[Prophylactic treatment of oral sildenafil citrate for pulmonary hypertension in an infant treated with inhaled nitric oxide after open-heart surgery].

A 3-month-old boy with coarctation of the aorta (CoA), ventricular septal defect (VSD), atrial septal defect, and severe pulmonary hypertension (PH) underwent one-stage repair consisting of patch closure of VSD and coarctation repair. Inhalation of nitric oxide (iNO) was commenced to treat residual severe PH on the day of the operation. Oral sildenafil citrate was commenced on the day 1 and iNO was gradually weaned off on the day 3. There was no "rebound", severe increase in pulmonary artery pressure, which commonly occurs after discontinuation of iNO. Then the patient was extubated without any difficulties or recurrent PH. The oral sildenafil citrate therapy was ceased on the day 8. Prophylactic use of oral sildenafil citrate for PH might be an useful alternative to shorten the duration of iNO therapy and intensive care unit (ICU) stay in the selected patients after congenital open heart surgery.

A TRH analog (DN-1417): motor stimulation with rearing related to catecholaminergic mechanisms in rats.

The effect of an analog of TRH, gamma-butyrolactone-gamma-carbonyl-histidyl-prolinamide citrate (DN-1417) on motor activity was studied in rats. Peripheral administration of DN-1417 (0.2-20 mg/kg, i.p.) caused a significant, dose-dependent increase in total spontaneous motor activity, with a definite increase in rearing behaviour. Both increases in spontaneous motor activity and rearing behaviour were markedly inhibited by pretreatment with chlorpromazine (1, 5 mg/kg, i.p.), haloperidol (0.1, 0.5 mg/kg, i.p.), pimozide (1 mg/kg, i.p.) or alpha-methyltyrosine (250 mg/kg, i.p.). Only stimulation of rearing behaviour was selectively attenuated by phenoxybenzamine (5 mg/kg, i.p.) or FLA-63 (25 mg/kg, i.p.) at doses producing no significant effect on spontaneous motor activity. Although propranolol (10 mg/kg, i.p.) and methysergide (10 mg/kg, i.p.) had no effect, atropine (10 mg/kg, i.p.) and mecamylamine (10 mg/kg, i.p.) respectively potentiated and counteracted the effects of DN-1417. Concerning the stimulation of spontaneous motor activity, the nucleus accumbens and lateral hypothalamic area were most sensitive to DN-1417, and the lateral hypothalamic area was the most sensitive site for the stimulation of rearing. Furthermore, DN-1417 (5 X 10(-5) M) significantly enhanced the spontaneous release of [3H]dopamine from the rat nucleus accumbens slices in vitro. These findings indicate that the motor stimulatory action of DN-1417 appears to be mediated primarily via a dopaminergic mechanism by enhancing the release of dopamine from nerve terminals, including the nucleus accumbens in the mesolimbic dopamine system, and, in turn, the rearing may be mediated via noradrenergic mechanism.

Sequential grafting of the right gastroepiploic artery in coronary artery bypass surgery.

BACKGROUND: Only a few studies have been done on sequential grafting using the right gastroepiploic artery (GEA). METHODS: Forty patients (35 males, ages 36 to 74 years) who underwent sequential grafting of the GEA were reviewed. Angiography of the GEA was performed preoperatively in all patients. GEAs with a luminal diameter greater than 2 mm at the presumptive distal anastomosis on the angiogram were used. The dissected GEA was led into the pericardial cavity through the antegastric route. We used GEAs to graft 89 branches (2.2 per patient) in the inferoposterior region. RESULTS: In 24 patients who had angiographic examinations, all the GEAs were patent, although luminal narrowing was noted in the segment between the two anastomoses in 3 patients. Eight-year actuarial survival was 92.5% and the cardiac-related event-free rate was 95%. CONCLUSIONS: Sequential grafting of the GEA can be performed effectively in selected patients. Performing preoperative angiography to assess the size of the GEA for sequential grafting is strongly recommended.

Limited flow capacity of the right gastroepiploic artery graft: postoperative echocardiographic and angiographic evaluation.

BACKGROUND: The flow capacity of the right gastroepiploic artery graft has not been clarified. METHODS: Angiographic and echocardiographic studies were conducted in 30 patients who had undergone coronary artery bypass grafting using both the internal thoracic and right gastroepiploic arteries. The luminal diameter of the arterial grafts was measured from the postoperative angiograms. The adequacy of the myocardial blood supply from the arterial grafts was evaluated by dobutamine stress echocardiography. RESULTS: With echocardiography, 14 patients exhibited an ischemic response in the gastroepiploic artery grafted region, whereas no patients exhibited an ischemic response in the internal thoracic artery grafted area. The luminal diameter of the gastroepiploic artery and a younger age were correlated with the ischemic response observed in the dobutamine stress echocardiography. A luminal diameter of the gastroepiploic artery of greater than 2.6 mm had the highest sensitivity and specificity for a nonischemic change. CONCLUSIONS: To generate the maximal flow reserve, the luminal diameter of the gastroepiploic artery when used as a graft should be sufficiently large enough, nearly 3 mm at the anastomosis.

Adequacy of flow capacity of bilateral internal thoracic artery T graft.

BACKGROUND: With the T graft configuration, multiple arterial revascularization can be accomplished using bilateral internal thoracic arteries. However, concern remains about the flow capacity of the main stem of the left internal thoracic artery (LITA). METHODS: Forty patients who underwent multiple revascularization of the entire territory of the left coronary system with a T graft were investigated. Six months after the operation, they were examined angiographically. During the same period, dobutamine stress echocardiography was performed to evaluate the adequacy of the myocardial blood supply from the T graft. The T graft revascularized two branches in 5 patients, three branches in 23, four branches in 11, and five branches in 1 of the left coronary system. Other conduits were used if revascularization was required for the right coronary system. RESULTS: Complete revascularization was achieved in the left coronary territory in all patients. The LITA main stem showed a wide lumen in all patients. Luminal narrowing was present in the distal segment of the LITA in 3 patients. The right internal thoracic artery (RITA) was patent in all patients, whereas luminal narrowing was observed in the distal segment of the RITA in 5 patients. No patient exhibited ischemic wall motion abnormality in the anteroseptal, lateral, or posterolateral region of the left ventricle where the T graft revascularized. Eight patients showed ischemic response in the inferoposterior region, that is, the territory of the right coronary artery. CONCLUSIONS: The LITA main stem, forming a T-graft configuration with the free RITA, has an adequate flow reserve to supply at least the entire left coronary arterial system with sufficient blood. Therefore, multiple coronary revascularization using the T-graft technique is feasible.

Streamline phenomena in liver metastasis of gastrointestinal tumors - a clinical-study based upon 172 patients.

Location and number of liver metastasis of gastrointestinal tumors were detected preoperatively and intraoperatively. The distribution of the liver segment(s) occupied by metastatic tumors varied significantly (p<0.05). Significantly more frequent distributions were demonstrated in the lateral segment with gastric cancer (p<0.05), in the posterior segment with left colic cancer (p<0.001), in the medial segment with rectal cancer (p<0.01), in the anterior segment with bile duct cancer (p<0.05) and the whole of the liver with pancreatic cancer (p<0.05). Significantly less frequent distribution was demonstrated in the posterior segment with gastric cancer (p<0.01). When the liver was divided into the right and the left halves, the distribution of each half of the liver occupied by metastatic tumors varied significantly (p<0.05). Liver metastases of whole colic cancer were significantly more frequent in the right half of the liver (p<0.05). The results suggest that the tumor distribution in liver metastases of gastrointestinal tumors differ depending upon the primary tumors, basically in accordance with the 'streamline' phenomena.

Thyrotropin-releasing hormone (TRH) and its analog (DN-1417): interaction with pentobarbital in oxygen consumption and cyclic AMP formation of rat cerebral cortex slices.

Effects of TRH or its analog DN-1417 (gamma-butyrolactone-gamma-carbonyl-L-histidyl-L- prolinamide ) and pentobarbital, alone or in combination, on oxygen consumption and cyclic AMP formation in rat cerebral cortex slices were investigated. The oxygen consumption of rat cerebral cortex slices as measured with a Warburg apparatus, increased linearly over time (0 to 60-min incubation at 37C). Addition of pentobarbital (1 to 7 x 10-4M) inhibited oxygen consumption, in a concentration-dependent manner, up to 45% of control. A concomitant application of DN-1417 (10-5M) or TRH (10-4M) and pentobarbital (5 x 10-4M) led to a partial recovery of the pentobarbital effect. The similar anti-pentobarbital effects were observed with the addition of carbachol (10-4M) or dibutyryl cyclic AMP (10-3M), but not norepinephrine (10-4M) or dopamine (10-4M). DN-1417, TRH, carbachol, norepinephrine or dopamine at 10-4M stimulated cyclic AMP formation in the cerebral cortex slices. Addition of pentobarbital (1 to 7 x 10-4M) inhibited the cyclic AMP formation, in a concentration-dependent manner. DN-1417, TRH or carbachol at 10-4M but not norepinephrine or dopamine at 10-4M significantly reversed the reduction of cyclic AMP formation induced by pentobarbital (5 x 10-4M). Atropine (10-4M) almost completely abolished DN-1417-, TRH- and carbachol-induced cyclic AMP formation in the presence and absence of pentobarbital.

TRH and its novel analog (DN-1417): antipentobarbital action and involvement of cholinergic mechanisms.

Possible neuroanatomical loci and the mode of action of thyrotropin-releasing hormone (TRH) or its analog, gamma-butyrolactone-gamma-carbonyl-histidyl-prolinamide citrate (DN-1417), in reducing the pentobarbital-induced sleeping time were investigated by using an intracerebral microinjection technique in rats. Intravenous, intraperitoneal or intracerebroventricular (ICV) injection of TRH or DN-1417 produced a dose-related reduction of the sleeping time induced by pentobarbital. TRH or DN-1417 given into the posterior hypothalamic regions including the dorsal premammillary nucleus, lateral hypothalamic area and posterior nucleus of hypothalamus had a significant pentobarbital sleep shortening action in low doses. Injection of these peptides into the dorsomedial nucleus of thalamus, mesencephalic reticular formation, medial septal nucleus or hippocampus was also effective, in comparatively low doses. However, higher doses were required to elicit the effect when the injections were made into the nucleus accumbens, lateral preoptic area or caudate nucleus. In this respect, the parietal cortex was insensitive to TRH or DN-1417. The pentobarbital sleep shortening action of TRH or DN-1417 injected peripherally or into the hypothalamic regions was markedly antagonized by ICV or intrahypothalamic pretreatment with atropine methyl bromide. On the contrary, ICV injection of atropine methyl bromide had a weak or no antagonizing action on the effect of TRH injected ICV or into the reticular formation, medial septal nucleus or hippocampus. These results suggest that possible neuroanatomical sites mediating the pentobarbital sleep shortening action of TRH or DN-1417 may be posterior hypothalamic regions, dorsomedial nucleus of thalamus, reticular formation, medial septal nucleus or hippocampus. A cholinergic mechanism may also be involved in the effect of TRH on the hypothalamus.

A simple less invasive method of radial artery harvesting in coronary artery surgery.

A simple, less invasive radial artery harvesting technique involving small skin incisions is described. Only 2 retractors, one of which is light-sourced, are required to construct the operating field. Full harvesting can be accomplished under direct vision with a long-bladed low-voltage electrocautery and forceps through 3 small skin incisions on the forearm. The time required for the harvesting is no longer than that of the standard technique. Spasm of the radial artery has not been seen. Esthetic results are satisfactory.

Congenital biliary dilatation with pancreatico-biliary maljunction: a comparative study between children and adults.

A comparative study of congenital biliary dilatation with pancreatico-biliary maljunction in 15 children and 16 adults was undertaken. Cystic and fusiform dilatation of the common bile duct was seen in 9 and 6 cases respectively in the child group, with 8 and 8 cases respectively in the adult group. Cholangiographically, neither the length of the common channel nor the type of pancreatico-ductal union varied significantly between groups. Furthermore the incidence of higher amylase levels of bile showed no apparent variance from group to group. This was also true when looking histologically at the number and distribution of periductal glands surrounding the intra-hepatic bile duct. Therefore, we concluded that there was no essential etiological difference between the two groups.

Surgical treatment of coarctation complex in neonates and infants.

BACKGROUND: There remains controversy regarding the appropriate surgical treatment of coarctation of the aorta associated with intracardiac anomalies in neonates and infants. Furthermore, the relative benefits of one versus two-stage repair, and subclavian flap aortoplasty versus end-to-end anastomosis for some of these lesions, remain controversial. The purpose of this paper is to review our experience with two-stage repair using subclavian flap aortoplasty and to seek an appropriate procedure. METHODS AND RESULT: From June 1996 to November 1999, thirteen patients underwent subclavian flap aortoplasty in our department. The age range was 16 to 101 days (mean 52 days), and the body weight range was 1.9 to 4.5 kg (mean 3.0 kg). Anatomic diagnosis was coarctation with ventricular septal defect (six patients), double outlet right ventricle (two patients), atrioventricular canal defect (one patient), tricuspid atresia (two patients), mitral atresia (one patient), and single atrium and subaortic stenosis (one patient). There was one hospital death in our series due to the progression of pulmonary hypertension 3 months after the operation. The mean follow up for remaining twelve patients was 28 months (range 7 approximately 48 months). There was one reoperation for recurrent coarctation. Three patients underwent pulmonary artery plasty in a second operation because of right pulmonary artery stenosis. We performed the definitive operation for six patients with coarctation with ventricular septal defect and two patients with double outlet right ventricle, and we performed a bidirectional cavopulmonary shunt for four univentricular hearts who are candidates for the Fontan operation. Two patients required Damus-Kaye-Stansel procedure to release restrictive bulboventricular foramen. Three patients underwent a modified Fontan operation after these palliations. In our series, the intraoperative mortality rate for subclavian flap aortoplasty was 0% and the post operative mortality rate was 7.7% (1/13). Ten patients underwent the final operation successfully, and further two patients are considered good candidates for the final operation. The overall mortality was 7.7% (1/13). CONCLUSION: Two-stage repair appears to offer a good prognosis for neonates and infants with a coarctation complex. Subclavian flap aortoplasty showed the lowest rate of restenosis. However, late mortality may be associated with the progression of pulmonary vascular disease and the presence of associated severe cardiac anomalies. Although Fontan candidates need staged operations, if biventricular repair is feasible, one-stage repair would be a reasonable procedure considering the progression of the pulmonary vascular disease and the distortion of the pulmonary artery due to pulmonary artery banding. It would appear to improve the quality of life of those children if a one-stage operation can be performed with reasonable risk and good midterm outcome.

Coronary bypass surgery using the internal thoracic artery after reconstruction of occluded subclavian artery.

We present two cases with an occluded left subclavian artery requiring coronary artery bypass grafting. A preoperative angiogram confirmed that the subclavian artery, including the internal thoracic artery distal from the occlusion, was thoroughly intact, in both cases. Immediately after reconstructing the subclavian artery using an aortoaxillary bypass with an 8 mm ring-reinforced polytetrafluoroethylene graft, each patient underwent double coronary artery bypass grafting using the affected left internal thoracic artery with either the right internal thoracic artery or a saphenous vein in the same anesthetic setting. Symptomatic relief was excellent. In both cases, a postoperative angiographic study showed good function of the left internal thoracic artery graft supplying blood to the coronary artery through the aortoaxillary bypass graft.

[In vitro susceptibility of bacterial isolates from patients with respiratory tract infections to beta-lactam antibiotics].

In vitro susceptibilities of bacterial pathogens to beta-lactam antibiotics were determined. Bacterial pathogens examined included various isolates from the patients of respiratory tract infections at the hospitals of Kyoto-Shiga area in 1981 and 1983. Major organisms isolated from clinical specimens were Haemophilus spp., Klebsiella spp., Pseudomonas spp., S. aureus and Streptococcus spp. An increase in the isolation frequency of P. aeruginosa, a decrease in the isolation frequency of H. influenzae and no change in the isolation frequency of the other organisms were observed between the years 1981 and 1983. Data from susceptibility tests of clinical isolates confirmed that cefazolin (CEZ) and cefotiam (CTM) showed good antibacterial activity against S. aureus and cefmenoxime (CMX) was highly effective on Streptococcus spp., but that the susceptibilities of both organisms to CEZ, CTM, and cefmetazole (CMZ) in 1983 were lower than in 1981. Although CMX also showed good antibacterial activity against Klebsiella spp., there were no changes in the effectiveness of CTM, CMZ, and CEZ between the years 1981 and 1983. The in vitro antibacterial activities of CMX and cefoperazone against Haemophilus spp. were superior to those of the other beta-lactams tested, but there was a decline in the efficacy for CEZ. Although cefsulodin and piperacillin were highly active against Pseudomonas spp., declines in their effectiveness was observed between the years 1981 and 1983.

[A case of small cell undifferentiated carcinoma (SCUC) of the rectum treated with etoposide, cis-platinum and radiotherapy].

A 29-year-old-woman with recurrent cancer of rectum was treated with Etoposide, cis-platinum and external irradiation. Previous postoperative chemotherapies consisted of MMC, CPA, VCR and HCFU. Histologically, the tumor invaded in sheets and nests, and consisted of round to ovoid malignant cells with high nuclear/cytoplasmic and hyperchromatic nuclei with a coarse, clumped, or stippled chromatin pattern. Most cells demonstrated a positive reaction by Grimelius and NSE staining. Eight months after surgery, we switched to Etoposide cis-platinum and external irradiation, because of local recurrence. Etoposide (total 725 mg) and cis-platinum (total 100 mg) were injected into bilateral iliac artery and 60 Gy radiotherapy was performed. The patient showed a good response, and a complete response (CR) was evident for the following 42 months. Thus, Etoposide, Cis-platinum and radiotherapy are considered an effective combination therapy for a patient with small cell undifferentiated carcinoma.

[Surgical treatment of chronic constipation with megarectum in children].

In this paper, a new operative procedure for patients with chronic constipation with megarectum and its results are presented. Nine cases of idiopathic chronic constipation and one case of short aganglionosis showing megarectum underwent this operation. An incision was placed on the dentate line at 6 o'clock and the internal sphincter muscle was identified. The incision was extended to this muscle. The blunt division between the internal and external sphincter muscles was orally advanced 5 cm from the dentate line. The all layers of anus and lower part of rectum in length of 5 cm were clamped by 2 forceps in width of 1 cm. The mucosal and muscular layers were bilaterally cut in the outer side of the forceps. The rectum on the top of the forceps was pulled through to the dentate line and was anastomosed there; i.e. the posterior part of the anus was replaced by the rectal wall. Bowel habits of operated patients were evaluated at 1 to 3 years after the operation. Complete cure was obtained in 7 cases (including 1 case with aganglionosis). Three cases improved but needed sometimes suppositories. This procedure, sphinctero-myectomy and-plasty may be an operation of choice for chronic constipation with megarectum.