Long-term results of concurrent chemoradiotherapy with daily-low-dose continuous infusion of 5-fluorouracil and cisplatin (LDFP) for Stage I-II esophageal carcinoma.

We investigated long-term treatment outcomes and the feasibility of chemoradiotherapy consisting of daily-low-dose 5-fluorouracil and cisplatin (LDFP) chemotherapy plus radiotherapy for Stage I-II squamous cell esophageal cancer. Treatment records from the 2000 through 2008 period were reviewed retrospectively. Fractionated radiotherapy was performed with a total dose of 60 Gy delivered in 2 Gy per fraction. LDFP chemotherapy, as continuous infusion of 200 mg/m2 5-fluorouracil combined with one hour infusion of 4 mg/m2 cisplatin, was administered on the same days as radiotherapy. Survival was calculated by the Kaplan-Meier method. Survival, responses, failure patterns, and toxicities were evaluated. Seventy-six (47 stage I and 29 stage II) patients were analyzed with a median follow-up of 93.6 months. The 8-year overall survival (OS), progression-free survival (PFS) and cause-specific survival (CSS) rates were 63.4%, 49.8%, and 76.7%, respectively. The 8-year OS, PFS, and CSS for stage I and stage II patients were 71.0%/56.1%/82.9% and 45.2%/40.2%/66.6%, respectively. Sixty-eight patients (89.5%) completed the treatment regimen. A complete response (CR) was achieved in 68 patients (89.5%). Twenty-five patients (36.8%) experienced recurrence after CR. The failure patterns were (overlap included): local failure (n = 12), nodal metastasis (n = 12), distant metastasis (n = 3), details unknown (n = 2). Salvage therapy was performed for local failure; endoscopic therapy (n = 7) or surgery (n = 2). Six patients remain alive without relapse after salvage endoscopic therapy. Major Grade 3 or higher acute adverse events were leukopenia (22%), anorexia (17%), and esophagitis (11%). Major late toxicities (Grade 3 or 4) involved pericardial effusion (12%), pleural effusion (4%), and esophageal stenosis (3%). Chemoradiotherapy with LDFP provided favorable long-term survival with acceptable toxicity for Stage I-II squamous cell esophageal cancer. The tumor response was excellent, but close endoscopic follow-up is essential for detecting and treating local recurrence.

Aortocaval fistula after endovascular stent-grafting of abdominal aortic aneurysm.

The authors present a case report of a 79-year-old man with insufficient cardiac contractile function who underwent endovascular stent-grafting for an abdominal aortic aneurysm. Thirty months later, the aneurysm ruptured into the inferior vena cava and subsequently formed an aortocaval fistula caused by migration of the stent-graft. Urgent secondary endovascular stent-grafting successfully excluded the blood flow into the vena cava. Endovascular stent-grafting is deemed suitable for treating this serious disorder, especially in severely debilitated or compromised patients who might not withstand a standard surgical intervention. Furthermore, in patients with previous stent-grafting, since the primary stent-graft makes repair by open surgery more difficult, a secondary endovascular intervention is recommended if feasible.

Influence of pulmonic position on durability of bioprosthetic heart valves.

BACKGROUND: The insertion of bioprosthetic valves into the pulmonic position is not performed commonly because of uncertainty concerning the necessity and durability of such valves. METHODS: We reviewed the long-term outcome of 10 patients who underwent pulmonary valve replacement with bioprostheses between March 1985 and March 1997. A Carpentier-Edwards supraannular bioprosthesis was used in 7 patients, a Hancock II bioprosthesis was used in 2 patients, and a Carpentier-Edwards pericardial bioprosthesis was used in 1 patient. The mean patient age at the time of pulmonary valve replacement was 38.9 +/- 16.3 years (range, 15 to 63 years). The diagnoses were pulmonary valvular regurgitation after corrective surgery for tetralogy of Fallot in 7 patients, right ventricular outflow tract stenosis and absent right pulmonary artery combined with a double-outlet right ventricle in 1 patient, pulmonary valvular regurgitation with pulmonary artery dilatation in 1 patient, and aortic valve stenosis treated with our modification of the Ross procedure using a pulmonary bioprosthesis in 1 patient. Survivors were followed up for a mean of 5 years and 5 months. RESULTS: One patient underwent reoperation because of infective endocarditis of the bioprosthesis. No bioprosthetic valve dysfunction has been observed on Doppler echocardiography during a maximum follow-up period of 12.2 years, except in the patient who underwent replacement at 15 years of age. CONCLUSIONS: Bioprostheses in the pulmonic position are durable in adult patients because they face a minimal hemodynamic load, but they may undergo early leaflet degeneration in younger patients.

Re-replacement for prosthetic valve dysfunction: analysis of long-term results and risk factors.

BACKGROUND: Prosthetic heart valve re-replacement still remains a challenging situation. Although some studies have examined the early results, the long-term survival has not yet been well analyzed. The aim of this study was to detect the factors that affect the long-term outcome of operation. METHODS: Between April 1964 and September 1996, 231 prosthetic valve re-replacements were performed including 16 cases of third valve replacement. There were 100 men and 131 women with a mean age of 47 +/- 14 years. RESULTS: The actuarial survival rate was 65% +/- 4% at 5 years and 41% +/- 7% at 10 years. Multivariate analysis revealed that New York Heart Association class IV and left ventricular ejection fraction were found to be independent predictors of late death. CONCLUSIONS: Our study showed that advanced New York Heart Association functional class and lower left ventricular ejection fraction were found to be independent predictors of late death. If operation is performed before patients reach such a deteriorated condition, long-term results are excellent.

A surgical method for selecting appropriate size of graft in aortic root remodeling.

We describe a surgical technique for selecting the appropriate size of a tube graft in aortic root remodeling procedures. As the technique has a geometric basis, we believe that our method is more accurate in determining the graft size than others.

Alternative to reconstruction of the pulmonary outflow tract in the Ross procedure.

We report our experience with 2 cases in which we used the native ascending aorta and a porcine valve to reconstruct the right ventricular outflow tract in the Ross procedure. Unfortunately, in many parts of the world, the lack of homografts for reconstruction of the right ventricular outflow tract limits the use of the Ross procedure. The technique described herein can be an alternative to a cryopreserved pulmonary homograft replacement for adult patients.

Enlargement of ulcer-like projections after repair of acute type A aortic dissection.

We treated two cases of enlargement of ulcer-like projections in the descending thoracic aorta, which were recognized after emergency graft replacement from the ascending aorta to the aortic arch for acute type A aortic dissection. The intimal tear, which was near the left subclavian artery, was resected during the initial operation. Graft replacement of the descending thoracic aorta was successful.

Is atrial fibrillation resulting from rheumatic mitral valve disease a proper indication for the maze procedure?

BACKGROUND: There are a few patients without detectable atrial contraction despite restoration of atrial rhythm after the maze procedure for atrial fibrillation (AF) associated with mitral valve disease. METHODS: From January 1995 to March 1997, 29 consecutive patients with AF associated with mitral valve disease underwent our modified maze procedure combined with mitral or other valve operations. The causes of mitral valve disease were rheumatic mitral stenosis (n = 22) and nonrheumatic mitral regurgitation (n = 7). The 17 patients with postoperative atrial rhythm were divided into group I with rheumatic mitral stenosis (n = 10), and group II with mitral regurgitation of nonrheumatic origins (n = 7). RESULTS: Seventeen patients regained atrial rhythm, 2 patients had junctional rhythm, and another 10 remained in AF. Between the group of patients with restoration of atrial rhythm and that of patients remaining in AF, significant differences were found in the percentage with rheumatic disease, history of AF, and maximum f-wave voltage. The postoperative peak velocity of the atrial filling wave to peak velocity of early filling wave ratio for the left atrium measured using Doppler echocardiography was 0.25 in group I, which was significantly lower than that (0.42) in group II. CONCLUSIONS: Reconsideration of the indications for the maze procedure for AF associated with rheumatic mitral stenosis may thus be reasonable, particularly for cases in which replacement using a prosthetic valve is necessary, but we believe that patients with nonrheumatic mitral valve disease, especially those able to undergo reconstructive operations, are the best candidates for the maze procedure.

Breast-conserving therapy for ductal carcinoma in situ.

This retrospective analysis evaluates the treatment results and prognostic factors of 114 patients with ductal carcinoma in situ (DCIS) undergoing breast conserving therapy (BCT) at Keio University Hospital Department of Radiology, between 1988 and 1997. A total of 132 patients with DCIS of the breast came to our hospital between 1988 and 1997, and 114 cases were suitable candidates for BCT. All of the patients were female and ranged in age from 26 to 81 years (median 46). Ninety-one patients were premenopausal, and 23 were postmenopausal. Median clinical tumor size was 2.0 cm (0-8.0 cm). Postoperatively 48 cases received 50 Gy/25 fractions of external irradiation to the whole breast via tangential ports. The follow-up period after treatment ranged from 11 to 162 months (median 46.7). The local relapse-free rate and overall survival rate of the 114 patients were 89.5% and 100%, respectively. Local failure and regional nodal failure occurred in 12 and 1 patient, respectively. Radiotherapy was a significant risk factor for local failure (p=0.05). No postmenopausal patients developed local failure, but the difference did not reach statistical significance (p=0.103). The 12 recurrent cases underwent additional surgery and all remain alive without recurrence, to date, i.e., at least 16 months. Breast-conserving surgery plus irradiation is appropriate treatment for DCIS patients.

Surgical treatment of thoracoabdominal aortic aneurysm after repairs of descending thoracic or infrarenal abdominal aortic aneurysm.

OBJECTIVE: The outcome of thoracoabdominal aortic aneurysm repair after operations for descending thoracic or infrarenal abdominal aortic aneurysm was investigated. METHODS: Between May 1982 and July 2000, 102 patients underwent thoracoabdominal aortic aneurysm repair. Of these patients, 36 had previously undergone operations for descending thoracic or abdominal aortic aneurysm. To evaluate the influence of previous descending thoracic or infrarenal abdominal aortic aneurysm repair on the results of TAAA replacement, patients were divided into two groups: one group of patients who had previously undergone descending thoracic or infrarenal abdominal aortic aneurysm repair (group I, n=36) and one group of patients who had not previously undergone descending thoracic or infrarenal abdominal aortic aneurysm repair (group II, n=66). RESULTS: Patients with previous descending thoracic or infrarenal abdominal aortic aneurysm repair had more chronic dissection and extensive thoracoabdominal aortic aneurysm. The distal aortic perfusion time and total aortic clamp time were both longer in group I. The total selective visceral and renal perfusion time and operation time did not differ significantly between the two groups. In 30-day mortality rates were 5.5% in group I and 13% in group II. Major postoperative complications included paraplegia in 14% of patients in group I and 3.1% in group II, renal failure requiring hemodialysis in 22% of patients in group I and 19% of patients in group II, respiratory failure in 36% of patients in group I and 30% of patients in group II, postoperative hemorrhage in 11% of patients in group I and 16% of patients in group II. CONCLUSION: The presence of a previous descending thoracic or infrarenal abdominal aortic aneurysm did not adversely affect the outcome of thoracoabdominal aortic aneurysm repair.

Significance of distal fenestration in graft replacement for chronic aortic dissection.

It is recently controversial whether distal fenestration is necessary in graft replacement for chronic aortic dissection. Several groups started to try the exclusion of intimal entry by the insertion of a stent-graft as a treatment for chronic aortic dissection, while conventional surgical techniques consisted of graft replacement with distal anastomosis to both the true and false channels. It should be kept in mind that the resultant occlusion of the false lumen after obliteration of the false channel could promote spinal cord ischemia. We report a patient with delayed paraplegia after graft replacement without distal fenestration for chronic type B aortic dissection. It is possible that not all cases of chronic aortic dissection are good for stent-grafting.

Surgical removal of a stent entrapped in the left main coronary artery.

A stent entrapped in the coronary artery, which can not be removed by a trans-catheter approach, is extremely rare but is the biggest problem cardiologists face. Surgical retrieval appears to be the only possible treatment to avoid sudden death due to stent thrombosis. We experienced with a New Parmaz-Schatz stent entrapped in the left main coronary artery (LMT) of a 65-year-old man. He underwent surgical removal of the stent with ascending aorta incision and double coronary artery bypass grafting (CABG) using saphenous veins. We believe that a stent entrapped in the LMT must be removed as rapidly as possible to avoid sudden death. Furthermore, in order to avoid the risk of peripheral thrombosis, retrieval is also the case in patients whose distal coronary flow can be maintained with CABG.

A single-stage operation for bicuspid aortic valve, annulo-aortic ectasia, hypoplastic aortic arch, and coarctation of the aorta: A case report.

The patient was an 18-year-old man who had been diagnosed as having a bicuspid aortic valve and dilatation of the ascending aorta six years previously. As he grew up, aneurysmal change of the ascending aorta and hypertension in the upper body gradually progressed. Preoperative evaluation showed annulo-aortic ectasia and the following congenital abnormalities: bicuspid aortic valve, hypoplastic aortic arch, and coarctation of the aorta. Composite graft replacement and extended total aortic arch replacement were carried out.

[A case of graft replacement of the ascending aorta to the aortic arch and the partial descending aorta in a single stage for thrombosed aortic dissection (DeBakey type II + IIIb)].

We report here a case of graft replacement of the ascending aorta to the aortic arch and the middle portion of the descending aorta in a single stage for thrombosed aortic dissection. The patient was a 53-year-old male who was transferred to our hospital with a diagnosis of thrombosed aortic dissection. Conservative therapy was continued but three weeks after the onset, chest enhanced CT scan and digital subtraction angiography revealed an opacified false lumen in the ascending aorta and a ulcer like projection in the middle portion of the descending aorta. He was therefore diagnosed as having redissecction in DeBakey type II + IIIb thrombosed aortic dissection. Graft replacement of the ascending aorta, the aortic arch, and a part of the descending aorta was performed in a single stage via median stenotomy with the aid of extracorporeal circulation and selective cerebral perfusion. Postoperative digital subtraction angiography showed satisfactory reconstruction of the thoracic aorta. The patient is still leading a normal life two years after the operation.

Simultaneous cardiac operations with pulmonary resection for lung carcinoma.

OBJECTIVES: A procedure remains to be established for managing patients with both cardiac and pulmonary diseases requiring surgical interventions. We review our experience with 6 patients having cardiac disease and lung cancer surgically treated simultaneously to determine whether simultaneous surgery is safe and effective. METHODS: Subjects were 6 men with a mean age of 64 +/- 10 years undergoing cardiac surgery combined with pulmonary lobectomy from January 1986 through June 2000. Cardiac procedures consisted of coronary artery bypass in 3, coronary artery bypass plus left ventricular aneurysm repair, aortic valve replacement, and minimally invasive direct coronary artery bypass surgery in 1 patient each. All underwent lobectomy. RESULTS: No early deaths occurred. Bleeding complications occurred in 2 patients and lymph node dissection was incomplete in 3. Two died of carcinoma-related events, 1 at 28 and the other at 84 months after surgery. One died suddenly from a cardiac-related event 42 months after surgery. Only 1 patient is currently alive and disease-free at 104 months after surgery. CONCLUSION: Simultaneous surgery can be conducted with acceptable mortality. The occurrence of bleeding complications and incomplete lymph node dissection, however, indicates combined procedures only in patients requiring simultaneous surgery due to their disease or unable to tolerate a second operation.

[Sense of coherence, stressful life events and psychological health].

Aaron Antonovsky's Sense of Coherence (SOC), as a stable disposition of personality that serves as a major coping resource for the preservation of health, has been widely used in many studies. However, few empirical studies are conducted on the concept of SOC. We examined the stability of SOC and the buffering effect of SOC on the psychological health in dealing with stressful life events. The subjects were 200 adults randomly selected in Tokyo, and follow-up survey was conducted one year after the first survey. Goldberg's General Health Questionnaire (GHQ) was used for assessing psychological health. Antonovsky's SOC scale was translated into Japanese (and reverse translated) in this study. The test-retest reliability of SOC scale was 0.78. Cronbach's alpha was 0.91. The factors related to the SOC supported previous findings and Antonovsky's theory about the positive correlation with educational and economic status. In the follow-up survey, the subjects were also asked about the experience of 56 stressful life events (SLE) composed of four aspects of life during the previous year: personal, family, work and environment. The SLE was assessed through the total number and the weighted score. Contrary to the theory, the results showed that the SOC score has no intra-individual stability. The mean score of SOC in 1998 was 131.1 +/- 23.9, significantly lower than that in the previous year. When the subjects were divided into two groups based on a median 1997 score, the effect of SLE negatively affected SOC scores after one year among those who had a low SOC, although this effect was not observed among those who had a high SOC. The effect of SLE on changes of SOC was stronger among men compared to women. Also, the results showed the SOC was positively related to psychological health, and the buffering effect of SOC on the psychological health in dealing with stressful life events was only observed among men. Findings in this study suggest that SOC is variable for those with weak SOC if they experienced stressful life events. Also, the stressful life events differentially affect the SOC among men and women. The buffering effect was not sufficiently proven in this study. Methodological issues to confirm Antonovsky's theory are also presented.

[Internalized norms and social norms relating to negative health behaviors. The relationship of sociodemographic characteristics and reference groups].

So-called "negative health behaviors" (e.g. smoking, excessive eating/drinking), which are related to morbidity and mortality, are generally well known to the public. However there are many who undertake negative health behaviors despite knowing of their negative health effects. Using a mail survey of subjects aged 25 to 54, we examined reasons and justifications for engaging in negative health behaviors and their related factors from the lay person's perspective. Concerning the reasons for negative health behaviors, we hypothesized seven concepts (work priority, group harmony priority, the contribution to relaxation, tools for communication, prior orientation focused on the present, individualistic priority, and appearance), and devised multiple questions for each concept. The results are as follows. 1. Compared to females, males tended to support of the five concepts about the internalized norms concerned with negative health behaviors (e.g. the tendency of each individual to approve or disapprove of the reasons for negative health behaviors). In females, the younger generation and those that were married expressed more support than the older and the unmarried. There were differences in males according to occupation. 2. Concerning which reference groups had the largest influence on the social norms concerned with negative health behaviors (e.g. the perceptions as to what degree a group regards the reasons about negative health behaviors as desirable), most perceived that the "office" and "friends" groups would be more supportive of reasons for negative health behaviors than the "family" groups. 3. The health behaviors, which correlated with the internalized norms or the social norms concerned with negative health behaviors, were eating breakfast, smoking, and drinking (frequency and amount). In particular, drinking behavior was influenced most by the internalized norms and the social norms.

[A case report of total aortic arch replacement for distal aortic arch aneurysm in an octogenarian].

A 81-year-old man was admitted to our hospital because of hoarseness. Chest CT scan and aortogram showed distal arch aneurysm measuring 7.5 cm in diameter. Under deep hypothermia and selective cerebral perfusion, the distal aortic arch aneurysm was completely replaced with a woven Dacron graft with three limbs for the arch vessels. After the aortic cross clamp was released, severe low output syndrome (LOS) continued because of perioperative myocardial infarction. Then, a coronary artery bypass grafting (CABG) to the left anterior descending artery (LAD) was performed, after which the cardiopulmonary bypass was easily weaned under intra-aortic balloon counterpulsation (IABP) assistance. The postoperative course was uneventful. The perioperative myocardial infarction was thought to be induced by left coronary spasm, as comparison of the preoperative and postoperative coronary arteriograms showed no change.

[Thoracoabdominal aortic aneurysm repair after detection of the Adamkiewicz artery by magnetic resonance angiography; a way to shorten operating time and improve outcome].

Surgical results were compared between 18 patients (group A) who underwent preoperative anatomic characterization of the Adamkiewicz artery by magnetic resonance angiography (MRA) and 38 patients (group B) without such imaging. In group A, intercostal or lumbar arteries related to the aneurysm were reattached to the graft only when they represented the origin of the Adamkiewicz artery. In group B, reconstruction from the Th 7 intercostal and the L2 lumbar arteries was performed whenever possible. In-hospital mortality was 16.7% in group A and 15.8% in group B. Total aortic clamp time and operating time were only 84 and 437 min in group A, compared with 134 and 589 min in group B. Three patients showed postoperative paraplegia in group B. No spinal cord injury occurred in patients whose artery had been detected preoperatively. Preoperative anatomic delineation of the Adamkiewicz artery by MRA can reduce risk of ischemic injury to the spinal cord and decrease operating time required for repair of thoracoabdominal aortic aneurysms.

[A successful case of PA debanding after percutaneous transluminal angioplasty for restenosis of coarctation complex].

A 11-year-old boy, who had undergone the initial surgical repair for Coarctation complex at 6 months of age was readmitted to our hospital for radical correction. The initial repair at 6 months of age was patch angioplasty of coarctation, PDA division and PA banding. When he was 5 years old, a cardiac catheterization revealed spontaneous closure of VSD, restenosis of coarctation and RV outflow tract stenosis due to PA banding. This time he was treated with 2 steps of procedures. The first step was percutaneous transluminal angioplasty for restenosis of coarctation. Then RV outflow tract repair was performed at the second step. Postoperative course was uneventful.