[Congenital esophagobronchial fistula treated with thoracoscopic assisted surgery].

A case of congenital esophagobronchial fistula in a 58-year-old woman was described. The patient had presented with repeated attacks of pulmonary infection from her childhood and had a history of recurrent cough after eating or drinking. Preoperative examinations including esophagogram by barium swallow revealed existence of a fistula between the upper thoracic esophagus and the right B3 bronchus. The fistula was recognized as type I of Braimbridge classification. Thoracoscopic assisted fistulectomy and diverticulectomy for esophagobronchial fistula with esophageal diverticulum were performed. The neck of the diverticulum and the fistula were divided with endo-stapling technique. Intraoperative esophagoscopy was found to be useful for the definite localization and complete excision of the fistula and the diverticulum and the avoidance of stenosis of the esophagus. Postoperative course was uneventful. It is to be considered that the present thoracoscopic assisted procedure with intraoperative esophagoscopy can be used as a standard operative procedure for esophagobronchial fistula with esophageal diverticulum.

[Modified bentall operation using composite graft without resection of aortic valve].

A 27-year-old male whose diagnoses were aortic dissection (Stanford A), aortic regurgitation, annulo-aortic ectasia, and Marfan syndrome underwent modified Bentall operation using composite graft and total arch replacement. Modification of proximal suture without resection of aortic valve like intravalvular implantation might have resulted in good recovery without blood transfusion. Another 63-year-old male who suffered from spontaneous aortic rupture with aortic regurgitation also underwent modified Bentall operation in the similar manner as the first case with good result. Spontaneous aortic rupture reported here is a rare case, and operation is thought to be prerequisite for the patient who suffers from this disease to survive.

[An adult case of Bochdalek hernia without an obvious cause; report of a case].

A 72-year-old female was transported by ambulance to our department to undergo transthoracic surgery. She had previously undergone transabdominal surgery under a diagnosis of adult Bochdalek hernia, but the restoration was believed to have been incomplete. During the transthoracic procedure, a dorsolateral defect of the diaphragm was detected and reinforcement with a Gore-Tex patch was performed. The patient's postoperative course was uneventful. Adult Bochdalek hernia is rare, but it requires immediate surgical intervention. Although transabdominal surgery is generally considered the first line treatment approach to restore Bochdalek hernia, restoration of the diaphragm is occasionally difficult. On the other hand, a transthoracic approach is thought to be effective as it allows for observation of the lung and diaphragm, and easy closure of the diaphragmatic defect. As complete restoration through early surgical intervention is important, a transthoracic approach in conjunction with transabdominal surgery should be considered whenever necessary.

Myocardial protection of the pressure overload hypertrophied heart in human cardiac surgery by acceleration of anaerobic glycolysis.

BACKGROUND: Because of the decreased tolerance to ischemia and increased reperfusion injury in hypertrophied myocardium, myocardial hypertrophy is a well known risk factor for cardiac surgery. We have previously demonstrated in a left ventricular hypertrophy (LVH) model that a highly buffered cardioplegic solution (HBS) that provided glucose as a substrate and promoted anaerobic glycolysis during ischemia afforded superior myocardial protection when compared to standard formulations. And we reported the superiority of this cardioplegia in human cardiac surgery. METHODS: In this study, 16 patients with aortic stenosis (AS) and LVH receiving HBS were reviewed and compared to another patient group with AS and LVH who received either cold blood cardioplegia (CBC; n=5) or glucose insulin potassium (GIK; n=6). RESULTS: Postoperative cardiac index was better in the HBS group than the other two groups with similar or lower catecholamine. CK-MB was lower in HBS group than GIK group, but this was not significant. Only one DC cardioversion was required in the HBS group, whereas 2 DC in the CBC group and total 7 DC in the GIK group. CONCLUSIONS: We found that histidine buffered cardioplegic solution provided comparable or better pump performance after surgery with relatively lower inotropic requirement, less DC cardioversion and homologous blood requirements for left ventricular hypertrophied heart associated with aortic stenosis.

[Surgical treatment of infectious endocarditis complicated by discrete subaortic stenosis: report of a case].

A 39-year-old male with a history of cardiac murmur from early childhood was diagnosed as having infectious endocarditis (IE) complicated by discrete subaortic stenosis (DSS). Echocardiography revealed severe aortic regurgitation, subaortic membranous structure and mild mitral regurgitation. The pressure gradient across the subaortic stenosis was 105 mmHg according to continuous Doppler wave ultrasonography. Aortic valve replacement and resection of subaortic membranous tissue and mitral annuloplasty were performed. Postoperative cardiac catheterization demonstrated that the hemodynamic data were remarkably improved, and the patient was free of symptoms. He is currently well at 6 months after the operation.

[A new instrument for insertion of anvil head for circular stapled anastomosis].

Difficulty associated with the insertion of the anvil head into the esophageal stump, caused by narrowing of the cervical esophagus, is a big problem for staple anastomosis during esophageal reconstruction. Postoperative cervical stricture also has been a major complication of esophagogastric anastomosis using a circular stapler. The stricture results from esophageal laceration caused by the anvil insertion. To avoid these complications, we designed a new retractor with triple-flap arms, which spreads out in a concentric circle from 20 mm to 35 mm in diameter. This instrument is useful for gently expanding the cervical esophagus without lacerations, and facilitates an anvil insertion into the stump of esophagus. In the 8 patients in whom this instrument was applied for dilation, none of the patients suffered from any stricture. Our clinical result indicates the usefulness of this new instrument for avoiding esophageal laceration and preventing stricture of esophageal anastomosis performed by circular stapler.

Replacement of the canine inferior vena cava with a seeded graft.

The patency and microscopic findings of gelatin-coated Dacron grafts seeded with endothelial cells and implanted into the inferior vena cava of dogs was evaluated. A total of 25 mongrel dogs were divided into four experimental groups according to whether or not an antiplatelet agent was administered and a seeded or nonseeded graft was implanted. In the groups not given antiplatelet therapy that were implanted with a nonseeded graft, occlusion of the graft occurred soon after surgery. In contrast, in the majority of animals implanted with a seeded graft and given antiplatelet therapy, graft patency was evident for up to 4 weeks postoperatively. In the latter animals, scanning electron microscopy 4 weeks after surgery showed the formation of confluent endothelial-like cells within 5 mm from the anastomosis, as well as insular endothelial-like cells in the central part of the graft. The simple centrifugal seeding method enables endothelial-like cells to adhere to grafts, suggesting that it may be useful in venous replacement.

[A case of Terson's syndrome with an interesting MRI finding].

We report a case of a 62-year-old woman admitted to our hospital in a semicomatose state. CT scan and MRI on admission revealed a dense subarachnoid hemorrhage and intracerebral hematoma in the right frontal lobe. Digital subtraction angiography showed a saccular aneurysm located in the anterior communicating artery, so radical neck clipping of the aneurysm was performed via the right pterional approach. The operation was unevential. The patient complained of bilateral visual disturbance on the next day and FLAIR image of MRI demonstrated clearly crescent shaped and mobile high intense lesions corresponding to subhyaloid vitreous hemorrhage in both eye balls. The fundoscopic examination revealed an intravitreous hemorrhage which gradually disappeared over the next 12 days. Terson's syndrome after subarachnoid hemorrhage has been linked to an entity of poor prognosis, so it is beneficial that characteristic findings in FLAIR image of MRI can lead to correct diagnosis of Terson's syndrome earlier.

[Benefits of 0.5T MR diffusion-weighted images for super-acute-phase cerebral infarction].

Though diffusion-weighted images (DWI) have been increasingly used to detect super-acute-phase cerebral infarction in recent years, they have primarily been obtained through the use of high magnetic machines of more than 1.5T. In this study, we discussed the usefulness of DWI obtained using 0.5T MRI in comparison with CT, MRI (FLAIR and T2 weighted image) and SPECT (99mTc-HMPAO). DWI were able to detect ischemic lesions earlier than FLAIR or T2-weighted images. Scanning time was short at four seconds for eight slices, and the quality of image was sufficient for clinical usage. The most available b-value seems to be 800. There were less susceptibility artifacts in the 0.5T DWI than in the 1.5T DWI. From these data, we presume that it is possible to detect super-acute-phase cerebral ischemia on the 0.5T DWI, proving the clinical usefulness of DWI. Furthermore, DWI is considered useful in observing chronological changes in cerebral infarction, differentiation of abscess or brain tumor, diagnosis of moyamoya disease, degenerative disease and so on.

[A case of squamous cell carcinoma of the lung associated with exophthalmos and hypercalcemia].

A 69-year-old man visited in the department of ophthalmology of this university, complained with exophthalmos. He was pointed out hypercalcemia and transferred to the department of endocrinology. The chest X-ray and thoracic CT showed a large mass in lower lobe of the left lung. Cytological diagnosis of this tumor was squamous cell carcinoma. In clinical examination, serum CA was 12.2 mg/dl in spite of normal level of PTH, calcitonin, 1 alpha, -25 (OH) 2D3 and uric cAMP. On the other hand, PTHrP-intact in serum was 9.8 pmol/l. His thyroid gland had no abnormality in palpation or roentogenological examination. The thyroid functions, thyroglobulin, thyrotropin receptor antibody, thyroid test and microsome test were all in normal limit. From these results, he was diagnosed of lung cancer with humoral hypercalcemia of malignancy and euthyroid "isolated" Graves' ophthalmopathy. Left lower lobectomy with mediastinal lymph node dissection (R 2 a) was done and p-stage was IIIA. After operation, serum Ca decreased in normal level and the exophthalmos was also improved gradually. He was in well until 10 months after operation, and died with multiple lung metastases and hypercalcemia. Exophthalmos was also recurred in his terminal stage. Similar case could not find in literature and some discussion of the literatures was mentioned.

[A case of inflammatory pseudotumor of the lung with suppressed immune response in the patient with renal cell carcinoma after nephrectomy and administration of interferon].

A 60-year-old man with renal cell carcinoma was treated of right nephrectomy and high dose administration of Interferon-alpha (IFN) in 1990. Three and half years after operation, he complained of cough and hemoptysis. Chest X-ray showed a abnormal shadow (5.5 x 3.5 cm) in the upper lung field. On chest CT, a tumor mass with small cavity was located at S2, attended with the speculation and pleural indentation. A rough nodule suspected daughter tumor was pointed out near the tumor mass. Laboratory investigation revealed mild leucocytosis, an elevated ESR and C reactive protein. On lymphocyte subset, CD 4/8 ratio was 0.8 and NK cell activity was 11%. Immunosuppressive acid protein (IAP) in serum was 1,137 ng/ml. No organisms or malignant cells could be demonstrated in the biopsy materials or sputum. Right thoracotomy and upper lobectomy was carried out. Postoperative pathological diagnosis was inflammatory pseudotumor. Namely, the lesion was occupied with variable admixture of lymphocytes, plasma cells, histiocytes, phagocytes included hemosiderin, foam cells and whorled fibrosis. Daughter tumor was scar tissue. Now, he is well without recurrence and his immune response is within normal level. Some discussion of the literature was mentioned.

Immunoglobulin G lymphocytotoxic antibodies in clinical liver transplantation: studies toward further defining their significance.

Twenty-two consecutive liver allograft recipients, who tested positive for immunoglobulin G (IgG) lymphocytotoxicity were subjected to pretransplantation and posttransplantation immunologic monitoring of anti-donor IgG lymphocytotoxic antibody titers, total hemolytic complement activity (CH100), circulating immune complexes (CIC), and platelet counts in an effort to improve our understanding of the preformed antibody state in clinical hepatic transplantation. Ten contemporaneous liver transplant recipients whose crossmatch results were negative and who experienced severe hepatocellular damage early after transplantation were included as controls. Crossmatch test results were negative 1 day after transplantation and during the 1 month follow-up remained negative in 14 of 22 (64%) sensitized recipients, most of whom had relatively low (< or = 1:16) anti-donor IgG antibody titers before transplantation. After transplantation, this group and the control group experienced no thrombocytopenia, no increase of CIC, and a gradual increase in CH100 activity that reached normal levels within 1 week. A strong negative correlation between prothrombin time (PT) and CH100 activity in these groups of patients suggested that changes in CH100 activity (P < .0005) were tightly linked to liver synthetic function. In contrast, the crossmatch test results remained positive after transplantation in 8 of 22 (36%) sensitized recipients, all of whom had relatively high (> 1:32 to 1024) pretransplantation titers of anti-donor IgG antibodies. After transplantation these patients developed a syndrome that was characterized by decreased CH100 activity and increased CIC compared with pretransplantation levels and refractory thrombocytopenia that was associated with a 50% allograft failure rate because of biopsy-proven humoral and acute (cellular) rejection.(ABSTRACT TRUNCATED AT 250 WORDS)

Can adenine nucleotides predict primary nonfunction of the human liver homograft?

Sixty-eight primary liver grafts were analyzed to see whether adenine nucleotides (AN: ATP, ADP, and AMP) or purine catabolites (PC: adenosine, inosine, hypoxanthine, and xanthine) of tissue or effluent can predict primary graft nonfunction. AN, PC, and nicotinamide adenine dinucleotide, oxidized form (NAD+) of the tissue before (pretransplant) and after graft reperfusion (post-transplant) and of the effluent were analyzed. The graft outcome was classified into two groups (group A: successful, n = 64; group B: primary nonfunctioning, n = 4). No significant differences were observed in pretransplant measurements between groups A and B, whereas ATP, ADP, total AN, total AN + total PC (T) and NAD+, in post-transplant tissues, were significantly higher in group A. Xanthine in the effluent was significantly higher in group B than in group A. ATP, ADP, total AN, T, and NAD+ in post-transplant tissue were significantly associated with primary graft nonfunction by logistic regression analysis.