[Single-stage operation for synchronous bilateral multiple lung cancer through median sternotomy].

An asymptomatic 65-year-old woman was incidentally found to have abnormal shadows on a chest X-ray during a medical examination. A chest computed tomography (CT) scan showed a pulmonary nodule in both right and left lung. Those were diagnosed as synchronous cStage IA bilateral lung cancer, and right upper lobectomy and segmentectomy of the left lung with lymphoadenectomy were sequentially performed through median sternotomy. The patient showed a favorable course after surgery, and was discharged on postoperative day 12. The pathological diagnosis was synchronous lung cancer and both were adenocarcinoma. The pathological stage was IA on the right side and IB on the left. A single-stage operation through median sternotomy was a useful surgical procedure for treating this case of synchronous bilateral lung cancer.

[Bronchoplastic procedures for lung cancer].

Bronchoplastic procedures for patients with lung cancer are designed to achieve radical cure with preservation of functioning lung parenchyma. The operative results of 139 cases of lung cancer who underwent bronchoplasty between 1963 through 2007 were reviewed. The mean age of the patients was 62.5 years (range, 20 to 78 years). Sleeve lobectomy (SL) was performed in 119 cases, wedge lobectomy (WL) in 10 cases, sleeve segmentectomy (SS) in 5 cases, wedge segmentectomy (WS) in 2 cases, sleeve resection (SR) in 2 cases, and wedge resection (WR) in 1 case. Squamous cell carcinoma was the most frequently encountered histological type of disease (78%), followed by adenocarcinoma (12%) and other histological types (10%). The tumor was central in 125 patients (90%) and peripheral with nodal involvement in 14 patients (10%). Vascular resection and reconstruction was performed in 16 patients. Early major bronchial anastomotic complications occurred in 6 patients (4.3%). The 5-year survival rate in the patients with squamous cell carcinoma was 63.2%, and in patients with adenocarcinoma was 26.3%. SS for patients with early-stage squamous cell carcinoma of the segmental bronchus is a curative operation with preservation of the pulmonary function. Bronchoplasty without lung resection (SR, WR) is a reliable method for patients with low-grade malignant polypoid tumors arising from the bronchus. Patients with adenocarcinoma, N2 disease or major bronchial anastomotic complication show a worse prognosis.

Effect of truncal vagotomy on intestinal phase of pancreatic polypeptide release in dogs.

In order to elucidate the role of the vagus nerve in the intestinal phase of pancreatic polypeptide (PP) release, mongrel dogs were given a 4-min intraduodenal infusion of saline, 20% glucose, or 10% soybean oil solution (50 ml each), before and one month after truncal vagotomy including pyloroplasty (TV). The saline infusion did not change the basal PP level, while the glucose infusion elicited a monophasic transient PP release, and the soybean oil infusion elicited a monophasic prolonged PP release in the intact dogs. The PP response following glucose infusion was almost abolished after TV, while the PP response to fat was attenuated, but a significant increase was nevertheless observed after TV. These results suggest that the vagus nerve has an important role in the intestinal phase of PP release and that other factors, e.g. hormonal, might also be involved in the regulatory mechanism, especially after fat loading.

Efficacy and safety of extended thymectomy for elderly patients with myasthenia gravis.

BACKGROUND: The number of elderly patients who are diagnosed as myasthenia gravis (MG) is increasing in Japan. Although several factors affecting thymectomy have been well documented, few studies have focused on the efficacy and safety of thymectomy for elderly patients older than 60 years. METHODS: We evaluated 94 patients with MG who underwent extended thymectomy, and divided them into two groups: patients younger than 59 years and patients older than 60 years. Preoperative patient data, pathology of the thymus, complications, and clinical outcome were evaluated. RESULTS: In 69 young patients and 25 elderly patients, we observed no significant differences between the two groups with regard to preoperative data. Thymic hyperplasia was present in 45% of the young group and 16% of the elderly group. Remission and improvement rate were 40% and 57% in the young group and 8% and 75% in the elderly group, respectively. There were no serious complications, except one early death due to gastrointestinal bleeding in the elderly group. CONCLUSIONS: We conclude that thymectomy is a safe and effective alternative for elderly patients with MG.

Successful tracheal transplantation using cryopreserved allografts in a rat model.

OBJECTIVES: The purpose of this study was to determine the appropriate cryopreservation period of tracheal allografts based on morphological and immunological findings and to test the possibility of tracheal transplantation in rats using cryopreserved allografts without immunosuppression. METHODS: Morphological and immunological studies were performed to compare the differences between non-cryopreserved grafts and cryopreserved grafts. Orthotopic tracheal transplantation using cryopreserved allografts, non-cryopreserved allografts, and non-cryopreserved autografts was performed and the rejection score of each group was evaluated. RESULTS: Epithelial cells were lost when the grafts were cryopreserved for more than 20 days. Immunohistochemical staining of the trachea revealed that the MHC classII antigen was expressed on normal epithelium. These findings suggest that cryopreservation for more than 20 days decreased the antigeneicity of allografts because of epithelial desquamation. All rats that received allografts cryopreserved for more than 20 days survived until the scheduled sacrifice day. Microscopically, cryopreserved allografts that had been preserved for more than 20 days had a significantly lower rejection score than that of non-cryopreserved allografts (P < 0.05). CONCLUSIONS: We conclude that the appropriate period for cryopreservation of allografts would be 20 days or more, because cryopreservation for more than 20 days depleted epithelium, which possessed the MHC classII antigen. Therefore, a longer period of cryopreservation decreases the antigeneicity of allografts. Rat tracheal transplantations using cryopreserved allografts is possible without immunosuppression when the grafts have been cryopreserved for more than 20 days.

Henoch-Schoenlein nephritis and IgA nephropathy in children: a comparison of clinical course.

The clinical presentation, initial laboratory and renal biopsy findings, and subsequent clinical course were studied and compared in 128 children with Henoch-Schoenlein (HS) nephritis and in 206 children with IgA nephropathy. The clinical and pathological findings of the two conditions were similar. After a mean follow-up period of 5 years, 72 patients (56%) with HS nephritis and 67 (32%) with IgA nephropathy showed no demonstrable abnormality, 29 (23%) with HS nephritis and 103 (50%) with IgA nephropathy had minor urinary abnormalities, 7 (5%) with HS nephritis and 26 (13%) with IgA nephropathy had heavy proteinuria and/or hypertension, and 20 (16%) with HS nephritis and 10 (5%) with IgA nephropathy had developed chronic renal failure. A worse outcome was significantly associated with the more severe clinical presentations and more severe glomerular changes by light microscopy in HS nephritis, whereas there was no relationship between the severity of clinical presentation and glomerular changes and prognosis in IgA nephropathy. These findings suggest that HS nephritis is an acute disease and prognosis is associated with the severity of glomerular changes at onset, while IgA nephropathy is a chronic, slowly progressive glomerular disease.

Usefulness of direct coronal CT in the diagnosis of urinary bladder tumor.

Direct coronal CT was performed on 6 cases of urinary bladder tumor in which conventional axial transverse CT failed to depict the relationship between the lesion and bladder wall. GE CT/T 8800 was used, and the bladder was scanned with patients crouched on the table opposite the gantry. The relationship between the tumor and bladder wall as well as the surrounding organs was visualized in 5 of 6 cases examined. THe CT diagnosis and histological findings coincided in 4 of these 5. Direct coronal CT was useful for diagnostic determination of clinical stage for tumors occurring in the apical or basal region of the urinary bladder.

[Serological assay for diagnosis of verotoxin-producing Escherichia coli (VTEC) infection in the patients with diarrhea].

A total of 239 serum samples from 136 persons were used for bacterial agglutination assay (BA) against predominant three O-antigens of VTEC. All VTEC isolates from stools of 30 patients were only O157:H7 serotype (these patients are called group I). The levels of positive BA antibody titers (over 1:160) to O157-antigen were recognized in each patients as follows. The VTEC isolated patients with HUS or without HUS in group I were all of 13 (100%) and 14 (82.4%) in 17 patients, respectively. And 21 (65.6%) patients of group II (HUS patients with stool negative cultures, or stool cultures were not performed in 32 patients), and 6 (15.0%) patients of group III (family members of group I and II; 40 persons), were also recognized. In group IV (patients with diarrhea due to other pathogen than VTEC; 11 patients), and V (clinically healthy persons; 23 persons), none were recognized as positive BA antibody titers. All patients in the group II except one who had a positive BA antibody titer to O111, were not recognized to O111 and O26. A few VTEC-positive patients without gastrointestinal syndrome did not have significant agglutinating titers to O157-antigen on the days after VTEC isolation. However, almost all patients with diarrhea due to VTEC and HUS, and with VTEC but no HUS, had a level of positive BA antibody titer on the 5 day after onset of diarrhea. These results suggest that this serological assay is a very simple and useful tool for diagnosis of VTEC infection when VTEC are not detected by culture method due to antimicrobial treatment, or due to the lapse of many days after onset of diarrhea.

[Four cases of hemolytic uremic syndrome (HUS) associated with serotype O165 verotoxin producing Escherichia coli (VTEC) identified by LPS-solid phase enzyme-linked immunosorbent assay (ELISA)].

Enzyme-linked immunosorbent assay using LPS derived from newly recognized serotype O165 verotoxin producing Escherichia coli (VTEC) could identify 4 cases of hemolytic uremic syndrome (HUS) associated with O165 VTEC. All 4 cases showed a typical clinical course seen in VTEC-associated HUS. We screened 33 cases of HUS whose pathogen was not identified by culture of serodiagnosis. The O165 serotype was not thought to be important not only as a VTEC but also as an enteropathogenic E. coli. However, the prevalence, 4 cases, was as high as of O111 serotype, which is the second major serotype of VTEC in Japan. We have to be careful for this serotype when we look for the pathogen of the patients with hemorrhagic colitis or with HUS.

[Measurements of cerebral blood flow by the noninvasive microsphere method with 123I-IMP and fan beam collimator: comparison with the continuous arterial blood sampling method].

PURPOSE AND METHODS: The noninvasive microsphere (NIMS) method quantifies cerebral blood flow with N-isopropyl-p-[123I]-iodoamphetamine (123I-IMP) without blood sampling of a patient, but when a fan beam collimator is used for collecting raw data in single photon emission computed tomography (SPECT), the procedure is complicated because we have to change the collimator. In phantom and clinical studies we investigated the validity of using a fan beam collimator in collecting planar and SPECT raw data. RESULTS: The phantom study suggested that using a fan beam collimator for planar imaging was feasible because of the image magnification rate and the count rate. Mean cerebral blood flow (mCBF) values obtained by the NIMS method with the fan beam collimator were compared with mCBF simultaneously estimated from the conventional continuous arterial blood sampling (microsphere: MS) method in twenty patients with ischemic cerebral vascular diseases. There was good correlation (y = 1.033x + 8.004, r2 = 0.729, p < 0.01) in mCBF between the fan beam NIMS method and the MS method. CONCLUSION: In conclusion, this method for the measurement of CBF was acceptable for routine clinical studies.

[Quantitative measurements of regional cerebral blood flow using technetium-99m-L,L-ECD SPECT activated with acetazolamide: fundamental study of measurement's accuracy, comparison with 123I-IMP ARG method].

We measured regional cerebral blood flow before and after acetazolamide administration using a serial noninvasive method with 99mTc-ECD developed by Matsuda and Takeuchi et al., and compared the accuracy of measured values with those obtained by the conventional 123I-IMP ARG method. When the regional cerebral blood flow was measured for 80 brain regions in 5 subjects without scatter correction, a differential of 0.5 +/- 8.4% was obtained between values measured before and after physiological saline administration as a placebo. A differential of -0.2 +/- 12.6% was obtained when the same regions were measured with scatter correction. These findings indicated that placebo administration did not affect measured values, regardless of whether scatter correction was performed. When 64 regions in 4 subjects at rest were measured on two successive days, a differential of -1.1 +/- 9.0% was obtained between the values measured on the two days. A differential of -4.0 +/- 11.7% was obtained for the same regions following acetazolamide administration. These findings showed that measurements were reproducible both when subjects were at rest and when they were administered acetazolamide. The above two methods were used for measurement of 80 brain regions in the same 5 subjects for comparison. Measurements of subjects at rest and with acetazolamide administration were performed on separate days. The regression line y = 0.99x + 1.47, r = 0.80, was obtained for the subjects at rest, and y = 0.86x + 7.76, with r = 0.76, for the subjects following acetazolamide administration. These findings demonstrated a good correlation between the values obtained using the two methods. The values obtained using the method of Matsuda and Takeuchi et al., before and after acetazolamide administration were thus consistent with those reported previously using the conventional method, and the former method proved to be both simple and reliable.

[Thoracoscopic partial lung resection using staplers and polyglycolic acid (PGA) felts in an 85-year-old patient].

An 85-year-old man was admitted to our hospital with complaints of dyspnea and palpitations. His chest roentgenogram and CT scan showed emphysematous lung and a right pneumothorax with bulla. In cases of emphysematous lung disease, it is well-known that postoperative pulmonary leakage tend to be prolonged, and that control of such leakage is often difficult. A felt-like bioabsorbable prosthesis (polyglycolic acid sheet: NEOVEIL) was used for partial lung resection under thoracoscopic guidance. On each side of the stapler, PGA strips (1 cm wide x 3.5 cm long) were fixed with absorbable sutures. We found that it was difficult to cut with the stapler knife and that the second staple line could not easily cut across the first. However, there was no postoperative air-leakage and his postoperative course was uneventful.

[A clinicopathological study of 90 children with acute renal failure].

Clinical presentation, laboratory findings, renal biopsy findings and subsequent clinical course were studied retrospectively in 90 children with acute renal failure to intrinsic renal damage. The mean age at presentation was 8.1 years. Diagnosis and number of patients were as follows: Hemolytic uremic syndrome (HUS) in 32 patients, tubulo-interstitial nephritis in 19, idiopathic nephrotic syndrome in 10, IgA nephropathy on 9, membranoproliferative glomerulonephritis in 8, lupus in 5, poststreptococcal glomerulonephritis in 4, cortical necrosis in 1, Henoch Schoenlein purpura nephritis in 1 and anti-neutrophil cytoplasmic antibody associated glomerulonephritis in 1. Thirty-nine patients needed dialysis, but 36 of these were able to stop dialysis, 3 patients with HUS without gastrointestinal symptoms needed chronic dialysis. The mean follow-up period was 7.3 years from onset, and the the latest follow-up 82 patients had normal renal function, 3 showed chronic renal failure, 2 had regular dialysis, 2 had successful renal transplantation, an 1 had died due to heart failure. A poor outcome was associated with diffuse crescents and the presence of severe vascular changes. The early biopsy findings were very useful for the management of children with acute renal failure.

[Intracavity suction and drainage in a patient with giant bulla accompanied by pneumoconiosis and emphysema: a case report].

A 74-year-old man with giant bulla accompanied by pneumoconiosis and emphysema was treated by intracavity suction and drainage procedure using chemical irritant and fibrin glue. About one month later, the bulla disappeared and the patient symptomatically improved on discharge from hospital. Intracavity suction and drainage is safe and effective treatment of emphysematous bulla in patients considered to be a bad risk for formal thoracotomy.

[Malignant fibrous histiocytoma of the chest wall: a case report].

A 74-year-old man was admitted to our hospital with a cough. His chest X-ray film, chest CT scan and MRI showed a tumor of the chest wall. Histology of a percutaneous needle biopsy revealed malignant fibrous histiocytoma (MFH). The tumor enlarged rapidly, and the patient underwent resection including the 6th, 7th and 8th ribs and partial resection of the right diaphragm and the right middle and lower lung lobes. Multiple pulmonary metastases were found 40 days after the operation, and the patient died of respiratory failure 4 months after surgery. Although MFH is one of the most common soft tissue sarcomas, lesions arising from the chest wall are uncommon. We stress the need for early diagnosis and aggressive surgical resection in the treatment of MFH arising from the chest wall.

[A case of Marfan's syndrome that required emergency Bentall's operation due to acute dissecting aortic aneurysm (DeBakey type II) following surgery of abdominal aortic aneurysm].

Graft replacement was performed in a 29-year-old man for an abdominal aortic aneurysm associated with Marfan's syndrome. Since the dissecting aortic aneurysm (DeBakey type II) accompanied by disruption of the right coronary artery developed 74 days after operation, the emergency Bentall's operation was successfully carried out with bypassing of the right coronary artery using a saphenous vein graft. Fifteen Japanese cases operated on for abdominal aortic aneurysm associated with Marfan's syndrome are reviewed, and the problems concerning surgery of abdominal aortic aneurysm and Bentall's operation are discussed.

[Completion pneumonectomy for local recurrence of lung cancer].

Completion pneumonectomy refers to an operation intended to remove what is left of a lung partially resected during a previous operation. The procedure is seldom indicated and the risk of operative mortality and morbidity is higher than standard pneumonectomy. Four patients underwent completion pneumonectomy for recurrence of lung cancer. The first patient had metastatic lesion of hilar lymph nodes more than five years after surgery. The second one had received preoperative radiation therapy and the third had very poor pulmonary function. The last one had underwent pulmonary resections twice during twelve years. Each case was relatively uncommon and gave the difficult surgical problem, but all patients survived the operation and are doing well at present.

[Thoracoscopic treatment of a giant bulla: a case report].

A 38-year-old man was admitted to our hospital because of left giant bulla and pneumothorax. His chest X-rays and CT scan showed giant bulla of the left upper lobe and left pneumothorax. We performed bullectomy using the ENDOPATH ENDO LINEAR CUTTER 60 mm and 35 mm disporsable surgical stapler under thoracoscopic guidance. Clipping with end-clips and fibrin glue were effective for miner air leakage. There were no complications such as prolonged air leakage or incomplete lung re-expansion. His post operative couse was uneventful and he was discharged from the hospital on the 11th post operative day. When performed along with mini-thoracotomy, thoracoscopic operation is useful in treating patients with giant bulla.

[Total arch replacement following partial replacement of the descending aorta for acute type A aortic dissection: report of a case].

A 42-year-old man was admitted to our hospital due to severe back pain. A computed tomographic scan revealed aortic dissection from the ascending aorta to the left common iliac artery. His blood pressure was well controlled untill he went into shock 21 hours after the onset. He was given a diagnosis of aortic rupture to the left pleural cavity by echocardiography and chest X-ray. He underwent emergent left thoracotomy under femoro-femoral bypass. We found a rupture of the descending aorta 3 cm above the diaphragma and replaced the ruptured segment with a woven Dacron graft. On postoperative day 9, we performed total arch replacement utilizing deep hypothermia and selective cerebral perfusion. We located the entrance tear in the aortic arch. His postoperative course was uneventful and he showed no neurological deficit. He was discharged from the hospital on postoperative day 36.

[A case of quadricuspid aortic valve associated with mitral regurgitation].

A case of a 60-year-old man associated with quadricuspid aortic valve and mitral regurgitation is reported. The aortic valve consisted of three larger cusps and a small accessory cusp situated between the right and the non-coronary cusps. The aortic regurgitation resulted from malcoaptation of the four cusps and the mitral regurgitation resulted from annulus dilatation and thickening of the anterior leaflet. The surgical treatment was performed successfully by the aortic and mitral valve replacements with St. Jude Medical valves. The patient is doing well fifteen months postoperatively. Sixteen Japanese cases of quadricuspid aortic valve which were corrected surgically are reviewed.