Successful Balloon-Assisted Hepatic Tract Embolization Using the Pull-Through Technique to Remove a Malpositioned Chest Tube Penetrating the Liver and into the Right Ventricle.

Intra-abdominal injury is an uncommon complication of chest tube insertion. A 66-year-old man had empyema and underwent chest tube insertion for drainage. Massive hemorrhage occurred; the postprocedural radiograph showed the malpositioned chest tube in the mediastinum. Computed tomography scan showed that the tube's tip penetrated through the liver capsule and passed through the hepatic vein to the right ventricle. Hepatic tract embolization with coiling was performed during chest tube removal under a controlled condition with the hepatic tract occluded by a balloon catheter. The balloon catheter was placed from the right jugular vein using the pull-through technique, establishing a through-and-through guidewire. This is the first report of successful removal of a chest tube malpositioned in the hepatic vein by balloon-assisted hepatic tract embolization without complication.

Successful non-operative management of traumatic extrahepatic portal venous injury without intraperitoneal hemorrhage: a case report.

Case: A 52-year-old woman was admitted to our hospital with hypotension after falling from the fifth floor of an apartment building. Contrast-enhanced computed tomography showed liver injury with extravasation of contrast material from the hepatic artery, and extrahepatic portal venous injury with extravasation and pseudoaneurysm. Intra-abdominal hemorrhage was not observed, and bleeding was confined to the retroperitoneal space. Hepatic arteriography showed extravasation, while portal venography showed pseudoaneurysm but no extravasation. After transarterial embolization, the patient's vital signs improved. Non-operative management was selected for the portal venous injury. Outcome: Computed tomography on the 58th hospital day revealed disappearance of the portal venous pseudoaneurysm. The patient was discharged on the 90th hospital day without any complications. Conclusion: This case shows that non-operative management can be selected for portal venous injury when there is no retroperitoneal injury and bleeding is confined to the retroperitoneal space.

Should the annulus be fixed in aortic valve-sparing root replacement with remodeling?

OBJECTIVES: If the aortic root dilates after native aortic valve-sparing root reconstruction with remodeling, aortic regurgitation may recur. However, it has not been demonstrated clearly that the aortic root dilates after remodeling. METHODS: This study enrolled 15 patients who underwent an aortic valve-sparing operation with remodeling (2002-2014) but without any ventriculo-aortic junction (VAJ) fixation. Technically, special care was taken to pass the sutures through the fibrous annulus. The diameter of the aortic root (VAJ, neosinus of Valsalva, and sinotubular junction), degree of aortic regurgitation, and effective height of the aortic valve were measured in the patients. All patients had postoperative follow-up, and the median follow-up period was 7.3 (IQR: 3.1-8.3) years. RESULTS: The mean preoperative diameters of the VAJ, sinus of Valsalva, and sinotubular junction were 23.5 ± 2.3 (20-27) mm, 51.1 ± 7.2 (43-60) mm, and 42.4 ± 9.4 (29-58) mm, respectively. The postoperative diameters of the VAJ changed from 21.6 ± 2.6 (early) to 21.8 ± 2.9 mm (late) (p = 0.75). The diameters of the sinus of Valsalva and sinotubular junction changed from 26.5 ± 3.0 (early) to 28.5 ± 4.2 mm (late) (p = 0.0013), and 22.4 ± 3.0 (early) to 24.3 ± 3.3 mm (late) (p = 0.0003), respectively. The effective height of the aortic valve changed from 9.7 ± 1.3 (early) to 8.9 ± 2.0 mm (late) (p = 0.08). The degree of aortic regurgitation (grade: 0-4) changed from 0.3 ± 0.5 (early) to 1.2 ± 0.8 (late) (p = 01558). CONCLUSIONS: Significant VAJ dilation and changes in aortic valve configuration after our remodeling procedure were not observed. Therefore, fixation of the annulus with remodeling may not be needed for cases without preoperative dilation of the annulus.

Involvement of GSK-3ß Phosphorylation Through PI3-K/Akt in Cerebral Ischemia-Induced Neurogenesis in Rats.

Glycogen synthase kinase (GSK)-3ß, which is abundantly expressed in the central nervous system, regulates various cellular processes including gene expression, cell proliferation, and differentiation. However, involvement of GSK-3ß in cerebral ischemia-induced endogenous neurogenesis is not yet fully understood. Appropriate strategies to prevent ischemic cell damage and subsequent severe sequelae are needed. The purpose of the present study was to determine the relationship between pathophysiological alteration of the GSK-3ß signaling pathway and cerebral ischemia-induced endogenous neurogenesis in rats. Severe cerebral ischemia was produced by the injection of 700 microspheres into the right internal carotid artery of rats. We demonstrated that phosphorylation of GSK-3ß at its Ser9 and that of Akt was significantly enhanced on day 7 after the cerebral ischemia, as was the number of NeuroD-positive cells. Treatment with a phosphatidylinositol 3-kinase (PI3-K) inhibitor decreased the cerebral ischemia-induced phosphorylation of Akt and that of GSK-3ß at its Ser9. In addition, as the protein levels of insulin-like growth factor-1 (IGF-1) and brain-derived neurotrophic factor (BDNF) were decreased, they might not have been essential for activation of the PI3-K/Akt/GSK-3ß pathway after severe cerebral ischemia. Although it remains to be determined what factors activate this pathway, our results suggest that PI3K/Akt-dependent GSK-3ß signaling and subsequent expression of NeuroD were involved in the neurogenesis elicited by cerebral ischemia.

[Intraoperative Endoscopic Evaluation of the Aortic Valve in Aortic Valve Repair].

This report discusses intraoperative endoscopic evaluation of the aortic valve performed in 2 cases of aortic valve repair. The "direct" or real image by the endoscopy helped to confirm the preoperatively-known lesion and even to detect a new legion which was not detected preoperatively. The endoscopy also enabled the evaluation of the aortic valve under the pressure-loaded condition without releasing the aortic clamp. Postoperative aortic regurgitation was grade I or less in both cases, although it progressed to grade II at 1 year in case 2. Echocardiographic parameters demonstrated no change in the size of the aortic root configuration for 8 and 5 years in case 1 and case 2, respectively. Intraoperative aortic endoscopy was useful to define the pathogenesis of aortic regurgitation and to evaluate the cusp repair procedures, which may contribute to a good mid-term result of aortic valve repair.

Mesohepatectomy with total caudate lobectomy of the liver for hepatocellular carcinoma.

BACKGROUND: Mesohepatectomy with total resection of the caudate lobe and extrahepatic bile duct is sometimes performed for hilar cholangiocarcinoma or gallbladder carcinoma; however, only a few reports on mesohepatectomy with total caudate lobectomy of the liver for hepatocellular carcinoma are available. METHODS: A 71-year-old woman was preoperatively diagnosed with hepatocellular carcinoma in the central bisections (Couinaud's segments 4, 5, and 8) and the paracaval portion of the caudate lobe. Mesohepatectomy with total caudate lobectomy of the liver permitted the removal of tumors to provide a cancer-free raw surface of the liver. Mobilization of the caudate lobe is an important procedure in this surgery. Before the liver parenchyma was dissected, all short hepatic veins were ligated and divided from the left to the right side as the left lateral section was retracted to the right, and the caudate lobe branches of the portal vein and hepatic artery were ligated and divided. After the liver parenchymal dissection, both between the left lateral and medial sections and between the right anterior and posterior sections, the Glissonean branches of the caudate lobe were ligated and divided as the central bisections were anteriorly retracted. Finally, liver parenchymal dissection was performed between the caudate lobe and the right posterior section, which was along the right side of the inferior vena cava. RESULTS: The surgery time was 538 minutes and blood loss was 1,207 mL. No blood transfusions were required during or after surgery. The postoperative course was uncomplicated. The patient is still alive 25 months after hepatectomy. CONCLUSION: Although mesohepatectomy with total caudate lobectomy of the liver is technically more difficult than mesohepatectomy of the liver because the caudate lobe must be completely detached from the inferior vena cava and the hilar plate, it is a safe and effective treatment method in selected patients with hepatocellular carcinoma located at both the central bisections and the paracaval portion of the caudate lobe.

Anatomical liver segmentectomy 2 for combined hepatocellular carcinoma and cholangiocarcinoma with tumor thrombus in segment 2 portal branch.

BACKGROUND: Hepatic resection is the only effective treatment for combined hepatocellular carcinoma and cholangiocarcinoma. CASE PRESENTATION: A 52-year-old man was preoperatively diagnosed with hepatocellular carcinoma in segment 2 with tumor thrombus in the segment 2 portal branch. Anatomical liver segmentectomy 2, including separation of the hepatic arteries, portal veins, and bile duct, enabled us to remove the tumor and portal thrombus completely. Modified selective hepatic vascular exclusion, which combines extrahepatic control of the left and middle hepatic veins with occlusion of left hemihepatic inflow, was used to reduce blood loss. A pathological examination revealed combined hepatocellular carcinoma and cholangiocarcinoma with tumor thrombus in the segment 2 portal branch. No postoperative liver failure occurred, and remnant liver function was adequate. CONCLUSION: The separation method of the hepatic arteries, portal veins, and bile duct is safe and feasible for a liver cancer patient with portal vein tumor thrombus. Modified selective hepatic vascular exclusion was useful to control bleeding during liver transection. Anatomical liver segmentectomy 2 using these procedures should be considered for a patient with a liver tumor located at segment 2 arising from a damaged liver.

[Total arch replacement through a mediansternotomy for an aortic arch aneurysm with an aberrant right subclavian artery].

The patient was a 77-year-old man. In 2004, he developed thrombosed aortic dissection extending from the distal aortic arch to the renal artery bifurcation. He was discharged after his condition improved with conservative treatment. He was followed up as an outpatient because there was an aneurysm, which measured 50 mm in diameter, at the aortic arch. Thereafter the aneurysm gradually enlarged. In May 2009, computed tomography (CT) showed that the aneurysm had increased to 10 cm in diameter and the patient began to have back pain. Thus, surgery was planned. CT revealed that the right subclavian artery originated distal to the left subclavian artery and coursed posterior to the esophagus and trachea. Surgery was performed using median sternotomy. Arch replacement and right subclavian artery reconstruction were performed under hypothermic circulatory arrest with selective cerebral perfusion. The right subclavian artery was controlled at the right border of the trachea, and cerebral perfusion was performed at this site. An end-to-side anastomosis to the reconstructed right common carotid artery was performed by an anterior tracheal approach. The patient had no cerebral complications and his postoperative course was uneventful.

Different patterns of vascular response between patients with or without diabetes mellitus after drug-eluting stent implantation: optical coherence tomographic analysis.

OBJECTIVES: We performed this study to investigate with optical coherence tomography (OCT) the vascular response after sirolimus-eluting stent (SES) implantation between patients with and those without diabetes mellitus (DM). BACKGROUND: The difference in vascular response after SES implantation between patients with and those without DM has not been fully evaluated with OCT. METHODS: Optical coherence tomography was performed to examine 74 nonrestenotic SES implanted in 63 patients (32 with DM and 31 without DM) at 9 months after SES implantation. For struts showing neointimal coverage, the neointimal thickness on the luminal side of each strut section was measured, and neointimal characteristics were classified into high, low, and layered signal pattern. RESULTS: Baseline patient characteristics and lesion and procedural characteristics data were similar between the 2 groups. In total, 11,422 struts were analyzed. High signal neointima was observed in 90.2 ± 13.9%, low signal neointima in 7.3 ± 10.0%, and layered neointima in 2.7 ± 5.8%/stents. There was higher incidence of low signal neointima (10.5 ± 10.3% vs. 4.5 ± 5.6%, p = 0.003), neointimal thickness was larger (median: 106.8 µm, interquartile range: 79.3 to 130.4 µm vs. median: 83.5 µm, interquartile range: 62.3 to 89.3 µm; p < 0.0001), and neointimal coverage of stent struts was higher (92.1 ± 6.2% vs. 87.2 ± 11.9%; p = 0.03) in DM patients. CONCLUSIONS: High signal neointimal pattern was predominantly observed, and low or layered signal pattern was observed in some cases. In DM patients, low signal neointima was observed with high frequency. Neointimal coverage and neointimal thickness was also higher in DM patients as compared with non-DM patients.

A Case of Neuroendocrine Cell Carcinoma with Sigmoidovesical Fistula.

Colonic neuroendocrine cell carcinoma (NEC), which is a rare subtype of colon epithelial neoplasm, has been reported to show extremely aggressive characteristics with a 1-year survival rate of 20%. We report herein a resected case of NEC that manifested bacterial sepsis due to sigmoidovesical fistula. Staged surgery consisted of resecting the sigmoid colon and part of the bladder four weeks after construction of an ileostomy to alleviate septic shock. The resected specimen was histologically diagnosed as NEC invading the wall of the urinary bladder with metastasis to the regional lymph nodes. The patient underwent four cycles of FOLFOX after surgery for additional treatment of residual metastatic lymph nodes around the abdominal aorta diagnosed preoperatively. Although the patient showed stable disease measured by computed tomography scan for the first three months after surgery, he rejected additional chemotherapy thereafter, and died ten months after the initial admission due to progression of residual tumor in the urinary bladder as well as the lymph nodes. This is the first case report describing colonic NEC manifesting perforation into the urinary bladder. Although the optimal chemotherapeutic regimen for colonic NEC has not yet been established, FOLFOX may be one of the choices.

The utility of a reusable bipolar sealing instrument, BiClamp((R)), for pulmonary resection.

OBJECTIVE: To assess the use of a combination of bipolar sealing and electrosurgical coagulation for pulmonary resection. METHODS: The procedure was used in both dogs and humans. Initially, lung wedge resections were performed on six healthy, Beagle dogs using a voltage controlled electrosurgical system. The area of lung tissue to be resected was first coagulated to provide a distinct line of seal. The lung was then resected along the peripheral site of the sealing scar. Efficiency of sealing was assessed using a tracheally applied air pressure of 30cmH(2)O. The electro-cauterized tissue was compared histologically to tissue sealed by a standard stapling technique. In the clinical phase, lung resections were performed after cauterization in 17 patients. Bullectomies were performed using video-assisted thoracic surgery in 4 patients, and thoracotomic procedures in 13 (1 bullectomy, 5 wedge resections, and 7 fissure separations). RESULTS: Dogs: Tissue sealing was highly successful, without any air leakage, in all six dogs. Histologically, the clamped lesion showed tissue-fusion probably due to both the compression and thermal effects. The proximal zone adjacent to the clamped lesion revealed both collapsed alveolar spaces and fused alveolar walls. In comparison, the stapled lesions showed no tissue-fusion. Humans: There were no major complications. The median operation time was 189min, and estimated median hemorrhage volume was 67ml. Median chest drainage duration was 3 days (range: 1-7) and no patient suffered from prolonged air leakage (>7 days). CONCLUSIONS: Lung parenchymal tissue resection following bipolar sealing and electrosurgical coagulation instead of staples was efficient and simple. Furthermore, the technique reduced the use of staples, reducing the cost of the surgery.

Dramatic hemostasis of the transected pulmonary artery model using SOFT COAG electrosurgical output.

We report the use of low-voltage, automatically regulated, electrosurgical coagulation to seal the bleeding from pulmonary arteries inadvertently during surgical intervention. Conventional electrosurgical coagulation uses high voltage, which generates intensive heat in the tissue. The heat results in carbonized eschar formation that can be easily broken by mechanical stress and lead to postoperative bleeding. SOFT COAG output automatically regulates the output voltage to a maximum of 200 Volts, preventing the generation of sparking. Thus, there is no formation of carbonized eschar. The instrument generates Joule heat alone in the tissue and the temperature rises to below boiling point, which effectively coagulates protein. Initial experiments, using a beagle model, clearly demonstrated the effectiveness and reliability of sealing both macroscopically and histopathologically. SOFT CAOG can be easily adopted both in open thoracotomy as well as in thoracoscopic procedures.

Double cancer of the cystic duct and gallbladder associated with low junction of the cystic duct.

We report a case of double cancer of the cystic duct and gallbladder associated with low junction of the cystic duct. A 73-year-old woman was admitted to the hospital complaining of upper abdominal pain. Endoscopic retrograde cholangiography showed a stenotic lesion in the lower common bile duct and no visualization of the cystic duct or gallbladder. Enhanced computed tomography revealed a heterogeneously enhanced tumorous lesion around the lower bile duct in the pancreatic head. A diagnosis of cancer arising from the cystic duct that entered the lower part of the common hepatic duct was made by intraductal ultrasonography, which showed an intraluminal protruding lesion in the cystic duct. Isolated gallbladder cancer was also diagnosed, by abdominal computed tomography. She underwent pancreaticoduodenectomy with dissection of regional lymph nodes. Histological examination revealed moderately differentiated adenocarcinoma of the cystic duct and well-differentiated adenocarcinoma of the gallbladder. Double cancer of the cystic duct and gallbladder is extremely rare, and this case also suggests a relationship between a low junction of the cystic duct and neoplasm in the biliary tract.

Management of intraoperative malperfusion syndrome using femoral artery cannulation for repair of acute type A aortic dissection.

BACKGROUND: The site of cannulation for repair of ascending aortic dissection remains controversial. The objective of this study was to evaluate the incidence and management of intraoperative malperfusion syndrome using femoral cannulation for repair of acute type A aortic dissection. METHODS: Between May 2002 and February 2007, 107 patients with initial femoral artery cannulation for the repair of type A aortic dissection were enrolled in this study. The mean age was 63.7 +/- 11.8 years; 51 patients were female. Preoperative findings indicated malperfusion in 16 patients. Intraoperative malperfusion syndrome was diagnosed by both radial arterial pressure measurements and transesophageal echocardiography. Clinical outcomes, including specific operative procedures and complications related to the cannulation, were assessed. RESULTS: The ascending aorta was replaced in 59 patients, hemiarch in 16, and total aortic arch in 32. Intraoperative malperfusion syndrome was noted in 3 patients (lowering of radial pressure in 2, obstruction of the true lumen in 1) at the initiation of cardiopulmonary bypass. After immediately switching to transventricular cannulation, the surgical replacement was successfully performed. The remaining 104 patients underwent surgery during femoral artery bypass without perfusion abnormalities. There was 1 in-hospital death (0.9%), but no deaths among the malperfusion patients. Cerebrovascular deficit occurred in 7 patients (6.5%). One vascular and 3 wound complications occurred related to the femoral cannulation. CONCLUSIONS: During the repair of acute ascending aortic dissection, malperfusion syndrome related to femoral artery cannulation has an acceptable incidence, and can be managed under appropriate intraoperative monitoring, particularly at the initiation of cardiopulmonary bypass.

Port site herniation of the small bowel following laparoscopy-assisted distal gastrectomy: a case report.

INTRODUCTION: Port-site herniation is a rare but potentially dangerous complication after laparoscopic surgery. Closure of port sites, especially those measuring 10 mm or more, has been recommended to avoid such an event. CASE PRESENTATION: We herein report the only case of a port site hernia among a series 52 consecutive cases of laparoscopy-assisted distal gastrectomy (LADG) carried out by our unit between July 2002 and March 2007. In this case the small bowel herniated and incarcerated through the port site on day 4 after LADG despite closure of the fascia. Initial manifestations experienced by the patient, possibly due to obstruction, and including mild abdominal pain and nausea, occurred on the third day postoperatively. The definitive diagnosis was made on day 4 based on symptoms related to leakage from the duodenal stump, which was considered to have developed after severe obstruction of the bowel. Re-operation for reduction of the incarcerated bowel and tube duodenostomy with peritoneal drainage were required to manage this complication. CONCLUSION: We present this case report and review of literature to discuss further regarding methods of fascial closure after laparoscopic surgery.

Intermediate-term results of surgical treatment of acute intramural hematoma involving the ascending aorta.

BACKGROUND: The treatment strategy of acute intramural hematoma involving the ascending aorta remains uncertain. The objective of this study was to evaluate the effectiveness of surgical treatment for this condition. METHODS: A total of 41 patients underwent operation for acute intramural hematoma involving the ascending aorta between 2000 and 2006. Mean age was 67.2 +/- 10.1 years, with 26 female patients and 10 in cardiogenic shock at presentation. Early and midterm results, including mortality, morbidity, survival, event-free rates, and the persistence of residual hematoma, were analyzed retrospectively in all patients. Mean follow-up period was 29.7 +/- 18.1 months. RESULTS: All but one patient underwent operation within 72 hours from the onset of symptoms. Thirty-four patients underwent isolated ascending aortic replacement, three had hemiarch repair, and four required total arch replacement. There were no in-hospital deaths. Stroke occurred in two patients and transient neurologic dysfunction in one. Postoperative computed tomographic scan showed residual distal hematoma progression to classical double-barrel dissection in two patients. At five years follow-up, survival was 100%. During the follow-up period, one patient had a new type B aortic dissection. A follow-up study confirmed hematoma resorption in 29 patients (70.7%). The estimated freedom from intramural hematoma-related events was 92.6 +/- 4.1% at five years. No independent predictor of intramural hematoma-related events was found on multivariate analysis. CONCLUSIONS: Immediate surgical treatment of acute aortic intramural hematoma involving the ascending aorta with open distal replacement of ascending aorta results in lower mortality rates and excellent midterm survival.

Ultrafast charge transfer process of 9,9'-bianthryl in imidazolium ionic liquids.

Excited state dynamics of 9,9'-bianthryl (BA) in 1-butyl-3-methylimidazolium ionic liquids with three different types of anions was investigated by means of femtosecond to nanosecond transient absorption (TA) spectroscopy and time-resolved fluorescence (TRF) measurements. TA spectroscopy revealed that charge transfer (CT) occurred multiexponentially in the time scale of hundreds of picoseconds while TRF measurement revealed that red-shift of the BA fluorescence peak extended into the nanosecond regime. It is concluded that an energy relaxation process slower than the CT reaction, which could be the solvation dynamics in the product state, is observed.