[New surgical procedure for patients with dilated heart and end-stage cardiac failure (Batista procedure)]

A 53-year-old man with dilated cardiomyopathy underwent left ventriculoplasty (Batista procedure), a new surgical procedure, which reduces ventricular volume to improve left ventricular function. Left ventricular ejection fraction increased from 19.7% to 43.7%. Unfortunately, he died of pneumonia 12 days after surgery. This is the first such procedure in a human in Japan.

Quantitative analysis of scatter- and attenuation-compensated dynamic single-photon emission tomography for functional hepatic imaging with a receptor-binding radiopharmaceutical

A new method for quantitative liver study was developed using the tracer technetium-99m diethylene triamine penta-acetic acid-galactosyl human serum albumin (99mTc-GSA), an analog ligand of the asialoglycoprotein receptor, which is a hepatocyte surface receptor specific for galactose-terminated glycoproteins. For quantitative dynamic single-photon emission tomographic (SPET) studies, attenuation compensation using transmission computed tomography (TCT) and the triple energy window (TEW) scatter compensation method were evaluated. As the TCT source, we used an uncollimated multi-tube source with the TEW scatter compensation method. To verify the accuracy of cross-calibrated SPET values as compared with measured radioactivities, we performed SPET of a cylindrical water pool phantom which contains seven hot rods filled with different concentrations of 99mTc activities, simulating the scan conditions in human studies. The results of the phantom studies showed good linearity and accuracy of the SPET values, with R2=0.993 and a regression line of y=0.941x+5.48. From the analysis of a kinetic model based on a one-compartment model, focussing on the initial stage of several minutes after 99mTc-GSA injection and taking the physiological expression presented in a three-compartment analysis into account, we introduced the Rutland equation (Patlak plot) in the 99mTc-GSA study by which the overall and regional effective hepatic blood flow (EHBF) and hepatic blood pool volume were determined. Preliminary clinical evaluations were performed for four normal male subjects (23-35 years of age) and one patient. Forty sequential 30-s dynamic SPET acquisitions were obtained for a period of 20 min following the intravenous injection of 99mTc-GSA with venous blood sampling at 10 min. After scatter compensation, the SPET images were reconstructed with attenuation compensation using an attenuation map obtained from TCT. The average normal value for the total EHBF was 468+/-83 ml/min and that for the hepatic blood pool volume, 777+/-123 ml. Functional images of the distribution of regional values of EHBF (ml/min/voxel) and hepatic blood pool volume (ml/voxel) were also generated corresponding to the original SPET images. The EHBF images showed regional liver function, higher in the right lobe than the left lobe in the normal cases, and the heptic blood pool volume images showed the distribution of intensified high values along major vascular structures. Receptor imaging with 99mTc-GSA using the Rutland method and dynamic SPET with scatter and attenuation compensation is an effective technique that allows the evaluation of total and regional hepatic functional parameters (EHBF, hepatic blood pool) in vivo.

Scatter and attenuation correction in technetium-99m brain SPECT

We propose a practical method for scatter and attenuation compensation in 99mTc-ECD brain SPECT using a simultaneous emission CT (ECT) and transmission CT (TCT) acquisition system that includes the following major components: (a) triple-headed SPECT gamma camera equipped with fanbeam collimators; (b) external line sources containing 99mTc placed at the focal lines of the collimators; and (c) scatter correction by the triple-energy-window (TEW) method.

METHODS

Projection images were obtained over a 360 degrees rotation scan. After acquisition, scatter correction was performed using the TEW method, which corrected scattered photons pixel by pixel in the projection data. Scatter-corrected ECT images were compensated for attenuation using the TCT images with Chang's iterative method, and were converted to activity concentration (kBq/ml) images by obtaining a cross-calibration scan. After validating this method with phantom studies, it was applied to clinical brain imaging using a combination of 925 MBq 99mTc-ECD as a radiopharmaceutical and 222 MBq 99mTc as an external source. ECT and TCT data were acquired separately or simultaneously.

RESULTS

SPECT quantification and image quality were improved by performing this correction. The activity concentration images obtained with the simultaneous acquisition were almost identical to those obtained with the separate acquisition.

CONCLUSION

This method was clinically practical and cost-effective for reconstructing quantitative 99mTc brain SPECT images.

A case of small cell carcinoma of the stomach

A case of small cell carcinoma of the stomach is reported. A 53-year-old male was referred to our hospital for elective surgery for gastric cancer. Pre-operative examinations revealed no metastases. Gastrectomy was performed curatively, and there were no gross findings of metastases. Histologically, the tumor was composed of intermediate-sized cells with hyper-chromatic nuclei and scanty cytoplasm. These cells were argyrophilic and positive for chromogranin A. A small portion of the tumor consisted of conventional adenocarcinoma (signet ring cell carcinoma and tubular adenocarcinoma). No lymph node metastasis was observed microscopically. However, 7 months after the operation, splenic and hepatic metastases were detected, and the patient died very soon thereafter. Small cell carcinoma of the stomach is a very rare disease. In literature, only 15 cases have been cured surgically. Among them, only one case had been diagnosed as small cell carcinoma before the operation, which suggests the difficulty of pre-operative diagnosis. The prognosis of this disease is very poor compared with the common type of gastric carcinoma. Considering the poor prognosis of this particular disease, adjuvant chemotherapy might be mandatory in all cases even if surgically curative resection is performed.

Neoadjuvant chemotherapy in scirrhous cancer of the stomach using uracil and tegafur and cisplatin

We administered a mixture of uracil and tegafur (UFT)/cisplatin (CDDP) chemotherapy in 28 patients with scirrhous gastric cancer. In the regimen, UFT was orally administered at a dose of 200 mg/m2 twice a day. The CDDP was administered at a dose of 90 mg/m2 by 24-hour continuous infusion every 4 weeks. As a result, antitumor effects for primary gastric foci were achieved in 14 of the 28 patients (50%). Ascites from peritoneal dissemination disappeared completely in eight of 13 patients (62%). Total gastrectomy was performed in ten patients after 2 to 3 courses of chemotherapy. Histological response grades assessed on the resected specimen were Grade 2 in four, Grade 1b in three, Grade 1a in one and Grade 0 in two patients. Neoadjuvant chemotherapy is feasible against scirrhous gastric cancer and a subsequent prospective randomized trial should be prepared to clarify the survival benefit of the treatment.

Evaluation of SPET quantification of simultaneous emission and transmission imaging of the brain using a multidetector SPET system with the TEW scatter compensation method and fan-beam collimation

A gamma camera system which is able to acquire simultaneous single-photon emission tomographic (SPET) data and gamma ray transmission computed tomography (TCT) data for brain study using external rod sources and fan-beam collimators was developed and evaluated. Since the three external rod sources were located at the focal points of fan-beam collimators, which also happened to be the apexes of the equilateral triangle defined by the three detectors, simultaneous SPET and TCT scan could be performed using a 120 degrees shared scan. Therefore, the proposed system required less than one-third of the scanning time of a single-head system. Since the combination of rod sources and fan-beam collimators decreased the scatter component in transmission data without a slit collimator for each rod source, the radioactivity of the rod source was less than one-tenth of the previous investigations. For evaluation, we used two isotopes, thallium-201 for TCT and technetium-99m for SPET. The cross-contamination of transmission and emission was well compensated using the triple energy window (TEW) method. In a separate TCT scan, the measured attenuation coefficient of 201Tl for water was 0.19+/-0.01 cm-1, while in a simultaneous scan, it was 0. 20+/-0.01 cm-1. The measured attenuation coefficient for water agreed well with the narrow-beam (theoretical) value of 0.187 cm-1. In SPET images, scatter compensation was also performed using the TEW method and attenuation compensation was done using the measured attenuation map. The results showed the feasibility of simultaneous SPET and TCT scanning using the TEW method to obtain quantitative SPET images.

A new isopatulin derivative pintulin produced by Penicillium vulpinum F-4148 taxonomy, isolation, physico-chemical properties, structure and biological properties

During our screening program of natural products from fungal metabolites for drugs effective against tumor cell lines, we discovered a new isopatulin derivative, pintulin, from the fermentation broth of Penicillium vulpinum F-4148. Pintulin shows weak activity against tumor cell lines, compared to that of adriamycin.

Malignant lymphoma of the gastric stump developing 25 years after a distal gastrectomy for benign gastric disease: report of a case

We report herein the case of a 57-year-old man in whom malignant lymphoma originating in the gastric remnant was confirmed 25 years after a subtotal gastrectomy with Billroth II reconstruction had been performed for gastric ptosis. Gastroscopy revealed an ulcerated tumor on the fornix, and histologic examination of the endoscopic biopsy specimens demonstrated malignant lymphoma. Thus, total gastrectomy with splenectomy, pancreatectomy, and resection of the previously anastomosed jejunal stoma were performed. Histologic examination of the stomach remnant confirmed a diagnosis of B-cell lymphoma of the large-cell type. Although we were unable to study the surgical specimen from the initial operation, the possible relationship between pseudolymphoma and malignant lymphoma has been presented in the literature, which is reviewed following this case report.

[Scatter and attenuation correction for quantitative myocardial SPECT imaging]

We performed scatter and attenuation compensation in 201Tl myocardial SPECT using the triple-energy-window (TEW) scatter correction method and 99mTc transmission scan (TCT). A dual-headed SPECT gammacamera system equipped with parallel-hole collimators was employed for imaging and a sheet source for TCT was attached to the surface of one of the two detectors. Two imaging protocols, a sequential mode and a simultaneous mode, were examined. In the sequential mode, TCT was performed prior to the administration of the tracer and then ECT was carried out. On the other hand, the injection was followed by a simultaneous transmission-emission scan, in the simultaneous mode. Results of phantom studies showed that reconstructed SPECT values of the whole myocardium were almost equal to the true value with errors of less than 5 per cent, and that more homogeneous images were obtained by performing scatter and attenuation correction. We conclude that this correction method was clinically practical and cost-effective because it uses parallel-hole collimators and does not require fan-beam collimators which may produce truncation artifacts.

The importance of the real-time fluoroscopic intraoperative direct cholangiogram in the laparoscopic cholecystectomy using a new instrument

BACKGROUND/AIMS

Laparoscopic cholecystectomy (LC) has become an accepted standard operative technique for gallstone treatment worldwide. On the other hand, complications, such as bile duct injuries, have been reported recently with the expansion of indication for LC. Intraoperative cholangiogram (IOC), to minimize the risk of bile duct injury, is now considered to be essential for safe LC. There are disadvantages to IOC such as increased operating time, the possibility of bile duct injury and the difficulties of manipulation.

MATERIAL AND METHODS

We have developed a method for real-time fluoroscopic cholangiograms using a new instrument designed by our group for safe LC. First, a round-tip stylet is inserted through a sheath to coax it gently through the spiral valves of the cystic duct. Secondly, the stylet is removed and the cholangiogram catheter is inserted smoothly. Digital C-arm fluoroscopy provides "real-time" imaging of biliary tree. As a result, we became able to obtain a clear cholangiogram easily in a very short time.

RESULTS

In the first 136 patients, direct cholangiograms were attempted in 106 cases and successfully completed in 102 cases (96.2%).

CONCLUSION

With the development of real-time fluoroscopic intraoperative direct cholangiogram, we are able to cope with bile duct injuries and anomalies, and unsuspected bile duct stones.

[A case of traumatic tricuspid regurgitation with bilateral pericardial laceration]

A case of traumatic tricuspid regurgitation with bilateral pericardial lacerations is presented. The patient was a 68-year-old male with a chief complaint of dyspnea on exertion, who had had chest contusion in an automobile accident 17 years before. Two dimensional echocardiography demonstrated a systolic prolapse of the tricuspid anterior leaflet resulting in massive regurgitation. The right atrial v wave was 25 mmHg. Intraoperative findings were as follows: Three healed tears of 4-6 cm long were present in the both sides of the pericardium. The chordae tendineae of the anterior leaflet were ruptured. The tricuspid valve was replaced with a SJM valve prosthesis. To our knowledge, no case of combined tricuspid insufficiency and bilateral pericardial laceration resulting from blunt injury has ever been reported.

[Case report of David's operation for annuloaortic ectasia and aortic regurgitation in a Marfan patient]

We report a 35-year-old Marfan patient who underwent David's operation for annuloaortic ectasia and aortic regurgitation. This new technique is done by excising the aneurysmal portion of the ascending aorta and sinuses of Valsalva but by leaving the aortic valve leaflets and some aortic wall attached to the left ventricular outflow tract inside the Dacron tube. Postoperative echocardiography revealed well coapted aortic valve leaflets and a very small amount of regurgitation. A rigid aortic route without sinuses of Valsalva may increase the mechanical stress on the leaflets and shorten their durability but this procedure have the advantage of so called Bentall's operation by preserving the native aortic valve.

Successful repair of tricuspid regurgitation 46 years after causal blunt trauma

Tricuspid regurgitation arising from chest trauma 46 years earlier was successfully corrected by valve reconstruction in a 67-year-old man. As the merits of valve repair are well established, it can be advocated for traumatic tricuspid regurgitation, regardless of the time from the causal injury.

[Quantitative brain SPECT imaging with scatter and attenuation compensation: comparison of sequential and simultaneous acquisition of transmission and emission data]

Scatter and attenuation correction for brain SPECT of a phantom and a normal volunteer was performed using the Triple Energy Window method combined with a transmission scan. 99mTc-ECD and 99mTc solution were used as an emission tracer and a transmission source, respectively. We employed a triple-headed SPECT gammacamera system equipped with fan-beam collimators for acquisition with line transmission sources placed at the focal lines of the fanbeam collimators. Two mode, sequential mode and simultaneous mode, of data acquisition protocols were examined. In the sequential mode, a transmission scan was carried out using three external sources for the brain phantom without emission tracer. After removing all sources, an emission scan was performed on the brain phantom containing the tracer. In the simultaneous mode, the injection was followed by a simultaneous transmission-emission scan using one transmission source. The same study was conducted out for the normal volunteer, after confirming the effectiveness of these protocols with phantom studies. Corrected SPECT count values obtained with two protocols were almost identical. Simultaneous mode had advantages in avoiding misalignment between transmission and emission data and in shorter acquisition time than sequential mode.

Intraoperative peritoneal washing cytology with the rapid immunoperoxidase method using microwave irradiation

The rapid immunocytochemical staining of gastrointestinal cancer-associated antigens, carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9), for intraoperative peritoneal washing cytology of pancreatic or biliary carcinoma can be completed in only 25 minutes by using microwave irradiation to accelerate incubation of the primary antibody. Only 3-second irradiation at 500 W for fresh smears produced specific antigen staining of malignant cells similar to that obtained with longer incubation, and the sensitivity of intraoperative cytology was greater than by the conventional staining method. The rapid immunocytochemical staining method of peritoneal washings at laparotomy can provide sensitive information for determining more aggressive therapy for intraperitoneal spread of malignant cells before closing the abdominal wall.

Flow cytometric functional analysis of multidrug resistance by Fluo-3: a comparison with rhodamine-123

Using four cell lines including drug-sensitive K562/Parent cells, P-glycoprotein (Pgp)-mediated multidrug resistant (MDR) K562/VCR, K562/ADR and revertant K562/ADR-R cells, two fluorescent agents, Fluo-3 and rhodamine-123 (Rh-123), were compared as indicators in a functional assay of MDR. Cells were incubated with 4 microM Fluo-3 or 1 microM Rh-123 for 45 min and then the intracellular accumulation of the agent was measured using a flow cytometer. Verapamil (20 microM) or cepharanthine (biscoclaurine alkaloid, 10 microM) was added just before the fluorescent agents. Efflux patterns were also studied 60 min after incubation with or without verapamil and cepharanthine. Increased intracellular accumulation and a delayed efflux pattern of Fluo-3 by verapamil and cepharanthine were demonstrated in multidrug resistant K562/VCR and K562/ADR cells, indicating that Fluo-3 is another good indicator of MDR. However, a similar, but lower, increase in uptake and a delayed efflux pattern of Fluo-3 by verapamil and cepharanthine were also demonstrated even in Pgp-non-overexpressed K562/Parent cells. In contrast, accumulation of Rh-123 was not affected by verapamil and cepharanthine. To further study the Pgp dependency of Fluo-3, another cell line, K562/NC16 expressing minimum MDR1 mRNA, was cloned. Increased uptake and a delayed efflux pattern of Fluo-3, but not Rh-123, with verapamil or cepharanthine were again demonstrated in K562/NC16 cells, indicating that intracellular accumulation of Fluo-3 may be non-specifically influenced by verapamil and cepharanthine at very low levels of Pgp-related MDR, while the influx and efflux patterns of Rh-123 may be specifically affected by Pgp overexpression.

Intraoperative quick immunoperoxidase staining: a useful adjunct to routine pathological diagnosis in pancreatic carcinoma

BACKGROUND/AIMS

This paper presents the results of a study comparing conventional and quick immunostaining. This paper aims to introduce the reliability of the immunoperoxidase method for rapid intraoperative pathological diagnosis of pancreatic cancer and the quick staining method.

MATERIALS AND METHODS

Intrapancreatic extension and intraperitoneal spread of pancreatic duct cell carcinoma were evaluated by both conventional and quick immunostaining using antibodies against cancer-associated antigens CA19-9, DUPAN-2, and CEA for intraoperative pathological examination during the course of laparotomy.

RESULTS

For the surgical cut margin, malignant lesions were identified in six of 30 cases by H-E staining. However, cancer cells were detected in 14 of 30 cases by the immunostaining method. On peritoneal washing cytological examination, malignant cells were recognized in four of 27 cases by conventional cytology. In two other cases, positive immunocytochemical findings were noted, and these clinical courses were suggestive of the immunostaining results.

CONCLUSIONS

This immunostaining method was particularly useful in defining cancer cells surrounded by dense fibrous connective tissue and a very small number of cancer cells within the mesothelium, in which malignant cells are usually difficult to identify by conventional staining. Thus, the application of such immunostaining, together with conventional staining, on the cryostat sections of biopsy or on the peritoneal washings may provide sensitive information for intraoperative pathological examination and for selection of the appropriate surgical method.

Mitochondrial encephalomyopathy with A to G transition of mitochondrial transfer RNA(Leu(UUR)) 3,243 presenting hypertrophic cardiomyopathy

In a 24-year-old woman with mitochondrial encephalomyopathy presenting hypertrophic cardiomyopathy, microscopical examination of myocardial biopsy specimen disclosed severe vacuolar degeneration of myocardium and aggregates of enlarged mitochondria with proliferated cristae. Limb muscle biopsy specimen showed "ragged-red fibers" light microscopically and enlarged abnormal mitochondria with markedly increased cristae ultrastructurally. Mitochondrial DNA analysis by polymerase chain reaction (PCR) revealed an A-to-G transition in the mitochondrial transfer RNA(Leu)(UUR) gene at nucleotide position 3,243 which is reported to be associated with mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes (MELAS). However, the clinical features of this case, presenting mainly cardiac abnormalities, were not consistent with the typical MELAS.

[Operative procedures for mitral prolapse and its clinical results]

Mitral valve plasty is the very important procedure for treatment of mitral regurgitation from the view point of post operative quality of life because patients may be possible to be free from postoperative drug therapy especially when the normal sinus rhythm is restored even if the concomitant maze procedure is necessary. In this report, 36 patients who underwent mitral valve plasty for mitral regurgitation were evaluated. In 18 patients who had posterior leaflet prolapse, McGoon's procedure was performed. Two of them required secondary mitral valve replacement 4 days after operation. Reoperation disclosed tissue detachment at the mitral annulus sutures which were not reinforced by a ring. It was considered that annular ring plasty is preferable after resection of prolapsed posterior leaflet by McGoon's procedure. Out of 18 patients who had mitral valve prolapse including anterior leaflet, 8 patients underwent such conventional procedures as transfer of chordae tendinae, leaflet resection and shortening of chordae. Four patients resulted in second look mitral valve replacement 11 days to 1 month after mitral valve plasty. On the contrary, the clinical results of repair of chordae tendineae with artificial chordae of extended polytetrafluoroethylene (ePTFE) were good. It is concluded that the resection of prolapsed leaflet and reconstruction of the annulus with reinforcement using a prosthetic ring is preferable for the posterior leaflet prolapse. For the anterior leaflet prolapse, good results can be obtained by replacement of chordae tendineae with ePTFE sutures.

A new device for exposing the circumflex coronary artery

We have devised a new retractor for use in coronary artery bypass grafting that is made from three woven Teflon tapes. This method allows sufficient counterclockwise rotation of the heart, provides excellent exposure of the posterior and inferior coronary artery systems, and creates a horizontal surgical plane for the circumflex anastomosis.

[A successful surgical case of bilateral partial anomalous pulmonary venous connection without atrial septal defect]

We performed the new operative method for bilateral partial anomalous pulmonary connections (PAPVC) without atrial septal defect (ASD). A 11-years-old boy was admitted for operation. The right upper pulmonary vein returned to the superior vena cave (SVC), and left upper pulmonary vein returned to the innominate vein. Atrial septum was intact. The Qp/Qs was 1.94. The right atrium (RA) was opened and ASD was created. Continuity between the distal end of the SVC and RA was re-established by end-to-end anastomosis to the right atrial appendage. The proximal end of the SVC was closed. The right anomalous pulmonary vein remained in situ on the lower segment of SVC, blood being directed to the left atrium (LA) through the created ASD by suturing the posterior flap of RA incision to the atrial septum well away from the sinoatrial node and artery, anomalous pulmonary vein and cavoatrial junction. The anomalous left vertical vein was dissected up to the innominate vein. The left pulmonary vein was mobilized as much as possible, and was anastomosed to the posterior wall of LA by end-to-side fashion. He has normal sinus rhythm and no evidence of pulmonary venous obstructions on both sides. We support the efficacy of this method as an alternative in the management of this disorder.