[Clinical outcome of emergency off-pump coronary artery bypass grafting]

From January 2001 to January 2003, we performed 25 emergency off-pump coronary artery bypass grafting (CABG) procedures for patients with acute myocardial infarction (AMI) or unstable angina pectoris. During the same period, we also performed 2 emergency on-pump beating CABG procedures for patients with left main coronary trunk (LMT) shock syndrome. For the present study, we evaluated the operative results of the 25 cases of emergency or urgent off-pump CABG. The patients were divided into 3 groups, those with acute AMI with cardiogenic shock (group 1; n = 8), acute myocardial infarction without shock (group 2; n = 8), and unstable angina (group 3; n = 9). There were no differences between groups 1 and 2 with regard to age, number of diseased vessels, and preoperative use of an intraaortic balloon pump, however, patients in group 1 had a higher number of completely obstructed coronary arteries. Patients in groups 1 and 2 underwent off-pump CABG within 3.5 hours after a coronary angiography or coronary intervention procedure, while those in group 3 underwent off-pump CABG within 2 days of coronary angiography. The mean number of grafts per patient was 1.8, 2.1, and 2.3 in groups 1, 2, and 3, respectively. One group 1 patient with an LMT lesion was transferred to on-pump beating CABG because of hemodynamic instability. The 30-day mortality rate was 38% (3 of 8) in group 1, whereas it was 0% in groups 2 and 3. Intubation time, ICU stay, and postoperative stay were similar among the 3 groups. An early angiographic study was undertaken in all surviving patients and the results demonstrated patency in all of the examined grafts. Although our results are limited, emergency off-pump CABG was found to be safe and feasible for AMI without cardiogenic shock or unstable myocardial ischemia. However, the outcome of this procedure for patients with preoperative cardiogenic shock was not satisfactory, therefore, a combination therapy of appropriate mechanical circulatory support, prior revascularization by catheter intervention, and emergency surgical revascularization are considered to improve survival of those patients.

[Aortic valve replacement with a freestyle stentless valve using the modified subcoronary technique and hemiarch replacement for bicuspid aortic valve and ascending aortic aneurysma; report of a case]

An association between bicuspid aortic valve disease and ascending aortic aneurysma has long been recognized. Root replacement with a composite valve graft for such disease is a well-established technique. But it may involve serious technical difficulties, and may be a more time-consuming procedure than separate valve replacement and graft replacement. We performed an aortic valve replacement with Freestyle stentless valve using the modified subcoronary technique and hemiarch replacement for a 72-year-old man with severe aortic stenosis and ascending aortic aneurysma. Angiographic studies after surgery showed no residual aortic regurgitation (AR) and no deformity of aorta. This technique is an acceptable option for an aortic disease and ascending aneurysma in elderly patients.

[Graft holding system; a new device for coronary artery bypass grafting]

A new graft holding system for coronary artery bypass grafting was described. This system was an application of a memo-clip, which was composed of a flexible arm and 2 paper clips at both ends. A graft was wrapped by a piece of sponge and pinched indirectly by one of the clips. The other clip was fixed at an edge of the sternal retractor. Regardless of the size of the graft or the amount of the surrounding tissue, the graft can be fixed securely at one's pleased position due to a flexible arm of the device. Intimal injury can be avoided referring to the gentle holding of a piece of sponge. It enables us to place precise stitches and to minimize handling, anastomosis time, and leakage.

Recurrent palmar dislocation of the distal radioulnar joint. A case report

Recurrent palmar dislocation of the distal radioulnar joint is not a common injury. We report one case in a 73-year-old female. This injury was incorrectly diagnosed at the first presentation because there has been no distinct deformity at the wrist and extension-flexion was normal. The need for proper physical examination and accurate radiographic positioning is stressed. Distal diaphysis resection combined with distal radioulnar arthrodesis (modified Sauve-Kapandji procedure) was the preferred method of treatment in an old patient. Two years after the injury, the patient was asymptomatic.

Hamatometacarpal fracture-dislocation: distinctive three dimensional computed tomographic appearance

We report here two fully documented cases of hamatometacarpal fracture-dislocation following trauma and treated in our hospital. In our cases, the patients suffered hamate fracture in association with metacarpal dislocation. In the first case, a dorsal oblique fracture of the hamate was associated with a dorsal dislocation of the base of the fourth metacarpal. In the second case, a dorsal oblique fracture of the hamate was not associated with a dorsal dislocation of the base of the fifth metacarpal. This diagnosis should be suspected on initial review of plain radiographs, which must include an oblique view because of diagnostic difficulty for this injury. We recommend three dimensional computed tomography (3D-CT) in any patient presenting with pain after blunt trauma to the hand to prevent in diagnosis. Open reduction and internal fixation of the fracture is indicated and relevant for displaced fracture.

Cervical fracture of the anterior and posterior elements without evidence of neurological deficit. A report of three cases

We present three cases of cervical spinal fracture, involving two columns without an obvious neurological deficit. Usually if two of three columns are fractured, the injury is considered unstable structurally and clinically. Fortunately our cases did not involve sensory or motor impairment because of an enlargement of the spinal canal.

Methods for determination of milt protein and epsilon-polylysine in food additive preparations and processed foods by capillary zone electrophoresis

A simple and rapid method using capillary zone electrophoresis (CZE) for the determination of milt protein (MP), which contains mainly protamine, and polylysine (PL) in food additive preparations and processed foods was developed. CZE separation was performed on poly(vinyl alcohol)-coated capillaries at a column temperature of 20 degrees C with 120 mmol/L phosphate buffer (pH 2.5) as the running buffer. The influence of various components in food additive preparations on CZE analysis of MP and PL was examined. Egg white lysozyme, glycine, sodium acetate, glycerol, fumaric acid, calcium carbonate, dextrin, emulsifiers and sodium polyphosphate and pyrophosphate had no effect. No peak of protamine was detected in preparations containing metaphosphate. The analysis method for processed foods was composed of extraction with 4% formic acid, precipitation of macromolecular compounds with ethanol, concentration in a water bath and determination by CZE. The average recoveries were 108.4% for protamine sulfate (PS) in red bean sticky rice, and 81.3% for PL in white rice, 118% in egg sandwiches, and 115% in shiraae. The limits of detection of PS in red bean sticky rice and PL in white rice were both 50 ppm.

[Daily intake of isoflavones based on the market basket method]

Daily intake of isoflavones (daidzin, glycitin, genistin, daidzein, glycitein, and genistein) was determined quantitatively, based on the market basket method. Acid hydrolysis during extraction of foods was chosen to convert phytoestrogenes into the respective aglycons, facilitating HPLC analysis and allowing quantitation of total isoflavones as aglycones including both originally present glycosides and "free" aglycones. The isoflavones were extracted from samples with methanol and determined by reversed-phase HPLC analysis using a linear gradient of methanol-water as the eluent. From the results of hydrolysis, the daily intake of total isoflavon was 38.1 mg/adult Japanese. The values obtained by the market basket method and the National Nutrition Survey method were similar.

Cancer regression induced by modified CTL therapy is regulated by HLA class II and class I antigens in Japanese patients with advanced cancer

Autologous cancer-specific bulk CTLs are unlikely to be induced by in vitro CTL generation (ivtCTLG) using peripheral blood mononuclear cells (PBMCs) of cancer patients when autologous cancer cells are used as in vitro stimulators. However, autologous cancer-specific bulk CTLs are frequently activated when allogeneic cancer cells are used as in vitro stimulators, regardless of the type of cancer cell. We have developed a cancer-specific immunotherapy called modified CTL therapy, which involves adoptive immunotherapy of autologous cancer-specific bulk CTLs after active immunization of autologous or allogeneic cancer cells screened as in vitro stimulators according to their ability to induce autologous cancer-specific CTLs (ACS. CTLs). Cancer did not regress in patients in whom ACS.CTLs were not induced by ivtCTLG using the patients' PBMCs in therapy. Cancer regression, albeit temporary, occurred solely in patients under the immunological condition that ACS.CTLs were induced by ivtCTLG using PBMCs through the therapy. The induction of ACS.CTLs by ivtCTLG using patient PBMCs in therapy was related to patients' HLA class II antigens. HLA DR8 was seen more frequently in ACS.CTL-inducible patients than in ACS.CTL-uninducible patients (P=0.051). On the contrary, HLA DQ3 was seen more frequently in ACS.CTL-uninducible patients (P=0.055). On the other hand, the success in therapy, albeit temporary, was related mainly to patients' HLA class I antigens. HLA B61 was seen more frequently in patients whose therapy proved effective than in patients whose therapy proved ineffective (P=0.018). HLA Cw7 was seen more frequently in therapy-ineffective patients (P=0.040).

Posterolateral dislocation of the ankle without fracture

We report an unusual case of open posterolateral dislocation of the ankle without fracture following a motor vehicle accident. Most of previously reported cases are posteromedial dislocation. The anterolateral, posterolateral, and purely superior dislocations of the talus make up smaller percentage. The mechanism of this injury appears to be forced eversion of the foot when it is maximally plantar flexed and axially loaded. Our case was treated by manual reduction and percutaneous fixation and anatomical repair of the disrupted deltoid ligament at the time of initial débridement, also achieved good long-term functional and radiographic results.

[Day surgery for cholecyst lithiasis]

Since 1997, laparoscopic cholecystectomy has been performed as one-day surgery (LC/DS) at our institution. Among the 122 patients enrolled in this program, 97 (80%) were successfully discharged within 24 hours after admission. Discharge was delayed for the other 25 patients, although 12 (48%) of them were discharged on postoperative day (POD) 2 or 3. This study not only verified the efficacy of LC/DS in shortening convalescence and allowing an early resumption of work but also confirmed the safety of LC/DS except in one patient with hemophilia A who required laparotomy for intraabdominal bleeding on POD 13. LC/DS is now the first choice of treatment for cholelithiasis regardless of symptoms. Discharge can be expected within 24 hours after admission in most cases, although the preference of patients should be considered when determining the timing of discharge.

Comparison of CT findings with resected specimens after chemoembolization with iodized oil for hepatocellular carcinoma

OBJECTIVE

We assessed the role of dynamic CT in the evaluation of the efficacy of transarterial chemoembolization with iodized oil for hepatocellular carcinoma.

MATERIALS AND METHODS

We examined 41 hepatocellular carcinoma lesions (mean diameter, 5.0 cm) in 40 patients (mean age, 60.6 years) who underwent transarterial injection of iodized oil alone (n = 3) or emulsion of iodized oil and doxorubicin hydrochloride (n = 10) followed by gelatin sponge particles (n = 27) and subsequent hepatectomy. On dynamic CT performed within 3 weeks before oily transarterial chemoembolization and within 4 weeks before surgery, we calculated the rate of necrosis on the basis of the assumption that the portion that retained iodized oil represented necrosis. We also calculated the reduction rate of the tumor. CT findings were compared with pathologic findings of resected specimens.

RESULTS

Pathologic specimens and the necrosis rate measured on CT showed a good correlation (r = 0.83) when the portion of tumor that retained iodized oil was considered necrosis. No correlation existed if the portion that retained iodized oil was considered viable. We noted no significant correlation (r = 0.38) between the reduction rate of the tumor and necrosis rate. Also, we noted no correlation (r = 0.52) between the interval between transarterial oily chemoembolization and surgery and the reduction rate of the tumor.

CONCLUSION

CT is suitable for the evaluation of the efficacy of oily chemoembolization for hepatocellular carcinoma on the basis of the assumption that the portion of tumor that retains iodized oil is necrotic. The rate of tumor size reduction measured on CT did not correlate with the therapeutic effect of chemoembolization.

Aneurysm in the pulmonary trunk associated with atrial septal defect, a left coronary artery fistula to the pulmonary trunk, and valvular pulmonary stenosis

A 78-year-old woman with an aneurysm in the pulmonary trunk associated with an atrial septal defect, left anterior descending coronary artery fistula to the pulmonary trunk and valvular pulmonary stenosis is reported. The aneurysm showed gradual dilatation over 16 years and was successfully treated using aneurysmorrhaphy. Although there has been some controversy regarding the optimum management for a pulmonary artery aneurysm, surgical correction is thought to be essential for aneurysms associated with congenital cardiac anomalies because of the high incidence of rupture.

[Vein holder--a new device for coronary artery bypass grafting]

A new saphenous vein graft holder for coronary artery bypass grafting was described. This graft holder is a modification of a tissue forceps, the tips of which were changed to hollow-beveled, spoon shape. A saphenous vein graft can be pinched between the tips of this holder securely and gently during anastomosis. It enables us to place precise stitches and to minimize handling, anastomosis time, and leakage.

Toxicity and blood concentrations of xylazine and its metabolite, 2,6-dimethylaniline, in rats after single or continuous oral administrations

To cast light on whether the carcinogenic risk of 2,6-dimethylaniline (DMA), a metabolite of xylazine, may increase by ingestion of edible tissues from domestic animals treated with xylazine, the following studies of xylazine and DMA were performed. In Experiment I, male F344 rats received a single oral administration of 150 mg/kg of xylazine hydrochloride. Rats showed symptoms suggesting loss of sensation and pain immediately after the treatment. These signs had disappeared after 3 hr, but the animals died of hydrothorax and pulmonary edema by 9 hr. The plasma concentration of xylazine was 2.88 +/- 0.95 micrograms/ml at 15 min, and then decreased to 0.10 +/- 0.01 microgram/ml at 6 hr. The plasma level of DMA remained at 0.03 to 0.04 microgram/ml during the measurement period. In Experiment II, male F344 rats were fed a diet containing 1000 ppm of xylazine hydrochloride, regarded as the maximum tolerated dose, for 4 weeks. No clear clinical signs were evident and the plasma levels of xylazine and DMA were at the detection limit (0.02 microgram/ml) or less, although follicular cell hypertrophy of the thyroid was observed in all the treated animals. In Experiment III, male F344 rats were fed a diet containing 3000 ppm or 300 ppm of DMA for 4 weeks. Histological changes, such as atrophy of Bowman's gland and irregular arrangement of olfactory epithelial cells, were only observed in the olfactory epithelium of the 3000 ppm group. The plasma levels of DMA were 0.20 to 0.36 microgram/ml in the 3000 ppm group, but under the detection limit in the 300 ppm group. These results suggest that the probability of nasal carcinogenic effects of DNA on consumers via ingestion of edible tissues from food-producing animals treated with xylazine is extremely low, since DMA levels in the blood of rats subjected to continuous administration of high doses of xylazine remained under the detection limit.

Oozing type cardiac rupture repaired with percutaneous injection of fibrin-glue into the pericardial space: case report

Two patients, a 56-year-old man and an 81-year-old woman who were admitted to hospital because of anteroseptal acute myocardial infarction, were initially treated successfully with direct percutaneous transluminal coronary angioplasty. However, both patients later developed sudden cardiogenic shock due to cardiac tamponade caused by left ventricular free wall rupture (LVFWR). Prompt, life-saving pericardiocentesis was performed, then fibrin-glue was percutaneously injected into the pericardial space. After the procedure, there was no detectable pericardial effusion on echocardiography and the hemodynamic state became stable. The surgical treatment was the standard procedure for LVFWR, but percutaneous fibrin-glue therapy can also be considered for oozing type LVFWR.

Advantages of Japanese response criteria for estimating the survival of patients with primary gastric cancer

BACKGROUND: We conducted a retrospective study to investigate the adequacy of the Efficacy Criteria for Primary Lesions in the Japanese Classification of Gastric Cancer (Japanese criteria) for evaluating the anti-tumor efficacy of chemotherapies and the relationship between tumor regression and the prognosis of gastric cancer.METHODS: The data for 90 patients with inoperable ad-vanced gastric cancer who received various chemotherapies, consisting of fluorinated pyrimidines and cisplatin, were retrospectively analyzed. Based on the Japanese criteria, we investigated the efficacy of the chemotherapies and the relationship between the response in primary lesions and survival. We also compared the efficacy of chemotherapies evaluated by the Japanese criteria to that evaluated by the WHO criteria.RESULTS: All 90 patients were evaluable by the Japanese criteria. The overall response rate was 53.3% (Partial response [PR] in 48 patients and no change + progressive disease [NC + PD] in 42 patients). The primary lesions were classified as measurable (a-lesions) in 27 patients, evaluable but not measurable (b-lesions) in 31 patients, and diffusely infiltrating (c-lesions) in 32 patients. Overall median survival time (MST) was 9.4 months. The MSTs of the responders and non-responders were 12.6 and 7.8 months, respectively. In contrast, by the WHO criteria, 49 patients (54.4%) were evaluable; the other 41 patients had gastric primary lesions alone but were not measurable by WHO criteria. The overall response rate was 67.3% (33/49), and overall MST was 9.4 months. The MSTs of the responders evaluated by both sets of criteria were both 12.6 months.CONCLUSIONS: We suggest that the Japanese criteria are useful for evaluating the anti-tumor effect of gastric cancer chemotherapies and that prospective studies to reconfirm their usefulness are warranted in Japan, and in Western countries.

[The effect of intraoperative high-dose tranexamic acid on blood loss after operation for acute aortic dissection]

The effect of high dose tranexamic acid on blood loss after operations for acute aortic dissection was evaluated. Twenty-eight patients undergoing emergent operations for acute aortic dissection were studied. There were two groups, group T with 13 patients (group T) who were given 7 g of tranexamic acid after induction of anesthesia and 3 g of it after CPB and group C with 15 patients who did not receive tranexamic acid. There was a tendency that group T had less bleeding during operation and after operation (559.6 +/- 865.8 ml in group T and 805.8 +/- 442.9 ml in group C, 1719.2 +/- 1008.7 ml in group T and 3547.7 +/- 4580.1 ml in group C, respectively), but there was no significant difference between two groups. The removal of drainage tubes after operation was significantly earlier in group T (5.0 +/- 2.3 post operative day in group T and 8.1 +/- 5.2 post operative day in group C; p < 0.05). FDP and D-dimer level as measures of fibrinolytic activity were elevated at pre- and postoperative period in both groups, but they tended to be lower in group T at postoperative period. One patient required reexploration because of excessive bleeding and no mediastinal infection was reported in group T, whereas 4 patients underwent reexploration and 2 patients developed mediastinitis in group C. There were 5 hospital death (33.3%) in group C and 2 (15.4%) in group T. High dose of tranexamic acid seems to control fibrinolytic activity, thereby reducing blood loss and requirements, which may contribute to lower morbidity and mortality in operations for acute aortic dissection.

Therapeutic results of resection, transcatheter arterial embolization and percutaneous transhepatic ethanol injection in 3225 patients with hepatocellular carcinoma: a retrospective multicenter study

The outcome in 3225 patients with hepatocellular carcinoma (HCC) was studied in groups with equivalent prognosis treated with resection, transcatheter arterial embolization (TAE), and percutaneous transhepatic ethanol injection (PEI). Significant factors for better clinical background included a tumor diameter of < or = 30 mm, tumor number < or = 3 and (clinical) Stage I. In patients with Stage I disease having tumors of < or = 30 mm and < or = 3 in number, survival afer resection and PEI did not differ, while survival after TAE was significantly worse. In those patients with Stage II disease, survival after PEI was significantly better than after resection or TAE. In patients with Stage I or II disease having tumors > or = 31 in size and < or = 3 number, survival after resection was significantly better than after TAE. In patients with Stage I disease having tumors of > or = 31 mm and > or = 4 in number, survival after resection was significantly better than after TAE. Our conclusions are as follows. Firstly, resection or PEI is recommended for patients with Stage I disease having < or = 3 tumors all < or = 30 mm in size. Secondly, PEI is recommended for patients with Stage II disease having < or = 3 tumors all < or = 30 mm in size. Thirdly, for patients with Stage I disease having tumors 31 mm or larger in size, whatever the number of tumors, resection should be selected rather than TAE.

Simple technique for pancreatogastrostomy and the histological findings of pancreatogastric anastomosis

The leakage of pancreatic juice is the most serious complication after pancreatoduodenectomy. In an attempt to lessen the incidence of this complication, we have developed a simple technique for the anastomosis of pancreatogastrostomy. Since March 14, 1995, we have already performed surgical procedures on 8 cases of pancreatogastrostomy using this technique and as yet have never experienced fatal complications. We report the autopsy findings of pancreatogastric anastomosis histologically. The specimen taken from the anastomosis reveals good mucosal continuity. This result suggests the importance of reliable sutures between the pancreatic parenchyma and the full thickness of the gastric wall for the anastomosis of pancreatogastrostomy.

Prospective and randomized trial of lipiodol-transcatheter arterial chemoembolization for treatment of hepatocellular carcinoma: a comparison of epirubicin and doxorubicin (second cooperative study). The Cooperative Study Group for Liver Cancer Treatment of Japan

A randomized, controlled clinical trial was conducted to compare the use of epirubicin (EPI) and doxorubicin (DOX) in Lipiodol (Laboratoire Guerbet, Roissy-Charles-de-Gaulle Cedex, France)-transcatheter arterial chemoembolization as a treatment of hepatocellular carcinoma. One hundred ninety-two hospitals participated, and 415 patients were enrolled in the study during the period between October 1989 and December 1990. The patients were randomly allocated to group A (EPI) or group B (DOX) by a centralized telephone registration. The actual doses of EPI and DOX were 72 mg/body and 48 mg/body, respectively. The 1-, 2-, and 3-year survival rates were, respectively, 69%, 44%, and 33% for group A and 73%, 54%, and 37% for group B. There were no statistically significant differences (P = .2296, log-rank test). When each group of patients was classified retrospectively into high-risk and low-risk subgroups based on the severity index calculated by the Cox regression model from the significant prognostic factors (the pretreatment tumor size, the pretreatment serum alpha-fetoprotein level, tumor encroachment, and Child's classification), the survival curve of the low-risk DOX subgroup was significantly superior to that of the low-risk EPI subgroup (P = .0182). However, there was no significant difference between the high-risk subgroups (P = .4606). The change in the serum alpha-fetoprotein level, the extent of Lipiodol accumulation in the tumor, and the extent of tumor reduction after the treatment did not show any significant differences between the groups. The white blood cell count in group B showed a tendency to decrease slightly more than in group A at 3 weeks after Lipiodol-transcatheter arterial chemoembolization. In conclusion, there was no statistically significant difference between the survival curves of the EPI and DOX groups in Lipiodol-transcatheter arterial embolization treatment of hepatocellular carcinoma.

[Left free wall rupture complicating acute myocardial infarction--a case report of surgical success by a new modified method]

The success rate of surgical treatment for blowout type free wall rupture of the left ventricle following myocardial infarction has been reported as 4 to 24%. A 64-year-old woman was admitted to our hospital for inferior acute myocardial infarction with cardiogenic shock. In the catheter laboratory, her hemodynamics disclosed electro-mechanical dissociation, and we had to perform an emergent operation there. In order to preserve left ventricular volume and reduce the risk of bleeding, we adopted a modified method using both patch and felt strip sandwich methods which obtained favorable result. The patient was sent to a rehabilitation hospital on the 43rd post operative day because of a mild cerebral complication and she is now doing well with only a slight speaking disturbance at a follow-up period of 10 months.