment option for critical limb ischemia (CLI) with lesions in the popliteal artery or below. SUBJECTS AND METHODS: A total of 150 patients (164 limbs) with CLI underwent endovascular intervention or bypass surgery for lesions in the popliteal artery or below at our department between May 1995 and June 2011. Therapeutic outcomes were examined by surgical technique. An indication for endovascular intervention was established with the combination of (1) poor general condition, and (2) a stenotic or occlusive lesion ≤5 cm. RESULTS: The bypass group (group B) comprised 119 patients (99 males, 20 females) with 131 affected limbs at 46 to 89 years of age (mean: 70 years). The endovascular intervention group (group E) comprised 31 patients (25 males, 6 females) with 33 affected limbs at 47 to 89 years of age (mean: 72 years). There was no significant difference in patient demography between the two groups. Regarding preoperative complications, hypertension was observed in 54% and 61% of the subjects in groups B and E, respectively, diabetes in 36% and 55%, renal dysfunction in 29% and 58%, ischemic heart disease in 27% and 32%, and cerebrovascular disorder in 18% and 23%; renal dysfunction accounted for a significantly higher percentage in group E. As for early postoperative complications, subjects in group B experienced wound infections (6 patients), hemorrhage (2), thrombosis (2), pneumonia (1), and another complication (1), and those in group E experienced wound infections (1) and another complication (1). The hospital mortality rate was 0.8% (1 patient) for group B and 0% for group E. The 3-year cumulative primary patency rate was 72% for group B and 54% for group E; the rate was significantly higher for group B. The 3-year secondary patency rate was 82% for group B and 60% for group E. The 3-year limb salvage rate was 86% for group B and 82% for group E; there was no significant difference between the two groups. The 5-year survival rate was 57% for group B and 42% for group E; the survival rate was significantly lower for group E. CONCLUSION: For the study population of CLI patients with lesions in the popliteal artery or below, the patency rate was higher for the bypass group than for the endovascular intervention group, whereas there was no difference in the limb salvage rate. Based on the findings in prognosis for survival, the indication for endovascular intervention at our department is believed to be appropriate. (English translation of Jpn J Vasc Surg 2013; 22: 715-718).

Total aortic arch replacement for a patient with poor left ventricular function and patent coronary artery bypass grafts: how to establish effective myocardial protection.

A 66-year-old man who had previously undergone coronary artery bypass grafting (CABG) was admitted to our institution for surgical treatment of a ruptured aortic arch aneurysm. He had three patent bypassed grafts including the left internal thoracic artery (LITA) to the left anterior descending artery (LAD), complicated by left ventricular dysfunction. Coronary angiography performed 1 year after the initial surgery revealed total occlusion of the LAD. In addition, the aneurysm was located next to the LITA; therefore, there was a significant risk of injury to the LITA during intraoperative dissection. For such a complicated and challenging case, we successfully performed a total aortic arch replacement using a Y-shaped composite saphenous vein graft (SVG) for the administration of cardioplegic solution to establish effective myocardial protection. This procedure, by which effective myocardial protection can be achieved, is a useful treatment option for aortic arch surgery after CABG with a patent LITA graft.

Two-stage Surgery for Double Infected Aneurysms in the Infrarenal Abdominal and Descending Thoracic Aorta.

A 61-year-old man complaining of lumbago and high-grade fever was admitted to our institution. Computed tomography (CT) revealed a saccular aneurysm in the infrarenal abdominal aorta and blood culture results were positive for Streptococcus pneumoniae. He was diagnosed with infected abdominal aortic aneurysm, and antibiotic therapy was initiated. Follow-up CT demonstrated a rapidly-enlarging abdominal aortic aneurysm and a newly-developed descending thoracic aortic aneurysm. For this case, two-stage surgery consisting of extra-anatomical bypass and in-situ reconstruction using rifampicin-soaked Dacron graft was performed after an interval of 37 days. The patient was discharged 14 days after the second surgery without any complications.

A granulomatous liver abscess which developed after a toothpick penetrated the gastrointestinal tract: report of a case.

An unusual case of a toothpick perforating the stomach, then penetrating the liver, and thereafter forming a liver abscess is reported. A 48-year-old woman who had ingested a toothpick 1 month earlier was admitted to our hospital because of severe epigastralgia which had progressively worsened. A laparotomy was performed because a granulomatous abscess in the liver due to this ingested foreign body was suspected. We found a granulomatous abscess in the liver due to the penetration of the toothpick through the stomach. The toothpick had become completely embedded about 2 cm deep in the left lobe of the liver. When dissecting the tumor, a 5.5-cm toothpick was removed, and a partial lateral resection of the liver was performed. The histological diagnosis was a hepatic abscess with granulomatous change. This was a rare case of a migration of an ingested toothpick into the liver through the stomach.