Ramucirumab plus FOLFIRI as second-line treatment for patients with RAS wild-type metastatic colorectal cancer previously treated with anti-EGFR antibody: JACCRO CC-16

BACKGROUND

Chemotherapy in combination with anti-epidermal growth factor receptor (EGFR) antibody is considered a first-line treatment regimen for RAS wild-type and left-sided metastatic colorectal cancer (mCRC), whereas second-line treatment regimens have not yet been established. Few studies have prospectively evaluated second-line treatment with anti-vascular endothelial growth factor antibody after first-line anti-EGFR antibody therapy for RAS wild-type mCRC.

PATIENTS AND METHODS

This non-randomized phase II trial investigated the clinical outcomes of second-line ramucirumab (RAM) plus fluorouracil, levofolinate, and irinotecan (FOLFIRI) after first-line anti-EGFR antibody in combination with doublet or triplet regimen in patients with RAS wild-type mCRC. The primary endpoint was the 6-month progression-free survival (PFS) rate. The secondary endpoints were PFS, overall survival (OS), objective response rate (ORR), rate of early tumor shrinkage (ETS), and safety. We hypothesized a threshold 6-month PFS rate of 30% and an expected 6-month PFS rate of 45%. Treatment was considered effective if the lower limit of the 90% confidence interval (CI) of the 6-month PFS rate was >0.30.

RESULTS

Ninety-two patients were enrolled in the study. The primary tumor was located on the left side in 86 (95.6%) patients. Twenty (22.0%) patients had received triplet plus cetuximab as previous therapy. Six-month PFS rate was 58.2% (90% CI 49.3% to 66.2%) with a median PFS of 7.0 months (95% CI 5.7-7.6 months). Median OS was 23.6 months (95% CI 16.5-26.3 months). The ORR and ETS rate were 10.7% and 16.9%, respectively, in 83 patients with measurable lesions. The 6-month PFS rate was comparable between patients previously treated with doublet and triplet regimens; however, median PFS was longer for the doublet regimen (7.4 versus 6.4 months, P = 0.036).

CONCLUSIONS

Our study demonstrated prospectively that RAM plus FOLFIRI is an effective second-line treatment after anti-EGFR antibody-containing first-line therapy in RAS wild-type and left-sided mCRC. Furthermore, the results were similar for patients who were previously treated with triplet regimen.

Prognostic significance of CD8+ tumor‑infiltrating lymphocytes and CD66b+ tumor‑associated neutrophils in the invasive margins of stages I‑III colorectal cancer

Tumor-infiltrating immune cells play an essential role in cancer progression and may help supplement the Tumor, Node, Metastasis (TNM) classification for cancer prognosis. Currently, there are numerous conflicting reports discussing the significance of tumor-associated neutrophils (TANs) in colorectal cancer (CRC). In particular, the role of TANs in the invasive margin is unclear. The present study investigated the prognostic significance of CD66⁺ TANs and CD8⁺ tumor-infiltrating lymphocytes (TILs) in the invasive margin of 103 patients with CRC. By using immunohistochemistry, survival analysis was performed on CD8⁺ TILs and CD66⁺ TANs individually, as well as models including TILs and TANs simultaneously. The findings indicated that the densities of CD8⁺ TILs and CD66b⁺ TANs in the invasive margin may provide significant prognostic value for predicting survival. Moreover, the combined evaluation of CD8⁺ TILs and CD66b⁺ TANs in the invasive margin could further improve the validity for the prediction of oncological outcomes. In addition, multivariate analysis revealed that simultaneous low tumor infiltration by CD8⁺ TILs and CD66b⁺ was an independent predictive factor for overall survival (HR=4.17, 95% CI, 1.55-12.5; P=0.004) and disease-free survival (HR=2.75, 95% CI, 1.27-6.12; P=0.01). Given the importance of CD8⁺ TILs and CD66b⁺ TANs in the tumor microenvironment, the assessment of their densities in the invasive margin may serve as a valuable prognostic marker for CRC.

The advanced lung cancer inflammation index predicts outcomes in patients with Crohn's disease after surgical resection

AIM

Precise biomarkers for predicting prognosis could help to identify high-risk Crohn's disease (CD) patients to facilitate better follow-up during the postoperative course. In this study, the primary aim is the identification of the most reliable nutrition marker that predicts surgical relapse in CD patients.

METHOD

We first evaluated the predictive value of various nutrition markers for postoperative surgical relapse in CD patients and identified the advanced lung cancer inflammation index (ALI) as a promising biomarker. Then, we assessed the clinical significance of preoperative ALI in CD patients using two cohorts.

RESULTS

Preoperative ALI showed the highest correlation with reoperation rate compared with other nutritional parameters in CD patients receiving surgical resection (sensitivity 53%, specificity 86%, area under the curve 0.71). Lower levels of preoperative ALI were significantly correlated with the presence of perianal disease. A lower level of preoperative ALI was an independent prognostic factor for reoperation rate after an intestinal resection (hazard ratio 3.37, 95% CI 1.38-10.12, P = 0.006), and the prognostic impact of preoperative ALI was successfully validated in an independent cohort using the same cut-off value.

CONCLUSION

Preoperative ALI might be useful for postoperative management of CD patients.

The association between 11C-methionine uptake, IDH gene mutation, and MGMT promoter methylation in patients with grade II and III gliomas

AIM

To evaluate the association between ¹¹C-methionine positron-emission tomography (¹¹C-methionine PET) findings, isocitrate dehydrogenase (IDH) gene mutation, and O⁶-methylguanine-DNA methyltransferase (MGMT) promoter methylation in patients with grade II and III gliomas.

MATERIALS AND METHODS

Data were collected from 40 patients with grade II and III gliomas who underwent both magnetic resonance imaging (MRI) and ¹¹C-methionine PET as part of their pre-surgical examination. IDH mutation was examined via DNA sequencing, and MGMT promoter methylation via quantitative methylation-specific polymerase chain reaction (PCR).

RESULTS

A threshold of MGMT promoter methylation of 1% was significantly associated with tumour/normal tissue (T/N) ratio. The T/N ratio in samples with MGMT promoter methylation ≥1% was higher than that in samples with MGMT promoter methylation <1%, and the difference was statistically significant (p=0.011). Reliable prediction of MGMT promoter methylation (<1% versus ≥1%) was possible using the T/N ratio under the receiver operator characteristic (ROC) curve with a sensitivity and specificity of 75% each (cut-off value=1.6: p=0.0226, area under the ROC curve [AUC]=0.76172). Conversely, the T/N ratio had no association with IDH mutation (p=0.6). The ROC curve revealed no reliable prediction of IDH mutation using the T/N ratio (p=0.606, AUC=0.60577).

CONCLUSION

¹¹C-methionine PET parameters can predict MGMT promoter methylation but not IDH mutation status. ¹¹C-methionine uptake may have limited potential to reflect DNA methylation processes in grade II and III gliomas.

P1782Synchrotron-based 4D-X-ray Phase Tomography of fresh chordae tendineae of mitral valve

Background

Mechanical properties of chordae tendineae of mitral valve (MV) are still not fully investigated. Synchrotron-based X-ray phase tomography (XPCT) is a powerful tool to measure biological soft tissues. Recently, we have developed dynamic X-ray phase tomography (4D-XPCT) to discuss the dynamic phenomena of biological samples quantitatively and applied to chordae tendineae of MV (MVCT).

Purpose

This study evaluated 4-dimensional changes of MVCT and clarified structural changes of MVCT during cardiac cycles.

Methods

The X-ray energy for 4D XPCT was set to 20keV. The effective pixel size was 7.8μm. Fresh MVCT extracted from a pig heart were measured in the specially designed container filled with normal cold saline. MVCT installed on the sample stage was stretched and released with a continuous oscillation of 0.5Hz during a phase tomographic measurement. The amount of stretch was 400μm where a mechanical load caused by stretching was approximately 1N. In this measurement, projection images were acquired with a frame rate of 20Hz during a single sawtooth wave. Therefore, apparent frame rate of 20Hz is expected in 4D phase tomography. Cross section was determined by simple thresholding based on the density. In this case, the threshold was set to 1.018g/cm3.

Results

X-ray phase tomographic images of MVCT at the released (A) and stretched (B) conditions are shown in Fig. 1a. The load applied to the sample and change of the cross section obtained from tomography during stretching and releasing are shown in Fig. 1b and 1c, respectively. The diameter of chordae tendinea were changed approximately 2.5% during stretching and returned to initial diameter during releasing.

Figure 1

Conclusions

This result demonstrated that the 4D-XPCT had a capability to trace the detail of deformation process in the biological soft tissues during continuous oscillation. Even chordae tendinea are mainly consisted of collagen fibers, diameter of the chordae was changed according to stretching and releasing.

P5599Prognostic impact of quality indicators on outcomes of acute aortic dissection in Japan

Background

Despite recent advances in diagnosis and management, the mortality of acute aortic dissection (AAD) remains high.

Purpose

This study aims to develop quality indicators (QIs) for the management of AAD, and to evaluate the associations between QIs and outcomes of AAD in a Japanese nationwide administrative database.

Methods

A total of 18,348 patients suffered from AAD (Type A: 10,131, Type B: 8,217) in the Japanese Registry of All Cardiac and Vascular Diseases database between 2012 and 2015 were studied. A systematic review was performed to establish initial index items for QIs. Evaluation was performed through the expert consensus meeting using a Delphi method. Associations between developed QIs and the mortality were determined by multivariate mixed logistic regression analyses.

Results

A total of nine QIs (five structural and four processatic) were developed. Achievements of developed QIs (High: 7–9, Middle: 4–6, Low: 0–3) were significantly associated with lower in-hospital mortality even after adjustment for covariates in both type A (Middle: odds ratio [OR], 0.257; 95% confidence interval [CI], 0.211–0.312; P<0.001; High: OR, 0.064; 95% CI, 0.047–0.086; P<0.001 vs. Low) and type B (Middle: OR, 0.447; 95% CI, 0.338–0.590; P<0.001; High: OR, 0.128; 95% CI, 0.077–0.215; P<0.001 vs. Low). Additionally, achievements of structural and processatic QIs were consistently associated with reduced in-hospital mortality.

QIs and in-hospital mortality

Conclusions

Developed QIs for AAD management were significantly associated with lower in-hospital mortality. Evaluation of each hospital's management with QIs could be helpful to equalize quality of treatment and to fill the evidence-to-practice gaps in the real-world treatment.

Effects of postoperative dietary intake on functional recovery of patients undergoing cardiac surgery

BACKGROUND AND AIM

Among elderly patients undergoing cardiac surgery, malnutrition is very common and related to muscle wasting known as sarcopenia. Cardiac surgery causes a further decline of nutritional status due to reduced dietary intake (DI); however, the impact of postoperative DI on functional recovery is unclear.

METHODS AND RESULTS

We enrolled 250 consecutive patients undergoing cardiac surgery. Daily DI was measured between postoperative days 3 and 7. Patients were categorized as having sufficient or insufficient DI based on whether their DI met or was less than estimated total energy requirements. Functional capacity was measured using the 6-minute walking distance (6MWD) preoperatively and at discharge. Mean postoperative DI was 22.4 ± 3.0 kcal/kg/day, and postoperative DI was insufficient in 92 patients (36.8%). The prevalence of sarcopenia was not different by postoperative DI. Although there was no significant difference in preoperative 6MWD results (P = 0.65), the sufficient DI group had longer 6MWD at discharge than the insufficient DI group (P = 0.04). In multivariate regression analysis, preoperative poor nutritional status (β = -0.29), duration of surgery (β = -0.18), and postoperative DI (β = 0.40) remained statistically significant predictors for improvement of 6MWD (P < 0.0001, adjusted R² = 0.41).

CONCLUSIONS

Postoperative DI was independently associated with functional recovery, but preoperative sarcopenia was not. Regardless of preoperative nutritional status or the presence of sarcopenia, aggressive nutritional intervention in the early stage after surgery helps support functional recovery.

Randomized evaluation of fibrinogen vs placebo in complex cardiovascular surgery (REPLACE): a double-blind phase III study of haemostatic therapy

BACKGROUND

Single-dose human fibrinogen concentrate (FCH) might have haemostatic benefits in complex cardiovascular surgery.

METHODS

Patients undergoing elective aortic surgery requiring cardiopulmonary bypass were randomly assigned to receive FCH or placebo. Study medication was administered to patients with a 5 min bleeding mass of 60-250 g after separation from bypass and surgical haemostasis. A standardized algorithm for allogeneic blood product transfusion was followed if bleeding continued after study medication.

RESULTS

519 patients from 34 centres were randomized, of whom 152 (29%) met inclusion criteria for study medication. Median (IQR) pretreatment 5 min bleeding mass was 107 (76-138) and 91 (71-112) g in the FCH and placebo groups, respectively (P=0.13). More allogeneic blood product units were administered during the first 24 h after FCH, 5.0 (2.0-11.0), when compared with placebo, 3.0 (0.0-7.0), P=0.026. Fewer patients avoided transfusion in the FCH group (15.4%) compared with placebo (28.4%), P=0.047. The FCH immediately increased plasma fibrinogen concentration and fibrin-based clot strength. Adverse event rates were comparable in each group.

CONCLUSIONS

Human fibrinogen concentrate was associated with increased allogeneic blood product transfusion, an unexpected finding contrary to previous studies. Human fibrinogen concentrate may not be effective in this setting when administered according to 5-minute bleeding mass. Low bleeding rates and normal-range plasma fibrinogen concentrations before study medication, and variability in adherence to the complex transfusion algorithm, may have contributed to these results.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov identifier no. NCT01475669; EudraCT trial no. 2011-002685-20.

Surgical strategy of esophageal resection and reconstruction for aortoesophageal fistula

Aortoesophageal fistula is a critical and life-threatening disease. The cardiovascular strategy for graft replacement has been widely discussed. However, the surgical strategy of esophageal resection and reconstruction for aortoesophageal fistula has rarely been discussed. The objective of this study is to establish a surgical strategy and procedure of esophageal resection and reconstruction for aortoesophageal fistula. Eleven patients with aortoesophageal fistula who underwent aortic graft replacement and esophagectomy between 2008 and 2015 at Kobe University Hospital were enrolled in this study. Patient characteristics, operative methods, and clinical outcomes were obtained by retrospective chart review. All 11 patients underwent graft replacement, esophagectomy, and omental wrapping. Ten esophagectomies were simultaneously accomplished in the same operative field as aortic graft replacement. Seven patients underwent subtotal esophagectomy from a left thoracotomy, and three patients underwent upper hemiesophagectomy from a median sternotomy. The other patient underwent staged esophagectomy from a right thoracotomy. Seven of 11 patients (63.6%) successfully underwent staged esophageal reconstruction. Pedicled jejunal transfer with supercharge and superdrainage were performed in six patients, and ileocecal reconstruction was performed in one patient. Median survival time in the patients with esophageal reconstruction was 21 months while that in the patients without esophageal reconstruction was 10 months. Six of 7 patients (85.7%) who underwent esophageal reconstructions were alive. Our surgical strategy for aortoesophageal fistula, which includes simultaneous graft replacement and esophagectomy in the same operative field and staged reconstruction by pedicled jejunal transfer to ensure omental wrapping, is feasible and promising.

Diagnostic and Prognostic Value of 11C-Methionine PET for Nonenhancing Gliomas

BACKGROUND AND PURPOSE

Noninvasive radiologic evaluation of glioma can facilitate correct diagnosis and detection of malignant transformation. Although positron-emission tomography is considered valuable in the care of patients with gliomas, (18)F-fluorodeoxyglucose and (11)C-methionine have reportedly shown ambiguous results in terms of grading and prognostication. The present study compared the diagnostic and prognostic capabilities of diffusion tensor imaging, FDG, and (11)C-methionine PET in nonenhancing gliomas.

MATERIALS AND METHODS

Thirty-five consecutive newly diagnosed, histologically confirmed nonenhancing gliomas that underwent both FDG and (11)C-methionine PET were retrospectively investigated (23 grade II and 12 grade III gliomas). Apparent diffusion coefficient, fractional anisotropy, and tumor-to-normal tissue ratios of both FDG and (11)C-methionine PET were compared between grade II and III gliomas. Prognostic values of these parameters were also tested by using progression-free survival.

RESULTS

Grade III gliomas showed significantly higher average tumor-to-normal tissue and maximum tumor2-to-normal tissue than grade II gliomas in (11)C-methionine (P = .013, P = .0017, respectively), but not in FDG-PET imaging. There was no significant difference in average ADC, minimum ADC, average fractional anisotropy, and maximum fractional anisotropy. (11)C-methionine PET maximum tumor-to-normal tissue ratio of 2.0 was most suitable for detecting grade III gliomas among nonenhancing gliomas (sensitivity, 83.3%; specificity, 73.9%). Among patients not receiving any adjuvant therapy, median progression-free survival was 64.2 ± 7.2 months in patients with maximum tumor-to-normal tissue ratio of <2.0 for (11)C-methionine PET and 18.6 ± 6.9 months in patients with maximum tumor-to-normal tissue ratio of >2.0 (P = .0044).

CONCLUSIONS

(11)C-methionine PET holds promise for World Health Organization grading and could offer a prognostic imaging biomarker for nonenhancing gliomas.

Prediction of reversibility of intestinal mucosal damage after ischemia-reperfusion injury by plasma intestinal fatty acid-binding protein levels in pigs

Objective:

The aims of this study were to elucidate the association between plasma intestinal fatty acid-binding protein (I-FABP) level and actual pathological damage of intestinal mucosa and its reversibility.

Methods:

An intestinal ischemia-reperfusion model was created by temporary occlusion of the descending aorta in 9 pigs which were divided into 3 groups according to the duration of visceral ischemic insult: 15-minute ischemia (n=3), 30-minute ischemia (n=3) and 60-minute ischemia (n=3). Blood samples and short segments of the jejunum for pathological examinations, including immunohistochemical staining of I-FABP, Ki-67 and E-cadherin, were taken at the beginning of the operation (T1) and 15 minutes (T2), 30 minutes (T3), 45 minutes (T4) and 60 minutes (T5) after reperfusion.

Results:

Plasma I-FABP after 15 minutes of ischemia reached a peak of 1859±1089 pg/ml at T3, while the level after 30 minutes of ischemia achieved a peak level of 5053±1717 pg/ml at T5. The level after 60 minutes of ischemia demonstrated a rapid increment up to 10734±93 pg/ml at T3. There was a significant difference in the trend of plasma I-FABP levels between 30 minutes and 60 minutes of ischemia (p=0.01). The strongest immunohistochemical staining of the intestinal epithelium for I-FABP was observed at T4 after 30 minutes of ischemia, with the shedding of injured epithelium followed by re-epithelialisation, with sequential up-regulation of Ki67 and E-cadherin. However, the intestinal epithelium after 60 minutes of ischemia demonstrated the lack of I-FABP expression with irreversible damage.

Conclusion:

Plasma I-FABP levels may be a crucial marker to recognize the reversibility of damage of the intestinal epithelium after an ischemic insult and the level of 5000 pg/ml is considered to be the critical borderline for irreversibility, which might prevent diagnostic delay in the clinical setting.

Characteristics of flexed knee gait and functional outcome of a patient who underwent knee reconstruction with a hingeless prosthesis for bone tumor resection: a case report with gait analysis and comparison with healthy subjects

We report on a patient after knee reconstruction for osteosarcoma in the distal femur using a hingeless prosthesis K-MAX KNEE system K-5 who walked without ipsilateral knee extension in the latter half of the stance phase (flexed knee gait). We evaluated the patient using three-dimensional gait analysis and isokinetic knee strength measurement, and compared the patient with five healthy subjects. The Musculoskeletal Tumor Society (MSTS) score was also used for evaluation. The patient kept his operated knee flexed during mid stance. The maximal ankle plantarflexion internal moment was lower on the ipsilateral side than on the contralateral side, and lower than in the healthy subjects. The negative ankle power during the stance phase was generally stronger on the ipsilateral side than on the contralateral side, and also in the healthy subjects. Unusual contralateral hip flexion occurred after the initial contact, indicating increased joint load on the ipsilateral ankle and the contralateral hip. The ratios of the peak knee extension/flexion torque were 0.7 on the ipsilateral side, 1.9 on the contralateral side, and 1.7 in the healthy subjects. The MSTS score of the patient was 23/30 (76.6%). Flexed knee gait might account for the reduction of ipsilateral hip flexion and ankle plantarflexion moment during the late stance phase. These results suggest the importance of focusing more on the ipsilateral ankle joint and the contralateral hip joint to maintain the function of the entire limb joints of the patients with flexed knee gait.

Characteristics of flexed knee gait and functional outcome of a patient who underwent knee reconstruction with a hingeless prosthesis for bone tumor resection: a case report with gait analysis and comparison with healthy subjects

We report on a patient after knee reconstruction for osteosarcoma in the distal femur using a hingeless prosthesis K-MAX KNEE system K-5 who walked without ipsilateral knee extension in the latter half of the stance phase (flexed knee gait). We evaluated the patient using three-dimensional gait analysis and isokinetic knee strength measurement, and compared the patient with five healthy subjects. The Musculoskeletal Tumor Society (MSTS) score was also used for evaluation. The patient kept his operated knee flexed during mid stance. The maximal ankle plantarflexion internal moment was lower on the ipsilateral side than on the contralateral side, and lower than in the healthy subjects. The negative ankle power during the stance phase was generally stronger on the ipsilateral side than on the contralateral side, and also in the healthy subjects. Unusual contralateral hip flexion occurred after the initial contact, indicating increased joint load on the ipsilateral ankle and the contralateral hip. The ratios of the peak knee extension/flexion torque were 0.7 on the ipsilateral side, 1.9 on the contralateral side, and 1.7 in the healthy subjects. The MSTS score of the patient was 23/30 (76.6%). Flexed knee gait might account for the reduction of ipsilateral hip flexion and ankle plantarflexion moment during the late stance phase. These results suggest the importance of focusing more on the ipsilateral ankle joint and the contralateral hip joint to maintain the function of the entire limb joints of the patients with flexed knee gait.

[Does aortic cusp repair influence the outcome of valve sparing aortic root replacement?]

BACKGROUND

Outcome of the patients who underwent aortic root replacement with valve sparing procedure concomitant with cusp repair was evaluated.

METHODS

Between October 1999 and April 2009, valve sparing aortic root replacement were performed in 62 patients. Isolated valve sparing procedure was performed in 38 patients (control) and concomitant cusp repair was performed in 24 patients (aortic valve plasty: AVP). Cusp prolapse was corrected by plication of Arantius body (n = 13), cusp perforations were closed by pericardial patch (n = 6) or reinforcement of free margin (n = 6).

RESULTS

No patient died during the hospital stay and no thromboembolic events occurred in the follow up. Pre-operative grade of aortic insufficiency was 3.0 +/- 0.9 in AVP group vs. 2.5 +/- 1.3 in control (NS). There was no significant difference between both groups regarding age, cardiac function and preoperative aortic root diameter. However, eccentric jet by preoperative transesophageal echocardiography (TEE) was more often in group AVP than in control (p<0.01). Five patients underwent reoperation because of recurrent aortic regurgitation (AR) or hemolysis. Postoperative AR grade were similar in both groups (0.9 +/- 0.5 vs 0.5 +/- 0.6). During follow up, the 5 year freedom from re-operation (aortic valve replacement: AVR) was 85.1+/- 8.2% in AVP and 94.0 +/- 4.1% in control (NS). 5-year-survival was 100% and 95.0 +/- 4.9% (NS), respectively.

CONCLUSIONS

Valve sparing aortic root replacement with concomitant cusp repair provided satisfactory midterm result.

[Intraoperative monitoring of the brain and spinal cord ischemia during thoracic aortic surgery]

Thoracic aortic surgery still involves a significant risk of neurological complications including stroke and paraplegia, associated with high morbidity and mortality. Intraoperative monitoring of the brain and the spinal cord ischemia, such as 4-channel cerebral In Vivo Optical Spectroscopy (INVOS) and myogenic transcranial motor evoked potentials (MEP), may enable us to prevent the devastating complications by prompt and proper intraoperative management. This review describes our standard methods for these procedures during thoracic aortic surgery.

[Perioperative management in cardiovascular emergency surgery]

Perioperative management in emergency cardiac operation is challenging because general condition of the patient is often poor and only little preoperative information is available. In order to obtain an optimal surgical outcome, careful assessment of preoperative problems and prevention and detection of complications must be done without any delay. Preoperative carotid duplex scan should be performed in every case to assess the steno-occlusive lesion or unstable plaque, which affect the surgical strategy (eg. selection of arterial cannulation site and cerebral protection). Regional cerebral oxygen saturation (rSO2) must be monitored in all the operation. If intraoperative drop in rSO2 is detected, administration of inotropic agents and increase in cardiopulmonary bypass flow is needed to maintain the mean blood pressure at higher level. Intraaortic balloon pumping (IABP) insertion should be considered when rSO2 cannot be recovered with those procedures. We have to keep in mind that many of the patients undergoing emergency surgery are at high risk for coronary artery disease. If one cannot be weaned from cardiopulmonary bypass, coronary artery bypass grafting to a major branch may be performed. Coronary angiography should be performed immediately when ST-T changes in electrocardiogram (ECG) or chest symptoms appear in the postoperative period. Hesitation in making a decision will only jeopardize the situation.

Preoperative visualization of the artery of Adamkiewicz by intra-arterial CT angiography

BACKGROUND AND PURPOSE

CT and MR angiographies have been reported to visualize the artery of Adamkiewicz (AKA) noninvasively to prevent spinal cord ischemia in surgery of thoracic descending aortic aneurysms. The purpose of this work was to compare the usefulness of CT angiography (CTA) with intra-arterial contrast injection (IACTA) with that of conventional CTA with intravenous contrast injection (IVCTA).

MATERIALS AND METHODS

We enrolled 32 consecutive patients with thoracic or thoracoabdominal aortic aneurysms who were scheduled for surgical repair or endovascular stent-graft treatment. All of the CTA images were obtained using a 16-detector row CT scanner and 100 mL of contrast material (370 mg/mL) injected at a rate of 5 mL/s. Contrast was injected via the antecubital veins of 15 patients and via a pig-tail catheter placed at the proximal portion of the descending aorta in 17 patients who underwent IVCTA and IACTA, respectively. Two datasets were reconstructed from 2 consecutive scans. The AKA was identified as a characteristic hairpin curved vessel in the anterior midsagittal surface of the spine and by the absence of further enhancement in the second rather than in the first phase. Continuity between the AKA and aorta was confirmed when the vessel could be traced continuously by paging the oblique coronal multiplanar reconstruction or original axial images.

RESULTS

Intra-arterial contrast injection was significantly more sensitive in identifying the AKA than IVCTA: 16 (94.1%) of 17 versus 9 (60.0%) of 15 (P = .033). Continuity between the AKA and aorta through intercostal or lumbar artery was confirmed in 14 (87.5%) of 16 and 5 (55.6%) of 9 of the IACTA and IVCTA groups, respectively.

CONCLUSION

Intra-arterial contrast injection detected the AKA at a high rate and verified continuity from the aorta to the AKA.

Five-band microwave radiometer system for non-invasive measurement of brain temperature in new-born infants: system calibration and its feasibility

Recent simulation studies have shown that a technique of multi-frequency microwave radiometry is feasible for non-invasive measurement of deep brain temperatures in the new-born infants. A five-band microwave radiometer system has been developed, and its operation in a normal electromagnetic environment is checked. Five receivers operating with a waveguide antenna and at center frequencies of 1.2, 1.65, 2.3, 3.0 and 3.6 GHz (0.4 GHz bandwidth) are calibrated using a temperature-controlled water-bath. Temperature resolutions obtained for each receiver are 0.183, 0.273, 0.148, 0.108 and 0.118 K, respectively. A temperature retrieval simulation based on these resolutions and the previously proposed algorithm shows that the confidence interval, as produced by thermal noise, is 0.62 K for the retrieved central brain temperature. If the conductivity of brain is estimated wrong by 10 %, this will result in an error of 0.3-0.4 K. The result of this work is encouraging for realization of radiometric measurement of temperature profile in a baby's head.

Naturally acquired regulatory mechanism of perioperative cytokine response in neonates

The inflammatory reaction is known to be controlled in neonates. We clarified the characteristics of cytokine profile in neonatal patients and assess its clinical significance. Serum levels of interleukin (IL)-6 and IL-1 receptor antagonist (ra) were determined in 152 pediatric patients and 33 each of maternal and cord bloods. Supernatant IL-1ra levels of cultured monocytes and granulocytes stimulated with IL-1beta or LPS, and IL-1ra mRNA expression of granulocytes were assayed in 15 each of cord and healthy adult bloods. Although surgical stress in neonates was heavier than that in infants, there was no difference in the occurrence of postoperative morbidity and mortality. In neonates, the perioperative serum level of IL-1ra was significantly raised, and the postoperative IL-6 response was well controlled. The serum concentration of IL-1ra in cord blood was not different from that in maternal blood, whereas, the serum concentration of IL-6 in cord blood was significantly reduced than that in maternal blood. In granulocytes, significantly more IL-1ra was produced from cord than from adult blood. An IL-1ra predominant immune status in neonates may be a naturally acquired adaptation system and play a crucial role in attenuating acute inflammatory reaction in a vulnerable host defense.

Aortic and vena caval reconstruction with retroperitoneal lymph node dissection for metastatic germ cell tumor

A 49-year-old man who had a huge testicular tumor with retroperitoneal lymph node metastasis and bilateral multiple pulmonary metastases was referred to our hospital. Firstly orchiectomy was done obtaining the pathological diagnosis of mixed type germ cell tumor. After cisplatin-based chemotherapy, he underwent resection of the retroperitoneal lymph node involving the abdominal aorta and the inferior vena cava. Both great vessels were resected with the tumor and reconstructed with prosthetic grafts. Two months after the laparotomy, 12 metastatic nodules in the left lung were resected. Seven months later, he furthermore underwent resection of 4 metastatic nodules in the right lung. Microscopically, all resected metastatic tumors were diagnosed to be mature teratoma without viable malignant cells. The patient remains well 30 months after the first operation. Follow-up CT scan demonstrates patency of aortic and vena caval bypass grafts without local recurrence or distant metastasis.

Redo aortic valve replacement with ''porcelain'' aorta in an aortitis patient. A case report

We report a successful reoperation of aortic valve replacement with the severely calcified, ''porcelain'' aorta due to Takayasu's disease. The patient was a 46-year-old female diagnosed with aortic prosthetic valve failure. Takayasu's aortitis had been noted at 17 years old and the patient underwent aortic valve replacement for aortic regurgitation at age 32. Chest CT scan revealed severe circumferential calcification of the whole thoracic aorta. Echocardiography revealed 100 mmHg of pressure gradient across the aortic prosthetic valve with pannus formation. Replacement of the aortic prosthetic valve was performed using the selective cerebral perfusion method under deep hypothermia. The postoperative course was uneventful without any neurological disorder. Selective cerebral perfusion was a useful method to avoid cross clamping in severely calcified ascending aortic.