TBI, etoposide, and cyclophosphamide conditioning for intermediate-risk relapsed childhood acute lymphoblastic leukemia

BACKGROUND

In children with intermediate-risk relapsed acute lymphoblastic leukemia (ALL), allogeneic hematopoietic stem cell transplantation (allo-HSCT) has markedly improved the outcome of patients with an unsatisfactory minimal residual disease (MRD) response. Total body irradiation (TBI), etoposide (ETP), and cyclophosphamide (CY) have been shown to be equivalent to or better than TBI + ETP for conditioning, so we hypothesized that even greater survival could be achieved due to recent advances in HSCT and supportive care.

PROCEDURE

We prospectively analyzed the efficacy and safety of allo-HSCT with a unified conditioning regimen of TBI + ETP + CY in children with intermediate-risk relapsed ALL, based on MRD in the bone marrow after induction, from the Japanese Pediatric Leukemia/Lymphoma Study Group (JPLSG) ALL-R08-II nationwide cohort (UMIN000002025).

RESULTS

Twenty patients with post-induction MRD ≥ 10-3 and two not evaluated for MRD underwent allo-HSCT. Engraftment was confirmed in all patients, and no transplantation-related mortality was observed. The 3-year event-free survival and overall survival rates after transplantation were 86.4% ± 7.3% and 95.5% ± 4.4%, respectively.

CONCLUSION

Allo-HSCT based on post-induction MRD with TBI + ETP + CY conditioning was feasible in Japanese children with intermediate-risk relapsed ALL.

The First Case of a Child Infected with SARS-CoV-2 Omicron Variant in Japan, December 2021

We report the first pediatric patient infected with the Omicron variant of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in Japan. The patient was a one-year-old boy who resided in Japan. He went abroad with his parents from November 12, 2021 to November 28, 2021 and had no known contact with coronavirus disease (COVID-19) patients there. Upon arrival at the Narita International Airport on November 28, 2021, his father tested positive for SARS-CoV-2 via a quantitative antigen test. Because the boy and his mother tested negative for SARS-CoV-2, they quarantined together at a hotel separately from his father. On December 4, 2021, the boy tested positive by reverse-transcription polymerase chain reaction (RT-PCR) for SARS-CoV-2, without symptoms, and was hospitalized with his mother; he and his father were both found to be infected with the SARS-CoV-2 Omicron variant. The boy was not vaccinated against COVID-19. RT-PCR results were negative starting on December 20, 2021. The incubation period and required period for negative conversion of SARS-CoV-2 RNA of the Omicron variant case were similar to those of the cases of conventional strains. We should carefully consider the potential of the SARS-CoV-2 Omicron variant to spread widely among unvaccinated children.

Adapting pediatric health care responses to the COVID-19 pandemic in Japan: A clinical perspective

The COVID-19 pandemic required our pediatric health care staff to adjust to many irregularities and solve serious issues in our routine clinical practice. In outpatient clinics, many children exhibited common cold symptoms that mimic COVID-19, thus we initially screened patients via an interview form, then later via SARS-CoV-2 antigen test. Cluster infections were entirely avoided by following systematic, everyday precautions. Patientsquality of life has been difficult to maintain during the pandemic, due to social and staffing restrictions. Other unexpected repercussions - such as an unexpected lack of seasonal virus infections, then a respiratory syncytial (RS) virus outbreak - required agile management of hospital resources. While we must continue to adapt our treatment programs in response to the evolving COVID-19 crisis, it remains essential to support the well-being of children through regular health check-ups, mental health support, educational opportunities, proper socialization, and close communication with parents and families.

Drug-induced crystalluria attributable to tosufloxacin in children

BACKGROUND

Drug-induced crystalluria is reportedly caused by a large number of drugs. Tosufloxacin (TFLX), a second-generation fluoroquinolone antibiotic, is reported to cause kidney injury and crystalluria. We retrospectively analyzed patients with crystalluria caused by TFLX to clarify the clinical course of TFLX-induced crystalluria in children.

METHODS

This study was designed as a retrospective case series using the database of the National Center for Global Medicine covering the period from January 1, 2020 to March 31, 2021. We enrolled pediatric patients aged 15 years or younger with crystalluria attributable to TFLX treated in our pediatric department and collected clinical data.

RESULTS

Thirteen patients were diagnosed with crystalluria attributable to TFLX. The median age of the patients at diagnosis was 4.0 years (range, 0.8-15 years; interquartile range = 1.2-8.8 years), and five patients (38%) were male. Six patients (46%) had gastrointestinal symptoms such as vomiting and abdominal pain, and 12 patients (92%) had decreased oral intake. The median time to diagnosis after TFLX administration was 4 days (range, 2-7 days; interquartile range = 3-6 days). All patients received TFLX at the appropriate dose. Two patients (17%) were diagnosed with acute kidney injury, and both had gastrointestinal symptoms such as vomiting and abdominal pain.

CONCLUSIONS

Crystalluria induced by TFLX occurred despite administration of the appropriate dose of TFLX. Physicians should recognize crystalluria and renal injury attributable to TFLX. It may be possible to prevent renal injury by discontinuing drug therapy.

[Hematological neoplasia associated with primary mediastinal germ-cell tumor treated with hematopoietic stem cell transplantation]

The occurrence of a primary mediastinal germ cell tumor and hematological neoplasia provides a poor prognosis that is known to be fatal at a median of 6 months after onset. We report the case of a 15-year-old male who was treated with chemotherapy and hematopoietic cell transplantation based on a report of a surviving case. At diagnosis, the patient had an unresectable mediastinal tumor with elevated alpha-fetoprotein and human chorionic gonadotropin levels and acute megakaryoblastic leukemia. We prioritized treatment with chemotherapy for the tumor owing to the oncological emergency. We then performed leukemia induction therapy and achieved complete remission. Although we used CDDP in combination with intensive therapy, the mediastinal tumor grew too large for it to be safely resected. We transplanted bone marrow from the patient's human leukocyte antigen-haploidentical sibling upon conditioning with busulfan-melphalan. After 44 days, the leukemia recurred in the patient's central nervous system. This was followed by various post-transplant complications, and the patient died of organ failure that was associated with infectious diseases. At necropsy, a poorly engrafted bone marrow was observed. The mediastinal tumor was primarily necrotic, although some immature teratoma components were observed. No leukemic precursor cells were detected. Residual mediastinal tumors may be associated with the recurrence of leukemias. We seek a treatment strategy that enables early tumor resection and high-dose chemotherapy. Further case studies are warranted along with the development of effective treatment methods.

SARS-CoV-2 infection among returnees on charter flights to Japan from Hubei, China: a report from National Center for Global Health and Medicine

Due to the significant spread of a new type of coronavirus (SARS-CoV-2) infection (COVID-19) in China, the Chinese government blockaded several cities in Hubei Province. Japanese citizens lost a means of transportation to return back to Japan. The National Center for Global Health and Medicine (NCGM) helped the operation of charter flights for evacuation of Japanese residents from Hubei Province, and this article outlines our experiences. A total of five charter flights were dispatched, and the majority of returnees (793/829 [95.7%]) were handled at NCGM. A large number of personnel from various departments participated in this operation; 107 physicians, 115 nurses, 110 clerical staff, and 45 laboratory technicians in total. Several medical translators were also involved. In this operation, we conducted airborne precautions in addition to contact precautions. Eye shields were also used. The doctors collecting the pharyngeal swab used a coverall to minimize the risk of body surface contamination from secretions and droplets. Enhanced hand hygiene using alcohol hand sanitizer was performed. Forty-eight persons were ultimately hospitalized after the triage at NCGM operation, which was more than the number of persons triaged at the airport (n = 34). Of those hospitalized after NCGM triage, 8.3% (4/48 patients) ultimately tested positive for SARS-CoV-2, significantly higher than the positive rate among subjects not triaged (4/48 [8.3%] vs. 9/745 [1.2%]: p = 0.0057). NCGM participated in a large-scale operation to evacuate Japanese nationals from the COVID-19 epidemic area. We were able to establish a scheme through this experience that can be used in the future.

Moyamoya syndrome in a pediatric patient with congenital human immunodeficiency virus type 1 infection resulting in intracranial hemorrhage

In the era of Antiretroviral Therapy (ART) in which human immunodeficiency virus type 1 (HIV-1) infection affected children can expect a better prognosis, the importance of careful follow up of pediatric HIV-1 cases for neurological complications has been growing. We present a case of hemorrhagic Moyamoya syndrome in a child with congenital HIV-1 infection. A 10-year-old girl was referred to our hospital for the treatment of Pneumocystis Jirovecii Pneumonia (PCP: Pneumocystis pneumonia). Her HIV-1 control was poor and Moyamoya syndrome was found during the opportunistic infection screening at admission. Despite subsequent successful treatment of PCP and HIV-1 infection, we could not save her life due to the intracranial hemorrhage caused by Moyamoya syndrome. A few reported cases of Moyamoya syndrome associated with HIV-1 infection have shown negative outcomes when the control of HIV-1 infection is unsuccessful. Recently "HIV-associated vasculopathy" has been used to describe the cerebrovascular disorder related to HIV-1 infection that is caused by the endothelial dysfunction induced from chronic inflammation and cytokine imbalances due to HIV-1 infection. We assumed that "HIV-associated vasculopathy" may have contributed to the development of collateral vessels impairment related to the bleeding, although the mechanism of vascular damage with HIV-1 infection is not yet well defined. Therefore proper management of the HIV-1 infection is crucial for Moyamoya syndrome with HIV-1 cases. Furthermore it is better to take into account the risk of intracerebral hemorrhage when considering the indication and timing of the revascularization surgery, although generally hemorrhaging is rare in Moyamoya disease in children.

Kawasaki disease refractory to standard treatments that responds to a combination of pulsed methylprednisolone and plasma exchange: Cytokine profiling and literature review

We present a case of Kawasaki Disease (KD) that was refractory to plasma exchange (PE), but which finally responded to concurrent intravenous methylprednisolone pulse (IVMP) and PE treatment. To determine direct and indirect evidence for the efficacy of this combination therapy, we analyzed data of patients with refractory KD by review of the literature using medical databases and cytokine profiling. For literature searches, we used the Pubmed™ and Ichushi™ databases. Search terms used included "Kawasaki disease" and "plasma exchange" to extract articles that described KD cases treated with PE. For cytokine profiling, we measured interleukin (IL)-6, soluble tumor necrosis factor-α receptor (sTNF-αR) type 1 and type 2 before and after PE and PE with IVMP. Our search revealed 201 KD patients treated with PE, of which PE treatment was effective in 188 patients (93.5%), but not in 13 cases (6.5%). All 13 cases were treated successfully with additional treatment. Of the 13 cases, only six (2.5%) had recurrence during the PE treatment period. In our case, cytokine profiling showed PE treatment decreased IL6, while sTNF-αR type1 and type2 remained at high levels. PE and IVMP decreased IL-6 and sTNFα-R type 1 and type 2 levels.

CONCLUSION

PE concurrent with additional anti-inflammatory treatment such as IVMP might be a very promising treatment option for PE refractory patients.

Salmonella meningitis: a report from National Hue Central Hospital, Vietnam

Four Vietnamese infants who survived infection with Salmonella meningitis are reported. A female infant who experienced relapse recovered without complications and another had neurological sequellae. The remaining 2 infants survived without complications. The initial treatment was chloramphenicol and ceftriaxone, whereas a change of antibiotics to imipenem and fluoroquinolone was required for 2 infants. Fluoroquinolone may be a treatment option in patients with Salmonella meningitis who experience complications even though the drug is contraindicated for the pediatric age group.

Continuous and high-dose cytarabine combined chemotherapy in children with down syndrome and acute myeloid leukemia: Report from the Japanese children's cancer and leukemia study group (JCCLSG) AML 9805 down study

BACKGROUND

The aim of the JCCLSG AML 9805 Down study was to evaluate the effect of continuous and high-dose cytarabine combined chemotherapy on the survival outcome of acute myeloid leukemia (AML) with Down syndrome (DS).

PROCEDURE

From May 1998 to December 2006, DS patients with newly diagnosed AML were enrolled. Remission induction therapy consisted of two courses of pirarubicin, vincristine, and continuous-dose cytarabine (AVC1). The patients who achieved complete remission (CR) after two courses of AVC1 were subsequently treated with mitoxantrone and continuous-dose cytarabine (MC), etoposide and high-dose cytarabine (EC) and pirarubicin, vincristine, and continuous-dose cytarabine (AVC2).

RESULTS

Twenty-four patients were enrolled. All patients were younger than 4 years and diagnosed as having acute megakaryoblastic leukemia. Twenty-one patients achieved CR. Three patients died during remission induction therapy due to serious infection. No toxic deaths were observed during remission. All but one patient maintained CR without serious complications. The 5-year overall and event-free survivals were 87.5%  ± 6.8% and 83.1%  ± 7.7%, respectively.

CONCLUSIONS

Continuous and high-dose cytarabine combined chemotherapy with reduced intensity would be effective in DS children with AML.

Lamellar nanocomposites based on exfoliated nanosheets and ionic polyacetylenes

Novel lamellar nanocomposites composed of exfoliated SbP2O8- nanosheets and poly(N-methyl-2-ethynyl pyridinium iodide) (PNMe) or poly(N-octadecyl-2-ethynyl pyridinium bromide) (PNO) have been synthesized by exfoliation and re-stacking method. The XRD data of the nanocomposites SbP2O8-:PNMe and PNO:SbP2O8- indicate the formation of nanostructures containing SbP2O8- nanosheets and PNMe or PNO with interlayer expansions of 2.22 and 4.2 nm along the stacking direction of SbP2O8- nanosheets. Formation of these nanocomposites is further supported by the results obtained by FT-IR spectroscopy, scanning transmission electron microscopy and thermogravimetry. The values of electrical conductivity of the polymers and nanocomposites have also been measured.

Liver resection and transplantation using a novel 3D hepatectomy simulation system

In liver surgery, accurate assessments of liver resection volume and anatomical variation are mandatory for preoperative planning of safe curative hepatectomy. In living donor liver transplantation (LDLT), estimation of hepatic venous drainage is important to avoid liver graft and donor residual liver congestion. This paper reviews the articles on simulation-guided liver surgery and describes our novel 3D hepatectomy simulation system for liver resection and transplantation. Our 3D simulation system, based on the hepatic circulation, provided accurate volumetric and stereotactic information for preoperative planning of curative hepatectomy. In addition, our simulation program was applicable to the hepatic venous system to predict liver congestion in LDLT. Future studies include assessment of the impact of the simulation technologies on surgical education, and their exact cost-effectiveness must be also assessed objectively.

Long-wavelength transverse modes in charged colloidal crystals

The dynamics of closely index matched colloidal crystals of charged silica spheres dispersed in deionized ethylene glycol-water mixture is investigated using dynamic light scattering. At variance with the reports of phonon dispersion measurements on thin colloidal crystals, our observations on millimeter-sized crystals show unambiguous evidence for overdamped transverse modes turning propagative in the range of small wave numbers in agreement with the theory of hydrodynamic interactions in charged colloidal crystals.

[A new surgical technique combining autologous intracordal transplantation of fat and fascia for sulcus vocalis]

We developed a new surgical technique combining autologous intracordal transplantation of fat and fascia for sulcus vocalis. Fat tissue from the abdominal wall and fascia from the postauricular region were obtained and an incision was made on the lateral portion of the vocal cord and a small pocket prepared in the lamina propria using an elevator. After inserting fat tissue into the pocket, fascia was inserted to cover the fat graft to prevent its escape from the pocket. The surgical wound was then sutured using absorbable sutures. No evidence of postoperative absorption of transplanted fat tissue was seen, and vocal function improved postoperatively. This method proved useful as surgical treatment for sulcus vocalis.

"Ordered" structure in ionic dilute solutions: dendrimers with univalent and bivalent counterions

As an intermediate sample of ionic solutes between colloidal particles (macroions) and simple electrolyte ions, we made small-angle x-ray scattering (SAXS) measurements for aqueous solutions of poly(amido amine) dendrimers of three generations (G4, G7, and G10). The SAXS curves of univalent acid solutions showed a single scattering peak, as observed for synthetic macroions. The peak position was dependent on the dendrimer concentration but independent not only of the acid concentration (degree of protonation) but also of the counterion species. The effective charge density of the dendrimer determined by conductivity measurements was found to be insensitive to the acid concentration and the counterion species. The nearest neighbor interparticle distance 2D(exp) calculated from the peak position of the structure factor of G7 and G10 was obviously smaller, though slightly, than the average interparticle distance 2D(0) calculated from molecular weights and concentrations of dendrimers, implying that acid solutions of dendrimers formed the two-state structures by the attractive force. The ultra-small-angle x-ray scattering curve for the hydrochloric acid solution did not show an upturn, which indicates the existence of large scale structural inhomogeneities such as localized ordered structures, probably due to the weak attraction and hence less clear distinction of the ordered and disordered regions. For sulfuric acid solutions, clear scattering peaks were not observed. The bivalent counterions were more strongly associated with the dendrimer ions than the univalent ones. The resulting low charge number of the dendrimers with the bivalent counterion was confirmed directly by the conductivity measurements. These observations confirm that the counterion-mediated attraction does exist even with the univalent counterions and point out that the frequently advanced claim that the effective potential is essentially repulsive with univalent counterions while attraction appears with bivalent counterions is not necessarily correct. It is noted that the intensity of the counterion-mediated attraction in dendrimer solutions is dictated by both the effective charge density and the effective charge number, in contrast with macroionic solutions or colloidal dispersions in which only the effective charge density appeared to be important.

[Direct laryngoscopic extirpation and wound suture for hypopharyngeal lipoma: a case report]

We report a case of hypopharyngeal lipoma. An 82-year-old woman referred to our clinic for 10 years of wheezing and intermittent breathlessness developing 1 month before admission was found on laryngoscopic examination to have a mobile mass arising from the hypopharyngeal region intermittently obstructing the laryngeal airway. After emergency tracheotomy, the tumor was removed under direct laryngoscopy, given the patients age and general status. Under general anesthesia, the tumor was extirpated using a laser and electric scalpel under microlaryngoscopy. The operative wound was sutured under direct laryngoscopy using a specially designed probe with a U-shaped tip. The tumor was histologically diagnosed as lipoma. The surgical procedure enabled the operative wound to heal rapidly and oral feeding to start early.

Left hemihepatectomy with microsurgical reconstruction of the right-sided hepatic vasculature. A strategy for preserving hepatic function in patients with proximal bile duct cancer

BACKGROUND

Right hemihepatectomy (RH) for proximal bile duct cancer occasionally results in liver failure. We report the feasibility of left hemihepatectomy (LH) with vascular reconstruction (VR) of the right-sided hilar vessels to preserve hepatic reserve.

METHODS

Among 110 patients with proximal bile duct cancer (PBC) treated between January 1980 and December 1998, 11 patients underwent LH with VR of eight portal veins and nine hepatic arteries, and 14 underwent RH with VR of four portal veins and one hepatic artery. Microsurgical techniques were used in 80% (8/10) of the hepatic arterial reconstructions.

RESULTS

Although operation time was significantly longer in the LH group, hospital mortality, blood loss and incidence of histologically cancer positive margin at the bilioenteric anastomotic site were similar in the two groups. Peak serum liver enzyme concentration was significantly higher in the LH group with longer inflow occlusion time, whereas peak serum total bilirubin concentration was significantly higher in the RH group, which had smaller liver remnant. No liver abscess occurred in any patients who underwent microvascular reconstructions. The cumulative survival of the LH group was worse than that of the RH group, in which the proportion of vascular invasion was lower, but not significantly.

CONCLUSION

LH with right-sided microvascular reconstruction is technically possible and a feasible option when RH is likely to result in postoperative liver failure.

Recyclable characteristics of hyaluronate-polyhydroxyethyl acrylate blend hydrogel for controlled releases

Hyaluronate-hydroxyethyl acrylate blend hydrogels which have a wide range of composition and characteristics were investigated. Glycidyl methacrylate derivatized hyaluronate (GMA-HA) were synthesized by coupling GMA to hyaluronate (HA) in the presence of a photoinduced initiator for polymerization. By copolymerizing radically GMA-HA and hydroxyethyl acrylate (HEA) under various compositions (weight ratios of HEA and GMA-HA: 1-20), GMA-HA hydrogels could be prepared in wide ranges of characteristics. These HA-PHEA gels possessed the feature that the dried ones recovered completely to the original swelling states on repeated runs, i.e. recyclable gels. The water contents of these hydrogels in equilibrium swellings in water (W(w)) were 0.99-0.86, and their viscoelastic properties were measured by a creep. The spontaneous elastic moduli were 1.05x10(5)-1.94x10(5) N m(-2), and they were mechanically tough. Their effective charge densities were estimated from the partition coefficients of sodium benzoate (NaBA) and decreased from -0.033 to -0.044 mol dm(-3) with increasing contents of HEA. Release of NaBA was studied, and the diffusion coefficients were found to be from 6.95x10(-10) to 0.12x10(-10) m(2) s(-1) with increasing the ratio of HEA. Their diffusion coefficients were found to be much less than the values estimated from the lattice model.

Evolution of and obstacles in surgical treatment for hepatocellular carcinoma over the last 25 years: differences over four treatment eras

This study was designed to clarify what differences the last 25 years have made in surgical results for patients with hepatocellular carcinoma (HCC). We examined results for 716 hepatectomized patients in four treatment eras: first era (1973-1980; n = 58), second era (1981-1985; n = 155), third era (1986-1990; n = 243), and fourth era (1991-1997; n = 260). Patient background, tumor characteristics, type of hepatectomy, treatment for intrahepatic recurrences, and surgical results in the four eras were compared by univariate analysis to clarify the factors that have contributed to or impeded progress in the surgical treatment of HCC. Although there were no significant chronological differences in liver pathology and surgical resectability, operative mortality was reduced to 2% in the fourth era, from 29% in the first era. With an increasing proportion of early-stage HCCs (TNM, stages I and II), the cumulative survival rate at 5 years improved in the course of the eras in our overall population of patients (12%, 31%, 38%, and 51%, respectively, for the first, second, third, and fourth eras) and in a subset of the population divided according to tumor stage. Also, we found a chronological improvement in the survival rate at 3 years after intrahepatic recurrence (10%, 28%, 36%, and 44%, respectively in the first second, third, and fourth eras). This improvement was associated with the establishment of an early detection program for intrahepatic recurrences. However, the recurrence rate was similar in any subset of the population through the four eras. Although this univariate study could not determine independent factors that contributed to the chronological progress in results for HCC surgery in the four eras, it is conceivable that the establishment of indication criteria for hepatectomy, an early detection program for primary and recurrent lesions, and the introduction of multimodal treatment for recurrence were contributory factors in this improvement. A strategy for alleviating the frequent recurrences originating from posthepatectomy metachronous carcinogenesis remains to be established.

Viral serostatus and coexisting inflammatory activity affect metachronous carcinogenesis after hepatectomy for hepatocellular carcinoma. A further report

Little data are available regarding the effects of hepatitis virus serostatus and the severity of coexisting chronic inflammation on intrahepatic recurrence after hepatectomy for hepatocellular carcinoma (HCC). We investigated the extent to which these factors modified the prognosis of hepatectomized patients. A total of 274 patients treated in the period January 1981 to December 1996 were divided into three groups: antihepatitis C-positive (HCV; n = 144), hepatitis B surface antigen-positive and HCV antibody (Ab)-negative (HBsAg; n = 106), and HBsAg-negative and HCV Ab-negative (NBNC; n = 20). Positivity for HBV-related antibody in the HCV group was 76%. Histologic grading of inflammatory activity from coexisting hepatitis was determined according to Knodel's histological activity index (HAI) scoring system. Post-hepatectomy crude survival rates and disease-free survival (DFS) rates were compared, according to tumor characteristics, between the three groups. In the patients overall and also in the patients with a single nodular HCC, the HCV group had significantly higher HAI scores and preoperative serum aspartate aminotransaminase (AST) levels than the other two groups. When the patients were limited to those with a single nodular HCC, the crude survival was similar in the three groups with comparable tumor characteristics; however, the DFS was different (NBNC > HBsAg > HCV). When the patients were further limited to those with a single nodular HCC without microscopic extracapsular spread, in whom removal of the tumor was expected to be microscopically complete, the difference in the DFS became more marked. Irrespective of the viral serostatus, better crude and disease-free survivals were observed in the patients with lower AST levels (< or =50 IU/ 1) than in those with higher AST levels (>50IU/l). In contrast, there were no differences in survivals and HAI scores according to the presence or absence of HBV-related antibody in the HCV group. From our univariate analysis, we can conclude that the severity of virally induced inflammation, which was well correlated with viral serostatus, may be a factor that affects intrahepatic recurrence, which is more likely to originate from metachronous carcinogenesis. Prior co-infection of HBV in HCV patients may not be an adverse risk factor for intrahepatic recurrence.

Preparation of a novel aggregate like sugar-ball micelle composed of poly(methylglutamate) and poly(ethyleneglycol) modified by lactose and its molecular recognition by lectin

We report the preparation and characteristics of a novel micellar aggregate of an amphiphilic diblock copolymer, poly(methylglutamate) (PMG)-poly(ethyleneglycol) (PEG), whose terminus was modified by lactose lactone (LA). Due to the terminal LA moiety, this aggregate could be specifically recognized by RCA120 lectin. PMG-PEG-LA was synthesized by polymerizing the N-carboxy anhydride of L-glutamic acid gamma-methyl ester with H2N-PEG-LA as a polymerization initiator. By applying a fluorescence method using pyrene as a probe molecule, we found that PMG-PEG-LA could form the aggregate in aqueous solution. Fluorescence measurements showed that the critical aggregation concentration (C.A.C.) was 1.1 x 10(-5) M. The average diameter of the aggregate was 220 nm at 25 degrees C, as determined by the dynamic light scattering method. Circular dichroism measurements for the aggregate solution showed that the PMG residue took an alpha-helical structure, and that they associated to constitute the hydrophobic core of the aggregate. By adding RCA120 lectin to the aggregate solution, the turbidity of the solution increased rapidly, due to association of the aggregates. This implies that the aggregate could be recognized by lectin, and also suggests that sugar residues locate at the surface of the aggregates. From these findings, we concluded that the PMG-PEG-LA molecules form an aggregate like a "sugar ball" micelle, whose surface is covered by the sugar moieties. Application of the present aggregate system as a drug carrier is briefly discussed.

Clinicopathologic analysis of stage II-III hepatocellular carcinoma showing early massive recurrence after liver resection

BACKGROUND AND AIMS

Prognosis after hepatectomy for hepatocellular carcinoma (HCC) has been improved by progress in the evaluation of hepatic functional reserve, surgical techniques and perioperative management. However, even when curative resection is performed at a relatively early stage, a considerable number of patients develop early intrahepatic and/or extrahepatic recurrence postoperatively. This study analyzed the clinicopathologic features of HCC with early recurrence.

METHODS

We reviewed records of 513 consecutive patients who had undergone liver resection for HCC. There were 48 deaths within a year after surgery from recurrence, including 21 patients with stage II or III HCC (group I). Clinicopathologic parameters of group I patients were compared with those of 188 patients (group II) who developed recurrence following resection of stage II or III HCC and died more than 1 year after surgery.

RESULTS

On univariate analysis, age, tumor diameter (phi), alpha-fetoprotein (AFP):phi and protein induced by vitamin K absence or antagonist II (PIVKA-II):phi were significantly greater in group I than in group II. Macroscopic portal vein invasion, microscopic vascular invasion, intrahepatic metastasis, poor differentiation, pleomorphism, sarcomatous change, vascular lake, and angiographic condensed pooling were more frequently observed in group I than group II. Five independent determinants were selected by multivariate analysis: AFP:phi, histologic pleomorphism, sarcomatous change, vascular lake and angiographic condensed pooling.

CONCLUSIONS

Highly malignant HCC with extremely poor prognosis exhibits peculiar clinicopathologic characteristics, particularly histologic immaturity, and can be predicted by preoperative indicators such as markedly elevated tumor marker concentrations and condensed pooling on angiography.

Surgical complications and long-term outcome in pediatric liver transplantation

BACKGROUND/AIMS

Liver transplantation has been widely accepted for the treatment of children with end-stage liver disease over the last 10 years particularly with the advent of reduced-size liver transplant technique. This study reviewed the perioperative and long-term results in the pediatric program of the Queensland Liver Transplant Service, Brisbane, Australia.

METHODOLOGY

Retrospective analysis was performed in 153 children who received 176 liver grafts between 1985 and 1995, including 109 (62%) reduced-size and 67 (38%) whole liver grafts. Median follow-up period was 5.3 years.

RESULTS

One-, 5-, and 10-year patient and graft survival rates were 82% and 74%, 75% and 63%, and 70% and 60%, respectively. Normal physical and intellectual development was observed in 98% of survivors. There were no significant differences in patient or graft survival rates between transplants using reduced-size and whole liver grafts. Portal vein thrombosis was the most common vascular complication, occurring in 8%. Hepatic artery thrombosis occurred in 7%, including 11% of children less than 1 year old and 8% of those under 10 kg. Biliary complication was found in 16% and posttransplant gastrointestinal perforation in 19%.

CONCLUSIONS

Liver transplantation has the potential to cure and allow development in children with end-stage liver disease.

[Usefulness of electroglottogram (EGG) and photoglottogram (PGG) for the analysis or vocal fold vibration--a high speed digital imaging study]

Simultaneous recordings of EGG, PGG and high-speed digital imaging (HSDI) of vocal fold vibration were made in 3 normal male subjects and the results were compared to evaluate the usefulness of EGG and PGG for the analysis of the vibratory pattern. Each subject was required to produce sounds of 3 different pitches at 3 different intensity levels in the recording sessions and the 27 sets of data samples were collected. For each data set, the glottal area waveform (GAW), glottal width waveform (GWW), EGG, differentiated EGG, PGG, differentiated PGG, and voice waveform were displayed in a graphic form on the same time axis and their patterns were compared. Based on the analysis of GAW and GWW, it was found that there were variations in the pattern of closing and opening of the vocal fold margin corresponding to the differences in the type of phonation. The EGG waveform appeared to correspond well to that of the movement of the vocal fold margin in the closing phase, while the correspondency was less apparent in the opening phase. It is considered that the EGG waveform is dependent on the mode of contact between the two vocal folds and that a careful observation of the EGG is useful and practical for predicting the pattern of vocal fold vibration. On the other hand, it was difficult to determine the onset of the closing and opening phases only from PGG waveform and there was a timing difference between the PGG and GAW. Although PGG seemed to be useful for judging the presence or absence of the opening phase and for the pitch measurement, it is considered to be unsuitable for a precise cycle-by-cycle analysis of the pattern of vocal fold vibration.

[Retrograde continuous cold blood cardioplegia for combined aortic valve replacement and coronary artery bypass grafting]

Efficacy of retrograde continuous cold blood cardioplegia (RCBC) during aortic valve replacement combined with coronary bypass grafting was studied. Forty patients underwent elective aortic valve replacement, either combined with coronary bypass grafting (7 patients: group I), or isolated (33 patients: group II) using RCBC between 1996 and 1999 were analyzed retrospectively. Aortic cross clamp time was significantly prolonged in group I (150 +/- 33 min) compared to group II (109 +/- 32 min). The postoperative peak creatine kinase-MB levels were similar in both groups (73.3 +/- 23.9 versus 97.6 +/- 88.7 ng/ml). The doses of dopamine and dobutamine administered during 24 hours after surgery did not differ between the two groups (7.5 +/- 3.9 versus 6.5 +/- 5.5 mg/kg). The early (< 30-day) mortality was 0 in group I, and 3.0% in group II. These results suggest that RCBC is a safe method of myocardial protection in patients undergoing aortic valve replacement combined with coronary artery bypass grafting.

[Autotransplantation of ectopic lingual thyroid--a case report]

A 22 year-old female came to our clinic complaining of a swallowing disturbance and dyspnea. ENT examination revealed a spherical mass at the base of the tongue partially obstructing the airway. Scintigraphy with an iodine isotope confirmed that the mass was an ectopic thyroid. Under general anesthesia, and the mass was carefully dissected together with its the feeding vessels and transplanted into the right submandibular gland was removed the space that had been created. The postoperative course was uneventful. Thyroid function one month after surgery was at the same level as before surgery, and scintigraphy two months after the operation revealed normal uptake in the area of the transplanted thyroid.

[The management of aortic root replacement using the Top-Hat/Gelweave composite graft]

Composite graft replacement of the aortic root has become a routine procedure for annuloaortic ectasia (AAE) and aortic valve insufficiency (AR) with aortic dissection and the results have improved. We treated six cases of aortic root reconstruction using the Carrel patch method in 1998. The Top-Hat/Gelweave Composite graft fit together well and the procedure is technically similar to standard valve replacement. Upon measuring the valve size a Gelweave graft 1 mm larger than the valve size should be selected. There were no incidence of hemorrhage or postoperative hemolysis. Further long-term follow-up is necessary.

Characteristics of complexes composed of sodium hyaluronate and bovine serum albumin

Complexes composed of sodium hyaluronate (NaHA) and bovine serum albumin (BSA) were studied to elucidate the exact composition of the complex, the phase separation, the electrophoretic mobility and the size using dynamic light scattering (DLS) and electrophoretic light scattering (ELS), etc. The phase diagram of the mixed solutions was determined. The complexes were soluble in neutral or weakly acidic pH regions and showed phase separation in the more acidic pH region. From the concentration of Na+ released from NaHA when it binds to BSA, the ratios of BSA to NaHA of the complexes were determined. In the region of soluble complexes, one BSA molecule was determined to bind with 15 carboxylic groups of NaHA and in the region of insoluble complexes to bind with 6 carboxylic groups. At the phase separation point, 117 BSA molecules bound with one NaHA molecule and 17% of the carboxylic groups of NaHA did not contribute to the binding of BSA. The sizes of the complexes decreased from several microm to several hundred nm as the binding ratio of BSA increases. Decreases in the viscosities of the mixed solutions were consistent with the decreases of the sizes. From these results, a model of complex formation is proposed.

Optimal route of administration of mixed endothelin receptor antagonist (TAK-044) in liver transplantation

It is well known that endothelin-1(ET-1) is a factor involved in the pathogenesis of ischemia-reperfusion injury. This study was undertaken to investigate the optimal route (intravenous vs intraportal) for administering mixed endothelin receptor antagonist (TAK-044) in a liver transplantation. First, in a rat isolated liver cold-perfusion model, the pharmacodynamics of TAK-044 and endothelin-1 (ET) in the liver tissue and the systemic circulation after cold perfusion were compared in the different administration routes. Next, in a rat orthotopic transplantation model, we compared the hepatoprotective effect of TAK-044 among different administration routes. In each model, there were three groups: IV group, intravenous injection of TAK-044 (10mg/kg) immediately before cold perfusion or anhepatic phase; IP group, intraportal administration with cold perfusion solution or with reflush solution for the graft; control group, no treatment. In the cold perfusion model, liver tissue ET level increased to a similar extent after reperfusion in the three groups, and the plasma and liver tissue TAK-044 concentrations after reperfusion were highest in the IV group. However, the increase in plasma ET was also greatest, and therefore, the ratio of liver tissue to plasma TAK-044 was lower in the IV group compared with the IP group. In the transplantation model, elevation of plasma ET was significantly higher in the IV group. Leakage of serum alanine aminotransferase (ALT), sinusoidal narrowing, and cell swelling after grafting were significantly suppressed in the IP group. We conclude that intraportal administration before reperfusion offers more efficient accumulation of TAK-044 in the liver tissue, without harmful systemic elevation of ET, and achieves a hepatoprotective effect on the graft compared with intravenous administration.

[The management of infectious mediastinitis after the open heart surgery]

Between October of 1992 and September of 1998, we performed 604 open heart operations. Among them, 12 cases (1.9%) were complicated with postoperative infectious mediastinitis. Five patients (Group A) were treated by conservative therapy which consists of open drainage and intermittent closed irrigation with dilute povidone iodine solution. Seven patients (Group B) were treated surgically in addition to the above-mentioned conservative treatment. Among those patients, one patient developed fatal complication. We have realized that mental care of the patients was also very important when long term hospitalization was necessitated. The hyperbaric oxygen therapy seemed to be also effective for postoperative mediastinitis caused by MRSA.

What patients can survive disease free after complete resection for hepatocellular carcinoma?: A multivariate analysis

BACKGROUND

Although there have been extensive studies to determine risk factors affecting survival after resection for hepatocellular carcinoma (HCC), we still do not know which patients can survive disease free after curative resection. This study was undertaken to determine independent risk factors affecting the length of disease-free survival.

METHODS

171 patients, who survived disease free more than 1 year after curative resection, were divided into four groups according to the disease-free period: Group I (n = 96) for the patients with intrahepatic recurrence between 1 and 3 postoperative years, Group II(n = 27) for those between 3 and 5 years, Group III (n = 40) for those between 5 and 10 years and Group IV (n = 8) for those without recurrence within 10 years. The 37 variables (host factors, tumor factors, non-tumor liver factors, surgical factors) were compared among the four groups. Activity of hepatitis and hepatic fibrosis was scored by the Histological Activity Index (HAI). In a multivariate study, possible prognostic variables with a statistical difference in the disease-free survival rate among each category were preliminarily selected from the 37 variables and the independent variables were finally selected using a proportional hazard analysis.

RESULTS

The patients' age, indocyanine green retention rate, microscopic tumor capsular invasion and portal invasion, cell differentiation, extent of hepatectomy, aggressiveness of chronic hepatitis and inflammatory activity assessed by HAI score were significantly different among the four groups. In the multivariate analysis, the following variables were selected as the independent determinants favorable for achieving a longer disease-free period: younger age, lower indocyanine green retention rate, solitary HCC with expansive growth, no microscopic portal invasion and lower activity of co-existing hepatitis.

CONCLUSIONS

The importance of inflammatory activity in addition to aging, hepatic reserve and tumor characteristics was confirmed as a risk factor for recurrence by multivariate analysis. To achieve better disease-free survival, not only early detection but also suppression of co-existing hepatitis is necessary.

Characterization of lattice defects in strontium titanate single crystals by X-ray topography and transmission electron microscopy

Lattice defects in SrTiO3 single crystals were characterized by X-ray topography and transmission electron microscopy. We examined two groups of crystals whose lapped faces were (001) and (011), respectively. After taking X-ray topographs, crystals which included relatively many defects were chosen for detailed investigation by transmission electron microscopy, which gave the following results: (i) some subgrain boundaries observed by X-ray topography were small-angle tilt boundaries; and (ii) many dislocations were found in the region where thick line contrast was observed in X-ray topographs. Most of them had <100> type Burgers vectors.

Idiopathic benign biliary stricture

A rare case of idiopathic benign biliary stricture is reported. A 50-year-old man with liver dysfunction underwent ultrasonography, which revealed dilation of the intrahepatic bile ducts, and endoscopic retrograde cholangiopancreatography, which revealed a short, ring-like stenosis at the junction of the left and right hepatic ducts. Although a benign stricture was suspected, radiologic tests alone were insufficient to make a firm diagnosis. Therefore, a cholecystectomy and resection of the extrahepatic biliary tract were performed. Microscopic examination of the resected specimen demonstrated no evidence of malignancy. The final diagnosis was mild, localized, chronic cholangitis. The patient had not had previous biliary tract surgery, choledocholithiasis, nor did he have a congenital abnormality of the biliary tract, bile duct carcinoma, or pancreatic disease. Since there was no evidence of primary sclerosing cholangitis, the stricture was considered to be idiopathic.

Additional techniques adopted for major vascular anastomoses during orthotopic liver transplantation

Of 372 patients who underwent liver transplants between January 1985 and March 1995, 7 required variations in vascular anastomoses due to discrepancies in the size-match of the donor and recipient vessels, the presence of a thrombosed hepatic artery or portal vein, or complete absence of the portal vein. The techniques described herein enabled us to perform successful transplantation in all patients. Although rethrombosis of the portal vein developed in one patient after a third transplant, this patient remains clinically well. The use of an operating microscope and the harvesting of an extended length of donor superior mesenteric vein or vascular grafts of the donor iliac or saphenous vessels, for potentially difficult transplants, are invaluable techniques.

Topical cooling assisted hepatic resection of segment 7 and 8 oriented by en-bloc interruption of the targeted portal pedicles

BACKGROUND/AIMS

The crucial points of hepatic segmentectomy include an accurate mapping of proposed segment(s) to be resected and minimization of intra-operative blood loss. This study reports a surgical technique of hepatic resection for segment 7 and 8, and a benefit of supplemental use of topical cooling during consecutive right hepatic inflow occlusion.

METHODOLOGY

From January 1993 to December 1996, ten hepatocellular carcinoma patients with pathologic livers underwent hepatic segmentectomy for segment 7 and 8. The mapping of the target segments was guided by en-bloc test occlusion of the relevant portal pedicles and subsequent discoloration, often after the opening hilum method. Of these, five tumors were resected with topical cooling by ice slush seeding during consecutive right inflow occlusion (cooling group) and the remainder without cooling (Normothermic group). In the normothermic group, inflow occlusion was carried out by cyclic clamping and unclamping method.

RESULTS

The inflow occlusion time was 54 +/- 9.4 min in the cooling group, much longer than in the normothermic group. Although the post-operative peak transaminase values were twice as high as those in the normothermic group, the blood loss was significantly less, and there was no detrimental effect of prolonged, consecutive ischemia on the other intra- and post-operative data.

CONCLUSIONS

En-bloc taping of the target portal pedicles with or without the opening hilum method is useful in the mapping of segments, and the use of topical cooling is beneficial in prolonged inflow occlusion during complicated right-sided segmentectomy.

Laparoscopic partial hepatectomy

This article describes the surgical techniques and indications of laparoscopic partial hepatectomy, which is not as widely available as laparoscopic cholecystectomy. Three patients with hepatocellular carcinoma and associated severe liver cirrhosis were candidates for this technique from July 1993 to August 1994. The tumor size was 4 cm or less and all the tumors were located in segment 5 or 8 which had grown nodularly and protruded from the liver surface. A microwave tissue coagulator was used for parenchymal dissection under ultrasonographic guidance in a gas-less method with or without low-pressure pneumoperitoteum of 4 mmHg. The principle of dissection consists of tissue coagulation and fragmentation with dissecting forceps. Three hepatectomies were performed uneventfully without blood transfusion and the patients rapidly returned to their preoperative conditions. The laparoscopic partial hepatectomy can be an option of treatment in selected cases where the tumor can be removed by minor, superficial resection.

Potential for bilateral nephrectomy to reduce oxalate release after combined liver and kidney transplantation for primary hyperoxaluria type 1

Primary hyperoxaluria type 1 (PH-1) is frequently associated with end stage renal failure due to urinary calculi, obstructive uropathy and interstitial deposits of calcium oxalate. The currently accepted treatment for PH-1 is liver transplantation to replace the deficient enzyme peroxisomal alanine glycoxylate aminotransferase (AGT) and a simultaneous renal transplant to restore renal function. The transplanted kidney may become significantly impaired or fail when systemic calcium oxalate is eliminated by renal excretion. The native kidneys are a major source of this oxalate. This study was undertaken to determine whether there is a difference in oxalate clearance following combined liver-kidney transplant in patients with PH-1 by comparing the effect of native kidney nephrectomy at the time of transplantation against leaving the native kidneys in situ. Regression analysis was used to compare daily urinary oxalate excretion corrected for body surface area. There was a significant reduction in urinary oxalate excretion (P < 0.05) in the patient who had undergone bilateral nephrectomy compared to the patient whose native kidneys remained in situ for the first 100 d following combined liver and kidney transplantation. No difference was observed in the serum oxalate levels between patients over the same period or in the renal function assessed by creatinine clearance corrected for body surface area. Total body oxalate load was not determined in this study. A larger study should be undertaken to examine the benefits of nephrectomy in reducing oxalate deposition in recently inserted allografts for patients with PH-1.

Hepatoprotective effect of a nonselective endothelin receptor antagonist (TAK-044) in the transplanted liver

This study was designed to investigate whether or not a novel nonselective endothelin A/B (ETA/ETB) receptor antagonist (TAK-044) provides hepatoprotection during porcine liver transplantation. The grafts were stored in chilled Euro-Collins solution and recirculated following reflush with lactated Ringer's with (TAK group) or without (control group) TAK-044 (10 mg/kg). Intracellular (cytoplasma, mitochondria, and nucleus) calcium (Ca) concentrations were measured in the hepatic biopsy materials obtained serially at varying time point from donor laparotomy to recipient closure using an electron probe X-ray microanalyzer. Liver function tests also were determined. The cold and warm ischemia times of the grafts were comparable between the two groups. The peak endothelin-1 T-1) concentration after recirculation was significantly higher in the TAK group than in the control group (129 +/- 30 pg/ml vs 26 +/- 6.5 pg/ml). However, release of liver enzymes, increases in total bile acid, and deterioration of indocyanine green retention rate were significantly suppressed in the TAK group. In the control group, the intracellular Ca concentrations, especially in the mitochondrial fraction, were elevated markedly following recirculation of the hepatic arterial flow. In the TAK group, this effect was suppressed. Thus, the supplementary use of the nonselective ETA/ETB receptor antagonist TAK-044 via a rinse route may alleviate an early postreperfusion microcirculatory disturbance of the liver grafts without adverse effects by the increased ET-1 on the systemic circulation.

Sclerosing inflammatory pseudotumor arising from the carotid artery region

We report a 42-year-old female patient with sclerosing inflammatory pseudotumor. She had found a mass in her left neck after she caught a cold. An elastic hard mass (25 x 15 mm), unaccompanied by any other symptoms, was palpated adjacent to the left carotid bifurcation. The mass extended vertically along the common carotid artery, partially adhering to the pulsating artery. Under ultrasonography, the mass was characterized by a homogenized low echoic shadow surrounding the left common carotid artery. Angiography revealed a slight narrowing of the common carotid artery with a surrounding hypovascular mass. Computerized tomography (CT) and magnetic resonance imaging (MRI) both showed a mass enclosing the carotid artery; a Ga scintigram also showed a highly concentrated mass. Surgical removal of the mass included removing part of the carotid artery, internal and external carotid arteries and sympathetic trunk. The left internal jugular vein was transplanted to connect the common carotid artery to the internal carotid artery. Although the hypoglossal and vagus nerves adhered to the mass, they were preserved by sharp dissection with the scalpel. Although hypoglossal and vagus nerve dysfunction were observed temporarily after the surgery, Horner's syndrome appeared and persisted. Histological examination revealed markedly fibrotic tissues surrounding the carotid artery with extensive lymphocyte and plasmacyte infiltration and a diagnosis of sclerosing inflammatory pseudotumor was made.

Correlation of hepatitis virus serologic status with clinicopathologic features in patients undergoing hepatectomy for hepatocellular carcinoma

BACKGROUND

This study investigated the relationship between clinicopathologic features and various viral serologies in patients who underwent hepatectomy in the treatment of hepatocellular carcinoma (HCC).

METHODS

Two hundred two patients were allocated to four groups, according to their positivity or negativity for hepatitis B surface antigen (HBsAg) and hepatitis C virus antibody (HCVAb): Group I (HBsAg[-], HCVAb[+], n = 151), Group II (HBsAg[+], HCVAb[-], n = 27), Group III (HBsAg[-], HCVAb[-], n = 20), or Group IV (HBsAg[+], HCVAb[-], n = 4). The mean age of the HBsAg positive patients (Groups II and IV) was 10 years younger than that of the HBsAg negative patients (Groups I and III).

RESULTS

The male-to-female ratio was higher in HCVAb negative groups (II and III). The HCVAb positive groups (I and IV) had a significantly poorer hepatic reserve and smaller resections than the HCVAb negative groups. Because the tumors were more advanced (as determined by TNM staging) in Group II, the 3-year crude and disease free survival rates were lower in Group II than in Group I. However, HCVAb negative groups (II and III), when compared at 5 years with the limited subsets of patients who had tumors at earlier stages or a curative resection, had significantly better crude and disease free 5-year survival rates than the HCVAb positive group (I).

CONCLUSIONS

Clinicopathologic features differ from one another in accordance with the viral seromarkers in HCC patients. Significantly better crude and disease free survival after complete resection were promising results for patients with non-HCV-related HCC. By comparison, for patients with HCV-related HCC, the risk of intrahepatic recurrences never subsided even in later years after complete resection. Therefore, posthepatectomy follow-up management should be individualized depending on the viral serologic status of HCC patients.

Topical cooling-assisted hepatic segmentectomy for cirrhotic liver with hepatocellular carcinoma

BACKGROUND

A safe limit for normothermic consecutive portal triad occlusion in hepatectomy for the cirrhotic liver was believed to be around 30 minutes. Possibly, the occlusion time can be prolonged by cooling the ischemic liver in vivo. We describe the technique of segmentectomy assisted by topical cooling and its usefulness in prolonging the hepatic inflow occlusion time for cirrhotic livers without causing further ischemic injury.

STUDY DESIGN

Fifty patients with hepatocellular carcinoma and chronic hepatic disease who underwent right-sided segmentectomy under hemihepatic inflow occlusion were divided into two groups: normothermic (n = 27), and hypothermic with hemihepatic topical cooling using ice slush (n = 23). Segmentectomies were carried out in the same way in both groups, guided by initial enbloc ligation of the corresponding portal pedicles.

RESULTS

The mean right hepatic inflow occlusion time was significantly longer in the hypothermic group than in the normothermic group (53 +/- 22 minutes compared with 17 +/- 9.3 minutes). Despite the significant difference in occlusion time, no differences were found in the recovery of hepatic functions and the incidence of postoperative complications between the groups. Intraoperative blood loss was significantly less in the hypothermic group.

CONCLUSIONS

The hepatic right-sided partial inflow occlusion time can safely be prolonged to 60 to 90 minutes in the presence of cirrhosis without causing another injury from ischemia and intermittent reperfusion.

[A case report of aorto-coronary artery bypass surgery in patient with essential thrombocythemia]

Essential thrombocytosis was detected by chance in a 55-year-old patient with angina pectoris when cardiac catheterization was performed. The diagnosis of thrombocytosis (platelet count > 1,000000/mm3) was established by detailed investigations. This patient had stenosis of the coronary arteries and the right common iliac artery. About one month after cardiac catheterization, the patient underwent coronary bypass surgery following normalization of the platelet count with interferon therapy, which was also used to control the platelet count perioperatively. The operation was completed without major problems, and the postoperative course was uneventful. This case is reported in detail.