Relationship between the diameter of the vein graft and postoperative ankle brachial pressure index following femoro-popliteal bypass.

AIM: We studied whether the diameter of the saphenous vein graft affects the result of femoro-popliteal bypass surgery. METHODS: Thirty-eight patients with bypasses from the femoral artery to the above knee popliteal artery were studied. Bypasses without a patent anterior or posterior tibial artery were excluded. The great saphenous vein was used as a bypass graft in 20 extremities and Dacron grafts (6 mm or 8 mm diameter) were used in 18 arteries. The smallest diameter of the saphenous vein was measured preoperatively with ultrasonography. Vein grafts were divided into two groups: small vein graft (< or =3 mm) and large vein graft (> or =3.5 mm). The ankle brachial pressure index (ABI) was measured at 1 week and 3 months after operation. RESULTS: The diameter of the vein graft (2.5 to 4 mm, 3.4+/-0.5 mm) was positively correlated with postoperative ABI (R2 0.607, P<0.0001). The postoperative ABI at 1 week was significantly lower in the small vein graft group (0.72+/-0.09) than in the large vein graft group (0.95+/-0.11) and in the Dacron graft group (1.05+/-0.16). The ABI at 3 months was still significantly lower in small vein graft group (0.78+/-0.07). CONCLUSION: The diameter of the vein graft was positively correlated with postoperative ABI after femoro-popliteal above knee bypass. Postoperative ABI was lower using a vein graft with a diameter of < or =3 mm than that using a bigger vein graft or a Dacron graft.

[A case of gastric cancer with liver metastases successfully treated with combination therapy of systemic and hepatic arterial infusion chemotherapy].

A 67-year-old man was admitted to our hospital because of advanced gastric cancer associated with metastases to the liver, the lymph nodes along the lesser curvature and the infradiaphragmatic lymph nodes. As we considered the primary lesion and the liver metastases to be unresectable, we treated him with combination therapy of systemic and hepatic arterial infusion chemotherapy. The regimen of systemic chemotherapy consisted of cisplatin (CDDP) and UFT. Hepatic arterial infusion chemotherapy included 5-fluorouracil (5-FU), doxorubicin (DXR) and mitomycin C (MMC). We repeated this therapy six times. The size of the primary lesion and the lymph node metastases decreased significantly after the chemotherapy. The size of the liver metastases did not change, but they appeared to necrotize. The patient maintained a good quality of life during the therapy. He finally died of peritonitis carcinomatosa 18 months after the diagnosis. This case indicated that combination therapy of systemic and hepatic arterial infusion chemotherapy was effective in cases of unresectable gastric cancer associated with liver metastases.

Malignant lymphoma of bronchus-associated lymphoid tissue (BALT) coexistent with pulmonary tuberculosis.

A case in which malignant lymphoma occurred in association with a tuberculosis focus in a 70-year-old man is reported. Surrounding the epithelioid cell granulomas with caseous necrosis was a dense and diffuse monotonous infiltration of atypical lymphoid cells. Acid-fast bacilli were found in the granulomas and pulmonary tuberculosis was diagnosed. The infiltrating atypical lymphoid cells occasionally invaded the respiratory epithelium producing lymphoepithelial lesions. Immunohistochemically, the lymphoid cells were positive for CD20, and clonal rearrangement of the immunoglobulin heavy chain gene was demonstrated by polymerase chain reaction (PCR). We diagnosed the lesion as a pulmonary malignant lymphoma of bronchus-associated lymphoid tissue (BALT) occurring in the background of tuberculosis. This is the first reported case of pulmonary BALT lymphoma coexistent with pulmonary tuberculosis.

Enhanced expression of mRNA coding for the adrenaline-synthesizing enzyme phenylethanolamine-N-methyl transferase in adrenaline-secreting pheochromocytomas.

PURPOSE: In some pheochromocytomas, the tumors contain and secrete greater amounts of adrenaline than do normal adrenal medullas. It is not yet known how adrenaline synthesis is enhanced in the adrenaline-secreting pheochromocytomas. MATERIALS AND METHODS: As a first step toward understanding the molecular mechanisms by which adrenaline synthesis is controlled in these tumors, we measured the level of mRNA coding for the adrenaline-synthesizing enzyme phenylethanolamine N-methyl transferase (PNMT) and the content of adrenaline in the pheochromocytomas (n = 9), including 3 cases of the adrenaline-secreting type (one of the patients had bilateral pheochromocytomas), and in normal adrenal medullas (n = 7). We then measured the concentration of cortisol, which is thought to regulate the PNMT activity. Finally, we examined the expression of the mRNA for Egr-1, which was recently reported to be a transcriptional factor regulating PNMT gene expression. RESULTS: In the 4 tissue specimens from 3 adrenaline-secreting pheochromocytomas, the contents of adrenaline and the PNMT mRNA expression were considerably greater than those of the normal adrenal medullas. PNMT immunoreactivity was only detected in the adrenaline-secreting tumors. Three of the 4 specimens showed high concentrations of cortisol. To show the capacity for cortisol production locally in the pheochromocytoma tissues, we showed the expression of a glucocorticoid biosynthetic enzyme, 17alpha-hydroxylase, in the tumors by Western blotting. PNMT expression was found to be associated with 17alpha-hydroxylase expression in the tumors. The glucocorticoid receptor expression was also correlated with PNMT expression in the tumors and the expression of Egr-1 was also high in 3 of the 4 specimens. CONCLUSIONS: These findings indicate that adrenaline production in adrenaline-secreting pheochromocytomas is primarily controlled by the level of PNMT gene expression, and that the gene expression may be enhanced by both cortisol and Egr-1.

The cell adhesion molecule E-cadherin is widely expressed in human atherosclerotic lesions.

OBJECTIVE: Various cell adhesion molecules are expressed in atherogenesis and the significance of their involvement in atherosclerotic lesion formation is well appreciated. In the present work, we examined whether the Ca(2+)-dependent cell adhesion molecule E-cadherin is also involved in atherogenesis. METHODS: Specimens of carotid artery and aorta were obtained at operation. Expression of E-cadherin was studied by an immunohistochemical method. The nature of E-cadherin-expressing cells was examined by comparative analysis of consecutive sections and by a double immunostaining procedure. An immunohistochemical approach was also applied to examine how the accumulation of oxidised low density lipoproteins (LDL) by intimal cells is associated with E-cadherin expression. RESULTS: No E-cadherin+ cells were found in normal non-atherosclerotic intima but E-cadherin+ cells were present in 96% of the atherosclerotic lesions. In atherosclerotic intima, E-cadherin was expressed by intimal cells showing varying degrees of transformation into foam cells. These E-cadherin+ cells also contained oxidised LDL in their cytoplasm. Differing numbers of CD68+ foam cells (15% to 60%) expressed E-cadherin but all the CD68+ macrophages without signs of transformation into foam cells were negative for E-cadherin. Neither smooth muscle cells nor foam cells of smooth muscle cell origin (smooth muscle alpha-actin+) were found to be positive for E-cadherin. T-cells (CD3+) and endothelial cells (von Willebrand factor+) were also negative for E-cadherin. Only a few vascular dendritic cells (S-100+) expressed E-cadherin and their expression was weak. We also found that a large proportion (40% to 85%) of E-cadherin+ cells did not stain with any cell-type specific markers. CONCLUSIONS: The finding that E-cadherin is expressed in atherosclerotic lesions expands our knowledge of cell adhesion molecules involved in atherogenesis. That E-cadherin is expressed in intimal cells transforming into foam cells suggests that lipid accumulation might be associated with the alteration and reorganisation of cell-to-cell interactions in atherogenesis. The present observations might assist in understanding the mechanisms associated with intracellular lipid accumulation.

Formation of Birbeck granule-like structures in vascular dendritic cells in human atherosclerotic aorta. Lag-antibody to epidermal Langerhans cells recognizes cells in the aortic wall.

It has previously been demonstrated that vascular dendritic cells reside in the arterial intima and are involved in human atherogenesis. During the present ultrastructural examination of aortic atherosclerotic lesions, pentalaminal structures, similar to Birbeck granules which uniquely present in Langerhans cells, were found in the cytoplasm of vascular dendritic cells and the formation of these Birbeck granule-like structures from dense granules was identified. To find out how Birbeck granule-like structures might relate to Birbeck granules of Langerhans cells, we used Lag-antibody which specifically stains Birbeck granules and Birbeck granule-associated structures in Langerhans cells. Lag-positive cells were found in the aortic wall. Our observations suggest a close relationship between vascular dendritic cells and Langerhans cells and this may imply that mechanisms of antigen presentation known for Langerhans cells might be similar to those involved in atherosclerosis.

Tuberculous pseudoaneurysm of the descending thoracic aorta: a case report and literature review of surgically treated cases.

Tuberculous aneurysm of the aorta is an extremely rare disease with a high mortality rate. Only 32 patients treated surgically have been reported in the literature. These reports indicate an 84.4% operative survival rate. We present a case of a tuberculous false aneurysm in the descending thoracic aorta that was successfully treated surgically with an extracorporeal circulation. The hole in the aorta within the false aneurysm was closed with a Dacron patch because the aortic wall appeared to be free of active infection as a result of long-term preoperative antituberculous chemotherapy.

Jaundice due to afferent loop obstruction following hepatectomy for a hilar cholangiocarcinoma.

A case of jaundice due to obstruction of Roux en Y-limb following hepatectomy for a hilar cholangiocarcinoma is presented. Percutaneous transhepatic biliary drainage improved the jaundice but promoted disseminated intravascular coagulopathy. Our limited experience suggested that afferent loops should be drained directly to prevent reflux of enteric contents into the biliary system.

Pedicled jejunal seromuscular flap for bronchocutaneous fistula.

We report the successful closure of a complicated bronchocutaneous fistula using a pedicled jejunal flap. The fistula, secondary to tuberculosis and irradiation, previously had been closed with a latissimus dorsi musculocutaneous flap. This initial repair failed. The recurrent fistulas were closed again using a jejunal seromuscular flap, and the chest wall defect was reconstructed with a rectus abdominis musculocutaneous flap.

Closure of the distal pancreatic stump with a seromuscular flap.

We describe herein our new method for transecting the pancreas and closing its stump in distal pancreatectomy, devised to decrease the risk of pancreatic fistula formation. With this technique, the pancreas is transected in such a way that a convex stump is left, whereby the pancreatic secretions from the parenchyma near the pancreatic stump are fully drained into the main pancreatic duct. A pedicled seromuscular flap of the stomach or jejunum is then used to cover the cut surface of the pancreas. This new technique provides tight closure of the pancreatic stump after distal pancreatectomy.

Fibromuscular dysplasia as a cause of abdominal aortic aneurysm.

A 53-year-old woman presented with abdominal discomfort and was diagnosed using ultrasonography to have an abdominal aortic aneurysm. Aortography revealed a saccular aneurysm 4 cm in diameter of the infrarenal aorta with a 'string of beads' appearance. The renal and other visceral arteries appeared to be normal. Resection and graft replacement was performed because of the possibility of rupture. Histological examination of the specimen revealed the most common type of fibromuscular dysplasia, namely medial fibroplasia. Fibromuscular dysplasia should be considered as a potential cause of abdominal aortic aneurysm in female patients with no atherosclerosis risk factors.

Aneurysm of bilateral persistent sciatic arteries with ischemic complications: case report and review of the world literature.

A case of bilateral persistent sciatic artery (PSA) aneurysms with thromboembolic complications is presented along with a review of the 167 cases of PSA reported in the world literature. Its embryology, anatomy, clinical features, diagnosis, and treatment are reviewed and provide the following findings: The incidence of PSA is estimated to be from 0.025% to 0.04%, based on angiographic studies. Ages range from 6 months to 89 years, with a mean of 54 years. There is no gender predilection. A PSA was present on the right side in 32%, on the left side in 29%, bilaterally in 22%, and on either side in 18%. The "complete" type of PSA was 69%. Aneurysmal change was present in 46% of all PSAs. Overall, 59% had symptoms, including ischemia in 31% (acute in 14% and chronic in 17%), a gluteal mass in 26% (painful in 10%, painless in 6%, and pulsatile in 13%), gluteal pain in 2%, and ischialgia in 5%. Exclusion of the aneurysm or PSA by surgical or interventional techniques, with a femorodistal bypass as required for the resultant ischemia is currently the treatment of choice.

The inclusion of an omental flap in pancreatoduodenectomy.

A technique for reducing the morbidity and mortality of pancreatoduodenectomy by using an omental flap to protect the anastomoses and splanchnic vessels exposed during dissection is described herein.

[The treatment of choice in deep vein thrombosis of the lower extremity].

Of 67 patients with acute deep vein thrombosis of the lower extremity (DVT), 43 patients were treated by venous thrombectomy and 24 patients were managed by conservative treatment. The clinical effect of thrombectomy was evaluated by analyzing follow-up results in the 2 groups. The cumulative incidences of pigmentation and stasis ulcer at the 5th year were 2.7% and 0% respectively in the thrombectomy group, and 24.3% and 10% respectively in the conservative treatment group. Pigmentation and stasis ulcer were significantly more frequent in the conservative treatment group (p < 0.01). It is concluded that venous thrombectomy is superior to conservative treatment to prevent late postthrombotic sequelae. Protein C, protein S and plasminogen were assayed in 40 DVT patients to determine the incidence of hypercoagulable state in DVT. Congenital deficiency or abnormality were found in 15 patients (37.5%). In such DVT patients with thrombophilia anticoagulant prophylaxis should be continued to decrease a risk of rethrombosis.

Abdominal aortic aneurysm due to congenital hypoplasia of the aortic media: a case report.

A 44 year-old woman with a family history of abdominal aortic aneurysm (AAA) underwent resection of an AAA. Histological examination revealed a lack of elastic fibers of the media and a diminished content of smooth muscle cells. A congenital hypoplasia of the aortic media was postulated as the etiology of this AAA. This condition may represent an aortic variety of medial defect observed in intracranial berry aneurysms, and be associated with a hereditary predisposition to AAAs.

Factors affecting the patency of small-caliber prostheses: Observations in a suitable canine model.

Lack of an endothelial surface is most often blamed for the relatively poor patency of polytetrafluoroethylene grafts used in infrageniculate bypass when compared to autogenous saphenous vein. Length, caliber, flow, and ability to withstand flexion are also acknowledged but have not been systematically examined. We report the results of our attempts to discriminate between the relative contributions of these factors and to develop a suitable canine model for evaluating small-caliber prostheses (4 mm x 10 cm thin-walled polytetrafluoroethylene). ASA/dipyridamole were given 1 week before and 4 weeks after operation. Patency was assessed by directional Doppler at frequent intervals (less than or equal to 3 days). The following were observed: (1) Iliac placement provided a useful patency reference point (40% to 50% patency at 60 days). (2) Carotid patency was not better than iliac patency. (3) Crossing a flexion crease decreased patency. (4) The low patencies were not technical but intrinsic to the graft. Iliofemoral vein grafts achieved 100% patency at 60 days. (5) External rings did not improve iliofemoral patency (equal in paired comparisons). (6) Neither baseline platelet aggregation nor platelet aggregation after ASA administration correlated with patency. This canine model is an excellent test for small caliber-low flow prostheses. It allows paired-site comparisons, which are essential, and meaningful patency data with reasonable numbers of subjects within 2 months' observation. Directional Doppler evaluation avoids need for angiography or serial postmortem analysis sacrifice.

[Arterial reconstructive surgery and myoglobin].

To assess the diagnostic value of myoglobin between elective surgery and acute arterial occlusion, serum and urine myoglobin (S-Mb, U-Mb) levels were measured before and for 7 consecutive days following arterial reconstructive surgery in 7 patients with abdominal aortic aneurysm or arteriosclerosis obliterans (elective surgery group), and in 20 patients with acute arterial occlusion due to embolism or thrombosis. They were divided into three groups based on symptoms and other features: mild, moderate, and severe groups. S-Mb and U-Mb levels were normal before surgery with a maximum of 389 ng/ml and 1,670 ng/ml after surgery in the elective surgery group, and 489 ng/ml and 11.7 ng/ml before surgery with a maximum of 703 ng/ml and 294 ng/ml after surgery in the mild cases. These two groups showed no complications after surgery. In the moderate group, high values of 2,420 ng/ml and 25,300 ng/ml were noted before surgery, and these values were elevated to 14,900 ng/ml and 175,000 ng/ml after surgery with complications of acute renal failure or peripheral nerve paresis. In the severe group, the values were 9,440 ng/ml and 260,000 ng/ml before surgery, and 160,000 ng/ml and 1,300,000 ng/ml after surgery, the elevation being associated with the severe clinical complication, myonephropathic metabolic syndrome (MNMS). All patients in this group died of MNMS. S-Mb and U-Mb levels before surgery proved useful for predicting the prognosis of patients with acute arterial occlusion. The findings obtained in our canine studies on the mechanism and treatment of MNMS suggest that alpha-tocopherol, a free radical scavenger, may be effective for treating dreadful complications such as MNMS.

(+)-Alpha-viniferin, an anti-inflammatory compound from Caragana chamlagu root.

The roots of Caragana chamlagu Lamarck (Leguminosae) are used as an anti-neuralgic, anti-rheumatic, anti-arthritic, etc. in the folk medicine of Korea. An ether extract was fractionated with monitoring of the anti-inflammatory activity, and the active principle was elucidated as (+)-alpha-viniferin on the basis of spectroscopic data, including two-dimensional nuclear magnetic resonance and circular dichroism spectra.

[An experimental study of tissue injury associated with reperfusion in ischemic limbs].

Twenty adult mongrel dogs were divided into three groups. Group I: control (n = 7), group II: limb ischemia for 6 hours followed by reperfusion (n = 6), and group III: administration of alpha-tocopherol after 6 hours of ischemia, and reperfusion (n = 7). In group II, serum CPK and LPO increased after reperfusion with peak levels of 38,000 +/- 9,800 mU/ml and 20.4 +/- 3.7 nmol/ml respectively, which were significantly higher than those in group I. (CPK: p less than 0.02, LPO less than 0.03). In group III, the peak levels of serum CPK and LPO were regulated to the low level of 1,060 +/- 290 mU/ml and 9.2 +/- 4.5nmol/ml, respectively, which were significantly lower than those in group II. (CPK: p less than 0.02, LPO less than 0.04). Additional 13 dogs were divided into two groups in order to assess tissue LPO in the limb, liver, and kidney. Group A: control (n = 5), group B: reperfusion after 6 hours of ischemia (n = 8). Tissue LPO level of 1.89 +/- 0.74nmol/mg-protein in the gastrocnemius muscle in group B was significantly higher than that in group A (p less than 0.02), although there was no significant difference in the gracilis muscle, liver, and kidney. These results prove indirectly the participation of lipid peroxidative reaction by active oxygen in the mechanism of development of reperfusion injury, and suggest the preventive effect of alpha-tocopherol to reperfusion injury.