The surgical treatment of a thoracoabdominal aortic aneurysm with total preservation of the intercostal and lumbar arteries using a permanent bypass technique--a case report

A 44 year old man underwent successful surgery for a thoracoabdominal aortic aneurysm using a permanent bypass graft and aneurysmoplasty. This technique reduces visceral ischemia to a minimum and the aneurysmoplasty, through total preservation of the intercostal and lumbar arteries, can avoid paraplegia caused by spinal cord ischemia. Our technique is recommended as it can be performed easily, safely, and effectively without heparinization, temporary shunts or bypass perfusion.

Left ventricular rupture following mitral valve replacement--a report of two cases

Left ventricular rupture is a rare and usually fatal complication of mitral valve replacement, and we report herein, 2 successfully treated cases of type III left ventricular rupture. The laceration in the posterior ventricular wall was repaired by a wide buttressed mattress suture with teflon felt belts on either side, then covered with Oxycel and fibrin glue or a large patch and fibrin glue. Naturally, the operation must be performed carefully and gently, however, the most important etiologic factor of left ventricular rupture is the extremely friable myocardium due to aging and a long history of heart disease. Utilizing fibrin glue for successfully repairing the rupture proved very effective.

[Evaluation of myocardial protection with DBcAMP in crystalloid cardioplegic solutions]

The potential for myocardial protection during cardiac operation was evaluated by adding Dibutyryl cyclic AMP (DBcAMP) to the crystalloid cardioplegic solutions. We have compared the cold crystalloid cardioplegia with DBcAMP (Group D n = 15) and without DBcAMP (Group n = 20) in patients undergoing cardiac operation. In hemodynamics, both groups were no difference before and after operation. CPK and CPK-MB was significantly (p < 0.01) high level after cardiopulmonary bypass (CPB) in group C. Myoglobin was also high value after CBP in group C, but not significant. Myocardial oxygen extraction rate and coronary blood PCO2 release were similar change in both groups. Insulin/glucose ratio was high level during and after CBP in group D. Myocardial lactate/pyruvate ratio was very high level after CBP in group C without significant difference. We consider that the cardioplegic solution with DBcAMP is effectual for the myocardial metabolism and preservation of myocardial damage during cardiac arrest.

[The use of the aortic bypass in the surgery of the esophageal carcinoma invading the thoracic aorta]

During the period from 1980 to 1989, five patients with carcinoma of the esophagus invading the thoracic aorta were treated by resection of the involved aortic segment combined with esophagectomy. Various types of arterial bypass were applied in order to provide blood flow to the distal aorta during aortic clamping. These included one permanent aorto-aortic bypass, two axillo-femoral bypass and one subclavian-aortic bypass. There was one death within 30 days and one developed paresis. These arterial bypasses are beneficial to esophageal surgery because it is technically easy and it does not necessitate systemic heparinization which maybe associated with profuse bleeding.

[Three staged operation for aneurysms of abdominal thoracoabdominal and aortic arch]

Sixty-one year old man, who was diagnosed as abdominal and thoracoabdominal aortic aneurysms, underwent only Y graft replacement for abdominal aortic aneurysm. Two years later, the graft replacement was carried out for the thoracoabdominal aortic aneurysm. Three years after the second operation, graft replacement of the aortic arch was performed under separate cerebral perfusion technique as a supportive measure, because of the gradual growth of the arch aneurysm. We recommend the distal aneurysm (abdominal aortic aneurysm) should be removed first to prevent the detachment of the thrombus in the aneurysm during proximal operation.

Abdominal aortic aneurysm in a 3-year-old child: a case report and review of the Japanese-language literature

A case of abdominal aortic aneurysm associated with renovascular hypertension in a 3-year-old boy is reported. The child was treated by resection of the aneurysm and replacement with a 12 mm polyester (Dacron) bifurcated graft. The cause of the aneurysm was not revealed by clinical and pathologic examination. In addition to the case report, the Japanese-language literature is reviewed. The most frequently reported etiologic factor was Kawasaki disease; we could not find any evidence of connective-tissue disorder as a cause for abdominal aortic aneurysms occurring in children.

Granulocytosis associated with malignant neoplasms: a clinicopathologic study and demonstration of colony-stimulating activity in tumor extracts

We studied seven cases of malignant neoplasms, taken from various sites in the body, that were associated with marked granulocytosis. The seven cases were characterized clinically by marked granulocytosis with mature neutrophils, nonspecific inflammatory signs, and a rapid and progressive fatal course of the disease. The elevation of granulocyte count generally paralleled the increase in tumor size. Postmortem examination revealed no evidence of extensive bone marrow metastases or significant suppuration in any case. The bone marrows showed varying degrees of granulocytic hyperplasia with or without a shift to the left in the maturation series. Erythroid cell hyperplasia was observed in some cases, and in one instance there was an increase in immature eosinophils. The spleen showed various degrees of infiltration by neutrophils, from minimal to extremely marked; some spleens had foci of extramedullary hemopoiesis. Colony-stimulating activity was demonstrated in tumor extracts from three of these cases and from the serum in another case. Thus, it is suggested that marked granulocytosis in these patients was caused, at least in part, by colony-stimulating factor produced by the neoplastic cells.

[Role and significance of extended operation in the treatment of stage IV carcinoma of the esophagus]

A total of 106 cases of esophageal cancers treated in our hospital between Jan. 1980 and Jan. 1989 were studied to evaluate the role and significance of extended surgical resection in the treatment of the stage IV patients with T3 tumors. Of those treated were included six patients of stage 0, four of stage II, twenty-nine of stage III, and fifty-two of stage IV. Resectability rate was 82.1%, direct death rate was 8.0%. An overall one-year and three-year survival rate were 54.0% and 21.8%, and those of stage IV were 26.6% and 6.4% respectively. For thirty-one of the 52 patients with T3 tumor, combined radical resection of the structures were performed, with a mortality rate of 12.9%, and a mean survival period of 720.2 days for n0, 239.5 days for n2 (+) and 299.4 days for n3-4 (+). Mean survival of the patients without combined resection of the involved structures were 465 days(n0), 156 days(n2) and 236 days(n3-4) respectively. The organs resected included the trachea(17), thoracic aorta(7), carotid artery(4), pericardium(4), lung(3) and so on. It is concluded that improved survival for even advanced T3 carcinomas especially without lymph nodes metastasis might be obtained by the combined radical resection of the involved neighboring structures.

[Bypass operation adaptable to stature increase in child with atypical coarctation of the aorta]

A 9-year-old girl was admitted with hypertension and severe congestive heart failure. Upon physical examination, a discrepancy of blood pressure between arm and leg was noted. Aortography revealed narrowing about 5 cm in length at the midportion of the descending thoracic aorta. Bypass operation of the narrow segment was performed under mild hypothermia with the diagnosis of atypical coarctation of the aorta. It was supposed that the patient might outgrow the graft and the graft would become too small for grown-up patient in diameter and length, then the haemodynamics would become less satisfactory and too much tension on the suture line would occur. A woven Dacron graft, 10 mm in diameter, 15 cm in length, was anastomosed proximally and distally to the coarcted segment at a distance of about 6 cm. So, the graft was disposed in a C-shaped configuration. It was expected that the arch of the graft would open more widely with increase of her stature, even if the graft does not increase in length. She has been followed for twelve years. Hypertension of upper extremity and arm-to-leg gradients of the systolic blood pressure were recognized from two years after the operation, particularly with exercise. However, cardiomegaly and left ventricular hypertrophy in ECG were improved. She appears to have been developing normally with no cardiac symptoms. Estimating from angiography, the distance between proximal and distal anastomoses stretched about 2 cm during the period of rapid growth, though calcification of the graft had been seen from four years after the operation, perhaps due to increased calcium turnover in childhood.

[Clinical examinations of thymic abnormalities and significance of thymectomy in the patients with autoimmune disease]

Results and significance of thymectomy in 427 patients with autoimmune disease, which include myasthenia gravis, ulcerative colitis. Behçet's syndrome and others, were studied. Preoperative pneumomediastinography was useful to delineate the outline of the nontumorous thymus and small "latent thymoma". The thymus was almost always successfully removed by our procedure "thymectomy via the suprasternal notch" (Method I), but the procedure combined with dissection through a parasternal incision (Method II) was frequently performed. Method II has been routinely adopted since 1976. Thymectomy was performed on a series of 180 patients with myasthenia gravis associated with nontumorous thymic abnormalities. In the resected thymuses, lymphoid follicle formations, which are often encountered in other autoimmune diseases, were found in 74% of cases. Follow-up observation, ranging 2 to 17 years after surgery, revealed complete recovery and significant improvement in 100 (75%) out of 133 patients with nontumorous thymic abnormalities. Thymectomy was also performed in 44 myasthenia gravis patients with thymoma, including 13 small "latent thymoma". Seventy-seven thymectomized patients with ulcerative colitis were also studied, and in these resected thymuses lymphoid follicle formations were fond in 45%. Follow-up observation revealed 84% inactive condition (counted by patient year) after thymectomy compared with 50% before operation. In the patients with Behçet's syndrome, recurrence and progression of skin, oral and genital lesions were markedly suppressed after thymectomy.

Use of a new stapling instrument for permanent occlusion of the aorta in the surgical procedure for thromboexclusion

Permanent aortic occlusion is required in the surgical procedures for the flow reversal and thromboexclusion technique and also for the permanent exclusion of aneurysms of the thoracic aorta. We have designed a stapling instrument for the permanent occlusion of the aorta and have used it in 5 patients with aortic dissections and 2 patients with aneurysms of the thoracic aorta. This report describes our newly designed surgical stapler for the closure of the aorta with 2 case reports.

[A simultaneous operation of closure of multiple congenital coronary artery-pulmonary artery fistulas and aortocoronary bypass grafting--a case report]

A 59-year-old male was admitted because of severe chest pain and diagnosed as inferior myocardial infarction by ECG and enzymologically, who had a Levine grade II continuous murmur in the left second intercostal space at the left sternal border. Cardiac catheterization revealed a 8% left to right shunt at pulmonary artery. Selective coronary cineangiography revealed left anterior descending-to-main pulmonary artery and left circumflex-to-main pulmonary artery fistulas, and severe atherosclerotic stenosis at right coronary and left anterior descending arteries. Operation was performed simultaneously, closure of two drainage orifices of the fistulous vessels through pulmonary arteriotomy and aortocoronary bypass grafting to left anterior descending under cardiopulmonary bypass. The postoperative course was uneventful, and the murmur was disappeared.

[Successful surgical treatment of incomplete type IB2 cor triatriatum (absent left innominate vein) with coronary sinus atrial septal defect]

The combination of type IB2 cor triatriatum and coronary sinus ASD is very rare in congenital heart condition. Up to present, only one case of IB2 cor triatriatum and thirteen cases of coronary sinus ASD were reported in Japan. In this combination, we have presented the first successful surgical treatment for type IB2 cor triatriatum (Lucas-Schmidt's classification), absent left innominate vein and coronary sinus ASD. The patient was a 52-year-old female admitted with chronic dyspnea. Echocardiography and cardiac catheterization revealed ASD, severe mitral regurgitation, cor triatriatum, left SVC connected to left atrium (accessory chamber) and absent coronary sinus. Under cardiopulmonary bypass she underwent surgical treatment which consisted of a resection of the intra-left-atrial diaphragm, closure of ASD with patch, mitral valve replacement with Omnicarbon #29 valve and ligation of left SVC. Her postoperative course was uneventful.

[Clinical studies of cefpodoxime proxetil in respiratory tract infections]

Twelve patients with respiratory tract infections were treated with cefpodoxime proxetil (CS-807, CPDX-PR), a new cephem antibiotic. It was given orally at a dose of 200 mg 2 times a day for 4 approximately 15 days. Its clinical effects were evaluated as excellent in 1 case, good in 9 cases and poor in 2 cases. The efficacy rate was 83.3%. Its bacteriological effects were evaluated as eradication in 5 strains and decrement in 1 strain. The eradication rate was 83.3%. No adverse reactions and disorder of laboratory findings due to CPDX-PR were observed.

[Right aortic arch with isolation of the left subclavian artery. A case report]

A 58 year old man was admitted to evaluate his swallowing disturbance. Preoperative aortogram demonstrated right aortic arch with isolation of left subclavian artery. Operative findings revealed the absent blood flow through the proximal portion of left subclavian artery which connected to the left pulmonary artery. Abnormal connection was divided and Kommerell's diverticulum was mobilized from the esophagus. His clinical symptom was slightly reduced postoperatively.

An isolated aneurysm of the common iliac artery associated with an arterio-venous fistula: autotransfusion technique and postoperative hemodynamic monitoring--a case report

Isolated aneurysms of the common iliac artery occur less frequently than abdominal aortic aneurysms. Moreover, the rupture of an isolated iliac aneurysm into a systemic vein is considered to be very rare. The case reported herein is of a patient with a left common iliac aneurysm which ruptured into the iliac vein, who was successfully treated surgically, using Doty's autotransfusion technique as a supportive measure. We describe our preoperative diagnosis, operative method, including the supportive measures, and the postoperative hemodynamic changes monitored by a Swan-Ganz catheter.

[Extra-anatomic bypass grafting for vascular occlusive disease in the upper and lower extremities]

Twenty-four patients with poor risk factors underwent an extra-anatomic bypass operation for aortoiliac occlusive disease and subclavian steal syndrome. A femoro-femoral bypass was performed on 5 patients, an axillo-femoral bypass on 15, a subclavian-subclavian bypass on 2 and an ascending aorta-femoral bypass on 2. There was only one operative death and there were 2 late deaths (8.3%). The patients were 20 males and 4 females with a mean age of 69.3 years. Among risk factors, high age (70 year old) was present in half of the patients, ischemic heart disease in 9, and cerebral vascular disease in 8. Seventy-five percent of the patients were suffering from two or more dysfunctions. During the limited follow-up period from 8 to 94 months (mean 46.1 months) there was a 96% patency rate. We had good results using externally supported ring graft and by the administration of prostaglandin E1 and ticlopidine during the pre and postoperative period.

[Clinical study of S 6472 granule preparation (sustained-release cefaclor) in chronic respiratory airway infections]

S 6472 granule preparation, a sustained-release preparation of cefaclor, was administered to 21 patients with chronic respiratory airway infections for its clinical study; a daily dosage between 750 and 1,500 mg was orally given in 2 divided doses after breakfast and dinner for a duration of 3 to 14 days. Clinical effects were good in 15 cases, fair in 1 case, poor in 4 cases and unknown in 1 case. No side effects were observed except for a case of impaired appetite. There appeared to be no abnormal laboratory test valued due to the drug.

[Clinical evaluation on the usefulness and safety of norfloxacin in a twice-a-day regimen against upper respiratory tract infections]

Sixty-six patients with tonsillitis or pharyngolaryngitis received oral norfloxacin (NFLX) 200 mg b.i.d. or 300 mg b.i.d. for not less than 3 days in general at School of Medicine, Yokohama City University, and 6 related hospitals. The results are summarized as follows: 1. Ten patients were excluded from the study because 4 patients did not present at the follow-up visits, 4 patients did not follow the protocol and 2 patients had unclear infections. Thus, 56 patients were evaluated. 2. The fifty-six evaluable patients were classified as follows: Twenty patients were with tonsillitis and 36 were with pharyngolaryngitis. Thirty-eight patients were treated with 200 mg b.i.d. while 18 patients received 300 mg b.i.d. Thirty-two patients were male and 24 patients were female. Three patients were inpatients and 53 patients were outpatients. Most of patients were light or moderate cases, and the 26 patients had mild underlying disorders. 3. Clinical improvements were observed in 11 of 15 patients (73.3%) with tonsillitis and 25 of 30 patients (83.3%) with pharyngolaryngitis (80.0% overall) within 7 days administration. 4. Clinical improvements were observed in 15 of all 20 patients (75.0%) with tonsillitis and 30 of all 36 patients (83.3%) with pharyngolaryngitis (80.4% overall). 5. Bacteriologically, "eradication", "decrease" and "replacement" were observed in 6, 2 and 1 patients, respectively. 6. As for adverse effects, nausea and headache were observed in 1 patient and abnormal changes in laboratory findings were noted in 1 patient (slight elevations of GOT and GPT). 7. Oral NFLX 200 mg b.i.d. or 300 mg b.i.d. was as almost equally effective as 200 mg t.i.d. in tonsillitis or pharyngolaryngitis. Thus NFLX 200 mg b.i.d. or 300 mg b.i.d. appears to give sufficient clinical efficiency. 8. When antibacterial activity and serum half-life of NFLX are considered, twice daily administration was confirmed to be sufficiently effective in the clinical application.

[A case of inferior vena cava thrombosis associated with cholelithiasis demonstrated by ultrasonic examination]

A case of a 44 year old female with inferior vena cava thrombosis associated with cholelithiasis was reported. The patient had chest and back pain due to pulmonary embolism. Ultrasonic examination showed stone echoes in the gallbladder and thrombus echoes in the inferior vena cava (IVC) at the height from renal veins to bifurcation of iliac veins, but iliofemoral thrombosis was not found by RI angiography and venography. Anticoagulant and urokinase were administered, then pulmonary embolus disappeared and IVC thrombus reduced. IVC thrombus was removed by incision of IVC. Thrombus was white thrombus. Etiology of thrombus was not clear. IVC ligation or plication for prevention of pulmonary emboli was not carried out. Etiology, diagnosis and treatment of IVC thrombosis were also discussed.

[Combined resection of the thoracic aorta associated with subtotal esophagectomy for carcinoma of the esophagus]

With recent advances in surgical techniques and post-operative care, surgical treatment of esophageal cancer has been safely performed. Nevertheless, prognoses of such cases in which the cancer is invading the ajacent aorta and when only an incomplete resection was performed are very poor. The following case in which annular resection of the thoracic aorta combined with subtotal esophagectomy was performed and an aorto-aortic bypass graft was replaced was reported. A 70 year old man came to our hospital, complaining of difficulty in swallowing. The upper GI series showed a 8 cm long filling defect in the middle esophagus. Computed tomography suggested that the tumor was directly invading the aorta. The patient underwent two staged procedure operations. During the first operation, the left chest was opened, and a side-to-end bypass graft was replaced to detour around the tumor bearing aorta with 20 mm phi Dacron Double Velour graft. The aorta was then transected. The second operation was performed through the right thoracotomy. During the operation, the thoracic esophagus and the tumor bearing aorta were resected en bloc. The patient died of hepatic failure and right pyothorax 4 months after the first operation.

[Clinical study of cefminox in respiratory tract infections]

A new cephem cefminox (CMNX, MT-141) was used in the treatment of 22 cases of respiratory tract infections without taking into account background factors of patients. The dosage was 2 to 4 g/day in 2 divided doses and the treatment was continued for a period 2 to 17 days. The breakdown of the diseases treated was; pneumonia in 7 cases, secondary lung abscess (rS3)+middle lobe syndrome in 1 case, chronic bronchitis in 3 cases, bronchiectasis in 10 cases and intrapulmonary lymphangitis carcinomatosa (suspected) in 1 case. The clinical results were rated as excellent in 7 cases, good in 11 cases, fair in 1 case and unknown in 3 cases, with an excellent rate of 36.8% and excellent+good rate of 94.7%. The causative organisms were identified in 10 cases and included H. influenzae for 8 cases, Klebsiella sp. for 1 case and S. aureus for 1 case. The analysis of bacteriological study revealed disappearance of all of these organisms. However, in 3 out of 8 cases where H. influenzae was isolated and in 1 case where Klebsiella sp. was isolated the changes of organisms to P. aeruginosa were observed. As the adverse reactions, rashes developed in 1 case and moreover laboratory test results revealed elevation in transaminase in 3 cases. All of these symptoms were mild in nature and none of our cases experienced serious adverse reactions attributable to CMNX. From these results, we believe that CMNX is one of the useful drugs for the treatment of respiratory tract infections.

[Acinic cell carcinoma of the trachea--a case report]

A 27-year-old woman was admitted to our hospital complaining of dyspnea. Bronchoscopic examination revealed an endotracheal mass in the lower trachea. Endoscopic removal of the lesion was done by the electrocoagulation method followed by wide circumferential excision and reconstruction of the trachea three days later. The patient made an uneventful recovery and has had no recurrence in two years of follow-up. The diagnosis of acinic cell carcinoma was made by light microscopy. This is the first description, to our knowledge, of a primary neoplasma of the intrathoracic trachea having the histological appearance of a salivary gland acinic cell tumor.

[Hyperthermia in cancer therapy]

Hyperthermia is being re-evaluated and currently used in the treatment of malignant tumor. There have been numerous in vitro and in vivo experimental data presented which confirm the selective heat damage on malignant cells. This review will attempt to summarize the information on experimental and clinical reports concerning hyperthermia. The results of extracorporeally induced hyperthermia of our series are also mentioned.

[Intrathoracic application of latissimus dorsi muscle flap for extended radical esophagectomy]

The problem of extensive surgery for patients with a carcinoma of the esophagus, involving the trachea, was discussed. The right latissimus dorsi muscle flap was utilized intrathoracically in order to cover up and reinforce the tracheal suture line. The technique of the intrathoracic application and merits of this procedure were discussed.

Clinical results of cardiopulmonary bypass with selective cerebral perfusion for aneurysm of the ascending aorta and the aortic arch

The purpose of this report is to describe our experience using cardiopulmonary bypass with selective cerebral perfusion in 10 patients whose aneurysms required cross-clamping the aorta and brachiocephalic vessels. Cerebral perfusion was carried out with individual roller pumps. Flow rate was 11.2 +/- 4.8 ml per kilogram of body weight per minute to the right axillary artery, 8.5 +/- 1.0 to the right common carotid artery, 7.0 +/- 2.0 to the left common carotid artery, and 3.9 to the left subclavian artery. All the patients came off bypass smoothly, and only 3 required small amounts of inotropic agents postoperatively. One patient with mycotic aneurysm died in the fourth postoperative week of massive bleeding due to disruption of the suture line. No cerebral complications were experienced. The operative results of this series suggest the usefulness of cardiopulmonary bypass with selective cerebral perfusion, and reasonably favorable outlook for patients with aneurysm involving the aortic arch and the ascending aorta.

Ascending aorta-supraceliac abdominal aorta bypass: successful removal of an infected graft in the descending thoracic aorta

An infected graft and a mycotic pseudoaneurysm were successfully resected by employing an ascending aortasupraceliac abdominal aorta bypass graft in a 19-year-old man. He had formerly undergone graft replacement surgery for traumatic aneurysm of the descending thoracic aorta, with the aid of a temporary external bypass graft. After this first operation, the patient had suffered from septicemia due to Psudomonas aeruginosa, which resulted in formation of mycotic pseudoaneurysms at the distal anastomotic site of the prosthetic graft and at both stumps of the formerly employed external bypass graft.