[Off-pump coronary artery bypass grafting for patients with cardiogenic shock due to acute myocardial infarction].

UNLABELLED: Off-pump coronary artery bypass (OPCAB) is less invasive, so we have recently been expanding the indication. We performed OPCAB for 3 patients with cardiogenic shock due to acute myocardial infarction (AMI). PATIENTS: All patients were supported hemodynamically by intra-aortic balloon pumping (IABP) prior to surgery. RESULTS: We performed the revascularization of territories for the left anterior descending artery (LAD) and right coronary artery (RCA) in these high risk patients using OPCAB technique to improve the hemodynamic state. In all patients, IABP was removed within 48 hours after surgery and the postoperative course was uneventful. CONCLUSIONS: It seems that OPCAB is a useful and effective procedure for a selected patient even with cardiogenic shock due to AMI.

Reoperative coronary artery bypass grafting using a minimally invasive direct coronary artery bypass procedure.

OBJECTIVE: Reoperative coronary artery bypass grafting with cardiopulmonary bypass tends to cause a higher mortality and morbidity than the primary operation. The purpose of this study was to discuss the effectiveness and safety of a minimally invasive coronary artery bypass procedure for patients who had previously undergone coronary artery bypass surgery. METHODS: We performed redo single coronary artery bypass grafting to the left anterior descending coronary artery in 9 patients and to the right coronary artery in 3 patients using minimally invasive cardiac surgery. The graft to the left anterior descending coronary artery was taken from the left internal thoracic artery in 5 patients, the right gastroepiploic artery in 3 patients, and from the saphenous vein in the other 1 patient. The graft to the right coronary artery was from the right gastroepiploic artery in all 3 patients. RESULTS: All grafts were patent. There was no major postoperative complication and no surgical or hospital death except one late death. CONCLUSIONS: In selected patients, we could safely and completely perform coronary artery bypass re-grafting to the left descending coronary artery or right coronary artery using a minimally invasive operation.

Lung volume reduction surgery and nutritional status in patients with severe emphysema.

OBJECTIVE: We studied the short-term effect of lung volume reduction surgery on nutritional status including body composition and the relationship between preoperative nutritional status and postoperative morbidity. METHODS: Subjects were 28 patients with emphysema who underwent bilateral thoracoscopic lung volume reduction surgery (23 simultaneously, 5 staged). Functional tests, body weight, and body composition were measured before and 6 months after surgery. Fat-free mass and fat mass were assessed by bioelectrical impedance analysis. RESULTS: FEV1.0 improved 35.2% following surgery and maximal oxygen uptake 23.8%. Body weight and fat-free mass increased significantly after surgery, while fat mass was unchanged. Of the 23 undergoing simultaneous bilateral lung volume reduction surgery, 8 had major complications-3 required additional surgery to close air leaks, 3 required mechanical ventilation (> 72 hrs), and 2 developed postoperative infection. The preoperative percentage of ideal body weight and fat-free mass was significantly higher among patients without major complications. CONCLUSIONS: Bilateral lung volume reduction surgery increases fat-free mass and provides functional improvement for underweight patients with severe emphysema. We found fat-free mass and body weight to be good predictors of unacceptable postoperative complications following bilateral lung volume reduction surgery.

Cloning and characterization of a p53-related protein kinase expressed in interleukin-2-activated cytotoxic T-cells, epithelial tumor cell lines, and the testes.

A human protein kinase, p53-related protein kinase (PRPK), was cloned from an interleukin-2-activated cytotoxic T-cell subtraction library. PRPK appears to be a homologue of a growth-related yeast serine/threonine protein kinase, YGR262c. However, a complementation assay using YGR262c-disrupted yeast indicated that PRPK is not functionally identical to the yeast enzyme. PRPK expression was observed in interleukin-2-activated cytotoxic T-cells, some human epithelial tumor cell lines, and the testes. The intrinsic transcriptional activity of p53 was up-regulated by a transient transfection of PRPK to COS-7 cells. PRPK was shown to bind to p53 and to phosphorylate p53 at Ser-15. These results indicate that PRPK may play an important role in the cell cycle and cell apoptosis through phosphorylation of p53.

The effect of nutritional status on morbidity in COPD patients undergoing bilateral lung reduction surgery.

BACKGROUND: Although candidates for lung reduction surgery (LRS) include malnourished patients with severe chronic obstructive pulmonary disease (COPD), the impact of preoperative nutritional status on surgical outcome has not been clearly elucidated. METHODS: We investigated the relationship between preoperative nutritional status and postoperative morbidity in 23 consecutive patients undergoing LRS. The percentage of ideal body weight (%IBW) and body mass index (BMI) were calculated, and fat-free mass (FFM) and fat mass (FM) were measured using a bioelectrical impedance analyzer. FFM and FM were expressed as height-normalized indices, FFM index [FFM (kg)/height (m)(2), or FFMI] and FM index [FM (kg)/height (m)(2), or FMI]. Serum levels of total protein and albumin were also determined. RESULTS: 8 patients had major complications. Preoperative %IBW and FFMI were significantly lower among patients with major complications, while no significant differences were observed in pulmonary function, FMI or serum protein. The complication rate was significantly higher among patients with low FFMI (FFMI < or = 16) but not with low %IBW or BMI. CONCLUSION: These results suggest that FFM depletion is an excellent predictor of unacceptable postoperative complication following LRS.

Intragastric endoscopic mucosal resection through a temporary gastrostomy for early gastric cancer: usefulness of Buess-type endoscope.

OBJECTIVE: To assess the feasibility of cure of early gastric cancer by the endoscopic procedure done through a temporary gastrostomy and to use it to treat patients with various severe complications. DESIGN: Prospective study. SETTING: University hospital, Japan. SUBJECTS: Four patients who required gastric mucosal resection for early gastric cancer. MAIN OUTCOME MEASURES: Ease of the procedure, cure rate, safety under epidural anaesthesia, and outcome. RESULTS: All patients had the procedure under epidural anaesthesia without pain or complaints during operation. Mean operation time was 120 minutes (60-200). Histological examination showed that the surgical margin was free of tumour in 3 of the cases. One patient who had microscopic invasion of lymph nodes subsequently underwent second-look conventional gastrectomy with lymphadenectomy. Postoperative recovery was rapid, and all patients were discharged from the hospital uneventfully. CONCLUSION: This organ-preserving procedure enables good visualisation of the tumour and is useful even for high-risk patients.

Tracheal allotransplantation maintaining cartilage viability with long-term cryopreserved allografts.

BACKGROUND: Cartilage viability of a cryopreserved tracheal allograft seems to affect graft function and durability. We previously reported the influence of warm ischemia and cryopreservation on cartilage viability of tracheal allografts. For the clinical application of tracheal allotransplantation, it is essential to preserve grafts for a long time. In this study, we assessed cartilage viability of tracheal allografts after long-term cryopreservation in transplantation models. METHODS: The tracheas were harvested from Lewis rats. The grafts were frozen to -80 degrees C in a programmable freezer immediately after being harvested and were then stored in liquid nitrogen (-196 degrees C) for different lengths of preservation (1, 2, 6, 9, 12, 18, and 24 months; n for each group = 8). Cartilage viability was evaluated by estimating proteoglycan synthesis. After harvest or thawing of the tracheas, the cartilage was labeled with 4 muCi/mL of Na2 35SO4. Specimens were then hydrolyzed in 0.5 mol/L NaOH, and a solution of the extracts was then counted by a liquid scintillation counter. 35Sulfur incorporation before and after cryopreservation was examined in each group. Tracheal allotransplantation was performed using Lewis rats as donors and Brown Norway rats as recipients. RESULTS: The average 35S incorporation in the cartilage before cryopreservation was 224 +/- 17 disintegrations per minute per milligram of tissue protein. The average 35S incorporation in the cartilage after cryopreservation decreased to 67% to 76% compared with that before cryopreservation. There were no significant differences among the groups in 35S incorporations after cryopreservation. Histologic examination after transplantation revealed normal tracheal cartilage in all groups. CONCLUSIONS: The viability of tracheal cartilage after cryopreservation decreased to 67% to 76%. There were no significant differences in viability of cartilage among the tracheas after different lengths of cryopreservation. Tracheal allotransplantation after long-term cryopreservation can be safely performed in the rat model.

Carcinoma of the cystic duct associated with pancreaticobiliary maljunction.

We report a rare case of carcinoma of the cystic duct (CCD) associated with pancreaticobiliary maljunction (PBM). A 63-year-old man had presented with relapsing cholecystitis of 4 months, duration. Computed tomography showed a distended gallbladder: however, small mass in the cystic duct was overlooked. Endoscopic retrograde cholangiopancreatography demonstrated a long common channel (20-mm-long) and fusiform dilatation of the common bile duct, findings, which were consistent with PBM. At laparotomy, we found a papillary tumor, 20 mm in diameter, that obstructed the cystic duct. The patient underwent resection of the gallbladder and the common bile duct, lymph node dissection in the hepatoduodenal ligament, and hepaticojejunostomy. Histologic study revealed a papillary adenocarcinoma confined within the subserosal space. There was no lymphatic or perineural invasion of cancer cells. The surrounding cystic ductal mucosa showed dysplasia and hyperplasia, and the gallbladder and common bile duct showed severe inflammation. The patient has been doing well for 16 months after surgery, without tumor recurrence. This case suggests a relationship between CCD and chronic biliary inflammation caused by PBM, as in cases of gallbladder carcinoma.

Distribution of muscle mass and maximal exercise performance in patients with COPD.

STUDY OBJECTIVE: To investigate the distribution of reduction in lean body mass (LBM) and whether LBM in legs (LBMlegs) can be a determinant of maximal exercise performance in COPD patients. METHODS: Thirty-eight male outpatients with COPD (mean +/- SD FEV1, 47.4 +/- 24.0% of predicted) who underwent complete pulmonary function testing were classified into two groups according to FEV1 expressed as a percentage of predicted value. Group A comprised 21 patients with mild-to-moderate airflow limitation (FEV(1) > or =35% predicted), and group B comprised 17 patients with severe airflow limitation (FEV1 < 35% predicted). LBM, which represents skeletal muscle mass, was measured by dual energy x-ray absorptiometry (DXA) and was assessed separately in arms, legs, and trunk. Maximal oxygen uptake VO2max was measured during maximal exercise on a cycle ergometer. RESULTS: LBM in each region was expressed as a percentage of ideal body weight (IBW). LBM in arms (LBMarms)/IBW, LBMlegs/IBW, and LBM in trunk (LBMtrunk)/IBW were significantly depleted in group B compared with group A (p < 0.01). LBMlegs expressed as a percentage of total LBM (LBMlegs/total LBM) was significantly lower in group B (p < 0.05), although there was no significant difference in LBMarms/total LBM and LBMtrunk/total LBM between the two groups. VO2max correlated significantly with LBMlegs/IBW in group A, but not in group B. By stepwise regression analysis, LBMlegs/IBW appeared to be a significant predictor of VO2max in group A, while not in group B. CONCLUSION: LBMlegs was a significant predictor of maximal exercise performance in patients with mild-to-moderate airflow limitation, but not in patients with severe airflow limitation who had disproportional reduction in LBMlegs.

Clinical evaluation of 99mTc-Technegas SPECT in thoracoscopic lung volume reduction surgery in patients with pulmonary emphysema.

UNLABELLED: 99mTc-Technegas (Tcgas) SPECT is useful for evaluating the patency of the airway and highly sensitive in detecting regional pulmonary function in pulmonary emphysema. The aim of this study is to evaluate regional ventilation impairment by this method pre and post thoracoscopic lung volume reduction surgery (LVRS) in patients with pulmonary emphysema. METHODS: There were 11 patients with pulmonary emphysema. The mean age of patients was 64.1 years. All patients were males. LVRS was performed bilaterally in 8 patients and unilaterally in 3 patients. Post inhalation of Tcgas in the sitting position, the subjects were placed in the supine position and SPECT was performed. Distribution of Tcgas on axial images was classified into 4 types, A: homogeneous, B: inhomogeneous, C: hot spot, D: defect. Three slices of axial SPECT images, the upper, middle and lower fields were selected, and changes in deposition patterns post LVRS were scored (Tcgas score). RESULTS: Post LVRS, dyspnea on exertion and pulmonary function tests were improved. Pre LVRS, inhomogeneous distribution, hot spots and defects were observed in all patients. Post LVRS, improvement in distribution was obtained not only in the surgical field and other fields, but also in the contralateral lung of unilaterally operated patients. In 5 patients some fields showed deterioration. The Tcgas score correlated with improvements in FEV1.0, FEV1.0% and %FEV1.0. CONCLUSION: Tcgas SPECT is useful for evaluating changes in regional pulmonary function post LVRS.

Painless lithotripsy by flashlamp-excited dye laser for impacted biliary stones: an experimental and clinical study.

OBJECTIVE: To find out the appropriate dye laser output and frequency for each kind of stone experimentally, and to use flashlamp-excited dye laser for impacted biliary stones. DESIGN: Prospective study. SETTING: University hospital, Japan. SUBJECTS: 12 patients undergoing lithotripsy for both intrahepatic and extrahepatic impacted biliary stones. MAIN OUTCOME MEASURES: Appropriate dye laser output and frequency, histological changes in the bile duct wall, and outcome. RESULTS: Stones were pulverised, and required a median 155 pulses (range 80-205) at 40 mJ for bilirubin stones and 355 pulses (range 205-405) at 50 mJ for cholesterol stones. At the standard energies used, the laser caused only superficial damage to the serosa of the common bile duct. It was successful in fragmenting 133/135 stones (99%), and in addition pulverised 125/135 stones (93%). No patients complained of pain during laser lithotripsy even under local anaesthesia. All patients were discharged from the hospital after an uneventful recovery, and no recurrent stones have been found at outpatient follow-up ranging between 2 and 85 months. CONCLUSION: Flashlamp-excited dye laser with a small choledochoscope seems to be safe and painless way of treating biliary stones, even if they are impacted in the peripheral biliary tree and patients are at high risk.

The relation of fat-free mass to maximum exercise performance in patients with chronic obstructive pulmonary disease.

To assess the factors determining maximum exercise performance in patients with chronic obstructive pulmonary disease (COPD), we examined nutritional status with special reference to body composition and pulmonary function in 50 stable COPD patients. Nutritional status was evaluated by body weight and body composition, including fat mass (FM) and fat-free mass (FFM) assessed by bioelectrical impedance analysis (BIA). Exercise performance was evaluated by maximum oxygen uptake (Vo(2max)) on a cycle ergometer. A total of 50 patients (FEV(1) = 0.98 L) was divided randomly into either a study group (group A, n = 25) or validation group (group B, n = 25). Stepwise regression analysis was performed in group A to determine the best predictors of Vo(2max) from measurements of pulmonary function and nutritional status. Stepwise regression analysis revealed that Vo(2max) was predicted best by the following equation in group A: Vo(2max) (mL/min) = 10.223 x FFM (kg) + 4.188 x MVV (L/min) + 9.952 x DL(co) (mL/min/mmHg) - 127.9 (r = 0.84, p < 0. 001). This equation was then cross-validated in group B: Measured Vo(2max) (mL/min) = 1.554 x Predicted Vo(2max) (mL/min) - 324.0 (r = 0.87, p < 0.001). We conclude that FFM is an important factor in determining maximum exercise performance, along with pulmonary function parameters, in patients with COPD.

Effects of warm ischemia and cryopreservation on cartilage viability of tracheal allografts.

BACKGROUND: For clinical use of a cryopreserved tracheal allograft, it is important to evaluate cartilage viability. We assessed cell viability of the cartilage in a cryopreserved tracheal allograft by measurement of Na2 35SO4 incorporation. We also investigated the effects of warm ischemic time on tracheal cartilage viability. METHODS: The tracheas from Lewis rats were harvested and preserved at different warm ischemic times from cardiac death to preservation (0, 1, 2, 4, 6, 9, and 12 hours, each group n = 8). The cartilage was labeled with 4 muCi/mL of Na2 35SO4. The specimen was hydrolyzed in 0.5 mol/L NaOH, and a solution of the extracts was then counted by liquid scintillation counter. Tracheas were transplanted into Brown Norway rats. RESULTS: 35Sulfur incorporation in the cartilage decreased as warm ischemic time increased. In addition, 35Sulfur incorporation decreased from 76% to 67% after cryopreservation. Histologic examinations of the normal tracheal cartilage before preservation and after thawing were done in all the groups. After transplantation, the cartilage had severe fibrous changes, and its layer was almost nonobservable in the 9- and 12-hour groups. CONCLUSIONS: The viability of the tracheal cartilage decreased with warm ischemic time and from 76% to 67% after cryopreservation. In the rat tracheal transplantation model, a cryopreserved tracheal allotransplant could be done safely with a graft that was cryopreserved within 6 hours of warm ischemic time.

Multiendoscope-assisted treatment for blue rubber bleb nevus syndrome.

Blue rubber bleb nevus syndrome is characterized by gastrointestinal and cutaneous hemangiomas and gastrointestinal bleeding causing anemia. We report a unique case of this syndrome in an adult woman. It was associated with congenital heart disease, for which the patient underwent surgery at 12 months of age, and cutaneous hemangiomas, for which surgery was performed later in childhood. Gastrointestinal bleeding was diagnosed and treated when she was 21 years of age after a workup for iron deficiency anemia. Successful total resection of all gastrointestinal hemangiomas was performed by minimally invasive surgery with gastric, small intestinal, and colonic fiberscopy and laparoscopy. The postoperative course was uneventful. The patient could walk the day after surgery, and she was discharged from the hospital 14 days after surgery. Our experience and findings given in other reports suggest that total resection of hemangiomas should be the final goal and that minimal skin incision is preferable for this benign disease, with multiendoscope-assisted treatment to ensure that any hemangiomas remaining in the gastrointestinal tract are not overlooked.

The change in body composition after bilateral lung volume reduction surgery for underweight patients with severe emphysema.

The aim of this study was to examine the short-term effect of lung volume reduction surgery (LVRS) on body composition and other nutritional indicators in 28 patients with emphysema underwent thoracoscopic LVRS. Functional tests, body weight (BW), and body composition were measured before and 6 months after surgery. Mean daily caloric intake (CI) was estimated by 3-day dietary record as well. Fat-free mass (FFM) and fat mass (FM) were assessed by bioelectrical impedance analysis (BIA). FEV1.0 and VO2max have improved after LVRS by 35.2% and 23.8%, respectively. Preoperatively, 75% of patients were underweight (% ideal body weight (%IBW) <90) with the mean %IBW at 84.5%. BW, CI, and FFM increased significantly after LVRS, whereas FM was unchanged. The change in BW correlated significantly with the change in FEV1.0, MVV, and VO2max (p < 0.01) but not with CI. Bilateral LVRS results in an increase in FFM and functional improvement for underweight patients with severe emphysema, and it may contribute to the improvement in maximal exercise capacity.

[Re-coronary artery bypass grafting using a MIDCAB technique in a patient with a patent RITA-LAD graft].

In a patient with a patent RITA-LAD (right internal thoracic artery-left anterior descending artery) graft, re-CABG (re-coronary artery bypass grafting) with re-median sternotomy has been a high risk procedure. A 56-year-old male underwent 4-CABG (RITA-LAD, LITA-Dx, SVG-PL, and SVG-RCA) nine years ago. Coronary angiography showed that the RITA-LAD graft was well patent, but there was 95% stenosis distal to RITA-LAD anastomosis site. We performed re-CABG (right gastroepiploic artery-LAD; RGEA-LAD), using MIDCAB (minimally invasive direct coronary artery bypass) technique with neither re-median sternotomy nor cardiopulmonary bypass. The right gastroepiploic artery was harvested through a small upper median laparotomy and anastomosed to LAD through a small left anterior thoracotomy. The postoperative course was uneventful. This technique seems to be useful for re-revascularization of the LAD in a patient with a patent RITA-LAD graft.