[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.

Allelic loss analysis of early-stage flat-type colorectal tumors.

BACKGROUND: Flat-type colorectal tumors are rare, but are known for their unusual flat morphology and aggressive clinical behavior despite their small size. To identify distinct genetic alterations, loss of heterozygosity (LOH) analysis was performed on microdissected tissues. MATERIALS AND METHODS: DNA was extracted from multiple microdissected foci in 43 cases of early-stage flat-type colorectal tumors and LOH analysis was performed on 2q, 4q, 5q, 12q, 14q, 15q, 17p, 18q, 18p and 22q. RESULTS: LOH patterns were detected in one of two forms: (i) homogeneous LOH throughout the microdissected foci, which indicated the early acquisition of LOH; and (ii) heterogeneous LOH, which were detected in a part of analyzed foci. Homogeneous and heterogeneous LOH were most frequently detected on 17p (92%) followed by 18q (81%), 18p (81%), 5q (61%), 22q (51%), 14q (44%), 15q (41%), 2q (39%), 12q (36%) and 4q (32%). Homogeneous LOH was detected most frequently on 17p (68%) followed by 18p (53%), 18q (53%), 22q (34%) and 12q (27%). The average fractional allelic loss (FAL) for heterogeneous and homogeneous LOH was 0.57 and the average FAL for homogeneous LOH was 0.37. CONCLUSIONS: Early flat-type colorectal tumors frequently shows the early occurrence of multiple LOH including 17p, 18p, 18q and 22q, which is coupled with additional LOH of other loci either simultaneously or in the early clonal progression phase. The extent and sequences of LOH may be the mechanisms responsible for the aggressive clinical behaviors of these tumors.

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.

[A case of severe systemic edema in an elderly hypertensive patient with systemic lupus erythematodes during long-term treatment with anti-hypertensive drugs].

A 71-year-old woman receiving both angiotensin II receptor antagonist and calcium antagonist suffered severe systemic edema. She had been treated for essential hypertension with amlodipine for 2 years and candesartan for 3 months, and systemic lupus erythematodes (SLE) with steroids. During treatment, severe systemic edema appeared, mainly on her face, arms, and legs. At first, we suspected drug-induced edema by candesartan, so it was halted, but the edema still continued. We then considered amlodipine to be the culprit, and finally, the severe systemic edema disappeared after cessation of amlodipine. To control her blood pressure, we recommended candesartan, but 3 months late she suffered severe systemic edema again, thus the causative we drugs of her edema were thought to be both amlodipine and candesartan. Edema is a common symptom in elderly patients and we frequently observe drug-induced edema. In this case, there was underlying acceleration of blood vessel permeability induced by SLE and steroids and moreover, vasodilatation by candesartan and/or amlodipine further accelerated blood vessel permeability, and thus might have caused severe edema. It is very difficult to determine the cause of edema, especially in elderly patients, but we should consider not only one but also two or more drugs as being involved in drug-induced edema.

Intrahepatic pseudoaneurysm after surgical hemostasis for a delayed hemorrhage due to blunt liver injury: report of a case.

We report herein a case of delayed hemorrhage occurring after blunt hepatic trauma which was further complicated by an intrahepatic pseudoaneurysm. The delayed hemorrhage with free rupture occurred 2 weeks after the injury and the pseudoaneurysm developed 8 weeks after surgical hemostatic intervention for the delayed hemorrhage. The pseudoaneurysm was successfully treated by transcatheter arterial embolization. This rare case is reported to demonstrate the possibility of delayed catastrophic complications occurring after blunt liver injury and to point out the necessity of continued surveillance until the liver has completely healed.

Double filtration plasmapheresis for the treatment of bullous pemphigoid: a three case report.

Bullous pemphigoid (BP) is an autoimmune disease caused by an antidermal basal lamina antibody. In recent years double filtration plasmapheresis (DFPP) has been reported to be an effective therapy for BP. We experienced 3 cases of BP treated by DFPP. DFPP resulted in an improvement in clinical symptoms and remission allowing a decrease in the required dose of corticosteroid. DFPP was found to be an effective treatment for all 3 patients without noticeable adverse events resulting from DFPP. From these results it is concluded that DFPP is worth considering as an option as treatment for BP patients who were unresponsive to conventional steroid therapy, those in whom corticosteroids should be reduced or discontinued because of complications such as diabetes mellitus and/or osteoporosis.

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.

Sex hormone-receptor-negative tumors have a higher proliferative activity than sex hormone-receptor-positive tumors in human adenocarcinomas of the gastrointestinal tract.

To determine whether a correlation exists between hormone receptors and their proliferative activities, the levels of estrogen receptors (ER) and progesterone receptors (PgR) in surgical specimens from 23 patients with gastric cancer and from 32 patients with colorectal cancer were investigated using an enzyme immunoassay. These values were examined in relation to the parameters of cell kinetics determined by DNA flow cytometry. When the cutoff value was determined as 2.0 fmol/mg of cytosolic protein, ER and PgR were found in 13 (56%) and 6 (26%) of the 23 patients with gastric cancer, respectively, and in 10 (31%) and 10 (31%) of the 32 patients with colorectal cancer, respectively. There was a significant correlation in the expressions of ER between the cancer tissues and normal mucosa (P = 0.040). Although the expressions of ER or PgR were apparently not related to pathological status, better correlations of hormone receptor-negative tumors with increased hyperaneuploid levels were evident. According to a multiple regression analysis, ER levels significantly correlated with changes in the DNA index (P = 0.041) and in the heterogeneity index score (HIS) (P = 0.034). Thus, sex hormone receptors proved to be relevant factors associated with the proliferative activity of adenocarcinoma of the gastrointestinal tract. These findings indicate that the expression of hormone receptors provides pertinent biological information required to determine adequate therapeutic regimens in patients with gastrointestinal cancer.

Peritoneal collagen type IV concentration in adenocarcinoma of the gastrointestinal tract and its relationship to histological differentiation, metastasis, and survival.

To determine if peritoneal collagen type IV levels could serve as a parameter for predicting metastasis and the subsequent course of disease, the concentration of collagen IV in the peritoneal fluid of 85 patients with adenocarcinoma of the gastrointestinal tract, including 50 with gastric cancer and 35 with colorectal cancer, was measured radioimmunologically. The peritoneal collagen type IV levels were elevated in 13 (26%) of the patients with gastric cancer, in 8 (23%) of those with colorectal cancer, and in none of the control subjects. The mean concentration of collagen type IV in tumors characterized by peritoneal dissemination was significantly higher than that in those without metastasis; however, there were no significant differences in the collagen type IV levels between tumors with and those without liver metastasis, or between those with and those without lymph node metastasis. There was a significant correlation between the peritoneal collagen type IV level and survival time in patients with clinically evident peritoneal dissemination. A positive correlation was also found between collagen type IV and carcinoembryonic antigen levels. In conclusion, the levels of peritoneal collagen type IV provide evidence of peritoneal dissemination, and can aid in the prediction of life expectancy in patients with adenocarcinomas of the gastrointestinal tract.

Histopathologic changes in the infundibular septum after balloon pulmonary valvuloplasty in tetralogy of Fallot.

Balloon pulmonary valvuloplasty (BPV) has been applied to tetralogy of Fallot (TOF) as a palliative procedure. To investigate the histopathologic changes by BPV in the infundibular septum of TOF, we performed histopathologic examinations of the infundibular septum resected at corrective surgery. The subjects were 5 patients with TOF, who underwent BPV at the median age of 2.2 months and the corrective surgery at the median age of 15.0 months (BPV group), and 4 patients with TOF who had no prior BPV and who underwent the corrective surgery at the median age of 14.5 months (control group). There was no significant difference between the two groups in the endocardial thickness, myocardial vacuole degeneration, or fraction of fibrous and interstitial space. However, the specimens from 3 patients in the BPV group had localized dense fibrous lesions in the myocardium. The findings in this limited sample suggest that BPV for TOF does not produce overall histopathologic alterations such as fibrosis, thick endocardium, and myocardial vacuole degeneration, but may sometimes damage the myocardium of the infundibular septum resulting in the formation of localized dense fibrous lesions. The clinical significance of this damage is still unknown, and further cases should be investigated.

[A Rastelli operation with a reconstruction of the central pulmonary artery for a pulmonary atresia with an absent left pulmonary artery].

A Rastelli procedure was successfully performed on a 6-year-old girl with an absence of the intrapericardial pulmonary artery and the left pulmonary artery (PA), following a right B-T shunt. The central PA was reconstructed with an 18 mm diameter xenopericardial roll behind the ascending aorta and the superior vena cava. After intracardial repair, the Rastelli operation was performed using an 18 mm diameter composite graft which consisted of a valved xenopericardial roll and a knitted Dacron graft. Since the size of the right PA was large enough to undergo this surgical procedure (the preoperative right PA index was 300 mm2/m2), the postoperative peak systolic pressure ratio of the right ventricle to the left ventricle declined from 1.0 to 0.64. Although the patient showed slight signs of right ventricular failure on the operative day, the postoperative course was uneventful.

Pathological appearance of the stomach after endoscopic mucosal resection for early gastric cancer.

BACKGROUND: The pathological findings of the resected stomach after endoscopic mucosal resection (EMR) for early gastric cancer were reviewed. EMR was indicated when a lesion consisting of well or moderately differentiated adenocarcinoma had a diameter of less than 2 cm. METHODS: Of 39 patients with early gastric cancer were treated with EMR between 1990 and 1995, 11 required additional surgery. RESULTS: Malignant tissue in the gastric wall was completely removed in four patients, while cancer cells remained in the mucosa adjacent to the scar in five and infiltrated into the submucosa in two. Most of these residual cancers were characterized by a lesion with a diameter exceeding 15 mm and by the location in the body or cardia of the stomach. Lymph node metastases were observed in one patient whose carcinoma invaded the deeper submucosal layer. Assessment of the depth of entire invasion from the endoscopically-resected specimen was correct for six of 11 patients. CONCLUSION: Gastric carcinomas to be resected by EMR should be smaller, especially if located in the body or cardia. Accurate diagnosis of the width and depth of invasion is indispensable before proceeding to EMR. Surgery may be the treatment of choice when there is submucosal invasion.

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.

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.

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 comparison of open and laparoscopic cholecystectomy for patients with cirrhosis.

To evaluate the benefits of performing laparoscopic cholecystectomy (LC) in patients with cirrhosis, data on 13 patients with liver cirrhosis who underwent cholecystectomy for gallstones between 1989 and 1995 were retrospectively collected from charts filed at Fukuoka City Hospital. These 13 patients were classified into two groups; one, comprised of 7 who underwent LC, and another, comprised of 6 who underwent open cholecystectomy (OC). No statistical differences were observed in the duration of surgery or the intraoperative blood loss between the two groups; however, the C-reactive protein (CRP) level in the serum was significantly higher in the OC group than in the LC group. LC was followed by a significantly earlier resumption of a normal diet (P < 0.05) and a shorter hospital stay (P < 0.05) in comparison to OC. All of the patients who underwent OC had an uneventful clinical course; however, one of the patients who underwent LC suffered from intractable ascites postoperatively. The difference in the cost of hospitalization between the two groups was not statistically significant. These findings suggest that the therapeutic significance of performing LC in patients with cirrhosis should be assessed after carefully evaluating all factors including mortality, morbidity, and cost-effectiveness. Thus, further controlled trials are necessary.

Studies on quinolone antibacterials. V. Synthesis and antibacterial activity of chiral 5-amino-7-(4-substituted-3-amino-1-pyrrolidinyl)-6- fluoro-1,4-dihydro-8-methyl-4-oxoquinoline-3-carboxylic acids and derivatives.

We previously demonstrated that 5-amino-7-(3-amino-1-pyrrolidinyl) -1-cyclopropyl-1,4-dihydro-8-methyl-4-oxoquinoline-3-carboxylic acid (7) has strong in vitro antibacterial activity even against quinolone-resistant bacteria. We examined optimization of the 3-aminopyrrolidine moiety of 7 by introduction of C-alkyl (Me, Et, Pr, di-Me, cyclopropyl) and N-alkyl groups (Me, di-Me). C-Alkylation at the 4-position of the 3-aminopyrrolidine moiety enhanced in vitro and in vivo antibacterial activity. (S)-5-Amino-7-(7-amino-5-azaspiro[2.4]hept-5-yl)-1-cyclopropyl-pyr rolidinyl) -1-cyclopropyl-6-fluoro-1,4-dihydro-8-methyl-4-oxoquinoline-3-carboxylic acid (15b) showed strong antibacterial activity (in vitro antibacterial activity including quinolone-resistant bacteria is 4 times more potent than that of ciprofloxacin (CPFX) (1); in vivo antibacterial activity is 1.5 to 20 times more potent than that of CPFX (1)) and reduced quinolone toxicity (free from both phototoxicity at a dosage of 30 mg/kg in guinea pigs (i.v.) and convulsion when coadministered with 4-biphenylacetic acid at a dosage of 20 micrograms in rats (i.c.v.)). Their selectivity between DNA topoisomerase II (derived from eukaryotic cells) and DNA gyrase (derived from bacterial cells) was about 3000-fold.

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.

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.