Removal of cartilage rings of the graft and omentopexy for extended tracheal autotransplantation

BACKGROUND

One of the serious problems in longer-size tracheal transplantation is infection or severe stenosis of the graft, probably caused by an inadequate blood supply even with omentopexy. For obtaining an appropriate blood supply, we experimentally developed a new technique that included removal of some cartilage rings of the graft and omentopexy.

METHODS

Twenty-one adult mongrel dogs were used. In group A (n = 11), a nine-cartilage ring length of the trachea in which six of nine rings were removed, leaving one cartilage ring at each end of the graft and another in the center, was autotransplanted with omentopexy. Two artificial tracheal rings outside the graft were used for maintaining the lumen. In group B (n = 10), a nine-cartilage ring length of the trachea was autotransplanted with omentopexy.

RESULTS

In group A, all dogs survived until being sacrificed, whereas 5 group B dogs died of graft infection and mediastinitis (p<0.05 versus group A). Mucosal blood flow of the graft in group A was normal and higher than in group B (p<0.05). Grade of the graft stenosis at death or sacrifice was 14%+/-1% in group A and 58%+/-25% in group B (p<0.05).

CONCLUSIONS

Removal of some cartilage rings improved blood supply to the graft and resulted in satisfactory survival and nonsignificant tracheal stenosis in extended tracheal autotransplantation.

Surgery of giant bulla with tube drainage and bronchofiberoptic bronchial occlusion

A case of emphysematous bullae and right lung cancer is presented. At first, left giant bulla was managed by minithoracotomy and tube drainage combined with bronchofiberoptic bronchial occlusion to preserve the respiratory function. Four weeks later, right lung cancer was successfully resected.

Possible phase transition deep inside the hidden order phase of ultraclean URu2Si2

To elucidate the underlying nature of the hidden order (HO) state in heavy-fermion compound URu(2)Si(2), we measure electrical transport properties of ultraclean crystals in a high field, low temperature regime. Unlike previous studies, the present system with much less impurity scattering resolves a distinct anomaly of the Hall resistivity at H;{*} = 22.5 T, well below the destruction field of the HO phase = or approximately 36 T. In addition, a novel quantum oscillation appears above a magnetic field slightly below H;{*}. These results indicate an abrupt reconstruction of the Fermi surface, which implies a possible phase transition well within the HO phase caused by a band-dependent destruction of the HO parameter.

Possible role of local hypoxia in the de novo formation of dural and osteodural arteriovenous fistulas after encephalitis. A case report

A rare case of de novo formation of dural and osteodural arteriovenous fistulas after encephalitis is presented. We review and discuss the etiological angiogenetic factors and processes in intracranial dural arteriovenous fistulas formation. Local tissue hypoxia may have played a role in the initial step causing sprouting angiogenesis as the main pathogenesis of DAVFs formation.

Enhanced Hypercoagulability Using Clot Waveform Analysis in Patients with Acute Myocardial Infarction and Acute Cerebral Infarction

Background: Routine activated partial thromboplastin time (APTT) and prothrombin time (PT) measurements do not indicate hypercoagulability in patients with acute myocardial infarction (AMI) and acute cerebral infarction (ACI). Methods: Hypercoagulability in patients with AMI or ACI was evaluated using a clot waveform analysis of the APTT or a small amount of tissue factor activation assay (sTF/FIXa). In the CWA, the derivative peak time (DPT), height (DPH), width (DPW), and area the under the curve (AUC) were evaluated. Results: The APTT did not indicate hypercoagulability, but the second DPT of CWA-sTF/FIXa was significantly shorter in patients with ACI than in healthy volunteers (HVs). The first DPH values of CWA-APTT and CWA-sTF/FIXa in patients with ACI and AMI were significantly higher than in HVs. In the receiver operating characteristic (ROC) analyses of ACI or AMI vs. non-thrombosis, the AUC was >0.800 in the DPHs of CWA-APTT and CWA-sTF/FIXa. The AUC of CWA-APTT and CWA-sTF/FIXa in patients with AMI and ACI was significantly higher than in HVs. The AUC/second DPT of CWA-APTT and CWA-sTF/FIXa in patients with AMI and ACI was significantly higher than in HVs. Regarding the ROC analyses of ACI or AMI vs. HVs, the AUC of ROC was higher than 0.800 in the AUC and AUC/second DPT of CWA-APTT and CWA-sTF/FIXa. Conclusions: The AUC/second DPT of CWA-APTT and CWA-sTF/FIXa may be a useful parameter for detecting a hypercoagulable state in patients with AMI and ACI.

[Radiation induced osteosarcoma of the chest wall]

We report a successful resection of an osteosarcoma in the chest wall developed 25 years after irradiation. A 74-year-old woman was admitted to our hospital for her swelling in the left chest wall at August 24, 1995. At 49-year-old, she had undergone an operation and postoperative irradiation for left breast cancer. A computed tomography demonstrated a mass in the left chest wall that destructed the first rib, extending into the pleural space and invaded into the left common carotid and subclavian arteries. We planned a radical resection of the mass after repeated CT scannings, since it was histopathologically diagnosed as a chondrosarcoma and showed a rapid growth. The tumor was completely removed with radical transmediastinal forequarter amputation of the partial chest wall and total left upper extremity. The left common carotid artery was partially replaced with 6 mm EPTFE vascular prosthesis. The chest wall was reconstructed with Marlex-mesh prosthesis and a myocutaneous flap. She was discharged uneventfully and has not shown any evidence of recurrence.

G-CSF mobilization in steady state for peripheral blood stem cell transplantation

Peripheral blood stem cells were collected by granulocyte-colony stimulating factor (G-CSF) mobilization in normal volunteers and patients with hematological malignancy in complete remission without anti-cancer drug synchronization. The yields of PBSC and the possibility of G-CSF mobilization in steady state for PBSC transplantation (PBSCT) were studied. For collecting PBSC, G-CSF was subcutaneously injected at the dose of 100 micrograms/m2 on 5 consecutive days. PBSC collection was performed on day 4 and/or 5 by using cell separator, CS-3000. In normal volunteers, the yields of colony forming unit in granulocyte and macrophage (CFU-GM) was 1.9 x 10(4) kg by processing the plasma of 1.5L, and CD34 positive cell was 1.4% on the average. In patients with hematological malignancy in complete remission, the processing volume ranges from 10 to 18L/1-2 cycles, the average CFU-GM number was 2.2 x 10(5)/kg, and the average CD34 positive cell was 2.2%. In acute leukemia case, PBSCT was performed by using G-CSF mobilized PBSC, engraftment was achieved earlier. In conclusion, the yields of G-CSF mobilized PBSC from normal volunteers suggested the possibility of PBSCT and the yields of PBSC from patients in complete remission proved that G-CSF mobilization method in complete remission status could take the place of drug synchronized G-CSF mobilization for which the timing of collection and the drug choice for synchronization are intricate.

[Traumatic diaphragmatic hernia presenting with shock 1 year after blunt injury; report of a case]

A 62-year-old male who had had the left femoral neck fracture due to a traffic accident 1 year earlier was admitted to our hospital because of abdominal pain. He was diagnosed with a left traumatic diaphragmatic hernia due to the previous traffic accident; his condition was also complicated by shock because the mediastinum was compressed by his severely dilated stomach. We performed an emergent operation. A thoracotomy revealed a large defect, about 5 cm in size, at the central tendon of the left diaphragm and a severely dilated stomach in the left thoracic cavity. The ruptured diaphragm was closed directly after reduction of the stomach.

Phase II study of meloxicam with carboplatin plus docetaxel in first-line treatment of patients with advanced non-small cell lung cancer (NSCLC)

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Background: Preclinical and clinical studies showed that selective cyclooxygenase-2 (COX-2) inhibitor (celecoxib or rofecoxib) might improve efficacy of treatment of advanced NSCLC. Meloxicam is a non-coxib, non-steroidal anti-inflammatory drug (NSAID), and selectively inhibits COX-2. Comparing with coxibs, meloxicam shows less cardiovascular toxicity; however, anti-tumor efficacy has not been proved in clinical settings. Methods: Eligibility criteria included stage IIIB/IV histologically or cytologically confirmed NSCLC, no prior chemotherapy, no current use of NSAIDs, PS = 0–1, and no urgent symptoms. Patients received oral meloxicam (150 mg) daily, and carboplatin (AUC 5) plus docetaxel (60 mg/m2) day 1 every 3 weeks. Treatment was continued until disease progression or toxicity. The primary endpoint was anti-tumor effect, with secondary endpoints including the safety and time to progression. Calculated sample size was 45 patients (Simon’s two-stage minimax design). Results: From April 2005 to July 2006, a total of 50 patients (33 males/17 females, median age, 65 years) were accrued and 48 patients were eligible. Partial response was 40% (95% CI 24–56%), stable disease was 29% (95% CI 14–44%), and 23% had progressive disease. Grade 3/4 hematologic events included leukopenia (81%), neutropenia (96%), and thrombocytopenia (8%). Grade 3/4 non-hematologic events included hyponatremia (6%), anorexia (6%), fatigue (2%), and neuropathy (2%). Febrile neutropenia occurred in 2 patients, and one patient developed pneumonia. Conclusions: Meloxicam added to carboplatin plus docetaxel demonstrated acceptable tolerability with encouraging activity in advanced NSCLC patients.

No significant financial relationships to disclose.

[Completion pneumonectomy--a review of 29 cases]

From 1962 through 1988, a total of 29 consecutive patients had completion pneumonectomy (CP). Indications for initial pulmonary resection were primary lung cancer in 27 patients, metastatic lung tumor in 1, and mediastinal tumor with pulmonary invasion in 1. Indications for CP were lung cancer (including local recurrence, pulmonary metastasis from the first lung cancer, and second primary lung cancer) in 21 patients, complications after initial operations in 7, and pulmonary arterial injury during second operation in 1. Severe adhesion of the residual lung and the hilar structures made operative procedures extremely difficult. Injury of pulmonary arteries occurred in 6 patients. Especially, in cases the left upper lobe had been resected previously, deviation of the lower lobe and hilar adhesion lead to operative difficulty. Post-CP bronchial fistula occurred more frequently in what the bronchi had been dissected at more peripheral level than main bronchus, because of some severe hilar adhesions. Operative mortality was 13.8% (9.5% for second lung cancer, 28.5% for post-operative complication). Five-year survival for patients with lung cancer was 32.9% according to the Kaplan-Meier method. We conclude that the indications for CP are clinically resectable lung cancer and bronchial stenosis with residual pulmonary organic changes following bronhoplastic procedure. Postoperative bronchofistulae should be managed by other operative procedure.

[Experimental reconstruction of the mediastinal trachea with autogenous material-hydroxyapatite-omentum complex]

Reconstruction of extensive tracheal defects remains a difficult surgical problem. An experiment with one stage reconstruction of the thoracic trachea was performed in 32 adult mongrel dogs using a complex consisted of 3 layers as follows; autogenous materials as the inner layer, Hydroxyapatite (HA) ring as the middle layer, pedicled omental flap as the outer layer. Mediastinal tracheal defects (3-5 rings) were created and primarily reconstructed with the autogenous materials (Group 1: Pericardium, Group 2: Full thickness skin), supported with horseshoe-shaped HA rings, then covered with the pedicled omental flap. In the tracheal lumen a temporary silicone tube stent was inserted, and following groups were provided according to the duration of insertion of the stent: Group 1a:1 week, Group 1b:6 weeks, Group 1c:6 months in the cases of pericardium, Group 2a:1 week and Group 2b:6 weeks in the cases of skin graft. Three were the cases of early death. In Group 1a (n = 4) and Group Ib (n = 8), severe or moderate stenosis was noted in most cases. In Group 1c (n = 7), no stenosis occurred and ciliated epithelium was seen in 2 dogs, however, stenosis occurred moderately in 3 dogs and severe in 2. In group 2a (n = 8), moderate stenosis was seen in 1 dog due to the displacement of HA ring. No stenosis occurred in 7 other dogs. In Group 2b (n = 2), HA rings had been naked due to necrosis or infection of the skin graft in both cases.(ABSTRACT TRUNCATED AT 250 WORDS)

[A case of small adenocarcinoma of the lung with giant bullae]

A 52-year-old male underwent right upper lobectomy for giant bullae which involved almost half of thoracic cavity and covered over the right upper lobe. Postoperative histopathological examination revealed emphysematous bullae of right upper lobe and adenocarcinoma (6 mm in diameter) was found in the bullae wall under the pleura. Since there was no metastasis in bronchial lymph nodes of upper lobe, additional procedure for lymph node dissection was not performed. Patient has been healthy for eight years after operation and there is no evidence of recurrent tumor. It is difficult to define the small lesion of neoplasma with giant bullae of lung. Therefore, the patient involved with bullae may require preoperative and intraoperative attentive investigation for possible malignant lesions.

[Two cases of wedge pneumonectomy in primary lung cancer involved into carina]

Right wedge pneumonectomy was performed on two cases of primary lung cancer involved into carina. A 59-year-old male involved with primary lung cancer was found with bloody sputum. Preoperative data confirmed as the superficial spread type of squamous cell carcinoma in carinal lesion and tumor was resectable with wedge pneumonectomy. In the second case, abnormal shadow was pointed out on chest X-ray film of a 61-year-old male patient. Preoperative examination defined as primary lung cancer of rt-S6 with subcarinal lymph node metastasis. The operation indicated wedge pneumonectomy with patch plasty using the wall of right main bronchus. Although wedge pneumonectomy is not common compared to sleeve pneumonectomy, if available this procedure is technically easier and post-operative management may be more successful. Wedge pneumonectomy limits resectable area, because the continuation of tracheo-bronchial wall must be remained in part. Therefore, the indication of this procedure for surgical treatment of lung cancer is limited. However, when this procedure indicates to selected case with limited lesion of carina, this may be an useful procedure as surgical treatment of primary lung cancer.

[Intracavitary suction for treating giant bulla]

Examination was made of 9 consecutive patients who underwent intracavitary suction for giant bulla. A second operation was required for one patient who had multiple giant bullae. In the other 8 patients, improvement of pulmonary function and symptoms was obtained immediately following the operation. This was particularly more apparent in patients with poor pulmonary function. The following results were obtained. Functional recovery was evident from the early postoperative phase. A one-stage operation was possible. Reduction in postoperative drainage time was realized by bronchial occlusion. The present operation is particularly applicable to compromised patients. Computed tomography scanning is essential for evaluation of the drainage site. For giant bulla with some septation and multivesicular, the present mode of treatment would not be indicated.

[Superior posterior mediastinal neurinoma with extrathoracic extension]

We have encountered a case of superior mediastinal neurinoma which grows through the intercostal space and advances into the erector spinal muscles. Neurinoma which shows such a growth pattern is rare. MRI is useful in making preoperative evaluation. For operation, non-open chest extrapleural extirpation was successfully performed by the supraclavicular and posterior approach. This type of operation has the following advantages: surgical stress is less; postsurgical pain is mild, etc.

[A case of intractable hepatic hydrothorax treated by pleuro-venous shunt]

A 64-year-old woman with Idiopathic Portal Hypertension was hospitalized for severe respiratory distress. Chest X-ray film showed a massive pleural effusion in the right hemithorax. Though repeated thoracentesis was performed, the patient was suffering from dyspnea frequently. A pleurovenous shunt was inserted. Follow up chest X-ray films showed resolution of pleural effusion and the patient remained free of symptoms. Two months after the placement of the shunt pleural effusion again began to develop with systemic edema caused by development of chronic renal failure. Reduction of effusion was obtained by hemodialysis. Pleurovenous shunting may provide satisfactory palliation for intractable pleural effusions.