[Cytomegalovirus infection in lung transplantation; current status, detection, prophylactic treatment]

The control of the postoperative infectious disease is one of the important elements in transplantation. Among them, the control of the cytomegalovirus (CMV) infection may be said the most important in the management of the transplant recipient who is under the immunosuppression. This time, we review the status of the pre-transplant CMV infection in the donors and recipients of both brain-death and living-related lung transplantation that we performed, and report our prophylactic treatment for CMV infection and its results. The CMV positive rate of the recipients and donors of the lung transplantation that we experienced in Okayama University was 87%. We experienced 4 cases that developed CMV infection after lung transplantation. However, there is no case that died of a CMV-related infectious disease after lung transplantation to date. By the CMV mismatch transplant, it seemed that the frequency of the postoperative CMV disease was high in comparison with the transplant of recipient CMV (+). But, the control of the CMV infection after lung transplantation is thought to be possible if we give a proper prophylactic treatment even in CMV mismatch transplantation.

[Living-donor lobar lung transplantation for infectious lung diseases]

The rate of infection among lung transplant recipients is several times higher than that among recipients of other organs and is most likely related to the exposure of the allograft to the external environment. Meticulous peri-operative management is mandatory in performing living-donor lobar lung transplantation for patients with infectious lung diseases. All 5 patients with end-stage infectious lung diseases are currently alive for 17-104 months after receiving living-donor lobar lung transplantation at Okayama University Hospital.

[Phrenic nerve paralysis following lung transplantation]

Phrenic nerve paralysis is a well-documented complication of cardiac operation, but there is less commonly reported after lung transplantation. A retrospective study of 49 lung transplantation was done at Okayama University Hospital. Phrenic nerve paralysis (unilateral in 3 patients and bilateral in 1) was found in 4 patients (8.2%). All of these paralyses were transiently recovered. The average length of ventilation, intensive care unit stay and hospitalization for recipients with phrenic nerve paralysis was not significantly longer than the other (no diaphragmatic paralysis) recipients, but there was a tendency to be longer. Diaphragmatic paralysis is most likely related to difficulty in detecting the phrenic nerve caused by adhesions, injury due to dissection, thermal injury by electrocartery, or local topical hypothermia using ice-slush. Therefore, it is important to take care of avoiding the injury of the nerve during the operation.

[Extensive traumatic pneumomediastinum. without injuries of organs in the thorax: report of a case]

A 57-year-old man was accidentally hit by concrete blocks weighing 3 tons on his right side, and was admitted to a hospital. The radiologic findings taken immediately after trauma demonstrated pneumo-mediastinum, subcutaneous emphysema with multiple rib fractures and right clavicle fracture. At computed tomography (CT) scan 16 hours after trauma, pneumomediastinum and subcutaneous emphysema turned out to be worsened with an increased bilateral pleural effusion. An emergency thoracotomy revealed no abnormalities of trachea or esophagus, and neither bronchoscopy or esophagogastroscopy, showed injuries anywhere inside. The chest cavities and mediastinum were washed well with 3 liters of saline solution. The patient had a good course after surgery without any complications, and was discharged at the 18th hospital day. Mediastinal drainage by an emergency operation should always be a choice to a patient having a progressively worsening pneumomediastinum which might cause tachycardia, low blood pressure, and severe dyspnea due to compression of blood vessels and trachea.

[Thoracoscopic repair of peritoneopleual communication with a giant diaphragmatic bullae in a patient with liver cirrhosis; report of a case]

Hepatic hydrothorax is defined as pleural effusion in patients with a cirrhotic liver. The pleural effusion occurs due to ascites flowing to the pleural cavity through a diaphragmatic communication. Recent literature has described the usefulness of a thoracoscopic repair and has shown that it can control pleural effusion very efficaciously. The patient was a 65-year-old woman who complained of dyspnea and was admitted to our hospital. A chest X-ray revealed marked right pleural effusion. We injected indigo carmine intraperitoneally and observed indigo carmine-colored pleural effusion; thus peritoneopleural communication was validated. After the failure of thoracic drainage and pleurodesis with minocycline hydrochloride, thoracoscopic surgery was performed 5 weeks after hospitalization. Obvious bulla formation was observed on the diaphragm, which was immediately resected with linear staplers. The postoperative course was excellent without any recurrence of pleural effusion.

Noncompaction of the left ventricular myocardium diagnosed in pregnant woman and neonate

Noncompaction of the left ventricular myocardium (NCLV) is an uncommon congenital cardiomyopathy with poor prognosis. We describe a case of NCLV that developed in a pregnant woman and her neonate. A nulliparous woman was referred at 24 weeks' gestation due to dyspnea and fetal hydrops. Maternal echocardiography demonstrated NCLV with characteristic findings of prominent and excessive ventricular trabeculations and deep intertrabecular recesses in the left ventricle. An M-mode echocardiography suggested depressed left ventricular systolic function. A fetal echocardiography at 24 weeks' gestation demonstrated cardiomegaly, but morphologic findings were not definitive for NCLV. An emergency cesarean section was performed due to maternal heart failure. A neonatal echocardiography diagnosed NCLV with depressed left ventricular systolic function. The neonate died of cardiac failure on the second day of life. Autopsy confirmed the echocardiographic findings. Since patients with NCLV may develop heart failure, multidisciplinary management is mandatory. In addition, awareness of familial occurrence of NCLV should be kept in mind for early diagnosis in the fetus and neonate.

[Staged operation of off-pump coronary artery bypass grafting using aortic connector system, and concomitant surgery for abdominal aortic aneurysm and gastric cancer; report of a case]

Recently the patient of the atherosclerotic disease associated with malignant disease has been increased. A 75-year-old man was referred to our section with an infrarenal abdominal aortic aneurysm (AAA) and a gastric cancer (GC). Preoperative coronary angiogram revealed the significant stenoses of the right coronary and the left anterior descending coronary artery. We selected the staged operation of off-pump coronary artery bypass grafting (CABG) [OPCAB] and the concomitant surgery for the AAA and the GC. Operative invasion could decrease with the surgical procedure of the OPCAB and the concomitant surgery compared to the conventional CABG or the separate operation. We used the aortic connector system during OPCAB to prevent such the serious complications of the aortic dissection or the systemic embolism due to the calcified ascending aorta.

Gallbladder aspiration for acute cholecystitis in average-surgical-risk patients

We conducted a retrospective case note review to assess whether or not gallbladder aspiration can be applied as a temporary measure for the treatment of acute cholecystitis in average-surgical-risk patients. Gallbladder aspiration was performed in 79 consecutive average-surgical-risk patients with acute cholecystitis, who had no indications of emergent surgery and who complained of severe colicky pain. Elective surgery became possible in 92% of patients by gallbladder aspiration. The percentage reached 97 when percutaneous cholecystostomy was added (four patients). Emergent surgery was needed in one patient suffering bile leakage following gallbladder aspiration. Colicky pain was controlled soon after the procedure in most cases. Neither major complications nor mortalities were observed in the following surgical therapies. It is suggested that gallbladder aspiration might be applied as a temporary measure for acute cholecystitis in average-surgical-risk patients, although early surgery should remain the primary choice of therapy in such patients.

Transbronchial administration of adenoviral-mediated interleukin-10 gene to the donor improves function in a pig lung transplant model

Interleukin-10 (IL-10) gene transfection of donor lungs prior to transplantation is an attractive strategy to reduce ischemia-reperfusion induced lung injury. However, experimental data with gene therapy in large animal models of lung transplantation are generally lacking. We have developed a simple clinically applicable technique for adenoviral-mediated gene delivery of human IL-10 to the lung of large animals that provides homogenous gene expression after 12-24 h of transfection. Using this technique of gene delivery, we have studied the dynamics of adenoviral gene delivery to the lung in the setting of lung transplantation. Although there is a persistent inflammatory response to the adenoviral vector, we achieved significant expression of human IL-10 in lung tissue before lung retrieval to obviate the deleterious impact of the adenoviral vector on the donor lung. The administration of adenoviral-mediated human IL-10 to the donor lung reduced ischemia-reperfusion injury and improved graft function after lung transplantation in this pig lung transplantation model. Transfection of adenoviral-mediated human IL-10 to the donor lung prevented the release of inflammatory cytokines such as IL-6 in lung tissue and plasma. We have demonstrated that IL-10 gene therapy has significant potential to prevent or treat the inflammatory response associated with ischemia-reperfusion injury in lung transplantation. In the future, IL-10 gene therapy could also be used for immunomodulation or tolerance induction.

[One-staged operation for multiple aortic aneurysms of the descending thoracic aorta and abdominal aorta; report of a case]

A 66-year-old man underwent successfully on one-staged operation for aneurysms of the descending thoracic aorta and abdominal aorta. For the operation of descending thoracic aortic aneurysm, a temporary bypass was used from the proximal side of aneurysm to the distal one. The sacculer aneurismal wall of the descending thoracic aorta was repaired by patch formation using a knitted graft. Abdominal aortic aneurysm was replaced using a Gelsoft graft. The operation time was 7 hours and 35 minutes. Blood transfusion was not needed. The postoperative course was uneventful. It is suggested that one-staged operation for descending thoracic aortic aneurysm under the assist of temporary bypass and abdominal aortic aneurysm is possible.

Serum KL-6 level and pulmonary function in preterm infants with chronic lung disease

The purpose of this study was to determine the usefulness of serum KL-6 (sKL-6) level as a clinical marker, in terms of pulmonary function, for infantile chronic lung disease (CLD). The study population comprised 23 infants less than 31 weeks of gestational age admitted to the neonatal intensive care unit of Kobe University Hospital between March 2002 and August 2003. Blood samples were obtained on day 1, 3, 7, and then weekly until 36 weeks. sKL-6 was measured by means of electro-chemiluminescence immunoassay. For evaluation of pulmonary function, static respiratory system compliance (Crs) was measured on the same day. There were nine infants with CLD and 14 without (non-CLD). Peak sKL-6 levels of the non-CLD infants were less than 200 U/ml except for two cases, while those of CLD infants were over 200 U/ml except for one case. Infants of earlier gestational age, exposed to longer mechanical ventilation and with reduced pulmonary function had the higher sKL-6 levels. However, there was no significant relationship between sKL-6 level and Crs at any postnatal age.

Effects of epinephrine and phosphodiesterase III inhibitors on bupivacaine-induced myocardial depression in guinea-pig papillary muscle

BACKGROUND

This study was designed to investigate the effects of epinephrine and the phosphodiesterase III inhibitors amrinone and milrinone on bupivacaine-induced myocardial depression in guinea-pig papillary muscles using an electrophysiological method.

METHODS

Electrophysiological studies of the effects of bupivacaine, epinephrine, amrinone and milrinone in normal and high K(+) Tyrode's solution were measured with guinea-pig papillary muscles. Specifically, epinephrine, amrinone and milrinone reversal of bupivacaine-induced depression was measured.

RESULTS

Bupivacaine reduced the action potential duration (APD), the maximum rate of rise of the AP (V(max)) and contractile force. Although epinephrine increased the contractile force similarly to amrinone and milrinone, it shortened the APD at 50% repolarization (APD(50)) and 90% repolarization (APD(90)). A high concentration of amrinone shortened APD, while milrinone did not affect APD except for a prolongation of APD(20). In high K(+) Tyrode's solution (25 mM), epinephrine, amrinone and milrinone increased the APD and the contractile force. Epinephrine reversed bupivacaine depression of APD and contractile force to control levels. Amrinone and milrinone restored not only the contractile force but also APD. There was an incomplete recovery of APD(50) for amrinone and the prolongation of APD(20) for milrinone.

CONCLUSIONS

Our results suggest that bupivacaine decreases the Ca(+) current (I(Ca)) and Na(+) current (I(Na)). Epinephrine and amrinone may increase I(Ca) and the delayed outward current (I(k)), whereas milrinone may increase I(Ca). The profound cardiovascular depression caused by bupivacaine was effectively reversed by amrinone and milrinone in a manner similar to epinephrine.

[DeBakey IIIb type dissecting aneurysm with adrenal myelolipoma; report of a case]

We report a case of DeBakey IIIb type dissecting aneurysm with adrenal myelo-lipoma in a 50-year-old woman. The patient was referred to our hospital for severe back pain with severe hypertension. The chest computed tomography (CT) scans and aortography showed the DeBakey IIIb type dissecting aneurysm. And the round-shaped masses on her both side adrenal glands were detected by abdominal CT scans. First, the thoracic aneurysm was replaced with a 26 mm woven dacron graft under cardiopulmonary bypass. Six months later a right adrenal tumor was removed under a postero lateral approach. Her postoperative course was uneventful. And her blood pressure control was good with no antihypertensive drug. Pathological findings for the resected tumor was diagnosed as myelolipoma. To our knowledge, a dissecting aneurysm with adrenal myelolipoma has not been previously reported.

[Aneurysm of the diverticulum of the ductus arteriosus in the adult with left pneumonectomy; report of a case]

A 51-year-old man with dyspnea was admitted to our hospital. Chest computed tomography (CT) scan and aortogram indicated a diagnosis of aneurysm of diverticulum of the ductus arteriosus. Aneurysm of the diverticulum of the ductus arteriosus in the adult is rare. To our knowledge, 34 cases have been reported in the Japanese literature. Operation was performed through standard left postero-lateral thoracotomy. Initially left pneumonectomy was performed because of severe left lung collapse. And subsequently graft replacement of distal aortic arch was performed with hypothermic retrograde cerebral perfusion. The aneurysmal wall directly penetrated into the trachea with occluded orifice by thrombus. The penetrating wall of the trachea was closed by mattress suture with pericardial pledget. And an omental graft was placed. Five weeks after surgery, high fever and pus discharge from the wound of the thoracotomy developed. The debridement of the thoracic cavity was performed, and the cavity was intermittently irrigated with an electrolyzed strong acid solution. The infection successfully subsided gradually and the patient has been well for 9 months after the initial surgery.

[Case of thoracoabdominal aortic aneurysm complicated with Buerger's disease]

We report a rare case of 65-year-old man who developed thoracoabdominal aortic aneurysm of Crawford type III complicated with Buerger's disease. He was admitted to our hospital with chief complaints of upper abdominal and back pain. CT showed that the aneurysm extended from the descending thoracic aorta to the aortic bifurcation and its had a maximum width of 95 mm. Angiogram (IA-DSA) revealed that both popliteal arteries were occluded slightly above the level of the knee joint, although collateral vessels were visualized. He underwent preliminary graft replacement of the abdominal aorta with the end-to-side supplemental branch for cannulation. Subsequently we performed graft replacement of the thoracoabdominal aorta with reconstruction of the celiac and superior mesenteric arteries and intercostal arteries on under partial cardiopulmonary bypass. This supplemental branch of abdominal aortic graft was useful in preventing ipsilateral leg ischemia. During the reconstruction of the major visceral branches, the branches were perfused selectively via partial extracorporeal circulation. Post operative courses were uneventful without paraplegia and leg ischemia. Angiographic examination revealed excellent hemodynamic results.

Highly selective iodide-sensing silicone ladder polymer membranes containing a porphyrin and a quaternary ammonium salt

It has been demonstrated that a glass-like silicone ladder-type polymer permits one to homogeneously incorporate high amounts of ionophores into the covalently-bonded double chain structure. Furthermore, by making use of this feature, we have successfully fabricated an iodide ion-sensitive field-effect transistor based on two kinds of ionophores and silicone ladder polymer matrix. As ionophores, 5,10,15,20-tetraphenyl-21H,23H-porphyrin and dimethyloctadecyl-3-trimethoxylsilylpropylammonium chloride were homogeneously incorporated into the matrix. The ion-sensitive field-effect transistor showed a linear potential response ranging in the I- concentration between 1.0 x 10(-5) and 1.0 x 10(-1) M. The selectivity coefficients for I- towards interferences of ClO4- and NO3- were estimated to be Kpot(I-,ClO4-) approximately 6.2 x 10(-4) and Kpot(I-,No3-) approximately 4.9 x 10(-4). The matrix has proved to be so stable that the selectivity coefficients have not been altered over six months.

Ionization of dichlorophenols for their analysis by capillary electrophoresis-mass spectrometry

In order to develop an advanced analytical method using capillary electrophoresis (CE) for non-volatile environmental pollutants such as endocrine disruptors, combination with mass spectrometry (MS) is necessary for their identification. We chose dichlorophenols (DCPs) as test samples because one of their isomers, 2,4-DCP, is suspected to have endocrine disrupting effects. A preliminary study on their separation by CE-MS was performed using a laboratory-made electrospray ionization (ESI) interface. For the effective ionization of 2,4-DCP at the

Radiation therapy in combination with transcatheter arterial chemoembolization for hepatocellular carcinoma with extensive portal vein involvement

AIM

The aim of this study was to examine the effectiveness and toxicity of radiation therapy in combination with transcatheter arterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) with extensive portal vein tumor thrombus (PVTT).

METHODS

The combined therapy was performed in 24 HCC patients with extensive PVTT. External radiation targeted for PVTT (50 Gy in 2 Gy fractions) was performed in combination with repetitive TACE for intralobar lesions using 30-60 mg epirubicin every 3 months, and associations of the following variables with the survival rate were evaluated: gender, age, viral etiology, Child's class, performance status, extrahepatic metastasis, size and number of HCC, and location of PVTT.

RESULTS

The local response confined to PVTT was complete response (CR) in four patients, partial response (PR) in eight patients, no change (NC) in eight patients, and progressive disease (PD) in four patients. By using the stepwise Cox's regression analysis, only Child's class was associated with the survival rate. The survival rates after 1 and 2 years were 73 and 21% in Child's A, 10 and 0% in Child B or C, and 61 and 21% in patients in whom the local response was CR or PR, and 19 and 9% in those in whom the local response was NC or PD, respectively. By using the multiple logistic regression analysis, Child's class was the only factor associated with the local response (P = 0.006).

CONCLUSIONS

The combined therapy is feasible and may be useful to reverse PVTT in patients with good hepatic function reserve.