[Covering with absorbable mesh for treatment of spontaneous pneumothorax by thoracoscopic surgery].

It became a severe problem that the rate of recurrence after video-assisted thoracoscopic surgery (VATS) for spontaneous pneumothorax was higher than open surgery. It has been reported that the newly bullae formation near the stapled line was one of reasons. From December 1997, We have performed the method of covering the stapled line with both adsorbable mesh and the fibrin glue. The additional utility of the mesh was assessed by comparing with the method using fibrin glue only for the reinforcement of the stapled line. Rate of recurrence is 2.1% in the mesh group and 14.6% in the only fibrin glue group. These results suggested usefulness of covering with absorbable mesh.

The effect of combination splenectomy and low-dose FK506 therapy on graft survival after liver allograft transplantation in rats.

The effect of splenectomy on allograft survival was investigated using orthotopic liver transplantation in a rat experimental model (ACI rat liver grafted to LEW rat). Control rats without any immunosuppressive treatment died, on average, 10.4 +/- 1.4 days after operation. Splenectomy alone somewhat prolonged the survival (13.4 +/- 2.0 days), and low-dose FK506 therapy moderately prolonged it (22.7 +/- 7 days). The graft survival period was significantly prolonged (39.7 +/- 6.3 days) when them two treatments were combined. The elevation of cytotoxic antiallograft antibodies was suppressed by splenectomy but not by low-dose FK506 therapy. The development of jaundice was moderately suppressed by FK506 but not by splenectomy. There was no difference between the pattern of body weight decline in either of them two groups and that in control rats. When these two treatments were combined at the same time, the elevation of cytotoxic antibodies, development of jaundice and decline of body weight were suppressed. These data indicate that B cells play an important role in the acute rejection of the rat liver allograft at least partially via production of cytotoxic antiallograft antibody. Splenectomy or other immunosuppressive methods affecting B cells can be a supplement for immunosuppression when using reduced-dose FK506.

Sequential percutaneous microwave coagulation therapy for liver tumor.

BACKGROUND: Percutaneous microwave coagulation therapy (PMCT) is effective for small liver tumors. To enhance the radicality of PMCT, we developed a sequential coagulation technique. METHODS: After inserting the first guide-needle under sonography, multiple needles were placed through a disk-type introducer that was devised to guide needle puncture at regular intervals, and microwaves were irradiated. Six patients, including 4 with hepatocellular carcinoma and 2 with liver metastasis, underwent this technique for tumors of 15 to 80 mm in diameter. RESULTS: This technique can coagulate an area up to 60 mm in diameter in one session. Insertion of multiple needles, ranging from 2 to 11, was successful without complications. Three patients undergoing curative PMCT developed no tumor recurrence. The other 3 received incomplete PMCT due to the large size and location of the tumor. CONCLUSIONS: This preliminary study indicates the efficacy of this technique to facilitate and secure PMCT in selected patients with liver tumors.

Enteric absorption of FK 506: estimation by a block liver perfusion technique in rats.

This perfusion model enables a pharmacokinetic study of enteral absorption and hepatic metabolic rate simultaneously. FK 506 is absorbed mainly via the proximal small intestine and metabolized rapidly by the liver during single passage. These results may lead to further analyses of absorption and metabolism of FK 506 under various conditions.

Effect of coronary artery bypass grafting on native coronary artery stenosis. Comparison of internal thoracic artery and saphenous vein grafts.

BACKGROUND: The purpose of this study was to investigate the influence of coronary artery bypass grafting on the degree of stenosis of the native coronary artery. EXPERIMENTAL DESIGN: retrospective data analysis. SETTING: University hospital. PATIENTS: consecutive patients undergoing coronary artery bypass grafting (n=52). Bypasses using internal thoracic artery grafts (n=26) and saphenous vein grafts (n=37) to incompletely occluded coronary arteries were studied. INTERVENTIONS: coronary artery bypass grafting using internal thoracic artery or saphenous vein grafts. MEASURES: stenosis of the native coronary artery on angiography. RESULTS: Three recipient coronary arteries bypassed with internal thoracic artery grafts (12%) and 14 recipient coronary arteries bypassed with saphenous vein grafts (38%) showed progression of narrowing (p=0.024). Two recipient coronary arteries bypassed with internal thoracic artery grafts (8%) and 13 recipient coronary arteries bypassed with saphenous vein grafts (35%) showed total occlusion (p=0.016). Hypertension, hyperlipidemia, diabetes mellitus, and smoking history did not correlate with progression of stenosis of the native coronary arteries. Graft flow measured during surgery in the saphenous vein grafts was not significantly different between the group that exhibited progression of the native stenosis and the group that did not. CONCLUSIONS: Coronary artery bypass grafting with saphenous vein grafts may result in progression of stenosis of the recipient coronary artery. This is less likely after coronary artery bypass grafting with internal thoracic artery grafts. This difference may be due to the ability of the pedicled internal thoracic artery graft to regulate flow. Thus competitive flow in the native coronary artery is minimized. This has significant clinical implications.

Intrahepatic cholangiocarcinoma associated with hepatolithiasis.

BACKGROUND/AIMS: Despite sporadic reports of cholangiocarcinoma (CC) associated with hepatolithiasis, this entity has not been widely studied. The purpose of this study was to clarify its clinical features and optimal management by studying the 10 patients we have encountered with this condition. METHODOLOGY: There were six women and four men, with a mean age of 61 years. The patients underwent anatomic hepatic resection (n = 5) or biliary drainage (n = 5). The clinical features and results of surgery were studied. RESULTS: The characteristic findings included tumor-related symptoms, irregular ductal stricture or obstruction, and hepatic lobar atrophy with a whitish mass. The tumor and stones were located in the same hepatic lobe. Eight patients had advanced CC with periductal tumor infiltration, while two had in situ carcinoma characterized by intraductal tumor growth, papillary adenocarcinoma, and mucin-hypersecretion. Seven patients died within 6 months after surgery, while the remaining three, including the two with in situ carcinomas and one with an involved node at the dissected hilum, are alive more than 4 years after anatomic hepatic resection. CONCLUSIONS: Recognition of the clinical features of CC associated with hepatolithiasis, which were clarified in this study, is important in treating patients with hepatolithiasis. An anatomic hepatic resection with hilar nodal dissection offers long-term survival in selected patients.

Laparoscopic hepatic resection: a new and safe procedure by abdominal wall lifting method.

HCC is well known for its high incidence of intrahepatic tumor recurrence and many patients suffering from them, usually undergo further treatments, such as PEI, TAE, MCNT or hepatic resection. However, conventional hepatic resection by large skin incision causes severe intraabdominal adhesions, which disturb US examination and further treatments. The aim of the laparoscopic procedure is to prevent intraabdominal adhesions. This is a study of the feasibility of laparoscopic hepatic resection without CO2 pneumoperitoneum, which is not yet popular, as a safe and effective procedure. The patient in this study had a solitary HCC in the lateral segment. Mobilization of the lateral segment, dissections of the left hepatic artery and portal venous branches, i.e. P2 and P3, were performed under CO2 gas insufflation. However, to avoid CO2 gas embolism, further procedures, including parenchymal compression and hepatic venous dissection, were performed using the abdominal wall lifting method without pneumoperitoneum. The patient could eat on the second postoperative day and had an uneventful postoperative recovery and was discharged from the hospital 13 days after surgery. Hospital stay was shorter than conventional hepatic resections with large skin incisions. The importance of this procedure lies in that it is not only a minimally invasive procedure, but also provides us with the possibilities of further treatments, including PEI and re-hepatic resection.

Results from coronary artery bypass surgery combined abdominal aortic aneurysm repair.

OBJECTIVE: Complication from coronary artery disease is a major cause of mortality and morbidity in patients undergoing abdominal aortic aneurysm repair. We report our results from coronary artery bypass surgery performed in combination with abdominal aortic aneurysm repair in patients with coronary artery disease and abdominal aortic aneurysm, each being an indication for an emergency operation. METHODS: Seventeen patients underwent combined coronary artery bypass surgery and abdominal aortic aneurysm repair. The mean age of the patients was 67.6 +/- 5.2 years. Four had left main disease, 8 patients had triple-vessel disease, and 12 had a prior myocardial infarction. The average left ventricular ejection fraction was 0.49 +/- 0.13. The average abdominal aortic aneurysm diameter was 6.2 +/- 1.0 cm (range 4.5-8.0 cm). Thirteen patients underwent coronary artery bypass surgery followed by abdominal aortic aneurysm repair after discontinuation of cardiopulmonary bypass. In the remaining four patients, including one patient with severe left ventricular dysfunction, cardiopulmonary bypass was continued as a circulatory assist until the abdominal aortic aneurysm repair was completed. The left internal thoracic artery was used in 14 patients, and the right internal thoracic artery in one patient. RESULTS: Postoperative surgical complications occurred in three patients (bleeding in one patient requiring reoperation, abdominal subcutaneous wound infection in another and transient neural disorder in the others). There were no surgical or in-hospital death. There was no late cardiac complication and no late cardiac death after a mean of 29 months follow-up. CONCLUSIONS: We concluded that combined surgery was reasonable for selected patients with combined coronary artery disease and abdominal aortic aneurysm, each of which is an indication for an urgent operation. The aortic aneurysm repair during cardiopulmonary bypass for patients with severe left ventricular dysfunction was safe and effective.

[Surgical treatment for giant ascending aorta-arch aneurysm coexisted with DeBakey type II dissection on elderly women: report of a case].

A 78-year-old woman was admitted to our hospital after computed tomography (CT) had revealed in her the presence of a giant ascending aorta-arch aneurysm. This aneurysm was about 8 cm in diameter and associated with DeBakey type II dissection. Aortography showed the same condition as the CT view with the entry on the ascending aorta. The ascending aortaarch was replaced with a Hemashield 24 mm, by using deep-hypothermic selective cerebral perfusion and the open distal method. There were no complications during her peripostoperative state and no evidence of leakage and remnant dissection on CT and aortography. This is a rare case in which thoracic aortic aneurysm coexisted with dissection. In this case of severe atherosclerosis, deep-hypothermic selective cerebral perfusion and the open distal method provided effective treatment.

[A simultaneous operation on coronary artery disease and abdominal aortic aneurysm during extracorporeal circulation in patient with impaired left ventricular function].

A 74-year-old man had an previous antero-septal and inferior myocardial infarction and an abdominal aortic aneurysm (AAA) 48 mm in diameter. Coronary angiography showed obstruction of the left anterior descending artery and of the right coronary artery, and 95% stenosis of the circumflex artery. The value of an ejection fraction of the left ventricle was 33%, measured by left venticulography. CABG and replacement of the aneurysm were performed simultaneously, because of the necessity of an intra-aortic balloon pumping (IABP) due to the impaired left ventricular function. First, CABG was performed under cardiac arrest. After declamping the ascending aorta, subsequently, replacement of AAA was performed while extracorporeal circulation (ECC) assisted heart beating. Weaning from ECC was smooth, and the operation was successful without using IABP. The patient was discharged 32 days after the operation. Consequently, cardiopulmonary bypass during AAA operation could decrease heart loads when hemodynamic states change in aortic clamping or after declamping. A simultaneous operation of CABG and AAA using ECC is safe and effective for impaired left ventricular function.

[Successful removal of an infected pacemaker electrode adhered to the tricuspid valve].

A 77-year-old male suffered from pacemaker lead infection with pacing failure. Because he had a severe fever, we performed an interventional removal procedure with the help of a lead removal kit. However, the tip of the lead could not be withdrawn via the right internal jugular vein because it adhered tightly to the tricuspid valve. Two days later, we proceeded with an open removal procedure under cardiopulmonary bypass. The lead could be removed without any complication, and no inflammation was observed postoperatively. We report the case and discuss the indications and limitations of both the interventional and open methods.

[A case of gastric cancer with recurrent bone metastases successfully treated with induced hypertension chemotherapy using cisplatin].

A sixty-eight-year-old female with bone metastases from gastric cancer successfully treated with induced hypertension chemotherapy using cisplatin is reported. She had undergone R2 curative subtotal gastrectomy in June 1985, and had orally taken tegafur 600 mg/day and then changed to doxifluridine 800 mg/day as postoperative adjuvant chemotherapy. Five months after the operation she had back pains and both 99mTc-MDP and 67Ga-citrate scintigram showed L1 vertebra and rib bone metastasis. Induced hypertension chemotherapy using cisplatin was then intermittently performed from January 1986 to September 1990, a single course of which was 25 mg/body div x 2/week for serial 4 weeks; a total of seven courses were carried out and consequently the total volume of the administered cisplatin reached 1,100 mg. Neither medullar nor renal toxicities were observed, but mild gastrointestinal symptoms were noted. The patient no longer has back pains, and no signs of bone metastases were seen on both scintigrams for two years and eight months from December 1988 to August 1991. This case is very rare because her bone metastases were successfully treated with induced hypertension chemotherapy using cisplatin. However, metastatic bone tumors from gastric cancer usually resist any treatments. It is expected that the successfully treated patients even with bone metastasis will be increasingly reported from now as various new approaches including induced hypertension chemotherapy are introduced.

The functional role of 55- and 75-kDa tumour necrosis factor receptors in human polymorphonuclear cells in vitro.

The expression and biological role of 55- and 75-kDa tumour necrosis factor-receptors (TNF-RI and TNF-RII) in human polymorphonuclear cells (PMN) in vitro were studied using agonistic rabbit polyclonal anti-TNF-R antibodies. PMN express TNF-RII predominantly, and release the superoxide anion on stimulation by human recombinant lymphotoxin (LT) in vitro. Anti-TNF-RI but not anti-TNF-RII antibody stimulated the superoxide release mimicking LT. Release of the elastase from azurophilic granule of PMN was augmented by LT in vitro. Anti-TNF-RI but not anti-TNF-RII antibody augmented the elastase release. Release of the lactoferrin from the specific granules of PMN was enhanced by LT in vitro. Anti-TNF-RI but not anti-TNF-RII antibody augmented the elastase release. Release of the lactoferrin from the specific granules of PMN was enhanced by LT in vitro. Anti-TNF-RI but not anti-TNF-RII antibody enhanced the lactoferrin release. These antibodies failed to co-stimulate these PMN functions. The adhesiveness of PMN to a plastic plate and the expression of Mac-1 on PMN were upregulated by LT in vitro. Anti-TNF-RI but not anti-TNF-RII antibody upregulated the adhesiveness and Mac-1 expression of PMN mimicking LT. Though anti-TNF-RII antibody by itself did not alter the adhesiveness and marginally suppressed Mac-1 expression, it maintained the adhesiveness and adhesion molecule expression in the presence of anti-TNF-RI antibody. In summary, PMN predominantly express TNF-RII, the signalling of LT (and TNF) in PMN is mediated mainly by TNF-RI, and the adhesion function can be modulated also by TNF-RII when TNF-RI is stimulated.

Identification and biochemical characterization of human plasma neutrophil inhibitor in vitro.

In this study, assessment by a flow cytometric method using dichlorhydroxy fluorescin diacetate (DCFADH) in vitro revealed that human peripheral blood inhibits the production of active oxygen species by human peripheral neutrophils. It was also revealed that among the blood components, the plasma fraction inhibits active oxygen production most strongly. This plasma inhibitory activity was dose-dependent. Human serum also exerted an inhibitory activity; however, its activity was only one-third that of plasma. Moreover, when HL-60 human promyelocytic leukemic cells, with or without differentiation into the neutrophils by culturing with dimethyl sulfoxide (DMSO), active oxygen, which was also inhibited by plasma, was produced. Heat inactivation of the plasma did not alter the inhibitory activity, and gel filtration analysis showed that the peak activity was associated with a molecular mass of 70,000. The results of this study indicate that human plasma contains one or more substances that inhibit the active oxygen production of neutrophils, which may play an important role in inhibiting unneeded neutrophil activation in the bloodstream.

Long-term results of hepatic resection for hepatolithiasis.

Long-term results of hepatic resection for hepatolithiasis in 34 patients having intrahepatic biliary strictures were studied. The left lateral and the right posterior segmental ducts were commonly and often simultaneously involved. Fourteen patients had multiple segmental involvement. Hepatic resection included left sided resection (n = 27), right sided resection (n = 6), and repeated bilateral resection (n = 1). Seven patients had biliary tumors: 3 cholangiocarcinomas, 2 gall bladder cancers, 1 cystadenocarcinoma, and 1 dysplasia of intrahepatic ducts. Nineteen patients received bilioenteric anastomosis. Retained stones and recurrent stones developed in 3 and 4 patients, respectively. Twenty-six patients had no remaining symptoms; 2 died of operative complication or cholangiocarcinoma; 6 presented symptoms caused by retained stones (n = 2), recurrent stones (n = 2), bile stasis (n = 1), or neuralgia (n = 1). In 4 of the 6 patients, unrelieved posterior duct strictures caused the symptoms. With a mean follow-up period of 4.5 years, 30 patients are symptoms free, and 27 are stone free. In patients with right lobar or bilobar type, intra- and extrahepatic type, and confluence strictures, bilioenteric anastomosis is required. Hepatic resection is a rational treatment for hepatolithiasis, however, meticulous management of biliary tract abnormalities, particularly the posterior duct stricture, is mandatory.

Prolongation of rat liver graft survival by splenectomy combined with low dose FK506 therapy.

The effects of low dose FK506 therapy (0.1 mg/ kg/day x 1 day) on graft survivals were analyzed, and the feasibility of splenectomy was assessed. ACI strain liver grafts were orthotopically implanted into LEW male rat recipients. In the control group, the survival period was 10.4 +/- 1.4 days. In the group treated with splenectomy, the survival period was 13.4 +/- 2.0 days. In the groups with low dose FK506 therapy, the survival periods were 22.7 +/- 6.7 and 39.7 +/- 6.3 days with or without splenectomy, respectively. Rats in the group with average dose FK506 (1.0 mg/kg/day x 7 days) survived more than 100 days. In summary, the effect of low dose FK506 therapy was relatively limited. Splenectomy by itself was marginally effective; however, this effect was enhanced when combined with low dose FK506 therapy.