Pharyngoesophageal reconstruction with the use of vascular anastomoses: operative modifications and long-term prognosis.

OBJECTIVE: Vascular surgical techniques have contributed to the success of pharyngoesophageal reconstruction. We report our methods and analysis of postoperative complications, quality of life, and long-term prognosis. METHODS: Sixty-seven patients who underwent pharyngoesophageal reconstruction with use of vascular anastomoses comprised the study population. The operative procedures performed were free jejunal autograft transplantation in 54 patients, gastric pedicle placement with vascular anastomoses in 2, jejunal pedicle with vascular anastomoses in 4, colonic pedicle with vascular anastomoses in 4, free jejunal graft and gastric pedicle in 2, and free jejunal graft and jejunal pedicle in 1. The common carotid artery and internal jugular vein were primarily used as the recipient vessels. The period of postoperative observation ranged from 3 days to 145 months. RESULTS: The postoperative complications noted were dehiscence in 7 patients, graft failure in 1, wound infection in 2, small bowel intussusception in 4, pneumonia in 2, disseminated intravascular coagulation in 1, and pancytopenia in 1. Revascularization was successful in all but 1 patient, and oral intake was achieved in 58. Persistent swallowing dysfunction was recognized in 4%. Speech restoration was achieved in 57% of the patients with esophageal speech in 7% and with an artificial larynx in 50%. In the long-term follow-up, 36% of our patients died of the primary disease, 9% died of other diseases, and 55% are alive. CONCLUSIONS: Esophageal reconstruction with the use of vascular anastomoses affords low morbidity and mortality. Postoperative swallowing and speech are satisfactory, and the function of the reconstructed esophagus is well preserved for as long as 10 years.

Enhanced embryonic nonmuscle myosin heavy chain isoform and matrix metalloproteinase expression in aortic abdominal aneurysm with rapid progression.

Abdominal aortic aneurysms (AAAs) are characterized by structural deterioration of aortic wall leading to progressive dilatation. The histopathological changes in AAAs are particularly evident within the elastic media, which is normally comprised mainly of vascular smooth muscle cells (SMCs). There are vascular myosin heavy chain (MHC) isoforms; SM2 is specifically expressed in differentiated SMCs and SMemb is a nonmuscle-type MHC abundantly expressed in SMCs of the fetal aorta with an immature phenotype. Although AAA altered expression of matrix metalloproteinases (MMPs) and their tissue inhibitors (TIMPs), pathophysiological role of SMC phenotypic modulation in the AAA progression remains uncertain. To determine whether phenotypic modulation in vascular SMCs contributes to arterial medial degeneration, we examined MHC expression in SMCs of AAA. Aortic specimens were obtained from patients with slowly progressed AAA (n = 12) and rapidly progressed AAA (n = 5), and compared with normal aortic tissue (n = 3). Immunohistochemical staining was performed for detection of SMemb, SM2, MMP (types 2 and 9) and TIMP (types 1 and 2). Faint SMemb and abundant SM2 were observed in normal aorta, while the balance shifted to SMemb predominance in AAAs. Compared with slowly progressed AAA tissue, rapidly expanded AAA tissue demonstrated marked increases in SMemb expression with suppressed SM2. Predominant SMemb expression indicates presence of phenotypic modulated SMCs and enhanced MMP; while abundant TIMP was seen in mature SMCs expressing SM2. SMemb expression is markedly increased in AAA with MMP enhancement, and a significant imbalance between SMemb and SM2 results in rapid progression of AAA.

Long-term results of flow reversal and thromboexclusion method for thoracic aortic aneurysm.

BACKGROUND: The long-term results of flow reversal and thromboexclusion for the elimination of a thoracic aortic aneurysm were studied. METHODS: We monitored the posttreatment course in 10 patients with a thoracic aortic aneurysm who underwent thromboexclusion between 1981 and 1990. All patients had comorbid factors, such as renal failure, myocardial infarction, or respiratory dysfunction, and the entire descending thoracic aorta was involved in all. One patient with impending rupture underwent permanent occlusion of both the proximal and distal aortas, and the remaining 9 patients underwent proximal aortic occlusion only. RESULTS: Two patients died within 30 days of operation. Postoperative cerebral infarction occurred in 1 patient, possibly as the result of the release of atheroma emboli at the time of permanent clamping. Incomplete paraplegia occurred in 1 patient 15 months postoperatively. Two patients died as the result of comorbid conditions 3 and 39 months after operation; 1 patient died as the result of penetration of the lung by the permanent clamp 12 months after operation. An aortic aneurysm recurred in 4 patients, and 3 of them died of aneurysmal rupture 50,55, and 63 months after operation, respectively. The fourth patient with aneurysmal recurrence underwent reoperation and is alive 124 months postoperatively. Another patient is alive without recurrence 140 months postoperatively. CONCLUSIONS: Because of the postoperative complications and the risk of aneurysm recurrence, the thromboexclusion method should be used only in patients with an infected aneurysm or in those with a severely morbid condition.

Reconstruction with free jejunal autograft after pharyngolaryngoesophagectomy.

Twenty-four patients with hypopharyngeal or cervical esophageal carcinoma were treated surgically. All had squamous cell carcinoma, and none had intrathoracic lymph node involvement by preoperative computed tomography. Endoscopy in 18 patients confirmed there was no intramural spread into the thoracic esophagus. The patients underwent pharyngolaryngoesophagectomy and bilateral modified radical neck dissection. Reconstruction of the cervical esophagus was performed with transplantation of a free jejunal autograft. Postoperative complications included anastomotic leak in 2 patients (8.3%), wound infection in 3 (12.5%), and intussusception in 4 (16.7%). Reconstruction of the cervical esophagus was successful in 23 (95.8%) of the 24 patients. The operative mortality rate was 4.2%, and the 5-year survival rate was 39.7%. We emphasize that pharyngolaryngoesophagectomy followed by transplantation of a free jejunal graft is suitable for cervical esophageal carcinoma or hypopharyngeal carcinoma when the disease is limited to the cervical region.

Bilateral Jejuno-mesenteric flap for reconstruction of complicated pharyngoesophageal defect.

The surgical management of an infectious and fistulous wound with a pharyngoesophageal tumor is one of the greatest challenges for head and neck and plastic surgeons. The free jejunal transfer has been the standard technique for pharyngoesophageal reconstruction, and the free omental flap has been one of the most reliable methods for reconstructing contaminated wounds. A jejuno-mesenteric flap is suitable for such complicated wounds. Pharyngoesophageal defects are reconstructed by the jejunum, and contaminated and heavily irradiated neck wounds are covered with the mesenteric flaps connected with a revascularized jejunum. The technique described here possesses the advantages of both a free jejunal flap and an omentum flap. Therefore, it is a reliable method for reconstructing the pharyngoesophageal defects of complicated wounds.

Graft replacement of the dissecting aneurysm originating in the suprarenal abdominal aorta. A case report.

Spontaneous dissection originating in the suprarenal aorta is very rare. We successfully treated a patient with this type of aneurysm by a safe and reliable operative method. During aortic clamping, the visceral organs were perfused with oxygenated blood. And for reconstruction of visceral arteries, a graft with multiple branches was used. In spite of renal dysfunction before surgery and aortic clamping time extending for 40 minutes, the patient recovered almost uneventfully, and postoperative angiography confirmed good patency of the graft.

Branched graft technique for middle aortic syndrome. Three case reports.

BACKGROUND: Middle aortic syndrome is a rare disease caused by stenosis of the distal thoracic and abdominal aorta involving the visceral and renal arteries. METHODS: We performed reconstructive bypass surgery for three middle aortic syndrome patients. We used magnetic resonance angiography as well as conventional angiography to assess the stenotic vessels. According to these data, branched graft was fabricated preoperatively. We selected Dacron for aortic bypass graft, and ePTFE for the branch graft. In previous reports, branched graft was not applied for the surgery for middle aortic syndrome. RESULTS: Using this branched graft, the clamping time and ischemic time of the organs were shortened. CONCLUSIONS: Using branched graft prefabricated according to accurate preoperative angiographic findings, the reconstructive surgery is thought to proceed more safely.

Bypass grafting for a right proximal subclavian artery pseudoaneurysm patient using a long temporary bypass.

We report an 80-year-old woman, with pseudoaneurysm of the right proximal subclavian artery despite the absence of a history of trauma. On preoperative examinations, the aneurysm involved to the common carotid arteries. A long temporary bypass using a heparin-coated tube from the right femoral artery to the right common carotid artery was created under low dose systemic heparinization. A Dacron bifurcation graft bypassing was then performed successfully. At surgery for right proximal subclavian artery aneurysm, which often involves the right common carotid artery, intraoperative accident or bleeding can induce brain ischemia. A temporary bypass should be prepared. Although the short temporary bypass from the aorta to the right common carotid artery was reported, this carries the risk of complications due to microemboli. The heparin-coated tube provided excellent anti-thrombosis. Inflow cannulation should be placed at the peripheral artery not the aorta.

Saphenous neuralgia and limb edema after femoropopliteal artery by-pass.

One hundred thirty-one limbs of 109 patients who underwent femoropopliteal artery by-pass were studied for postoperative saphenous neuralgia and limb edema. The following factors were analyzed: age, sex, underlying disease (arteriosclerosis obliterans or Buerger's disease), grade of symptoms (Fontaine's classification), presence of diabetes mellitus, the site of distal anastomosis (above or below the knee), vascular graft material (reversed saphenous vein, expanded polytetrafluoroethylene or composite), presence of postoperative hematoma, and levels of serum creatinine and albumin 3 weeks after surgery. To examine limb edema, radioisotope (RI) venography and RI lymphography were performed. Saphenous neuralgia occurred in 22 limbs (16.8%) and limb edema in 27 limbs (20.6%). None of the factors examined was found to be significantly associated with saphenous neuralgia. The risk of developing limb edema was higher in diabetic patients and in patients in whom the distal anastomosis was performed below the knee. Although no case of limb edema was associated with signs of obstruction on RI venogram, 80% of the cases showed lymphatic obstruction on RI lymphograms.

A solitary iliac artery aneurysm caused by Candida infection. Report of a case.

We report a very rare case of an infected aneurysm of solitary common iliac artery by Candida albicans. The patient, a 70 year-old male, had a history of systemic Candidemia infected through intravenous hyperlimentation (i.v.H) catheter 2 years ago. By physical examinations and laboratory data, infectious disease was suspected. Computed tomography showed right hydronephrosis and right solitary common iliac artery aneurysm, and operation was performed with diagnosis of infected aneurysm. The aneurysm was removed with the end of the abdominal aorta, and the arterial blood flow was restored by axillo-bifemoral bypass. Histopathological findings revealed abscess formation around the aneurysm with phlogocytes infiltration in both outer media of aneurysmal wall and vasa vasorum. Candida albicans was found as causative pathogen from resected specimens. This aneurysm is considered to be resulted from surviving candida in vasa vasorum after previous candidemia.

Physiological changes during acute obstruction of the superior vena cava, azygos, and internal thoracic veins in dogs.

PURPOSE: In the surgery for superior vena cava (SVC) reconstruction, the cross-clamping of the SVC may cause brain damage. Experimental study was performed to clarify the safe limit of the clamping time and the appropriate monitoring method during the surgery. METHODS: In anesthetized dogs, the internal thoracic and azygos veins were ligated, and the SVC was clamped for 120 min. Arterial blood pressure, intracranial venous pressure, regional cerebral blood flow, and electroencephalogram were monitored in six dogs. Somatosensory evoked potentials were recorded in one other dog, and in another dog postoperative neurological changes were evaluated for 3 weeks. The brains of the dogs were subjected to the histological examination including tetrazolium stain. RESULTS: The arterial blood pressure decreased and the intracranial venous pressure increased during the clamping. Oscillation of the pressure was noted at 45 to 74 min after clamping. The regional cerebral blood flow was 57.4 ml/100 g/min on average before clamping, and decreased to 15.5 ml/100 g/min at 105 min after clamping. The electroencephalogram demonstrated no pronounced change during clamping, but the amplitude of the somatosensory evoked potentials decreased and the latency was prolonged during clamping. No neurological defect was noted in the dog observed for 3 weeks. All areas of the brain showed staining with the tetrazolium, indicating intact mitochondria. The microscopic findings for the brains included no marked changes. CONCLUSION: The SVC clamping for 120 min was tolerated by the dogs, and the most reliable monitoring method was concluded to be the recording of somatosensory evoked potentials.

Exclusion of internal iliac arterial aneurysm concomitant with abdominal aortic aneurysm repair.

BACKGROUND: To study the long-term outcomes after exclusion of internal iliac arterial aneurysm performed concomitantly with abdominal aortic aneurysm repair in patients with ruptured aortic aneurysm or other high-risk conditions. METHODS: The 31 patients who participated in this study underwent emergency (N = 9) or elective surgery (N = 22). The abdominal aortic aneurysm and the common iliac artery were excluded together with the internal iliac aneurysm in 7 patients. Forty-three (12 bilateral and 19 unilateral) internal iliac aneurysms were excluded: 35 by proximal ligation only, 5 by proximal and distal ligation, and 3 by partial resection of the proximal part of the aneurysm. The platelet count and fibrinogen level were evaluated pre- and postoperatively. Pelvic organ ischemia, classed as ischemic colitis, buttock claudication and sexual dysfunction, was examined. RESULTS: The inferior mesenteric artery was reimplanted in 21 patients. The platelet count dropped significantly postoperatively, but the fibrinogen level increased and no bleeding tendency was noted. Ischemic colitis occurred in 7 patients, resulting in colonic infarction in 2 patients. The operative mortality was 16%, and the postoperative observation periods ranged from 4 days to 217 months (mean, 60 months). The incidence of buttock claudication and sexual dysfunction was 12% and 39%, respectively. The excluded aneurysms were all thrombosed at discharge, and no late rupture was noted. The 5- and 10-year survival rate after surgery was 56% and 51%, respectively. CONCLUSIONS: Exclusion of the internal iliac aneurysm concomitant with abdominal aortic aneurysm repair shows acceptable outcome when performed in patients with high-risk conditions.

Rupture of pseudointima in an implanted vascular prosthesis: immunohistological study of plasminogen activators and matrix metalloproteinases.

We investigated late-onset anastomotic stenosis in an implanted prosthetic graft. Rupture of the pseudointima and hemorrhaging from the vasa vasorum were observed at the border of the collagenous tissue and fibrin layer. An immunohistological study showed that the fibrin layer was positive for tPA, but weakly positive for PAI-1. Some neutrophils and monocyte/macrophages in the fibrin layer were immunostained for tPA, uPA, uPAR, and MMP-1, -2 and -3. Some spindle-shaped cells surrounding the graft were immunostained for uPA, uPAR, MMP-1, -2, -3, -7 and -9, and TIMP-1 and -2. The endothelial cells of some microvessels were positive for MMP-1 and -2, and tPA. Some multi-nucleated giant cells were immunostained for MMP-7 and-9, tPA, PAI-1, uPA, and uPAR. Overexpressed MMPs and PAs possibly caused instability of the pseudointima.

Pathological study of implanted dacron grafts in surgery of thoracic aortic aneurysms.

We studied woven dacron grafts that had been implanted in 5 patients of thoracic aortic aneurysms. In addition to usual stains, immunocytochemical analysis was performed using monoclonal antibodies to the muscle actin (HHF35) and to the macrophage (HAM56). In the graft of 5 and 24 days implantation, thin thrombi containing red cells and fibrin covered the luminal surface in some places, and macrophages came into the thrombi. In the grafts of 12 and 38 months implantation, intimal hyperplasia of 0.2-1.0 mm thickness was seen at the anastomotic segments with the accumulation of smooth muscle cells. Except for the anastomotic segments, connective tissue matrix with collagen fibers covered the luminal surface, and in some hollows of the graft crimps, old and fresh thombi were seen in layers. Organizing thrombi of 1.0 mm thickness attached where the branched graft was anastomosed to the main graft. Anastomotic intimal hyperplasia in the graft of 148 month implantation was 0.4-1.0 mm in thickness and 5-10 mm in length, and aside from the intimal hyperplasia, an endothelial lining did not cover the luminal surface of the graft. In the thoracic aorta, woven dacron graft implantation did not cause a critical stenosis with the intimal hyperplasia. The mural thrombi formed at the branched graft, however, threatened to result in graft occlusion or embolization.

Comparison of cilostazol with warfarin as antithrombotic therapy after femoro-popliteal bypass surgery using an ePTFE graft.

BACKGROUND: Cilostazol (6-[4-(1-cyclohexyl-1H-tetrazol-5-yl)butoxy]-3,4- dihydro-2(1H)-quinolinone) is a new antiplatelet agent with a vasodilating action. The purpose of this study was comparison of cilostazol with warfarin as antithrombotic therapy after femoro-popliteal bypass surgery using an expanded polytetrafluorethylene (ePTFE) graft. EXPERIMENTAL DESIGN: This report is a retrospective study and the patients were followed up for five years. SETTING: Outpatients of university hospital. METHODS: Sixteen arteriosclerosis obliterans patients, who were diagnosed as having only superficial femoral artery stenosis or occlusion, underwent femoro-popliteal (above the knee) bypass using an ePTFE graft 6 mm in diameter. Cilostazol (150-200 mg/day) was administered to 6 cases (9 bypasses), and warfarin (prothrombin time was controlled to 15-25%.) was administered to 10 cases (14 bypasses). RESULTS: No clinically characteristic differences were found between the two groups. The cumulative 1-, 3-, and 5-year primary and secondary graft patency rates were 69% and 80%, 69% and 80%, and, 69% and 80% in the cilostazol group, vs 61% and 91%, 51% and 91%, and, 51% and 91% in the warfarin group, respectively. These differences were not significant (p < 0.05). No hemorrhage complications were observed in the cilostazol group. The management of cilostazol administration was safe and simple. CONCLUSIONS: Although the number of cases was small in this study, cilostazol was considered to be as effective as warfarin and suitable for the postoperative antithrombotic therapy after the ePTFE bypass surgery.

Distortion of the radial artery by a mucinous cyst. Case reports.

Three cases of mucinous cyst situated close to the radial artery are reported. The patients complained of pain, a throbbing mass, or both at the wrist. Colour Doppler sonography showed distortion of the radial artery by the cyst in all three patients. In one patient the cyst was connected to a synovial sac by a pedicle, in another it was adherent to the radial artery but was identified histopathologically as a simple ganglion, and in the last patient a branch of the radial artery was involved in the cyst, which was identified histopathologically as an adventitial cyst. Mucinous cysts enlarge when subjected to mechanical stress. Excision is recommended for cysts that distort the radial artery.

[Treatment and prognosis of renal cell carcinoma extending into the inferior vena cava].

Out of 173 patients with renal cell carcinoma diagnosed at our department between January 1984 and December 1994, 9 (5.2%) had an inferior vena caval tumor thrombus. They consisted of 6 men and 3 women between 43 and 74 years old with a mean age of 59.8 years. The tumors were on the right and left sides in 5 and 4 patients, respectively. According to the Novick's classification, 2, 1, 4 and 2 patients had level 1 (perirenal), level 2 (infrahepatic), level 3 (intrahepatic) and level 4 (suprahepatic) tumors, respectively. Five patients without distant metastases underwent nephrectomy and removal of the vena caval tumor thrombus. Although renal tumors and vena caval tumor thrombi were completely resected in all of the 5, 4 died of disease within 3 years. Only 1 patient without tumor invasion into the inferior vena caval wall survived over 5 years without disease. Since surgical treatment is the sole radical method for renal cell carcinoma, surgery is recommended for the patients even with a vena caval tumor thrombus unless there are metastases.

[A case of renal cell carcinoma extending into the inferior vena cava in a long-term hemodialysis patient].

We report a case of left renal cell carcinoma extending into the inferior vena cava associated with the acquired cystic disease of the kidney (ACDK). The patient was a 46-year-old man, who had been treated with hemodialysis for 12 years. In November 1992, ACDK was observed on computed tomography (CT) for routine check up, but no tumorous lesions were detected. He noticed bleeding from the urethra in May 1994. CT and magnetic resonance imaging (MRI) revealed left renal tumor with intrahepatic vena caval tumor thrombus. There were no findings of distant metastasis. Left radical nephrectomy and partial removal of vena cava were performed. Histopathologically, renal cell carcinoma, pT3b, pN0, stage III was diagnosed.

[Brain dysfunction after operation of aortic arch aneurysm].

Postoperative brain dysfunction was studied for 18 patients who survived more than 30 days after operations of aortic arch aneurysms. The operative procedures were graft replacement in 12 patients, resection with direct or patch closure in 3, and thromboexclusion in 3. Except for thromboexclusion, adjuncts were used: temporary bypass in 1, partial EPC (extracorporeal circulation) in 2, and selective cerebral perfusion during EPC in 12. As for intra-operative monitoring, the temporal artery blood pressures were more than 50 mmHg in all, but the electroencephalogram changed to flat wave just after clamping the aorta in one patient. Postoperative brain dysfunction occurred in 5 patients, including temporary loss of consciousness in 2, lasting loss of consciousness in 1, and paralysis with loss of consciousness in 2. Postoperative brain dysfunction occurred more often in old aged men with atherosclerotic aneurysms. Patients with temporary brain dysfunction had no remarkable change in CT scan, but patients with lasting brain dysfunction had low density areas. It is recommended to prevent this complication as follows: 1) pre-operative evaluation of cerebral vascular disorders, 2) gentle maneuver of atherosclerotic lesions, 3) bilateral cerebral perfusions and intra-operative monitorings, 4) intensive perioperative care of circulation and respiration.

[Strategy for cerebral protection during aortic arch replacement].

We analyzed cerebral protection of twenty-five patients, 11 of whom underwent ascending-arch aortic replacement and 14 underwent aortic arch replacement, supported with cardiopulmonary bypass. Twenty of patients underwent selective cerebral perfusion (SCP) with moderate hypothermic circulatory support; 12 of single SCP, 8 of double SCPs. Major arch branch reconstruction were performed with 11 patients; 3 of triple branches, 2 of double branches and 6 of single branch reconstruction. Cerebral impairment was found in 7 patients (25%) with SCP; 3 of them died of low output syndrome and major bleeding during perioperative period. Four of 17 patients, who survived more than one month, showed cerebral infarction in 2 patients and temporary neurological deficit in 2 patients. Our strategies for cerebral protection are (1) careful cerebral four vessels study, (2) SCP with perfusion pressure more than 40 mmHg and flow rate of 7-10 ml/kg/min under moderate hypothermia, (3) bilaterally double branches perfusion minimally for arch replacement, (4) intensive cerebral monitoring from multiple aspect, (5) pharmacological support with barbiturate or aprotinin, (6) gentle maneuver and reliable major branch cannulation to prevent debris embolism.