[Emergent endovascular stent-graft treatment for traumatic injury of descending aorta; report of a case].

A 71-year-old man was transfered to our hospital with acute aortic rupture due to a hit in the back by a log. Chest computed tomography (CT) demonstrated dissecting aneurysm of thoracic descending aorta, mediastinal hematoma, rib fracture and pulmonary contusion, We performed emergent endovascular stent-graft placement with local anesthesia successfully. The post operative course was uneventful. Chest CT scan after four months showed disappearance of aneurysm and hematoma.

Brain tissue pH, oxygen tension, and carbon dioxide tension in profoundly hypothermic cardiopulmonary bypass. Comparative study of circulatory arrest, nonpulsatile low-flow perfusion, and pulsatile low-flow perfusion.

The pH, oxygen tension, and carbon dioxide tension of canine brain tissue were experimentally examined during profoundly hypothermic cardiopulmonary bypass. After core cooling, a 60-minute period of circulatory arrest was performed in group 1 (n = 8), a 120-minute nonpulsatile low-flow perfusion (25 ml/kg/min) in group 2 (n = 8), and a 120-minute pulsatile low-flow perfusion (25 ml/kg/min) in group 3 (n = 8). When the animal was rewarmed, the core temperature was raised to 32 degrees C. Brain tissue pH kept decreasing in group 1, but it showed a delayed recovery in group 2 and a rapid recovery in group 3 during core rewarming. Brain tissue oxygen tension decreased significantly in group 1. Brain tissue carbon dioxide tension increased irreversibly in group 1, increased to about 100 mm Hg and recovered to 89.9 +/- 15.3 mm Hg in group 2, and reached a plateau of about 85 mm Hg and recovered to 55.4 +/- 6.7 mm Hg in group 3. We concluded that a 120-minute period of nonpulsatile low-flow perfusion provides more protection from brain damage than a 60-minute period of circulatory arrest. Furthermore, pulsatile flow will increase the safety margin of cardiopulmonary bypass even if the flow rate is reduced to 25 ml/kg/min.

Brain tissue pH, oxygen tension, and carbon dioxide tension in profoundly hypothermic cardiopulmonary bypass. Pulsatile assistance for circulatory arrest, low-flow perfusion, and moderate-flow perfusion.

The brain tissue pH, oxygen tension, and carbon dioxide tension were experimentally examined during profoundly hypothermic cardiopulmonary bypass with core cooling and core rewarming. Sixty-minute circulatory arrests (n = 28, group I), 120-minute low-flow perfusions (25 ml/kg/min; n = 16, group II), and 120-minute moderate-flow perfusions (50 ml/kg/min; n = 16, group III) were accomplished with and without pulsatile flow. In group I, progressive brain tissue acidosis and hypercapnia were recovered with pulsatile assistance. In group II, brain tissue acidosis and hypercapnia were recovered completely with pulsatile assistance but incompletely without it. In group III mild acidosis was eliminated with pulsatile assistance where the pH was significantly higher than in groups I and II, and brain tissue carbon dioxide pressure was significantly lower than in groups I and II with and without pulsatile assistance. Brain tissue hypoxia was severe in group I, slight in group II, but not found in group III. We concluded that a perfusion flow rate will decide the safe period, and a pulsatile assistance will promote brain protection at any flow rate in profoundly hypothermic cardiopulmonary bypass.

Cardiac myocyte functional and biochemical changes after hypothermic preservation in vitro. Protective effects of storage solutions.

In this study, we evaluated cardiac myocyte viability and function under hypothermic conditions with four types of storage solutions, saline solution, Euro-Collins solution, University of Wisconsin solution, and MCDB 107 medium. Cardiac myocytes were isolated from neonatal rat ventricles by collagenase dispersion and cultured for 4 days with MCDB 107 medium. A total of 12.5 x 10(5) myocytes per culture dish was used and the myocytes were incubated at 4 degrees C for 6, 12, 18, and 24 hours in the various storage solutions. After each incubation time, creatine kinase and lactate dehydrogenase were measured in the storage solutions. The myocytes were then incubated for 24 hours at 37 degrees C to evaluate the recovery of the myocyte beating rate. In the MCDB 107 group (n = 7), the recovery ratio of myocyte beating rate was complete by 12 hours, then decreased to 44.8% of control (beating rate before hypothermic incubation) at 24 hours. The saline, Euro-Collins, and University of Wisconsin groups (n = 7 each) had significantly lower recovery ratios than the MCDB 107 group (at 12 hours: 61.0%, 32.2%, and 48.9%; at 18 hours: 0.0%, 5.5%, and 15.1% of control, respectively). Release of creatine kinase and lactate dehydrogenase in the MCDB 107 group gradually increased and at 24 hours was 143.2 mIU/flask and 486.2 mIU/flask, respectively. However, the saline and University of Wisconsin groups had significantly increased creatine kinase and lactate dehydrogenase values at 24 hours (creatine kinase: 334.6 and 319.6 mIU/flask; lactate dehydrogenase: 821.6 and 654.4 mIU/flask, respectively). The Euro-Collins group showed the greatest increase in both markers (creatine kinase: 1587.5, lactate dehydrogenase: 2106.9 mIU/flask). In summary, saline and University of Wisconsin solutions showed a beneficial effect on recovery of myocyte viability at 12 hours compared with Euro-Collins solution, however MCDB 107 medium had the best overall protective effect on cultured myocytes. Accordingly, alternate hypothermic storage solutions, such as cell-culture medium, may have protective characteristics that are suitable for cardiac preservation.

Serum carcinoembryonic antigen concentration doubling time correlates with tumor biology and life expectancy in patients with recurrent gastrointestinal carcinoma.

OBJECTIVE: To determine if carcinoembryonic antigen (CEA) concentration doubling time (DT) can predict the course of disease and characterize tumor biology. DESIGN: Retrospective case series of patients who exhibited a distinct increase in circulating CEA during disease recurrence in the routine postoperative follow-up. SETTING: A tertiary general hospital. PATIENTS: Twenty patients with recurrent gastric carcinoma and 17 patients with recurrent colorectal carcinoma. INTERVENTION: The CEA DT was determined from semilogarithmic plots of CEA concentration time courses. MAIN OUTCOME MEASUREMENTS: The quantitative analyses of the CEA DT as related to various host and tumor characteristics, modes of recurrence, and life expectancy. RESULTS: The mean CEA DTs for gastric and colorectal carcinomas were 229 days and 86 days, respectively. Although there were no significant differences with regard to patient age, tumor size, gross appearance, and histological differentiation, women had shorter CEA DT than did men. Flow cytometric analysis showed that tumors with a higher proportion of cells in S phase (> or = 15%) had significantly shorter CEA DT than those with a lower S-phase fraction (< 15%). There was a significant correlation between the CEA DT and the length of survival after the initial CEA concentration increase in patients with recurrent gastric and colorectal carcinomas. In the multiple regression analysis of patients who had been treated with curative surgery and chemotherapy, CEA DT proved to be a major independent prognostic factor. CONCLUSIONS: Carcinoembryonic antigen DT predicts life expectancy in patients with adenocarcinoma of the gastrointestinal tract. Differences in survival time are closely associated with variations in the biological aggressiveness of individual tumors.

Possible deleterious effects of glucose on immature myocytes under hypothermic conditions.

The purpose of the present study was to evaluate the functional and biochemical effects of glucose-based solutions in combination with potassium or insulin (or both) on immature myocytes under hypothermic conditions. Myocytes were isolated from neonatal rat ventricles and cultured for 4 days with MCDB 107 (University of Colorado solution). Initially, myocytes (12.5 x 10(5) myocytes/flask) were incubated at 4 degrees C for 6 hours in 5% glucose solution containing various potassium concentrations ranging from 0 to 80 mEq/L to evaluate the protective effects. Next, myocytes were incubated at 4 degrees C for 3, 6, 12, 18, and 24 hours in three types of solutions: normal saline solution (control), glucose-potassium solution, and glucose-insulin-potassium solution (glucose: 50 g/L; NaHCO3, 20 mEq; potassium, 20 mEq; insulin, 20 IU/L). After each incubation, creatine kinase and lactate dehydrogenase levels were measured in the incubation solutions. The myocytes then were cultured for an additional 24 hours at 37 degrees C to evaluate the recovery of myocyte beating rate. The 20-mEq potassium treatment showed significantly better beating rate recovery and lower enzymal release than the glucose-only control. The saline solution showed the best protection of all three solutions, both functionally and biochemically, by 12 hours. The greatest damage was observed with glucose-potassium solution, beginning at 3 hours of hypothermic incubation. Although potassium and insulin have additional protective effects on hypothermic preservation, the high concentration of glucose has noxious characteristics for immature myocytes that may not be suitable for cardiac preservation in the neonatal period.

Argyrophilic nucleolar organizer region in endoscopically obtained biopsy tissue: a useful predictor of nodal metastasis and prognosis in carcinoma of the stomach.

BACKGROUND: Argyrophilic nucleolar organizer region (AgNOR) staining is a simple and economical technique for investigating proliferative activity. We examined AgNOR measured in biopsy specimens of carcinoma of the stomach in humans. STUDY DESIGN: Argyrophilic nucleolar organizer region staining was done on 76 biopsy specimens and corresponding resected cancer tissues. All estimations were made at the invasive tumor margin. RESULTS: Of the 76 cases, intratumoral heterogeneity of AgNOR count (more than 1.0 difference) between superficial and deep layers was recognized in six (7.9 percent) cases, all of which were advanced. In biopsy specimens, the AgNOR count ranged from 1.68 to 7.74 (mean, 3.79). A significant correlation was found between AgNOR counts of biopsied materials and those of resected specimens, both in early and advanced cases. Tumors with a high AgNOR count (greater than or equal to 3.79) were more likely to be of a larger size (p < 0.01), to have metastasized to lymph nodes (p < 0.01), and to be associated with a lower survival rate (p < 0.05) compared to tumors with low AgNOR counts. CONCLUSIONS: Estimating the AgNOR count in endoscopically biopsied specimens at the margin of invasive gastric carcinoma is useful for assessing nodal metastasis and clinical prognosis. These preoperative estimates may aid in tailoring the operative procedure and administrating adjuvant therapy.

Kimura disease: CT and MR findings.

The lesions of Kimura disease showed slightly high and very high intensity on T2-weighted MR, and low and intermediate intensity, respectively, on T1-weighted images. The degree of enhancement also differed between the two cases. These discrepancies may be attributable to differing degrees of fibrosis and vascular proliferation.

Postoperative adjuvant immunochemotherapy and infiltration of dendritic cells for patients with advanced gastric cancer.

To determine the group of patients for whom a biological response modifier is useful, the efficacy of postoperative adjuvant immunotherapy was investigated with regard to infiltration of dendritic cells (DC) in patients with advanced gastric cancer who underwent absolute curative resection. The infiltration of DC was classified into marked and slight. The chemotherapy group was prescribed mitomycin C and tegafur, while for the immunochemotherapy group a biological response modifier, PSK, was also prescribed in survival between the chemotherapy and immunochemotherapy groups. In patients with slight infiltration, however, the 5 - year survival rates were 0% in the chemotherapy and 15% in the immunochemotherapy group. Patients given PSK survived longer than those given chemotherapy only (P less than 0.05). Therefore, adjuvant immunotherapy may be considered for patients with advanced gastric cancer with slight infiltration of DC.

Laparoscope-assisted distal gastrectomy for early gastric cancer in a 76-year-old man with situs inversus totalis.

We report a case of a 76-year-old man with situs inversus totalis (SIT) who developed early gastric cancer. He was successfully treated by laparoscope-assisted distal gastrectomy for the gastric cancer. This case suggests that patients with SIT with malignancy could also undergo laparoscopic surgery. To the best of our knowledge, no case of laparoscopic surgery for malignant neoplasms associated with SIT has been reported in the English literature. We therefore believe this is the first case report.

Critical limb ischemia in a patient with von Recklinghausen's neurofibromatosis. Report of a case.

A 42-year-old woman complicated with neurofibromatosis underwent both balloon percutaneous transluminal angioplasty (PTA) of the iliac artery and femoropopliteal (FP) bypass grafting for critical lower limb ischemia. Seven months after the initial intervention, a recurrence of stenosis in the iliac artery and at the anastomoses of the FP bypass necessitated both PTA and a repeat thrombectomy and finally resulted in the amputation of her left thigh. This is a rarely documented case of chronic arterial occlusion associated with neurofibromatosis, in which the prognosis of arterial reconstruction for such patients is suggested to be poor.

Long-term results and prognostic factors after repair of abdominal aortic aneurysm with concomitant malignancy.

OBJECTIVE: Long-term results after repair of abdominal aortic aneurysm (AAA) with concomitant malignancy were reviewed, and factors which may affect survival were analyzed. DESIGN: Retrospective series with follow-up of three to 125 months. Setting. Department of Surgery, Matsuyama Red Cross Hospital, Matsuyama, Japan. PATIENTS: Among 112 consecutive repairs of AAA, 16 cases had concomitant malignancy. The malignant lesions included eight gastric cancers and eight other malignant tumours. The malignancies were divided using TNM Classification into an early stage (stage O or I) group (n=9) and an advanced stage (stage II, III, or IV) group (n=7). INTERVENTIONS: All aneurysms were successfully repaired, and simultaneous resection of the concomitant malignancy was performed in five cases. While 13 malignant lesions were resected completely, three could not be resected completely, but were treated by other surgical procedures. MEASURES: Survival rates were predicated using the Kaplan-Meier method. The log-rank test was used to compare survival rates. RESULTS: The one-, two-, and five-year survival rates after repair of AAA were 80%, 72% and 63%, respectively. The survival rates for the early stage group were significantly higher than those for the advanced stage group (p<0.05). Patients with concomitant gastric cancer or who underwent complete resection of the malignant lesion survived longer. CONCLUSION: In patients with concomitant AAA and malignancy, factors influencing survival for those with malignant lesions also affected survival after aneurysmectomy. Detection of early-stage concomitant malignancy and more aggressive treatment for the malignancy may improve the outcome.

Metastatic potential of colorectal adenoma containing carcinoma determined by pre-operative assessment of morphology.

BACKGROUND/AIMS: Colectomy with lymphadenectomy is sometimes considered to be the appropriate management for patients with colorectal carcinoma in adenoma invading beyond the muscularis mucosa. Our study was done to determine whether gross features of the tumor would provide information to predict the metastatic potential. MATERIAL AND METHODS: Thirty one carcinomas in adenomas from 29 patients were surgically resected. Macroscopic findings with regard to size and morphologic type were compared with the presence or absence of lymph node metastasis and vessel invasion. RESULTS: The rate of lymph node metastasis in all cases was 20.0% (6/30). Lymphatic and venous invasion was also identified in 7 (22.6%) and 5 (16.1%) cases, respectively. There was no evidence of nodal involvement in pedunculated lesions, but the incidence of nodal involvement was 18.8% and 60.0% in sessile and protruded tumors, respectively. There was a significant correlation between morphologic type and the incidence of lymph node metastasis. The mean size of node positive tumors was 5.9 cm with a range of 3.8-9.0 cm, that is significantly larger than the value of 3.8 cm in cases of node negative tumors. All the node positive tumors exceeded 3.5 cm. With adjustment made for the morphology, the estimated risk of nodal involvement of tumors with a sessile shape and larger than 3.5 cm was 33.3%. Therefore, both large sessile and protruded types mean a high risk for lymph node metastasis. CONCLUSIONS: Macroscopic features, size and gross type are critical factors in determining the metastatic potential of carcinoma in colorectal adenoma. We recommend segmental colectomy with lymphadenectomy for such patients.

Margins of resection of the esophagus for gastric cancer with esophageal invasion.

BACKGROUND/AIMS: We retrospectively examined the rate of infiltration of proximal margins of resection in patients resected for gastric cancer with esophageal invasion. MATERIAL AND METHODS: In the 175 proximal margins examined, the incidence was related to the gross appearance, histologic type, size, depth of invasion, shape of the oral edge, length of grossly tumor-free edge and length of histologic esophageal invasion. RESULTS: Multivariate analysis indicated that undifferentiated adenocarcinoma and length of histologic esophageal invasion are significant risk factors for positive margin. Infiltration occurred in 13.7% (24 cases) of the oral margins of transection. Eight patients were potentially curative other than positive margin and 5 were caused by underestimation of the distance of oral margin. With reference to the length of margin of resection, no involvement was found when the cranial distance between the lesion and the line of transection exceeded 2 cm in patients with orally well-defined type esophageal invasion. In patients with the orally ill-defined type, transection with a distance greater than 4 cm commonly guarantee safety of the proximal margin, except for cases with lymphatic invasion. CONCLUSIONS: These data provide the surgeon with a rational basis for assessing the extent of resection when performing esophagectomy combined with gastrectomy for cancer.

Lymph node metastasis and macroscopic features in early gastric cancer.

The relationship between macroscopic features and the frequency and extent of lymph node metastasis was examined retrospectively in 421 patients with early gastric cancer. Nodal involvement was evident in 48 patients (11.4%): 7 out of 204 (3.4%) with mucosal cancer and 41 out of 217 (19.3%) with submucosal lesions. The incidence of metastasis to perigastric nodes and extraperigastric nodes was 2.9% and 0.5% for mucosal cancer, and 13.8% and 5.1% for submucosal cancer, respectively. There was no metastasis in lesions less than 1 cm in diameter, but the incidence of positive nodes increased with the size of the primary lesion. There was a low incidence of lymph node metastasis associated with lesions confined to the mucosa and less than 3 cm in size, elevated types of I and IIa less than 2 cm, and the flat type of IIb, while types consisting of a depressed portion such as IIc, III, IIc + III, and IIa + IIc often had not only perigastric but also extraperigastric nodal involvement, even when the lesion was small. As early gastric cancer can be cured by surgery, this modality is the treatment of choice. Endoscopic therapy in cases with a low involvement of lymph node metastasis can be considered when the patient is in a poor clinical state of health.

Transcolonic approach for a stapled end-to-end colorectal anastomosis in low anterior resection.

We designed the transcolonic approach for a stapled end-to-end colorectal anastomosis using a premium curved EEA in low anterior resection. The advantage of this repair is the elimination of transanal introduction of the stapler by a second assistant from below, which make the stapled anastomosis technically easier and safer. The fact that the anvil can be removed from the center shaft by pressing on the anvil release button allows the anvil to be released from anus, which theoretically prevents suture break down. This procedure can be considered for selected patients who have anal structure and where it is impossible to insert the instrument.

Relationship between hormone receptor levels and cell-kinetics in human colorectal cancer.

BACKGROUND: This study was done to determine the potential role of sex steroid hormone receptors in the development of human colorectal cancer. METHOD: Receptors for estrogen (ER) and progesterone(PgR) were investigated in surgical specimens from 22 patients with colorectal cancer, using enzyme immunoassay. These values were examined in relation to cell kinetics parameters determined by DNA flow cytometry. RESULTS: ER and PgR were detected in 27% and 41%, respectively. There were no significant differences in the expression of ER or PgR according to the age, sex of the patients, tumor size, location, histological differentiation and lymph node metastasis. Although ER status appeared to be independent of DNA parameters, there were better correlations of PgR-negative tumors with increased hyperaneuploid levels. There were significantly higher values of heterogeneity index score in PgR-negative tumors compared with PgR-positive tumors. In the multiple regression analysis, PgR levels proved to be a major independent factor for changes in DNA index and heterogeneity index score. CONCLUSION: The PgR status is a critical factor for determining the proliferative activity of colorectal cancer tissue and may play a biological role in regulating the growth of the tumor.

c-erbB-2 expression is predictive for lymphatic spread of clinical gastric carcinoma.

BACKGROUND/AIMS: In patients with gastric carcinoma, the prognostic significance of c-erbB-2 oncogene expression was elucidated, but its role in the aggressive behavior of tumors is not clear. PATIENTS AND METHODS: We asked whether or not cerbB-2 gene expression may have predictability with regard to the metastatic potential in 160 patients with gastric carcinoma using a immunohistochemical staining and a multivariate analysis. RESULTS: c-erbB-2 immunoreactivity was observed in 11% (17/160) of tumors. Patients with c-erbB-2 product positive tumors had a significant shorter prognosis (p < 0.05), and were characterized by a high incidence of peritoneal dissemination (41%), liver metastasis (18%) and lymph node involvement (94%). In the multivariate logistic analysis revealed that c-erbB-2 expression was a significant risk factor related to lymph node involvement (p < 0.01). CONCLUSIONS: Our multivariate analysis revealed that c-erbB-2 expression is linked to the metastatic potential in patients with gastric carcinoma.

[A rare case of total anomalous pulmonary venous connection to the right atrium confounding with cor triatrium].

Three-days-old newborn baby underwent ligation of the ductus arteriosus under the diagnosis of TAPVC and PDA with high flow heart failure. Her UCG showed the direct connection of common pulmonary venous chamber (CPVC) to the upper and medial portion of right atrium. CPVC positioned just above the left atrium but does not communicated with the left atrium. These findings characterized this anomaly as II A cor triatriatum classified by Lucus-Schumidt. At 5-month-old, corrective operation was performed. Both right and left venous chambers joined just before the connection to right atrium and drained to right atrium at the upper portion of atrial septum. CPVC and left atrium had independent wall. Accordingly, operative diagnosis was made as TAPVC (IIb). Intraatrial routing was performed using porcine pericardial patch. At 6 months after operation, patient is doing well without the sign of venous obstruction. This type of TAPVC is rare and may confound with cor triatriatum. Our case may suggest the pathological mechanism of cor triatriatum and that at least some of cor triatriatum may be identical with TAPVC.

[Palliative management of left atrioventricular valve atresia with normal aortic valve].

We present three cases of the left atrioventricular valve atresia (LAVVA) with normal aortic valve. All cases showed [S,D,D] and had concordant AV connection. First case had two functional ventricles with multiple VSD and ventriculo-arterial connection was normal. Interatrial communication was maintained through ASD and the infant underwent pulmonary arterial banding (PAB). Four years later, the patient underwent Blalock-Hanlon (B-H) procedure for an inadequate ASD. Second case showed the univentricular heart of right ventricle with double outlet. In this case, PFO was restrictive and the infant underwent B-H procedure. Ten days after initial palliation, patient underwent PAB. Third case showed the univentricular heart of left ventricle and transposed great arteries. This patient had also the coarctation of the aorta. B-H procedure, PAB and subclavian flap aortoplasty were performed simultaneously by bilateral thoracotomy. All patients have done well, with normal growth and development at the time of their last outpatient evaluation at 10 year, 9 months and 9 months after surgery respectively.