Indications and outcomes of transjugular intrahepatic portosystemic shunt insertion in two regional Australian hepatology centres

BACKGROUND

Transjugular intrahepatic portosystemic shunt (TIPS) is an important therapy for complications of portal hypertension but remains underutilised in regional settings.

AIMS

The aim of this study is to explore the demographics, indications, outcomes and complications in patients undergoing TIPS in two regional hepatology centres.

METHODS

Retrospective analysis was undertaken of all patients undergoing TIPS at two regional centres between January 2017 and March 2023. The primary outcome measures were efficacy and complications of TIPS. Patient demographics (such as age, baseline liver severity scores and aetiology of liver disease) and indications for TIPS are detailed.

RESULTS

Forty-eight patients underwent TIPS. Median age was 56 years (interquartile range (IQR): 46-65). The most common indications for TIPS were refractory ascites (n = 17) and failure of secondary prophylaxis of variceal bleeding (n = 13). Cumulative survival at 3 months and 1 year was 93% and 77% respectively. There was no significant difference in outcomes based on TIPS indication. The median number of paracenteses in patients undergoing TIPS for refractory ascites 1 year pre- and post-TIPS were 10 (IQR: 4.5-16) and 2 (IQR: 0-4) respectively (P < 0.001). There were no procedure-related deaths. Inpatient management of liver disease complications had a mean cost of $32 874.67 (SEM: 7779) in 1 year pre-TIPS compared with $12 304.70 (SEM: 3531.1) in 1 year post-TIPS (P < 0.001).

CONCLUSIONS

TIPS is a safe and effective treatment to reduce complications of portal hypertension and can be performed successfully in the regional setting.

Efficacy of Tumor Necrosis Factor Antagonist Treatment in Patients With Refractory Ulcerative Proctitis

BACKGROUND & AIMS

It is a challenge to manage patients with ulcerative proctitis (UP) refractory to standard therapy. We investigated the effectiveness of tumor necrosis factor (TNF) antagonists in a large cohort of patients with refractory UP.

METHODS

We conducted a nationwide retrospective cohort study of 104 consecutive patients with active UP refractory to conventional therapies, treated at 1 of 15 centers in France or 1 center in Belgium (the GETAID cohort). Patients received at least 1 injection of anti-TNF (infliximab, adalimumab, golimumab) from October 2006 through February 2017. Clinical response was defined as significant improvement in UC-related symptoms, and remission as complete disappearance of UC-related symptoms, each determined by treating physicians. We collected demographic, clinical, and treatment data. The median duration of follow-up was 24 months (interquartile range, 13-51 months). The primary outcome was clinical response of UP to anti-TNF treatment.

RESULTS

Overall, 80 patients (77%) had a clinical response to anti-TNF therapy and 52 patients (50%) achieved clinical remission. Extra-intestinal manifestations (odds ratio OR, 0.24; 95% CI, 0.08-0.7), ongoing treatment with topical steroids (OR, 0.14; 95% CI, 0.03-0.73), and ongoing treatment with topical 5-aminosalycilates (OR, 0.21; 95% CI, 0.07-0.62) were significantly associated with the absence of clinical remission. Sixty percent (38/63) of the patients who had endoscopic assessment during follow up had mucosal healing. Among the overall population (n = 104), the cumulative probabilities of sustained clinical remission were 87.6% ± 3.4% at 1 year and 74.7% ± 4.8% at 2 years.

CONCLUSIONS

In a retrospective study of 104 patients with refractory UP, anti-TNF therapy induced clinical remission in 50% and mucosal healing in 60%. About two thirds of the patients were still receiving anti-TNF therapy at 2 years.

Oral vancomycin induces sustained deep remission in adult patients with ulcerative colitis and primary sclerosing cholangitis

Ulcerative colitis (UC) is a chronic inflammatory bowel disease of unknown etiology. The treatment of UC is challenging, especially when it is associated with primary sclerosing cholangitis (PSC), a chronic inflammatory disease of the bile ducts that affects around 5% of patients with UC, and leads to an increased risk of cholangiocarcinoma and colorectal cancer. Microbiota is considered to play an important role in the pathogenesis of UC, although the efficacy of antibiotics in this context is only limited and transient. Several studies have investigated the use of antibiotics for the treatment of PSC in adult and pediatric populations, with conflicting results. In this brief report, we describe the effect of oral vancomycin treatment in three patients with UC and PSC refractory to conventional and biologic therapies. All three patients achieved clinical remission and mucosal healing with vancomycin 500 mg twice a day administered orally. Maintenance treatment with oral vancomycin was well tolerated and led to sustained clinical and endoscopic remission in all three patients. Oral vancomycin also improved liver function tests in two patients who did not have pre-existing cirrhosis.

Diagnosis, Natural History and Treatment of Eosinophilic Enteritis: a Review

PURPOSE OF REVIEW

To review recent findings regarding eosinophilic enteritis, including epidemiology, pathogenesis, natural history, and treatment.

RECENT FINDINGS

A 2017 population-based study using a US healthcare system database identified 1820 patients with a diagnosis of eosinophilic enteritis among 35,826,830 individuals. The majority of patients with eosinophilic enteritis in this study were women (57.7%), Caucasian (77.5%), and adults (> 18 years of age) (83.5%). The overall prevalence of eosinophilic enteritis was estimated at 5.1/100,000 persons. Eosinophilic enteritis, also known as eosinophilic gastroenteritis, is a rare primary eosinophilic gastrointestinal disorder (EGID) of unknown etiology characterized by the presence of an intense eosinophilic infiltrate on histopathological examination of the intestinal mucosa. The etiology of eosinophilic enteritis remains unknown. However, there is evidence to support the role of allergens in the pathogenesis of this disorder, as children and adults with EGIDs often have positive skin testing to food allergens and a family history of allergic diseases. Recent studies unraveling the role of IgE-mediated but also delayed Th2-type responses have provided insight into the pathogenesis of this disease. Eosinophilic enteritis causes a wide array of gastrointestinal symptoms such as abdominal pain, diarrhea, nausea, vomiting, bloating, or ascites, and its diagnosis requires a high degree of clinical likelihood, given the nonspecific clinical presentation and physical examination findings. Oral corticosteroids are considered to be the mainstay of treatment and are generally used for a short period with good response rates. Antihistamine drugs and sodium cromoglycate have also been used to treat patients with eosinophilic enteritis. Preliminary studies have demonstrated the potential benefit of biological therapies targeting the eosinophilic pathway such as mepolizumab, an anti-IL5 antibody, or omalizumab, an anti-IgE monoclonal antibody. Eosinophilic enteritis is generally considered to be a benign disease without relapse, but up to 50% of patients may present a more complex natural history characterized by unpredictable relapses and a chronic course.

Stricturing Crohn’s disease-like colitis in a patient treated with belatacept

Cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4) modifying agents have been involved in the development of intestinal inflammation, especially therapeutic monoclonal antibodies directed against CTLA-4. Here we report the appearance of a severe stricturing Crohn’s disease-like colitis in a patient with a kidney allograft who was treated with belatacept, a recombinant CTLA-4-Ig fusion protein.

The role of genetic factors in patients with hepatocellular carcinoma and iron overload - a prospective series of 234 patients

BACKGROUND & AIMS

Iron overload (IO) in HFE-related hereditary haemochromatosis is associated with increased risk of liver cancer. This study aimed to investigate the role of other genes involved in hereditary IO among patients with hepatocellular carcinoma (HCC).

METHODS

Patients with HCC diagnosed in our institution were included in this prospective study. Those with ferritin levels ≥300 μg/L (males) or ≥200 μg/L (females) and/or transferrin saturation ≥50% (males) or ≥45% (females) had liver iron concentration (LIC) evaluated by MRI. HFE C282Y and H63D mutations were screened. Genetic analyses of genes involved in hereditary IO (HFE, HJV/HFE2, HAMP, TFR2, SLC40A1, GNPAT) were performed in patients with increased LIC.

RESULTS

A total of 234 patients were included; 215 (92%) had common acquired risk factors of HCC (mainly alcoholism or chronic viral hepatitis). 119 patients had abnormal iron parameters. Twelve (5.1%) were C282Y homozygotes, three were compound C282Y/H63D heterozygotes. LIC was measured by MRI in 100 patients. Thirteen patients with a LIC>70 μmol/g were enrolled in further genetic analyses: two unrelated patients bore the HAMP:c.-153C>T mutation at the heterozygous state, which is associated with increased risk of IO and severe haemochromatosis. Specific haplotypes of SLC40A1 were also studied.

CONCLUSIONS

Additional genetic risk factors of IO were found in 18 patients (7.7%) among a large series of 234 HCC patients. Screening for IO and the associated at-risk genotypes in patients who have developed HCC, is useful for both determining etiologic diagnosis and enabling family screening and possibly primary prevention in relatives.

Endoscopic treatment of fistula after sleeve gastrectomy: results of a multicenter retrospective study

BACKGROUND AND STUDY AIMS

Fistula is the main complication of laparoscopic sleeve gastrectomy (LSG), for which healing is difficult to achieve. The aims of the study were to evaluate the efficacy of interventional endoscopy for post-LSG fistula treatment, to evaluate various endoscopic techniques used and identify their complications, and to identify predictive factors of healing following endoscopic treatment.

PATIENTS AND METHODS

This retrospective multicenter study included patients with post-LSG fistula. Therapeutic procedures were evaluated, taking into account complications and healing times. Endoscopic procedures were considered to have promoted healing if no other surgical procedure was performed. Predictive factors of healing were identified by univariate and multivariate analysis.

RESULTS

A total of 110 patients were included, of whom 6 (5.5 %) healed spontaneously, 81 (73.6 %) healed following endoscopic treatment, and 19 (17.3 %) healed following surgery. Healing rates following endoscopic treatment were 84.4 % in the first 6 months of treatment (65/77), 52.4 % for treatment lasting 6 - 12 months (11/21), and 41.7 % after 12 months of treatment (5/12). A drainage procedure (surgical, endoscopic, or percutaneous) was performed in 92 patients (83.6 %). A total of 177 esogastric stents were placed in 88 patients (80.0 %). Surgical debridement, clip placement, glue sealing, and plug placement were also performed. Multivariate analysis identified four predictive factors of healing following endoscopic treatment: interval < 21 days between fistula diagnosis and first endoscopy (P = 0.003), small fistula (P = 0.01), interval between LSG and fistula ≤ 3 days (P = 0.01), no history of gastric banding (P = 0.04).

CONCLUSION

Endoscopic treatment facilitated healing of post-LSG fistula in 74 % of patients. Early endoscopic treatment increased the likelihood of success, and was most effective during the first 6 months of management. After this point, surgical treatment should be considered.

Systematic review with meta-analysis: infliximab and immunosuppressant therapy vs. infliximab alone for active ulcerative colitis

BACKGROUND

The benefit of the combination of infliximab (IFX) and immunosuppressant (IS) therapy is debated in ulcerative colitis (UC).

AIMS

To determine whether the combination of IFX and IS therapy is more effective than infliximab alone for active UC regardless of prior IS use.

METHODS

We identified all controlled trials including patients with moderate-to-severe active UC, treated by either IFX or combined IFX-IS therapy. The main outcome was clinical remission at 4-6 months. Two statistical methods were used, Mantel-Haenszel and Der-Simonian and Laird. Inter-trial heterogeneity was taken into account and publication bias was assessed.

RESULTS

Four controlled trials were analysed and included in the meta-analysis. These four trials included 765 patients, 389 treated with IFX alone and 376 treated with IFX and IS. At 4-6 months' therapy, the clinical remission rate was significantly lower for the IFX monotherapy group OR 0.50, 95% CI [0.34-0.73], P < 0.01 (P-heterogeneity = 0.49). The Harbord test did not show evidence of publication bias (P = 0.29). Calculation of an adjusted OR using the Duval and Tweedie method did not significantly modify results [OR 0.63, 95% CI (0.47-0.85)]. According to Orwin's formula, four additional medium-sized nonsignificant studies would be necessary to reduce the effect size to a nonsignificant value. At 12 months of therapy, there was no significant difference between the two groups: OR 0.60, 95% CI [0.17-2.06], P = 0.41 (P-heterogeneity = 0.01).

CONCLUSION

Combination therapy with IFX-IS is more effective than IFX alone for achieving and maintaining clinical remission at 4-6 months for patients with moderate-to-severe ulcerative colitis, regardless of prior IS use.

Human induced pluripotent stem cells in hepatology: beyond the proof of concept

The discovery of the wide plasticity of most cell types means that it is now possible to produce virtually any cell type in vitro. This concept, developed because of the possibility of reprogramming somatic cells toward induced pluripotent stem cells, provides the opportunity to produce specialized cells that harbor multiple phenotypical traits, thus integrating genetic interindividual variability. The field of hepatology has exploited this concept, and hepatocyte-like cells can now be differentiated from induced pluripotent stem cells. This review discusses the choice of somatic cells to be reprogrammed by emergent new and nonintegrative strategies, as well as the application of differentiated human induced pluripotent stem cells in hepatology, including liver development, disease modeling, host-pathogen interactions, and drug metabolism and toxicity. The actual consensus is that hepatocyte-like cells generated in vitro present an immature phenotype. Currently, developed strategies used to resolve this problem, such as overexpression of transcription factors, mimicking liver neonatal and postnatal modifications, and re-creating the three-dimensional hepatocyte environment in vitro and in vivo, are also discussed.

Meta-analysis: beta-blockers versus banding ligation for primary prophylaxis of esophageal variceal bleeding

AIM

To perform an updated meta-analysis comparing β-blockers (BB) with endoscopic variceal banding ligation (EVBL) in the primary prophylaxis of esophageal variceal bleeding.

MATERIAL AND METHODS

Randomized controlled trials were identified through electronic databases, article reference lists and conference proceedings. Analysis was performed using both fixed-effect and random-effect models. Heterogeneity and publication bias were systematically taken into account. Main outcomes were variceal bleeding rates and all-cause mortality, calculated overall and at 6, 12, 18 and 24 months.

RESULTS

19 randomized controlled trials were analyzed including a total of 1,483 patients. Overall bleeding rates were significantly lower for the EVBL group: odds ratio (OR) 2.06, 95% confidence interval (CI) [1.55-2.73], p < 0.0001, without evidence of publication bias. Bleeding rates were also significantly lower at 18 months (OR 2.20, 95% CI [1.04-4.60], P = 0.04), but publication bias was detected. When only high quality trials were taken into account, results for bleeding rates were no longer significant. No significant difference was found for either bleeding-related mortality or for all-cause mortality overall or at 6, 12, 18 or 24 months. BB were associated with more frequent severe adverse events (OR 2.61, 95% CI 1.60-4.40, P < 0.0001) whereas fatal adverse events were more frequent with EVBL (OR 0.14, 95% CI 0.02-0.99, P = 0.05).

CONCLUSION

EVBL appears to be superior to BB in preventing the first variceal bleed, although this finding may be biased as it was not confirmed by high quality trials. No difference was found for mortality. Current evidence is insufficient to recommend EVBL over BB as first-line therapy.

Comparison of hepatic-like cell production from human embryonic stem cells and adult liver progenitor cells: CAR transduction activates a battery of detoxification genes

In vitro production of human hepatocytes is of primary importance in basic research, pharmacotoxicology and biotherapy of liver diseases. We have developed a protocol of differentiation of human embryonic stem cells (ES) towards hepatocyte-like cells (ES-Hep). Using a set of human adult markers including CAAT/enhancer binding protein (C/EBPalpha), hepatocyte nuclear factor 4/7 ratio (HNF4alpha1/HNF4alpha7), cytochrome P450 7A1 (CYP7A1), CYP3A4 and constitutive androstane receptor (CAR), and fetal markers including alpha-fetoprotein, CYP3A7 and glutathione S-transferase P1, we analyzed the expression of a panel of 41 genes in ES-Hep comparatively with human adult primary hepatocytes, adult and fetal liver. The data revealed that after 21 days of differentiation, ES-Hep are representative of fetal hepatocytes at less than 20 weeks of gestation. The glucocorticoid receptor pathway was functional in ES-Hep. Extending protocols of differentiation to 4 weeks did not improve cell maturation. When compared with hepatocyte-like cells derived from adult liver non parenchymal epithelial (NPE) cells (NPE-Hep), ES-Hep expressed several adult and fetal liver makers at much greater levels (at least one order of magnitude), consistent with greater expression of liver-enriched transcription factors Forkhead box A2, C/EBPalpha, HNF4alpha and HNF6. It therefore seems that ES-Hep reach a better level of differentiation than NPE-Hep and that these cells use different lineage pathways towards the hepatic phenotype. Finally we showed that lentivirus-mediated expression of xenoreceptor CAR in ES-Hep induced the expression of several detoxification genes including CYP2B6, CYP2C9, CYP3A4, UDP-glycosyltransferase 1A1, solute carriers 21A6, as well as biotransformation of midazolam, a CYP3A4-specific substrate.

Benefit of combination β-blocker and endoscopic treatment to prevent variceal rebleeding: A meta-analysis

AIM: To determine whether the association of β-blockers with endoscopic treatment is superior to endoscopic treatment alone for the secondary prophylaxis of oesophageal variceal bleeding.

METHODS: Randomised controlled trials comparing sclerotherapy (SCL) with SCL plus β-blockers (BB) or banding ligation (BL) with BL plus BB were identified. Main outcomes were overall and 6, 12 and 24 mo rebleeding rates, as well as overall and 6, 12 and 24 mo mortality. Two statistical methods were used: Yusuf-Peto, and Der Simonian and Laird. Inter-trial heterogeneity was systematically taken into account.

RESULTS: Seventeen randomised controlled trials were included, 14 with SCL and 3 with BL. Combination β-blocker and endoscopic treatment significantly reduced rebleeding rates at 6, 12 and 24 mo and overall [odds ratio (OR): 2.20, 95% confidence interval (CI): 1.69-2.85, P < 0.0001] compared to endoscopic treatment alone. Mortality at 24 mo was significantly lower for the combined treatment group (OR: 1.83, 95% CI: 1.16-2.90, P = 0.009), as well as overall mortality (OR: 1.43, 95% CI: 1.03-1.98, P = 0.03).

CONCLUSION: Combination therapy should thus be recommended as the first line treatment for secondary prophylaxis of oesophageal variceal bleeding.

Investigation of memory B cell responses to hepatitis B surface antigen in health care workers considered as non-responders to vaccination

Up to 20% of health care workers are considered as non-responders to hepatitis B vaccination (anti-HBs<10 m UI/ml in serum). We have explored memory B cells differentiated in vitro into anti-HBs antibody-secreting cells (anti-HBs-SCs) by ELISPOT assay. Anti-HBs-SCs were detected in vaccinated responders (n = 11) and non-responders (n = 10) but IgG anti-HBs-SCs were significantly lower in the non-responder group (p<0.001). Low amounts of HBs antibodies were also quantified by ELISA in non-responders' sera. These results indicate that a suboptimal B cell response exists in non-responders to HBV vaccination. This B cell response may mediate a protection against clinically significant breakthrough hepatitis B infection.

Plasma proteasome level is a reliable early marker of malignant transformation of liver cirrhosis

BACKGROUND

Proteasomes are the main non-lysosomal proteolytic structures which regulate crucial cellular processes. Circulating proteasome levels can be measured using an ELISA test and can be considered as a tumour marker in several types of malignancy. Given that there is no sensitive marker of hepatocellular carcinoma (HCC) in patients with cirrhosis, we measured plasma proteasome levels in 83 patients with cirrhosis (33 without HCC, 50 with HCC) and 40 controls.

METHODS AND RESULTS

Patients with HCC were sub-classified into three groups according to tumour mass. alpha-Fetoprotein (AFP) was also measured. Plasma proteasome levels were significantly higher in patients with HCC compared to controls (4841 (SEM 613) ng/ml vs 2534 (SEM 187) ng/ml; p<0.001) and compared to patients with cirrhosis without HCC (2077 (SEM 112) ng/ml; p<0.001). This difference remained significant when the subgroup of patients with low tumour mass (proteasome level 3970 (SEM 310) ng/ml, p<0.001) was compared to controls and patients with cirrhosis without HCC. Plasma proteasome levels were independent of the cause of cirrhosis and were weakly correlated with AFP levels. With a cut-off of 2900 ng/ml, diagnostic specificity for HCC was 97% with a sensitivity of 72%, better than results obtained with AFP. Diagnostic relevance of plasma proteasome measurement was also effective in low tumour mass patients (sensitivity 76.2% vs 57.1% for AFP).

CONCLUSION

The plasma proteasome level is a reliable marker of malignant transformation in patients with cirrhosis, even when there is a low tumour mass.

Lunate plasty for Kienböck's disease: use of a pedicled vascularised radial bone graft combined with shortening of the capitate and radius

We treated eight patients with Kienböck's disease (two patients each with stage 1, 2, 3a and 3b disease by Lichtman's classification) by removing a pedicled, vascularised bone segment from the dorsal aspect of the distal radius and engrafting it into the lunate. Additional shortening of the radius was performed in patients with the ulna-minus or null variant. Shortening of the capitate and capito-hamate fusion were also performed in patients with stage 3 disease. All patients were relieved of their wrist pain at rest and during movement, and the mean grip strength increased from 37% of that in the contralateral hand before surgery to 80% after surgery. The mean post-operative range of motion in the affected wrist was 92% of that in the opposite wrist in patients with stage 1 and 2 disease, and 53% in patients with stage 3 disease. Post-operative assessment revealed that four patients had excellent results, three had good results, and one had a fair result.

A new model of lung metastasis for intravital studies

We created anexperimental model of pulmonary metastasis based on subcutaneously implanted Lewis lung cancer in mice and observed in vivo the microcirculation of spontaneously metastasized tumors in the lung. The mice lung was held by a small handmade suction ring to stop cardiac and respiratory movement. Using fluorescent microscopy, tumor microcirculation and normal lung microcirculation in the same lung lobe were compared by measuring microvessel diameter and blood flow velocity [red blood cell (rbc) velocity]. In normal microcirculation, the mean values of microvessel diameter and rbc velocity were 10.4 +/- 2.7 microm and 188 +/- 63 microm/s, respectively. In tumor microcirculation, the mean values of the same were 10.6 +/- 3.3 microm and 105 +/- 40 microm/s. The rbc velocity in normal microcirculation was significantly higher (P < 0.001) than that in tumor microcirculation. The calculated shear rates of normal microcirculation and tumor microcirculation were 73.4 +/- 23.4 (/s) and 41.2 +/- 16.1 (/s), respectively. The shear rate of the tumor microcirculation was significantly slower (P < 0.001) than that of the normal microcirculation. We demonstrated a feasibility of observation and measurement of tumor microcirculation in the lung and confirmed that the physiologic data were compatible to those in the brain or in the liver reported by others. This model might be useful for studying metastatic tumor pathophysiology in the lung microcirculation.

Scintigraphic evaluation along with CT and MR images in a case of huge gravitation abscess

The authors presented a rare case of huge gravitation abscess. 67Ga scintigraphy was useful in the evaluation of the extent and activity of the disease. CT showed clearly the location and shape of the abscess. Enhanced MRI showed vertebral lesions as characteristic geographic and ring-like enhancement.

[Experiences of reoperative coronary artery bypass grafting by left thoracotomy without aortic clamping]

We reported two cases which had reoperative coronary artery bypass grafting (CABG) through the left thoracotomy approach without aortic clamping with good results. Case 1. A 50-year-old man, who underwent a double CABG to left anterior descending coronary artery (LAD) and right coronary artery (RCA) in 1983, had a recurrent unstable angina due to new significant stenosis of the diagonal branch (DG) and obtuse marginal branch (OM) in 1989. He was reoperated upon, having a new double CABG to DG and OM through the left thoracotomy using hypothermic ventricular fibrillation without aortic clamping for the myocardial protection without any blood transfusion. Case 2. A 61-year-old man, who underwent a double CABG to LAD and RCA in 1982, had a recurrent unstable angina and a left ventricular aneurysm in 1991. He had a reoperation of a single CABG to OM combined with left ventricular aneurysmectomy by the same approach. Both cases showed satisfactory recoveries of the left ventricular function in the early postoperative period and patent grafts on postoperative angiograms. The left thoracotomy approach is a preferable alternative to median resternotomy for the reoperative CABG to OM, DG and left ventricular aneurysmectomy.

[Myocardial protection during aortic valve replacement: effectiveness of continuous warm blood cardioplegia]

Effectiveness of continuous warm blood cardioplegia (CWBC) during aortic valve replacement (AVR) was studied by comparing with intermittent cold GIK cardioplegia (ICGC) in 32 patients who underwent AVR using CWBC in 16 and ICGC in the other 16 patients. There was no operative nor hospital death in this series. In CWBC group, spontaneous recovery of the heart beat following aortic declamping was seen in 14 of 16 patients (87.5%), in contrast only in 4 of 16 (25%) in ICGC group. During the early postoperative period, left ventricular stroke work index (g.m/beat/m2) significantly increased from 41.0 +/- 14.4 to 55.9 +/- 8.0 (p < 0.001) in CWBC group, whereas no significant increase was found in ICGC group. Right ventricular stroke work index significantly increased only in CWBC group as well. In CWBC group, myocardial oxygen and lactate extraction rates were maintained within normal range during aortic cross-clamping, suggesting satisfactory myocardial preservation with an aerobic metabolism. In conclusion, CWBC is superior to ICGC as a myocardial protection during AVR.

[Repeat open heart surgery using continuous warm blood cardioplegia]

Myocardial protection during repeat open heart surgery still remains to be further improved. The purpose of this study was to evaluate the usefulness of continuous warm blood cardioplegia (CWBC) comparing with intermittent cold GIK cardioplegia (ICGC) in repeat open heart surgery. Twenty-four patients underwent repeat open heart surgery through re-sternotomy (11 mitral, 6 aortic 5 double, 2 congenital) were divided into two groups, that is 10 received CWBC (warm group) and 14 ICGC (Cold group). Spontaneous recovery of heart beat was obtained in 9 of 10 patients (90.0%) in warm group, in contrast only 2 of 14 (14.3%) in cold group (p < 0.001) following aortic declamping. Postoperative peak level of serum CK-MB in warm group (25.9 +/- 7.4 IU/l) was significantly lower than that (83.1 +/- 24.6) in cold group. In warm group left and right ventricular stroke work index significantly increased at 24 hours postoperatively, whereas no significant increase was found in cold group. Postoperative bleeding in the first 24 hours was less (553.8 +/- 38.9 ml) in warm group than that (974.3 +/- 54.1 ml) in cold group. In warm group 3 patients were operated on without homologous blood transfusion, in contrast none in cold group. Our results clearly demonstrated that CWBC was preferable to ICGC for myocardial protection in repeat open heart surgery.

Optical-disk media fabrication for high data-transfer rate

Two media fabrication methods are developed in order to improve the data-transfer rate of optical disks. One is a beam-scanning method for multispiral pregroove recording. A sixfold spiral pregroove with a 1.6-µm spacing can be recorded with this method. The other is a method for fabrication of phase-change optical-disk media that provides signal reading at 670 nm, writing at 830 nm, and high erasability at high linear velocity. The linear recording density of disks fabricated in this way is 1.2 times higher than that of optical disks read at 830 nm, and the erasability is more than 25 dB at 40 m/s. These methods offer the possibility of a data transfer rate 10 times higher than with conventional methods.

[A surgically treated case of aortic arch aneurysm complicated with right middle cerebral artery occlusion]

A 65-year-old male diagnosed as an aortic arch aneurysm by computed tomography and angiography was treated surgically with success. He had had cerebral transient ischemic attack, but no symptoms of central nervous system. Cerebral angiography revealed complete occlusion of the right middle cerebral artery. The aneurysm was resected and replaced with Gelseal knitted Dacron prosthesis under the selective cerebral perfusion combining deep hypothermia. During cardiopulmonary bypass cerebral perfusion pressure was maintained over 50 mmHg, and arterial carbon dioxide tension was controlled by alpha-stat method. To our knowledge this is the first case of surgically treated aortic arch aneurysm complicated with middle cerebral artery occlusion. This experience would be valuable to decide about indication for surgical treatment of an aortic arch aneurysm complicated with cerebral vascular disease.

[Clinical study on transfer into lung tissue of cefminox]

Nineteen patients who underwent pulmonary resection due to lung diseases were administered with 2 g of cefminox (CMNX) by intravenous drip infusion just before surgery. CMNX levels in the serum and lung tissue were determined and pharmacokinetic parameters were derived. The obtained results are summarized as follows: 1. Pharmacokinetic parameter (K1/K2) derived from serum and lung tissue concentrations using deconvolution method was 0.46. 2. CMNX was useful for prophylaxis of postoperative infections with lung resection.

Left ventricular aneurysm, normal coronary arteries and embolization in a patient with systemic lupus erythematosus

We describe a 30-year-old woman with a normal appearing coronary artery associated with SLE who suffered myocardial infarction with left ventricular aneurysm and systemic embolization including cerebral infarctions and saddle embolism. The patient was surgically treated with good results. To our knowledge this is the first reported case of systemic embolism due to myocardial infarction occurring in SLE with a normal coronary artery.

[A clinical experience of continuous warm blood cardioplegia in two cases of repeat aortic valve surgery]

The continuous warm blood cardioplegia (CWBC) was used for myocardial protection during aortic cross clamping in two cases of repeat aortic valve operations with good results. Case 1: A 46-year-old man, who underwent an aortic valve replacement because of the rheumatic aortic regurgitation (AR) in 1978, have suffered from orthopnea due to para-prosthetic valvular regurgitation since 1983. He was revealed to have bi-ventricular hypertrophy with myocardial damage on ECG, EF 0.27 on UCG, PCWP 20 mmHg and severe AR on cardiac catheterization. Case 2: A 43-year-old man, who had an aortic valvuloplasty for the non-rheumatic incompetency in 1981, have had a recurrent regurgitation, resulting in left ventricular hypertrophy accompanied by chest pain. Both cases were reoperated upon, having aortic valve replacement with mechanical prosthetic valves through the re-median sternotomy, utilizing CWBC with good recovery. CWBC provides an ideal circumstances for myocardial oxygen utilization during aortic cross clamping and moreover a benefit that needs not the wide dissection of the heart in a redo case because it has no need of topical cooling and ventricular defibrillation following aortic declamping. In conclusion, CWBC is very useful in a repeat aortic valve surgery.

Influence of coronary artery disease and left ventricular dysfunction on postoperative mortality in vascular surgery

In an attempt to assess the influence of coronary artery disease and left ventricular dysfunction on postoperative mortality, 107 patients consisting of 32 AAA resections and 44 aortoiliac and 31 femoropopliteal reconstructions were reviewed. All patients had a preoperative coronary angiograms and underwent cardiac catheterization to prevent cardiac-related deaths. Severe coronary artery disease was angiographically demonstrated in 40.6% of AAA, 31.8% of AI and 3.2% of FP patients. Severe left ventricular dysfunction was found in 21.9% of AAA, 18.2% of AI and 6.5% of FP. Both of the early and 5 (45.5%) of the 11 late deaths were caused by cardiac events. The nine-year survival rate (53.3%) in the patients with a documented combination of coronary artery disease and left ventricular dysfunction was significantly lower than those in patients with normal disease, normal left ventricular function and either documented coronary artery disease or left ventricular dysfunction. It is suggested from this series that left ventricular dysfunction is one of the most important risk factors in patients who undergo AAA resection and AI reconstruction and that severe disease and postoperative mortality are possibly reduced by certain kinds of interventional coronary therapies.

[Successfully treated intraoperative coronary artery spasm in a patient with type B dissecting aortic aneurysm: a case report]

A 65-year-old man with chronic type B dissecting aortic aneurysm, complicated by variant from of angina pectoris without any coronary artery obstructed disease on preoperative angiogram was operated upon through left posterolateral thoracotomy under the left heart bypass with Bio-pump system using preoperative Ca antagonists and intraoperative nitroglycerin infusion. Shortly before the end of operation the patient suddenly developed shock status definitely due to coronary artery spasm, associated with ST-elevation in II, III, aVF and bradycardia, then ventricular tachycardia, finally cardiac arrest. The patient was resuscitated by cardiac massage and administration of nifedipine and nitroglycerin. Such attacks repeated five times at ten or twenty minutes intervals. The coronary artery spasm could be successfully suppressed with the additive use of noradrenaline infusion. The patient had no attacks at all postoperatively and was discharged with good success. This case suggests that the prevention of intraoperative coronary artery spasm is essential, but if it occurs, additive use of noradrenaline infusion is effective for the cessation of coronary artery spasm.

[Coronary artery bypass grafting in patients with severe left ventricular dysfunction: internal mammary artery vs saphenous vein, evaluation immediately after surgery]

Comparative studies of the changes in left ventricular (LV) function immediately after aortocoronary bypass graftings (CABG) and early postoperative results were carried out in two groups of patients with severe LV dysfunction (ejection fraction less than 0.4), which consisted of 9 patients received internal mammary artery grafts (IMAG) to at least LAD and 14 with saphenous vein grafts (SVG) only. The utilization of IMAG was limited to the patients with stable preoperative hemodynamics, whereas SVGs were used even in the emergency CABG. Free flow of IMAG measured during operation was 55.7 +/- 25.5 ml/min, which was significantly lower than that (83.5 +/- 27.3) of SVG to LAD. Cardiac index, LV stroke volume index and LV stroke work index immediately after surgery were sufficiently maintained and recovered almost similarly in both groups. Postoperative peak CK-MB (19.7 +/- 10.4 IU/L) in IMAG group was significantly lower than that (23.9 +/- 10.7) in SVG group. There was no significant difference between the two groups in the incidences of postoperative IABP and noradrenaline dependence. There were two hospital deaths in SVG group, whereas no hospital death was experienced in IMAG group. These results indicate that an application of IMAG to LAD in the patients with severe LV dysfunction surely induces satisfactory recovery of hemodynamics immediately after CABG as well as SVG, provided that use of IMAG is limited to the patients with stable preoperative hemodynamics.

[Arachidonic acid metabolism and effectiveness of aprotinin treatment during cardiopulmonary bypass]

Arachidonic acid metabolism was investigated in 30 open heart cases, utilizing nonpulsatile cardiopulmonary bypass (CPB), consisted of 15 untreated cases (Group I) and 15 cases treated with aprotinin mostly given into CPB circuit during CPB (Group II). In group I, arterial blood concentration of thromboxane B2 (TXB2, stable metabolite of thromboxane A2, pg/ml) significantly increased from 45.9 +/- 40.5 preoperatively to 560.2 +/- 381.5 (p less than 0.01) at 30 minutes of CPB (total bypass) and to 830.5 +/- 591.1 (p less than 0.005) at the end of CPB (partial bypass). TXB2 levels in pulmonary artery (PA) and left atrium (LA) did not significantly increase just before, 5 minutes of CPB as compared with preoperative value. At the end of CPB TXB2 levels in PA (625.0 +/- 186.3) and LA (817.0 +/- 320.0) were significantly higher than preoperative value. However there was no significant difference between PA and LA values. Contrarily in group II TXB2 levels were significantly suppressed as compared with the value at each corresponding time in group I. beta-thromboglobulin levels also changed almost parallel to TXB2 levels in both groups. In conclusion, arachidonic acid metabolic disorders could occur in CPB circuit rather than in pulmonary circulation during CPB. Aprotinin administration into CPB circuit suppressed to some extent the platelet activation.

[Acute occlusion of the iliac arteries due to blunt trauma]

Two cases of acute iliac occlusion due to blunt trauma are presented. The cause of injuries were a fall from bicycle in case 1 and a compression between an automobile and a wall in case 2. The end-to-end anastomosis was possible in case 2, but an interposition of an artificial prosthesis was necessary because of the length of damaged artery in case 1. Both cases were associated with the pelvic fracture, adding the perforation of small bowels and the bladder in case 2. Postoperative course was almost uneventful except fasciotomy was needed for the compartment syndrome of the right lower extremity in case 2.

[A young female case with simultaneous bilateral spontaneous pneumothorax operated upon submammarian incision for median sternotomy]

One of the characteristics of pneumothorax in female is considerably complicated with menses, histiocytosis X, diffuse pulmonary hamartoangiomyomatosis. So during thoracotomy, the thoracic cavity must be examined, as well as the hole of the diaphragm. And especially in female aesthetic attention is also required. A transverse submammarian skin incision with median sternotomy was used in a 18-year-old female with simultaneous bilateral pneumothorax. This approach was useful for the median sternotomy as well as more excellent aesthetics.

Effects of aprotinin on prostaglandin metabolism and platelet function in open heart surgery

The effects of the protease inhibitor, aprotinin, on plasma prostaglandin levels and platelet function during and after cardiopulmonary bypass (CPB) were studied in a group of 23 patients which consisted of 11 untreated patients (control group) and 12 aprotinin-treated patients (aprotinin group). Thromboxane B2 (TXB2, a stable metabolite of thromboxane A2) and beta-thromboglobulin levels in the control group increased significantly during CPB compared with preoperative values. These increases were significantly suppressed in the aprotinin group. 6-Keto-PGF1 alpha (stable metabolite of prostacyclin) increased significantly during CPB in both groups, and there was no significant difference between the two groups. In the aprotinin group, the TXB2/6-Keto-PGF1 alpha ratio decreased significantly during CPB compared with the preoperative value, whereas no significant decrease was observed in the control group. Platelet counts decreased significantly during and after CPB in both groups. Platelet aggregability decreased significantly during CPB in the control group, whereas no significant decrease was found in the aprotinin group. In conclusion, aprotinin treatment improved prostaglandin metabolism and preserved platelet function during open heart surgery.

[A case report of chest wall reconstruction utilizing microvascular surgery]

A 62-year-old man underwent left chest wall reconstruction after resection of the chest wall including 4-6th ribs for the metastatic tumor of squamous cell carcinoma of the left lung. The chest wall defect measuring 15 x 10 cm was reconstructed with double Marlex mesh in skeletal chest and covered with pedicled free mucocutaneous flap of tensor fasciae latae which was implanted by the vascular anastomoses to the thoracodorsal artery and vein using microvascular surgical technique. The flap was attached well and its blood supply was excellent on postoperative angiography.

Preservation of pancreatic beta cell function with pulsatile cardiopulmonary bypass

Pancreatic islet cell function and tissue metabolism were studied during and after cardiopulmonary bypass in 38 patients undergoing an open heart operation. Twenty patients were operated on with pulsatile cardiopulmonary bypass (group I) and 18, with nonpulsatile cardiopulmonary bypass (group II). Hyperglycemia was observed during and early after operation in both groups. In group I during cardiopulmonary bypass, the immunoreactive insulin and c-peptide levels and the insulin to glucagon molar ratio increased significantly compared with the preoperative values, but in group II, these variables did not alter significantly. An hour postoperatively, the immunoreactive insulin (71 +/- 34 muIU/mL) and c-peptide (8.3 +/- 3.0 ng/mL) levels and the insulin to glucagon molar ratio (11.0 +/- 5.2) in group I were significantly higher than those in group II (immunoreactive insulin, 29 +/- 20 muIU/mL; c-peptide, 4.8 +/- 1.8 ng/mL; insulin to glucagon molar ratio, 3.4 +/- 2.6). The blood lactate level in group I (41 +/- 22 mg/dL) was significantly lower than that in group II (78 +/- 30 mg/dL) an hour postoperatively. In conclusion, pulsatile cardiopulmonary bypass is quite effective in preserving pancreatic beta cell function and tissue metabolism during and early after open heart procedures.

[Clinical examination of resected cases of lung cancer with pleural dissemination]

Preoperative examination using chest computed tomography (CT) of cases with pleural dissemination and no pleural effusion revealed small disseminated nodules of the visceral pleura. However, chest CT could not exactly diagnose those of the parietal pleura. The indications of operation, especially pan-pleuropneumonectomy, for cases with pleural dissemination should be limited to the following cases; those in which no pleural effusion and no metastasis to the mediastinal lymphnodes has been clinically proved and in which it is not necessary to perform extensive combined resection other than pan-pleurectomy and partial resection of the diaphragm and/or pericardium. Well differentiated histological types of lung cancer are better indications for surgical treatment.

Gastric plasmacytoma with cylindrical crystalline inclusions

An 81 year-old female case of extramedullary plasmacytoma of the stomach is reported. Immunohistochemically, the tumor cells contained IgM-lambda immunoglobulin. Electron micrographs of the tumor cells showed centrally located nuclei with nuclear inclusions and cytoplasm filled with crystalline inclusions in the rough endoplasmic reticulum. IgM-lambda producing gastric plasmacytoma with cylindrical inclusions is rare.

The association of pyoderma gangrenosum with ulcerative colitis in Japan

A patient with pyoderma gangrenosum (PG) and ulcerative colitis (UC) is described. He had melena and systemic skin lesions. The skin lesions consisted of small discrete ulcers on the back and head and large punched-out ulcers on the legs. He was successfully treated with prednisolone and salazosulfapyridine. He became asymptomatic after two weeks' treatment. Although the association of PG with UC is well documented among Caucasians, it is very rare among Japanese.

LAV/HTLV-III antibodies in patients treated with intravenous gammaglobulins

The test sera from 50 patients treated with intravenous gammaglobulins (IVG) were examined for LAV/HTLV-III antibody by ELISA tests in order to evaluate the risk of transmission of LAV/HTLV-III virus via administration of IVG. The three ELISA-positive sera were negative for the antibody by both indirect immunofluorescence assay (IFA) and Western blot assay (WBA). Thus, all of the test sera were negative for LAV/HTLV-III antibody. Two of the ELISA-positive/IFA-negative/WBA-negative samples had HLA-DR4 antibodies causing positive ELISA results.

Agammaglobulinemia in a pregnant woman

A case of common variable immunodeficiency in a pregnant woman is presented. Lobar pneumonia developed in the sixth month of the pregnancy and her serum immunoglobulin levels were found to be extremely low. She was treated successfully with immune human serum globulin and antibiotics. She delivered a full-term baby without any troubles. Various immunologic studies were done in the peripheral blood of the patient and the neonate. Consequently, functional abnormalities of helper T cells were considered to be responsible for the hypogammaglobulinemia.

T-Lymphocyte subpopulations in hemophiliac patients

Laboratory data are presented on 15 patients with hemophilia A. Mean OKT4/OKT8 ratio in hemophiliac patients was significantly lower than in the controls. Although no patients with acquired immunodeficiency syndrome (AIDS) have been found in Japan, hemophiliac patients are supposed to be at increased risk of AIDS by our studies.

Autoantibodies, including antibasement membrane antibody, in patients with selective IgA deficiency

Laboratory data are presented on 48 patients with selective IgA deficiency. Sixty percent of the patients had autoimmune diseases or related disorders. We found antibasement membrane antibody (ABMA) in the sera of four IgA deficient patients and the incidence of ABMA seemed to be related to clinical symptoms. The incidence of various other antibodies was found to be increased in selective IgA deficiency. This phenomenon might be derived from the lack of local immune system. Inadequate IgA barrier might permit the exessive gastrointestinal absorption of food antigens or autoimmunogens in metabolic products which are excreted into the gut lumen.

IgM-producing gastric plasmacytoma

A case of gastric plasmacytoma is reported in an 81-year-old woman. Immunofluorescent and immunoelectrophoretic studies showed that the tumor cells produced IgM-lambda molecules, whereas no monoclonal immunoglobulin could be detected both in the serum and in the urine. Of more than 60 reported cases of gastric plasmacytoma, only a few reports referred to the production of monoclonal immunoglobulin by the tumor cells. This case is the first one of IgM-producing gastric plasmacytoma. Moreover, the produced IgM was found to be 7S-IgM. It is extremely rare that 7S-IgM alone is detected in the absence of 19S-IgM.