Successful surgical treatment for implanted intraperitoneal metastases of ruptured small hepatocellular carcinoma: report of a case.

We report herein the case of a 53-year-old man with disseminated intraperitoneal metastases caused by the rupture of small hepatocellular carcinoma (HCC). He was admitted to our hospital in shock after suffering a trauma injury to the upper abdomen. Ultrasonography revealed a massive hemoperitoneum. At surgery, 4000 ml of blood was drained from the abdominal cavity and a ruptured tumor, 2 cm in diameter, was found in the right lobe of the liver. The tumor was resected with an adequate surgical margin and subsequent microscopic examination confirmed a diagnosis of moderately differentiated HCC without associated liver cirrhosis. The patient was readmitted 14 months later following the development of right lower quadrant pain. Ultrasonography and computed tomography revealed extrahepatic abdominal tumors, and abdominal angiography demonstrated four intraperitoneal tumors. At surgery, four implanted metastases adhered to the greater omentum were found and resected. No other tumors were detected. Microscopically, all four tumors were confirmed as moderately differentiated hepatocellular carcinoma. Ruptured HCC may lead to implanted intraperitoneal metastasis, but rupture of small HCC is very rare. While hepatic resection is the treatment of choice for ruptured HCC, according to our review of the literature, only a few patients have survived long-term after resection of implanted metastasis.

Arteriovenous malformation of the rectum: report of a case.

We report herein the case of a 38-year-old man found to have a rectal arteriovenous malformation (AVM). The patient was admitted to our hospital for investigation of fresh anal bleeding and general malaise. Barium-enema examination showed a slightly elevated lesion in the rectum, and a selective superior rectal angiogram subsequently revealed an AVM in the peripheral region of the superior rectal artery, which was presumed to be the cause of the anal bleeding. Colonoscopic examination disclosed a submucosal tumor-like lesion in the left posterior wall of the rectum, 3cm above the anal verge. After marking the boundaries by clipping, transanal resection of the lesion was performed. Histological examination revealed an irregularly expanded arteriovenous aggregation in the submucosal layer. The patient had a favorable postoperative course, and no residual AVM was seen on a postoperative selective inferior mesenteric arteriogram. There have been no signs of recurrence in the 2 years since his operation.

Treatment of pancreas head carcinoma in a 91-yr-old man. Report of a case successfully treated with pylorus-preserving pancreatoduodenectomy.

The case of a 91-yr-old man who had a tumor of the pancreas head successfully resected is reported. He was admitted to our hospital because of obstructive jaundice, and then percutaneous transhepatic biliary drainage (PTBD) was performed. Cholangiography via PTBD tube showed marked stenosis of the bile duct in the head of the pancreas. Endoscopic retrograde pancreatography (ERP) showed obstruction of the main pancreatic duct in the head of the pancreas, and carcinoma in the head of the pancreas was diagnosed. Abdominal angiography showed stenosis of the celiac trunk caused by compression from the median arcuate ligament, but no tumor stain or encasement in the pancreas was detected. Because the patient had lived an extremely healthy life and had no serious concurrent disease before admission, laparotomy was performed. The tumor in the head of the pancreas was about 2 cm in diameter and restricted inside the pancreas. Pylorus-preserving pancreatoduodenectomy (PpPD) with regional lymph node dissection was performed. The tumor was 1.5 cm in its maximal diameter, and histopathologically was diagnosed as an invasive ductal carcinoma of the pancreas with moderately differentiated tubular adenocarcinoma. The patient had an uneventful postoperative course and now, 3 yr after surgery, he is doing very well and leading a normal daily life.

[A case of lung cancer avoidable right pneumonectomy due to external and intraluminal irradiation therapy].

A 54-year-old man with squamous cell carcinoma of the lung resected after external and high dose rate intraluminal irradiation (HDRII) therapy is reported. Cancer existed in right lower bronchus, extended to bifurcation of upper broncus and truncus intermedius. The patient received external irradiation of 40 Gy and HDRII of 18 Gy (Iridium192 was used) simultaneously. Effectiveness of irradiation was remarkable, tumor disappeared in chest CT and bronchoscopy. Middle and lower lobectomy and bronchial wedge resection was performed. Histologically, cancer was not existed in second carinal portion, so curative resection was done. The result suggests that HDRII is effective therapy as preoperative adjuvant irradiation.

Is it true that cardiac operations with cardiopulmonary bypass impair the reticuloendothelial system?

Reticuloendothelial system (RES) function after cardiac operations is a controversial issue. Sequential changes in plasma fibronectin levels and RES phagocytic function were studied after a cardiac operation and a lung operation (control). In the cardiac operation group, the plasma fibronectin level decreased until the third postoperative day and increased thereafter. Reticuloendothelial system phagocytic function remained unchanged on the third postoperative day and then it increased. However, in the control group it increased significantly after operation. In the past, investigators have demonstrated a decline in plasma fibronectin levels following cardiac operation and have assumed that RES function was impaired. However, this sequential study showed that phagocytic function was not impaired, but its enhanced phase was delayed. Moreover, our previous morphologic studies demonstrated that RES function was potentially activated after cardiopulmonary bypass. It appears that the delay of the enhanced phase is caused by the overloading of substances which must be processed by the RES during cardiopulmonary bypass. Thus, we conclude that cardiac operation produces hyperactive, yet oversaturated RES function. There is no impairment of RES function after cardiac operations.

Oversaturation status of reticuloendothelial system following cardiopulmonary bypass.

In the past, it was generally believed that the phagocytic function of the reticuloendothelial system (RES) was depressed after cardiopulmonary bypass (CPB), but several investigators reported differing results. Therefore, this study was performed to determine the effect of CPB on RES function, experimentally and clinically. Six dogs undergoing CPB (CPB group) were compared with an identical number of dogs subjected to thoracotomy without CPB (control group). A lipid emulsion test was performed in all dogs before and after the surgical procedure to measure RES phagocytic function. Any ultrastructural changes in Kupffer cells were observed by electron microscopy. In both groups, the RES phagocytic index showed a significant decline after surgery. However, comparison of the 2 groups revealed that there was a significantly greater decrease in the CPB group (p < 0.05). Electron microscopy of the Kupffer cells showed that the number of phagosomes, especially those containing deformed erythrocytes, increased after CPB. Twenty patients undergoing cardiac surgery requiring CPB (Group A) and 8 patients undergoing pulmonary resection (Group B) were studied. RES phagocytic function was determined 3 days prior to surgery and 3 days postoperatively using the lipid emulsion test. No significant difference was observed in the preoperative phagocytic indices between the 2 groups. The phagocytic function remained almost unchanged in Group A on the third postoperative day, compared with the preoperative value, but it increased significantly in Group B on the third postoperative day, compared with the preoperative value. The intergroup difference was significant on the third postoperative day (p < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Reticuloendothelial function following cardiopulmonary bypass: laboratory and electron microscopy findings.

Several studies on the effects of cardiopulmonary bypass (CPB) on the reticuloendothelial system (RES) function have been performed previously, but different results have been reported. This study was carried out to determine the effect of CPB on RES function in a canine model simulating clinical CPB. Nine dogs undergoing surgery with CPB were compared with an identical number of dogs subjected to thoracotomy without CPB. A lipid emulsion test was performed in all dogs before and after the surgical procedure to measure RES phagocytic index, i.e., phagocytic function. Kupffer cell iron uptake under conditions of iron loading following CPB was examined histologically, and any ultrastructural changes in the Kupffer cells were observed by electron microscopy. In both groups, the RES phagocytic index showed a significant decline after surgery. However, a comparison of the two groups revealed that there was a significantly greater decrease in the CPB group (P < 0.05). Moreover, histologic evidence of iron uptake in Kupffer cells was strongly suppressed in the CPB group. Electron microscopy of the Kupffer cells showed that the number of phagosomes, especially deformed erythrocytes, increased after CPB. These findings suggest that RES function is significantly impaired following CPB, and an increase in the amount of material, especially deformed erythrocytes, to be processed by the RES is responsible, in part, for the depressed RES phagocytic function. The prevention of hemolysis during CPB may preserve the RES function following CPB.

Surgical treatment of primary lung cancer in patients less than 40 years of age.

PURPOSE AND METHODS: The major purpose of this study was to determine whether the survival rate in young lung cancer patients after surgical treatment differs from that in older patients. An analysis was performed for all patients with bronchogenic carcinoma who underwent surgery at Mie University Hospital from 1965 to 1990. RESULTS: Of 803 patients, 24 (2.99%) were 33 to 39 years old. At the time of surgery, the disease was diagnosed as stage I in seven patients (29%), stage II in four (17%), stage IIIa in seven (29%), stage IIIb in two (8%), and stage IV in four (17%), while 46.3% of the patients older than 40 years of age had either stage IIIa, IIIb, or IV disease. All of the 24 patients less than 40 years of age underwent thoracotomy: curative resection in 14 cases, palliative resection in sex, and probe-thoracotomy in four. The 5-year survival rate for all stages of disease was 31.4% in these 24 patients, and 41.9% in 603 patients greater than 40 years of age. The 5-year survival rate for stage I disease was 35.7% in the seven younger patients and 78.0% in the 207 older patients; for stage II, it was 25.5% in the four younger patients and 40.6% in the 98 older patients; for stage III, it was 33.3% in the nine younger patients and 15.6% in the 250 older patients; and for stage IV, it was 25% in the four younger patients and 6.6% in the 48 older patients. There were no significant differences in survival rate between the two age groups for all patients or for those with each stage of disease. CONCLUSION: Although younger patients tended to have more advanced disease, long-term survival in these patients did not differ from that of older patients.

The role of surgical resection and the effects of neo-adjuvant therapy in the management of small cell lung cancer.

A study was conducted on 58 patients who underwent surgery for small cell lung cancer (SCLC) as resection or exploratory thoracotomy, and 43 patients encountered during the same period who received no surgical treatment. The following conclusions were drawn from our analysis: At stage I, an operation is desirable, regardless of the subtype of SCLC, but chemotherapy should be given first; at stages II and III, by the addition of surgery after neo-adjuvant chemotherapy, "state-of-the-art" results for limited SCLC can be surpassed; in patients with stage II disease on whom curative resection has been performed, particular attention must be paid to the possibility of metastasis to the brain; and finally, exploratory thoracotomy did not bring about the early death of patients or reduce the quality of life, but only delayed chemotherapy for about one week, while enabling the staging and histological subtype of SCLC to be clarified.

Measurement of myocardial blood flow in coronary artery bypass surgery.

It is now possible experimentally to measure myocardial blood flow of the beating heart using a helium-neon (He-Ne) laser Doppler flowmeter. A myocardial probe was redesigned to reduce its size and weight, and a method devised of fixing the probe to the beating cardiac surface to allow its clinical application. This modified laser flowmeter was used on 36 patients with ischaemic heart disease to measure myocardial blood flow before and after revascularization. Flow was measured in the right and left ventricles while patients were in a haemodynamically stable state as determined by electrocardiography, heart rate, blood pressure and double product (heart rate x systolic blood pressure). No significant difference was found between the mean(s.e.m.) preoperative and postoperative flow volume at the anterior wall of the right ventricle (77(15) versus 81 (12)ml/min per 100 g), which did not undergo revascularization, but mean(s.e.m.) myocardial blood flow at the ischaemic left ventricle increased significantly (from 68(15) to 88(13) ml/min per 100 g; P < 0.01). There was also no significant difference between preoperative and postoperative values of haemodynamic parameters of coronary blood flow. In conclusion, a means to measure myocardial blood flow with He-Ne laser Doppler flowmetry has been devised which shows coronary artery bypass grafting to increase myocardial blood flow in the ischaemic myocardium.

Ca2+(-)dependent and Ca2+(-)independent vasorelaxation induced by cardiotonic phosphodiesterase inhibitors.

Cardiotonic agents that belong to a group of phosphodiesterase inhibitors--vesnarinone, amrinone, enoximone, pimobendan, MS-857 and E-1020--inhibited the 35 mM KCl- and 10(-7) M norepinephrine-induced contractions of helical strips from rat thoracic aorta in a concentration-dependent manner. In the absence of extracellular Ca2+, 10(-7) M phorbol 12,13-dibutyrate caused a sustained contraction of the muscle strip without an increase in intracellular Ca2+ level ([Ca2+]i). The phorbol 12,13-dibutyrate-induced contractions in Ca2+(-)free buffer were also inhibited by the cardiotonic phosphodiesterase inhibitors. A cyclic GMP-inhibited cyclic nucleotide phosphodiesterase was partially purified from rat aorta and the activity of the phosphodiesterase was inhibited by the cardiotonic agents. The inhibitory effect of these agents on the KCl-, norepinephrine-and phorbol 12,13-dibutyrate-induced contractions showed good correlations to the concentrations of the agents producing 50% inhibition (IC50) of cyclic GMP-inhibited cyclic nucleotide phosphodiesterase. Vesnarinone inhibited the norepinephrine-induced contraction with a decrease in [Ca2+]i, but inhibited the phorbol 12,13-dibutyrate-induced contraction in Ca(2+)-free buffer without significant changes in [Ca2+]i. Dibutyryl cyclic AMP and NKH477 also inhibited the phorbol 12,13-dibutyrate-induced contraction in Ca(2+)-free buffer without significant changes in [Ca2+]i. The six cardiotonic phosphodiesterase inhibitors increased the cyclic AMP contents of the muscle strips. These results suggest that the inhibitory actions of these cardiotonic phosphodiesterase inhibitors on cyclic GMP-inhibited cyclic nucleotide phosphodiesterase may cause vasorelaxation through a decrease in [Ca2+]i and an inhibitory effect on a Ca(2+)-independent contractile process (or a decrease in Ca(2+)-sensitivity of contractile elements).

Selective cerebral perfusion in patients with aortic aneurysms involving the aortic arch.

Patients with aortic arch aneurysms underwent surgery using a selective cerebral perfusion (SCP) method. For this purpose, a protocol for SCP was established on the basis of an animal experimental study. Our SCP procedure is performed at a perfusion rate of 6 ml/kg/min with the patient under deep hypothermia at 20 degrees C. The subject group in the current study included 36 patients, 28 men and eight women, ranging in age from 23 to 84 years (mean, 61). There were five operative deaths (13.9%). The mean cardiopulmonary bypass time was 288 minutes, and the mean aortic clamp time was 135 minutes. Mean SCP time was 89 minutes, exceeding 90 minutes in 17 cases. The mean blood pressure during SCP was 43 mmHg and oxygen saturation rate in the internal jugular vein was at least 90%. There was no definite production of lactate in the brain. Cerebral disorders considered to have been caused by SCP occurred in only two cases. It appears that cerebral metabolism can be maintained safely, and that our SCP method is useful during surgery for aortic arch aneurysms.

[Selective cerebral perfusion and pharmacological cerebral protection in the patients with aortic arch aneurysm].

We have developed the protocol for selective cerebral perfusion (SCP) and pharmacological cerebral protection, and used it successfully in cases of aortic arch aneurysm. The subjects of the present study were 34 patients (28 males, 6 females) whose aortic arch aneurysm were surgically treated. Preoperative brain CT and brain scintigram showed high incidence of brain ischemia. However only 4 patients experienced a neurological episode. We conclude that our SCP technique and pharmacological cerebral protection are useful component to surgery of the aortic arch.

Effects of nafamostat mesilate on platelets and coagulofibrinolysis during cardiopulmonary bypass surgery.

The effect of nafamostat mesilate (FUT-175) on platelet membrane glycoproteins and the coagulofibrinolytic system were analyzed. Twenty-five patients undergoing aorto-coronary bypass surgery were randomly distributed into an FUT treated group and a control group. In the control group, anticoagulation was achieved with sodium heparin (3 mg/kg) immediately before cardiopulmonary bypass (CPB). In the FUT treated group, in addition to the usual treatment with heparin, FUT-175 was infused continuously at a rate of 2 mg/kg/hr. In the control group, alpha 2 plasmin inhibitor/plasmin complex (PIC) and fibrinogen/fibrin degradation products (FDP) D-dimer increased significantly during CPB, reaching 6.1 +/- 5.1 micrograms/ml and 576 +/- 200 ng/ml, respectively, at 60 min of CPB. PIC and FDP D-dimer remained significantly lower in the FUT treated group than in the control group. GPIb on platelets decreased significantly in both groups, but remained higher in the FUT treated group (81 +/- 5% vs. 56 +/- 21% at 60 min of CPB, P < 0.01). There were no significant changes in GPIIb/IIIa on platelets throughout the procedure in either group. Blood loss after CPB was significantly lower in the FUT treated group than in the control group (778 +/- 277 ml vs. 1,342 +/- 426 ml, P < 0.01). The authors conclude that FUT-175 improves hemostasis after CPB, not only by inhibiting fibrinolysis, but also by preserving platelet GPIb during CPB.

Platelet dysfunction during cardiopulmonary bypass surgery. With special reference to platelet membrane glycoproteins.

Changes in platelet membrane glycoproteins (GPIb, GPIIb/IIIa, and GMP-140) were evaluated using flow cytometry after binding with monoclonal antibodies in 22 adult patients undergoing cardiopulmonary bypass (CPB) surgery. The amount of GPIb on platelets decreased significantly during CPB, reaching a minimum level of 64 +/- 26% of the pre CPB value at 120 min of CPB. There was no significant change in the amount of GPIIb/IIIa on platelets. In accordance with these changes, ristocetin induced agglutination decreased to 56.7 +/- 16.2% of the pre CPB value during CPB. However, there were no significant changes in ADP and collagen induced aggregation throughout the procedure. The number of the activated platelets expressing GMP-140 on their surfaces increased significantly during CPB. There was an upper limit to the amount of GMP-140 expression on each platelet in the circulating blood, suggesting that excessively activated platelets are removed from the circulation. The authors conclude that CPB reduces the amount of GPIb on platelets, which results in platelet dysfunction. In addition, removal of excessively activated platelets from the circulation may lead to thrombocytopenia after CPB.

Aneurysm of the inferior mesenteric artery.

The case of a 48-year-old man with an aneurysm of the inferior mesenteric artery is described. This aneurysm was associated with extensive vascular disease characterized by multiple sites of stenosis and occlusion in addition to an upper abdominal aortic aneurysm. Repair of both aneurysms and reconstruction of the left renal artery and inferior mesenteric artery, which supplied all splanchnic circulation, were performed. The aetiology of the disease was thought to involve Takayasu's arteritis.