[A rational approach of limited resection for small peripheral lung adenocarcinoma with curative intent; analyses of multiple primary adenocarcinomas].

Hundred and forty-one small peripheral adenocarcinomas 2 cm or less in diameter were retrospectively studied to determine the rationale of limited resection with curative intent. We used a conventional computed tomography (CT) which used 2.5 mm thick sections to examine only the main tumor during from March 1985 to May 1999 and a spiral CT which produced 2.5 mm thick sections of the entire lung field during from June 1999 to July 2003. The incidence of small peripheral adenocarcinoma significantly increased from 12.6% to 29.1%, suggesting an increase in the rate of detection with spiral CTs. During the spiral CT era, the percentage of females, pathological stage I a tumors, predominant ground-glass opacity (GGO) tumors and limited resection were significantly higher. The incidence of multiple adenocarcinomas 2 cm or less in diameter significantly increased 2.6% to 14.1%. It increases to 21.9% in small adenocarcinomas and 63.6% in predominant GGO type, when minute GGO lesion which have been followed in 5 patients by a watch and wait policy would be bronchioloalveolar carcinoma (BAC). In conclusion, a paradigm shift of the treatment for small peripheral adenocarcinoma should be warrant, because localized BAC as noninvasive cancer is not rare and often found as multiple BACs.

[Acute purulent pericarditis due to Haemophilus influenzae treated successfully with subxiphoid pericardial drainage; report of a case].

A surgical case of acute purulent pericarditis in 1-year 2-month old boy who developed pericardial tamponade rapidly is reported. A subxiphoid pericardiectomy through a median incision was performed. Haemophilus influenzae was isolated from the effusion. He recovered successfully with an administration of antibiotics after the drainage procedures and did not develop constructive pericarditis. Our experience suggested that early subxiphoid pericardial drainage was effective in treatment of acute purulent pericarditis.

[Results of surgical treatment for thymic epithelial tumors with special reference to the WHO classification].

We examined the clinical significance of World Health Organization (WHO) classification based on a surgical experience with 71 patients. There were 6, 21, 6, 10, 14, and 14 patients with type A, AB, B1, B2, B3 and C tumors. In these patients, average stage by Masaoka's classification was significantly associated with the WHO classification. Invasive tumors of stage III and IV were seen more frequently in patients with type B2, B3 and C tumors than in those with type A, AB and B1. The incidence of tumors invading the lung, the pericardia or the pleura was higher in type B2, B3 and C than in type A, AB or B1. Furthermore, tumor recurrences and tumor-related deaths were seen only in patients with type B2, B3 or C. This study suggested that type B2, B3 and C tumors had more malignant nature in terms of invasiveness, recurrence and prognosis following operation, and that WHO classification may be a useful guideline for planning treatment of thymic epithelial tumors.

[Analyses of multiple primary lung cancers; recent trend].

We studied multiple primary lung cancers (MPLCs) in 921 patients who had undergone operation for primary lung cancer since March 1979 in Mie University Hospital. There were 14 synchronous and 5 metachronous MPLCs. Combination of synchronous MPLCs were adenocarcinoma (ADC)/ADC in 7, squamous cell carcinoma (SCC)/SCC in 3, and ADC/adenosquamous cell carcinoma, ADC/small cell carcinoma, ADC/large cell carcinoma and multiple AAH in one. The incidence of synchronous MPLCs was 0.7% (6/815 pts) before May 1999 and 7.5% (8/106 pts) after June 1999 when HRCT was introduced for preoperative evaluation and postoperative follow-up. Six cases with multiple bronchioloalveolar carcinomas (BACs) have undergone operation for last 5 years. Most of them were roentgenographically occult and the operative outcome was good in spite of limited resection. In summary, we need new strategy of diagnosis and operative procedure for peripheral small adenocarcinoma, because multiple MPLCs of BAC are not rare.

Transluminal placement of endovascular stent-grafts for the treatment of type A aortic dissection with an entry tear in the descending thoracic aorta.

PURPOSE: The current therapy for type A aortic dissection is ascending aortic replacement. Operative mortality and morbidity rates have been markedly improved because of recent advances in surgical techniques and anesthesiology. However, type A aortic dissection with an entry tear in the descending thoracic aorta is still a surgical challenge because of the need for extensive aortic replacement. METHODS: Ten patients with type A aortic dissection were treated with endovascular stent-grafts. The false lumen of the ascending aorta was patent in five patients, and it was thrombosed in the other five patients. The entry tears were located in the descending thoracic aorta in all cases. Seven patients had acute dissection, and three patients had subacute dissection. Four patients had pericardial effusion. Stent-grafts were fabricated from expanded polytetrafluoroethylene and Z-stents. RESULTS: Entry closure was achieved in all patients. Complete thrombosis of the false lumen of the ascending aorta was observed after stent-grafting in all patients. A second stent-graft was required in two patients to obtain complete thrombosis of the false lumen of the descending thoracic aorta. No procedure-related complications were observed, with the exception of a minor stroke in one patient. During a mean follow-up period of 20 months, no aortic rupture or aneurysm formation was noted in either the ascending or descending thoracic aorta, and all patients were alive and doing well. The abdominal aortic aneurysm enlarged after stent-grafting in one patient, and this was treated by closing the fenestrations of the abdominal aorta with stent-grafts. CONCLUSION: Stent-graft repair of aortic dissection with an entry tear in the descending thoracic aorta is a safe and effective method and may be an alternative to surgical graft replacement in highly selected patients.

Coronary artery aneurysm in a patient with Marfan syndrome.

True aneurysm of the coronary artery in Marfan syndrome is very rare. We present a patient with Marfan syndrome who had aneurysms from the ascending aorta to the thoracoabdominal aorta and a large aneurysm of the left main coronary artery after an original Bentall operation. Prosthetic graft replacement of total aorta, coronary artery bypass grafting, and removal of the aneurysm of the left main coronary artery were successfully performed.

Aneurysmal degeneration of the aorta after stent-graft repair of acute aortic dissection.

PURPOSE: Stent-graft repair of acute aortic dissection has only recently begun, and the true efficacy and safety of this technique have not yet been clarified. In this report, we describe a significant, previously unreported complication following stent-graft repair of acute aortic dissection. MATERIALS AND METHODS: Fourteen patients with acute aortic dissection underwent stent-graft repair. All of the entry tears were located in the descending thoracic aorta. Five patients had type A aortic dissection, and nine patients had type B aortic dissection. The entry tears were closed with stent-grafts, which were fabricated from expanded polytetrafluoroethylene and Z-stents. RESULTS: Stent-graft placement was successfully performed without any complications in all patients. Entry closure was achieved in 13 (93%) of 14 patients. The mean follow-up period was 18 months (range, 9 days to 36 months). During this period, four patients had saccular aneurysms in the proximal descending thoracic aorta. A saccular aneurysm was noted during a mean follow-up period of 63 days (range, 38-99 days). Two of these patients were treated with stent-grafts. Conventional surgical repair is planned in one patient. The other patient is being treated with conservative management. CONCLUSIONS: Stent-graft repair is a technically feasible and effective method for the treatment of acute aortic dissection in selected patients. However, careful follow-up is mandatory to check for the development of saccular aneurysms.

Mr flow measurement in the internal mammary artery-to-coronary artery bypass graft: comparison with graft stenosis at radiographic angiography.

PURPOSE: To evaluate the sensitivity and specificity of breath-hold magnetic resonance (MR) flow measurement for detection of significant stenosis in internal mammary artery bypass grafts. MATERIALS AND METHODS: Twenty-six consecutive patients who had undergone coronary artery bypass surgery were examined. Breath-hold velocity-encoded cine MR images were obtained at the midpoint of the internal mammary artery between its origin from the subclavian artery and the distal anastomosis to the left anterior descending artery. RESULTS: MR images were obtained successfully in 24 patients. At conventional angiography, no significant stenosis was observed in 17 patients (group A), and significant stenosis (diameter > 70%) was observed in seven patients (group B). The mean diastolic-to-systolic peak velocity ratio in group B (0.61 +/- 0.44 [SD]) was significantly lower than that in group A (1.88 +/- 0.96; P <.01). Evaluation of graft stenosis with the diastolic-to-systolic peak velocity ratio revealed a sensitivity of 86% and a specificity of 88%. The mean blood flow rate at baseline in group B (16.9 mL/min +/- 5.5) was significantly lower than that in group A (79.8 mL/min +/- 38.2; P <.01). The sensitivity and specificity of MR blood flow measurement in predicting significant stenosis were 86% and 94%, respectively. The mean pharmacologic flow reserve ratios were 2.00 +/- 1.43 in group A and 1.39 +/- 1.46 in group B (P >.05). CONCLUSION: Fast MR blood flow measurement at baseline is highly useful for predicting significant stenosis in internal mammary arterial grafts.

Synchronous primary lung carcinoma and lung metastasis from extrathoracic carcinoma.

We present the cases of 2 patients in whom primary lung cancer was found unexpectedly when pulmonary resection was performed for metastatic lung cancer. The possibility of combined primary and metastatic carcinoma should be considered in patients with a diagnosis of multiple pulmonary metastases from extrathoracic tumor.

Treatment of chronic aortic dissection by transluminal endovascular stent-graft placement: preliminary results.

PURPOSE: To investigate efficacy of stent-graft repair for the treatment of patients with chronic aortic dissection. MATERIALS AND METHODS: Fifteen patients with chronic aortic dissection were treated with endovascular stent-grafts. Entry tears were located in the descending thoracic aorta in all patients. The mean maximum diameter of the descending thoracic aorta was 47 mm +/- 8. The mean diameter of the true lumen at the same level was 20 mm +/- 5. The mean interval between diagnosis and stent-graft procedure was 32 months +/- 91. Stent-grafts were fabricated from expanded polytetrafluoroethylene and Z-stents. RESULTS: Stent-grafts were placed successfully in all patients. Two stent-grafts were required in one patient. Entry closure and thrombosis of the false lumen of the descending thoracic aorta were also achieved in all patients. No procedure-related complications were observed except for postimplantation syndrome, including fever and leukocytosis. The diameter of the true lumen was significantly increased (mean, 31 mm +/- 6) at the level of the descending thoracic aorta (P <.01) and the diameter of the aorta was significantly decreased (mean, 44 mm +/- 8) at the same level (P <.01). There were no deaths and no instances of aortic rupture during the subsequent average follow-up period of 24 months. Secondary stent-graft procedures were required to treat the abdominal component of dissection during follow-up in one patient. CONCLUSIONS: Stent-graft repair of chronic aortic dissection is a safe and effective method and may be an alternative to surgical graft replacement in selected patients. However, further evaluation is mandatory before this method is widely employed.

[Total removal of infected pacemaker lead under cardiopulmonary bypass in a case of endocarditis, bacteremia and lung abscess].

A 60-year-old man, who had undergone implantation of a transvenous pacemaker system on the left chest wall for sick sinus syndrome 19 years ago, was admitted because of endocarditis with septicemia and lung abscess 2 months after reimplantation of the generator. His blood culture revealed Staphylococcus aureus. Following debridement of the infected pacemaker pocket and antibiotics therapy, we tried to remove the pacemaker system under cardiopulmonary bypass 1 month after admission. In intraoperative inspection, the electrodes had become firmly encased with fibrous tissue within the tricuspid valve and the right ventricle. After the operation, antibiotic therapy was performed for 4 weeks. His postoperative course was uneventful. Patients with pacemaker infection should undergo aggressive total removal of the pacemaker system, particularly incase with endocarditis and bacteremia.

[A case of surgically treated left atrial myxoma following acute multiple embolism including cerebral embolism].

The patient was a 59-year-old female who was admitted to the hospital due to acute pain of bilateral legs, a numbness of right hand and anarthria. Angiography of extremities revealed total occlusion of right ulnar artery, left radial artery and bilateral popliteal arteries. Brain MRI revealed multiple small infarctions. Echocardiography revealed a mass in the left atrium. She was diagnosed as multiple embolism including cerebral embolism caused by left atrial myxoma. Open heart surgery immediately after the attack is generally considered contraindicated due to problems of hemorrhagic infarction or brain edema. But, relapse of embolism may deteriorate the condition and miss the timing of surgery. Thus we performed removal of left atrial myxoma 4 days after the attack. The postoperative course was uneventful. This is a few report about open heart surgery immediately after the attack. We report about the indication and the optimal timing of open heart surgery following cerebral embolism.

Ultrafiltration of the priming blood before cardiopulmonary bypass attenuates inflammatory response and improves postoperative clinical course in pediatric patients.

The priming solution using in cardiopulmonary bypass (CPB) for infants undergoing cardiac surgery includes considerable amounts of stored blood. Our objective was to test the hypothesis that ultrafiltration (UF) of the stored blood before CPB reduces the unfavorable effects of stored blood and the production of inflammatory cytokines. Fifty pediatric patients with congenital heart defects took part in this study. The patients were randomly divided into two groups: the UF (27 pediatric patients who received UF) and control (23 pediatric patients who did not receive UF) groups. UF was performed with a polysulphone ultrafiltrator before CPB. Blood samples were collected immediately before, during, and 1 h after CPB. The levels of cytokines (TNF-alpha, IL-1beta, IL-8), NH3, and bradykinin were determined. The serum concentrations of NH3 and bradykinin decreased significantly after UF. Compared with the control group, the UF group had significantly lower cytokine production. Water balance in UF group was better than that of control group. The UF group received significantly less inotropic support and shorter duration of ventilator support and ICU stay. We conclude that removal of bradykinin and a decrease in the levels of NH3, potassium, and pH play a significant role in reducing water retention and postoperative lung injury. UF of the blood used to prime the circuit for CPB is a safe and efficient method for use in open heart surgery in small pediatric patients.

[A case of thymoma with pure red cell aplasia].

A 71-year-old man was admitted to the hospital because of general fatigue. There were few reticulocytes in the peripheral blood and no erythroblasts in the bone marrow. Chest CT revealed an anterior mediastinal tumor. Under a diagnosis of thymoma with PRCA, extended thymothymectomy was performed. Histological diagnosis was mixed type thymoma with no invasive growth beyond the capsule. Administration of predonisolone following surgery was not effective for PRCA. Otherwise, peripheral blood counts were significantly improved following occasional onset of acute bronchitis.

[The perioperative management for the patients to undergo open heart surgery with chronic renal failure].

From January, 1996 to December, 1999, eight patients with chronic renal failure received open heart surgery. They consists of six males and two females aged between 45 and 72 with a mean of 59.6. The duration of hemodialysis was 4.0 years in a mean. Seven of them had isolated coronary artery bypass grafting (CABG), one of them had CABG and aortic valve replacement. All patients were dialysed dialy two days before operation. Intraoperative hemodialysis (HD) was used in all patients. In recent six patients extracorporeal ultrafiltration methods (ECUM) were also performed intraoperatively in addition to HD. In postoperatively continuous hemodiafiltration (CHDF) has been preferred to HD in all patients, and nafamostat mesilate is a useful anticoagulation agent to prevent postoperative bleeding complications. The duration of CHDF was 3.2 days in a mean (the shortest for one day and the longest for eight days). When the circulatory situation were stable, HD was performed on early postoperative day. One patients died of low output syndrome and multiple organ failure. We reported problems in perioperative management of patients with chronic renal failure and our protocol.

Surgical repair of extracardiac unruptured acquired Valsalva aneurysms.

Two cases of extracardiac unruptured Valsalva aneurysms due to rare causes are reported. One patient had been suffering from hyper eosinophilic syndrome. Operative corrections consisted of total replacement of the aortic root. The other patient had an aneurysm of just noncoronary sinus of Valsalva and a dilated ascending aorta due to cystic mucoid degeneration. Replacement of the ascending aorta with patch closure for the aneurysm was successfully performed.

The role of cyclosporine A and interleukin-2 in obliterative airway disease in a rat tracheal transplant model.

The pathogenesis of obliterative bronchiolitis (OB) following lung and heart-lung transplantation remains unclear. We evaluated the role of CsA and IL-2 on the development of obliterative airway disease (OAD) by administrating exogenous IL-2 in a CsA-treated rat tracheal transplant model. Tracheal grafts were implanted into the peritoneal cavity from Brown Norway (BN) to BN rats or to Lewis (LEW) rats. Allotransplant: No treatment was given in group 1. Short-term CsA (25 mg/kg, i.m. on POD 2 and 3) was used in group 2. Group 3 was treated with long-term CsA (25 mg/kg, i.m. on POD 2 and 3, followed by 5 mg/kg on POD 4 to 27). Administration of IL-2 (300, 000 IU/kg, i.p. on POD 15 to 19 and 22 to 26) was performed to long-term CsA treated rats in group 4. Isotransplant: No treatment was given to group 5, group 6 was treated with IL-2 (same regimen as in group 4). Grafts were harvested at different time points after Tx for histological assessment. No luminal obliteration was observed in group 5 and 6. Complete luminal obliteration was noted 4 weeks after Tx in group 1. In group 2 and 3, obliterative lesion occurred 4-6 weeks after CsA withdrawal. IL-2 increased epithelial loss, lymphocytic infiltration, and obliterative changes in group 4. Our results suggest that OAD is an immune mediated disorder. Furthermore, administration of exogenous IL-2 might be able to abrogate the protection from OAD by CsA therapy.

Long-term follow-up after Carpentier-Edwards ring annuloplasty for tricuspid regurgitation.

BACKGROUND: Use of flexible rings for tricuspid ring annuloplasty is becoming popular. This study was undertaken to evaluate Carpentier-Edwards (C-E) rigid ring annuloplasty for tricuspid regurgitation (TR), secondary to mitral valve disease and clinical outcome on a long-term basis. METHODS: From December 1985 to March 1996, 45 patients with secondary TR underwent C-E ring annuloplasty. Thirty-nine patients (95.1%) were in New York Heart Association (NYHA) functional class III or IV. The mean follow-up was 96.7+/-48.5 months or 362.6 patient-years. RESULTS: There were three in-hospital and nine late deaths that were not related to tricuspid annuloplasty. Actuarial survival at 10 years was 68.3%. Echocardiographic studies showed that TR was well controlled within grade 2+ in all survivors. Residual pulmonary hypertension (PH) was recognized in 9 of 21 patients (42.9%) with preoperative PH, however, no TR was seen in 6 patients. A TR grade of 2+ was observed in 3 patients. Thirty of the total survivors (96.8%) were in NYHA class I and II, but 1 patient was in NYHA class III. The actuarial rate of freedom from tricuspid valve reoperation after 10 years was 97.5%. CONCLUSIONS: C-E ring annuloplasty is acceptable for repair of secondary TR and improvement in clinical status on a long-term basis.