Successful surgical treatment for implanted intraperitoneal metastases of ruptured small hepatocellular carcinoma: report of a case.

We report herein the case of a 53-year-old man with disseminated intraperitoneal metastases caused by the rupture of small hepatocellular carcinoma (HCC). He was admitted to our hospital in shock after suffering a trauma injury to the upper abdomen. Ultrasonography revealed a massive hemoperitoneum. At surgery, 4000 ml of blood was drained from the abdominal cavity and a ruptured tumor, 2 cm in diameter, was found in the right lobe of the liver. The tumor was resected with an adequate surgical margin and subsequent microscopic examination confirmed a diagnosis of moderately differentiated HCC without associated liver cirrhosis. The patient was readmitted 14 months later following the development of right lower quadrant pain. Ultrasonography and computed tomography revealed extrahepatic abdominal tumors, and abdominal angiography demonstrated four intraperitoneal tumors. At surgery, four implanted metastases adhered to the greater omentum were found and resected. No other tumors were detected. Microscopically, all four tumors were confirmed as moderately differentiated hepatocellular carcinoma. Ruptured HCC may lead to implanted intraperitoneal metastasis, but rupture of small HCC is very rare. While hepatic resection is the treatment of choice for ruptured HCC, according to our review of the literature, only a few patients have survived long-term after resection of implanted metastasis.

Arteriovenous malformation of the rectum: report of a case.

We report herein the case of a 38-year-old man found to have a rectal arteriovenous malformation (AVM). The patient was admitted to our hospital for investigation of fresh anal bleeding and general malaise. Barium-enema examination showed a slightly elevated lesion in the rectum, and a selective superior rectal angiogram subsequently revealed an AVM in the peripheral region of the superior rectal artery, which was presumed to be the cause of the anal bleeding. Colonoscopic examination disclosed a submucosal tumor-like lesion in the left posterior wall of the rectum, 3cm above the anal verge. After marking the boundaries by clipping, transanal resection of the lesion was performed. Histological examination revealed an irregularly expanded arteriovenous aggregation in the submucosal layer. The patient had a favorable postoperative course, and no residual AVM was seen on a postoperative selective inferior mesenteric arteriogram. There have been no signs of recurrence in the 2 years since his operation.

Treatment of pancreas head carcinoma in a 91-yr-old man. Report of a case successfully treated with pylorus-preserving pancreatoduodenectomy.

The case of a 91-yr-old man who had a tumor of the pancreas head successfully resected is reported. He was admitted to our hospital because of obstructive jaundice, and then percutaneous transhepatic biliary drainage (PTBD) was performed. Cholangiography via PTBD tube showed marked stenosis of the bile duct in the head of the pancreas. Endoscopic retrograde pancreatography (ERP) showed obstruction of the main pancreatic duct in the head of the pancreas, and carcinoma in the head of the pancreas was diagnosed. Abdominal angiography showed stenosis of the celiac trunk caused by compression from the median arcuate ligament, but no tumor stain or encasement in the pancreas was detected. Because the patient had lived an extremely healthy life and had no serious concurrent disease before admission, laparotomy was performed. The tumor in the head of the pancreas was about 2 cm in diameter and restricted inside the pancreas. Pylorus-preserving pancreatoduodenectomy (PpPD) with regional lymph node dissection was performed. The tumor was 1.5 cm in its maximal diameter, and histopathologically was diagnosed as an invasive ductal carcinoma of the pancreas with moderately differentiated tubular adenocarcinoma. The patient had an uneventful postoperative course and now, 3 yr after surgery, he is doing very well and leading a normal daily life.

Colonic and peritoneal tuberculosis associated with coloduodenal fistula.

We report a very rare case of tuberculous colitis that showed relatively long-segment involvement of the colon near the hepatic flexure with coloduodenal fistula that caused severe malnutrition. The formation of fistula in abdominal tuberculosis is very rare. This is the eighth reported case of abdominal tuberculosis with fistula and the first reported case with a coloduodenal fistula.

Effects of inhaled nitric oxide in single lung transplantation in rats with monocrotaline-induced pulmonary hypertension.

BACKGROUND: The edema of grafted lungs during the early postoperative period is one of the serious complications of single lung transplantation for primary pulmonary hypertension. METHODS: The effectiveness of inhaled nitric oxide in single lung transplantation for primary pulmonary hypertension during the early postoperative period was evaluated with the use of rats with monocrotaline-induced pulmonary hypertension. In the inhaled nitric oxide group, rats were given 60 parts par million of nitric oxide for 24 hours just after left lung transplantation; in the no inhaled nitric oxide group, rats were kept without nitric oxide inhalation; in the control group, normal rats received left isografts. RESULTS: Three hours after transplantation, the mean pulmonary artery pressure of the no inhaled nitric oxide group (28.0 +/- 4.6) was significantly higher than that of the control group (23.3 +/- 0.9, p < 0.05) and the inhaled nitric oxide group (22.7 +/- 1.7, p < 0.05). On the first postoperative day, the mean left-to-right pulmonary blood flow ratio in the inhaled nitric oxide group was 0.34 +/- 0.03; it showed no significant difference to those of the other two groups, whereas that of the no inhaled nitric oxide group (0.42 +/- 0.14) was significantly elevated compared with that of the control group (0.14 +/- 0.03, p < 0.05). Histopathologically, the edema of the grafted lungs 24 hours after operation in the inhaled nitric oxide group was less severe than that in the no inhaled nitric oxide group. CONCLUSIONS: The postoperative use of inhaled nitric oxide is effective to reduce the pulmonary edema of the grafts in single lung transplantation for pulmonary hypertension by reducing acute pulmonary blood flow shift toward grafts after transplantation.

[A case of lung cancer avoidable right pneumonectomy due to external and intraluminal irradiation therapy].

A 54-year-old man with squamous cell carcinoma of the lung resected after external and high dose rate intraluminal irradiation (HDRII) therapy is reported. Cancer existed in right lower bronchus, extended to bifurcation of upper broncus and truncus intermedius. The patient received external irradiation of 40 Gy and HDRII of 18 Gy (Iridium192 was used) simultaneously. Effectiveness of irradiation was remarkable, tumor disappeared in chest CT and bronchoscopy. Middle and lower lobectomy and bronchial wedge resection was performed. Histologically, cancer was not existed in second carinal portion, so curative resection was done. The result suggests that HDRII is effective therapy as preoperative adjuvant irradiation.

Is it true that cardiac operations with cardiopulmonary bypass impair the reticuloendothelial system?

Reticuloendothelial system (RES) function after cardiac operations is a controversial issue. Sequential changes in plasma fibronectin levels and RES phagocytic function were studied after a cardiac operation and a lung operation (control). In the cardiac operation group, the plasma fibronectin level decreased until the third postoperative day and increased thereafter. Reticuloendothelial system phagocytic function remained unchanged on the third postoperative day and then it increased. However, in the control group it increased significantly after operation. In the past, investigators have demonstrated a decline in plasma fibronectin levels following cardiac operation and have assumed that RES function was impaired. However, this sequential study showed that phagocytic function was not impaired, but its enhanced phase was delayed. Moreover, our previous morphologic studies demonstrated that RES function was potentially activated after cardiopulmonary bypass. It appears that the delay of the enhanced phase is caused by the overloading of substances which must be processed by the RES during cardiopulmonary bypass. Thus, we conclude that cardiac operation produces hyperactive, yet oversaturated RES function. There is no impairment of RES function after cardiac operations.

Descending necrotizing mediastinitis secondary to a retropharyngeal abscess.

A rare case of descending necrotizing mediastinitis (DNM) secondary to a nontraumatic retropharyngeal abscess is reported. Even in the era of antibiotics, the mortality of DNM is still around 40%. In spite of drainage of a localized neck abscess, and the administration of systemic antibiotics, the retropharyngeal abscess extended to the pericardial and pleural cavities. Several drainage procedures and thoracotomies were performed to treat the bilateral empyemas and purulent pericarditis. The patient was discharged on hospital day 52. Computed tomography was used to follow the progression of disease, and assess the efficacy of treatment. DNM is a very aggressive form of mediastinitis. The importance of proper mediastinal drainage, as well as the systemic administration of antibiotics, must be emphasized.

Effects of inhaled nitric oxide in rats with chemically induced pulmonary hypertension.

To determine the model animal with pulmonary hypertension in which nitric oxide (NO) inhalation reduces pulmonary arterial pressure (PAP), we examined the inhalation of 20-100 ppm NO gas on normal rats and rats with monocrotaline induced pulmonary hypertension. In the control group, mean PAP showed no change after spontaneous breathing of NO at the concentration of 20 to 100 ppm for 5 min. On the contrary, in both the severe (mean PAP > 40 mmHg) and moderate (mean PAP < 40 mmHg) pulmonary hypertensive groups, NO inhalation produced a prompt reduction of the mean PAP which had been elevated by monocrotaline. 20 ppm NO inhalation reduced mean PAP from 64.4 +/- 3.7 mmHg to 56.2 +/- 4.4 mmHg (mean +/- SEM, P < 0.01) in the severe pulmonary hypertensive group, from 31.0 +/- 2.0 mmHg to 24.2 +/- 0.9 mmHg in the moderate pulmonary hypertensive group (mean +/- SEM, P < 0.05). The onset of the reduction of mean PAP occurred within 30 sec after the start of NO inhalation and maximum reduction occurred within 4 min. 20 ppm NO inhalation significantly reduced mean PAP, and mean PAP was reduced dose-dependently at the concentration of 20 to 60 ppm and reaction to NO was almost constant at the concentrations of over 60 ppm.

Oversaturation status of reticuloendothelial system following cardiopulmonary bypass.

In the past, it was generally believed that the phagocytic function of the reticuloendothelial system (RES) was depressed after cardiopulmonary bypass (CPB), but several investigators reported differing results. Therefore, this study was performed to determine the effect of CPB on RES function, experimentally and clinically. Six dogs undergoing CPB (CPB group) were compared with an identical number of dogs subjected to thoracotomy without CPB (control group). A lipid emulsion test was performed in all dogs before and after the surgical procedure to measure RES phagocytic function. Any ultrastructural changes in Kupffer cells were observed by electron microscopy. In both groups, the RES phagocytic index showed a significant decline after surgery. However, comparison of the 2 groups revealed that there was a significantly greater decrease in the CPB group (p < 0.05). Electron microscopy of the Kupffer cells showed that the number of phagosomes, especially those containing deformed erythrocytes, increased after CPB. Twenty patients undergoing cardiac surgery requiring CPB (Group A) and 8 patients undergoing pulmonary resection (Group B) were studied. RES phagocytic function was determined 3 days prior to surgery and 3 days postoperatively using the lipid emulsion test. No significant difference was observed in the preoperative phagocytic indices between the 2 groups. The phagocytic function remained almost unchanged in Group A on the third postoperative day, compared with the preoperative value, but it increased significantly in Group B on the third postoperative day, compared with the preoperative value. The intergroup difference was significant on the third postoperative day (p < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Surgical treatment of primary lung cancer in patients less than 40 years of age.

PURPOSE AND METHODS: The major purpose of this study was to determine whether the survival rate in young lung cancer patients after surgical treatment differs from that in older patients. An analysis was performed for all patients with bronchogenic carcinoma who underwent surgery at Mie University Hospital from 1965 to 1990. RESULTS: Of 803 patients, 24 (2.99%) were 33 to 39 years old. At the time of surgery, the disease was diagnosed as stage I in seven patients (29%), stage II in four (17%), stage IIIa in seven (29%), stage IIIb in two (8%), and stage IV in four (17%), while 46.3% of the patients older than 40 years of age had either stage IIIa, IIIb, or IV disease. All of the 24 patients less than 40 years of age underwent thoracotomy: curative resection in 14 cases, palliative resection in sex, and probe-thoracotomy in four. The 5-year survival rate for all stages of disease was 31.4% in these 24 patients, and 41.9% in 603 patients greater than 40 years of age. The 5-year survival rate for stage I disease was 35.7% in the seven younger patients and 78.0% in the 207 older patients; for stage II, it was 25.5% in the four younger patients and 40.6% in the 98 older patients; for stage III, it was 33.3% in the nine younger patients and 15.6% in the 250 older patients; and for stage IV, it was 25% in the four younger patients and 6.6% in the 48 older patients. There were no significant differences in survival rate between the two age groups for all patients or for those with each stage of disease. CONCLUSION: Although younger patients tended to have more advanced disease, long-term survival in these patients did not differ from that of older patients.

Reticuloendothelial function following cardiopulmonary bypass: laboratory and electron microscopy findings.

Several studies on the effects of cardiopulmonary bypass (CPB) on the reticuloendothelial system (RES) function have been performed previously, but different results have been reported. This study was carried out to determine the effect of CPB on RES function in a canine model simulating clinical CPB. Nine dogs undergoing surgery with CPB were compared with an identical number of dogs subjected to thoracotomy without CPB. A lipid emulsion test was performed in all dogs before and after the surgical procedure to measure RES phagocytic index, i.e., phagocytic function. Kupffer cell iron uptake under conditions of iron loading following CPB was examined histologically, and any ultrastructural changes in the Kupffer cells were observed by electron microscopy. In both groups, the RES phagocytic index showed a significant decline after surgery. However, a comparison of the two groups revealed that there was a significantly greater decrease in the CPB group (P < 0.05). Moreover, histologic evidence of iron uptake in Kupffer cells was strongly suppressed in the CPB group. Electron microscopy of the Kupffer cells showed that the number of phagosomes, especially deformed erythrocytes, increased after CPB. These findings suggest that RES function is significantly impaired following CPB, and an increase in the amount of material, especially deformed erythrocytes, to be processed by the RES is responsible, in part, for the depressed RES phagocytic function. The prevention of hemolysis during CPB may preserve the RES function following CPB.

The role of surgical resection and the effects of neo-adjuvant therapy in the management of small cell lung cancer.

A study was conducted on 58 patients who underwent surgery for small cell lung cancer (SCLC) as resection or exploratory thoracotomy, and 43 patients encountered during the same period who received no surgical treatment. The following conclusions were drawn from our analysis: At stage I, an operation is desirable, regardless of the subtype of SCLC, but chemotherapy should be given first; at stages II and III, by the addition of surgery after neo-adjuvant chemotherapy, "state-of-the-art" results for limited SCLC can be surpassed; in patients with stage II disease on whom curative resection has been performed, particular attention must be paid to the possibility of metastasis to the brain; and finally, exploratory thoracotomy did not bring about the early death of patients or reduce the quality of life, but only delayed chemotherapy for about one week, while enabling the staging and histological subtype of SCLC to be clarified.

The effects of single lung transplantation in rats with monocrotaline-induced pulmonary hypertension.

Acute haemodynamic change after single lung transplantation for primary pulmonary hypertension was evaluated using a rat transplantation model. Inbred Fisher 344 rats were administered with 40 mg/kg monocrotaline in order to induce pulmonary hypertension. The rats whose mean pulmonary arterial pressure (PAP) was over 30.0 mm Hg received a left lung isograft from a normal donor after right heart catheterization. In the control group, PAP increased after single lung transplantation. On the other hand, in the pulmonary hypertensive group, PAP was significantly decreased 60 min after the transplantation, but 3 and 6 h after the transplantation, the PAP significantly increased again. On the day after the operation, it again decreased significantly. Left-to-right lung blood flow ratio was significantly increased in rats with pulmonary hypertension compared to rats with normal pulmonary pressure on both the 1st and 3rd postoperative days. The oedema of the grafted lung was more severe in the pulmonary hypertensive group than in the control group in the acute phase. In conclusion, single lung transplantation for pulmonary hypertension shifted pulmonary blood perfusion to the grafted lung and this shift made pulmonary oedema of the grafts more severe in the acute phase. These oedematous changes, which were more pronounced in the grafts in the pulmonary hypertensive rats, might have contributed to the transient rise in PAP in those rats after single lung transplantation.

Measurement of myocardial blood flow in coronary artery bypass surgery.

It is now possible experimentally to measure myocardial blood flow of the beating heart using a helium-neon (He-Ne) laser Doppler flowmeter. A myocardial probe was redesigned to reduce its size and weight, and a method devised of fixing the probe to the beating cardiac surface to allow its clinical application. This modified laser flowmeter was used on 36 patients with ischaemic heart disease to measure myocardial blood flow before and after revascularization. Flow was measured in the right and left ventricles while patients were in a haemodynamically stable state as determined by electrocardiography, heart rate, blood pressure and double product (heart rate x systolic blood pressure). No significant difference was found between the mean(s.e.m.) preoperative and postoperative flow volume at the anterior wall of the right ventricle (77(15) versus 81 (12)ml/min per 100 g), which did not undergo revascularization, but mean(s.e.m.) myocardial blood flow at the ischaemic left ventricle increased significantly (from 68(15) to 88(13) ml/min per 100 g; P < 0.01). There was also no significant difference between preoperative and postoperative values of haemodynamic parameters of coronary blood flow. In conclusion, a means to measure myocardial blood flow with He-Ne laser Doppler flowmetry has been devised which shows coronary artery bypass grafting to increase myocardial blood flow in the ischaemic myocardium.

Phosphorylation of a 62 kd porcine alpha-internexin, a newly identified intermediate filament protein.

A 62 kd protein was purified from the Triton-insoluble fraction of porcine brain white matter. This protein formed 10nm filaments, in vitro. The phosphorylation of the 62 kd protein by cAMP-dependent protein kinase caused electrophoretic mobility to shift to 66 kd on SDS-PAGE and a complete loss of the filament forming ability ensued. Amino acid sequences of four peptide fragments obtained from the 62 kd protein by lysylendopeptidase were identical with that of a 66 kd rat brain alpha-internexin. Amino acid analyses of the phosphopeptide fragment derived from phosphorylated porcine alpha-internexin revealed that the phosphorylation sites by cAMP-dependent protein kinase located in the amino-terminal head domain of this protein. These results strongly suggest that alpha-internexin polymerizes into 10nm filaments in vitro and that phosphorylation of the amino-terminal domain of alpha-internexin controls its polymerizability.

Comparison of the effects of various vasodilators on the rat portal vein and mesenteric artery.

The effects of various vasodilators on isolated helical strips of rat portal vein and mesenteric artery were examined. Dilazep, ibudilast, nifedipine, verapamil and papaverine relaxed the KCl- and norepinephrine-induced contractions of the portal vein to a greater extent than they relaxed those of mesenteric artery. Dibutyryl cyclic AMP and NKH477 did not show any significant difference in terms of the concentrations that produced 50% inhibition (IC50) of the KCl-induced contraction of the portal vein and mesenteric artery. The relaxant effects of nitroprusside and isosorbide dinitrate on the KCl- and norepinephrine-induced contractions of the portal vein were less potent than their effects on contractions of the mesenteric artery. The agents that inhibited the contractions of the portal vein more potently than those of the mesenteric artery were associated with parallel shifts to the right of the concentration-response curves for CaCl2 in both preparations. These results suggest that drugs with a Ca2+ channel blocking action may be preferable to those that cause a decrease in portal pressure for treatment of portal hypertension.