The Japanese journal of surgery最新文献

Five patients developed coronary artery spasm during open heart surgery in our institute between 1984 and 1988. One patient was undergoing coronary artery bypass grafting and the other four valvular surgery or surgery for congenital heart disease. In one of the patients undergoing non-coronary surgery, the preoperative induction of right coronary artery spasm by ergonovine had been documented angiographically while the remaining three patients did not possess organic or functional coronary disease. All five patients exhibited a sudden onset of hemodynamic collapse with ventricular tachyarrhythmias or ST elevation during the early period of reperfusion, the time to onset being 89.2 +/- 84.8 minutes after unclamping of the aorta. In addition, contraction of the right ventricular free wall was severely impaired. Although one patient died due to left ventricular rupture caused by direct cardiac massage, the early mortality thus being 20 per cent, the other four were successfully treated with the intravenous administration of nitroglycerin and diltiazem. Three patients required the assistance of intraaortic balloon pumping for severe cardiac failure. Thus, during open heart surgery, coronary artery spasm can occur even in patients without organic coronary lesions and the possible mechanisms of this condition are discussed herein.

We produced a septic model of rats in which lung water accumulation was developed. The degree of lung water accumulation was then compared with the hepatic energy status because the liver is not only a metabolic central organ but also one of the central organs of the reticulo-endothelial system (RES), and clinically, lung edema in sepsis seems to relate to failure of the RES. Three experimental models were examined to form lung water accumulation, namely: the lethal model, given E. coli 6.0 X 10(6) CFU/g BW, the sublethal model, given E. coli 2.0 X 10(6) CFU/g BW, and the repeated sublethal dose injection model, given E. coli 2.0 X 10(6) X 2 at 12 hour intervals. In the lethal models, the energy charge (EC) of the liver decreased markedly (p less than 0.001) without recovery and the lung water accumulated (p less than 0.05). In the sublethal models, EC decreased transiently (p less than 0.05) and the lung water did not increase. However, when the microbial challenge with a sublethal dose was repeated, the decreases in EC were prolonged and the lung water increased significantly after the second injection (p less than 0.001) despite a 4.9 per cent mortality during the subsequent 24 hours. It is suggested that when the decrease in liver EC is prolonged, even if it is not fatal, an accumulation of lung water is possible in septic states. This finding may help further analyses of the interrelationship between the lung and the liver in severely infected patients.

This report presents the case of an 88 year old man with tracheal hamartoma discovered through a chest X-ray film showing obstructive pneumonia before the manifestation of any symptoms associated with tracheal obstruction. Since surgical treatment was unfeasible, the tumor was removed with success through electric cauterization using a gastrointestinal fiberscope.

This report presents a very rare case of a malignant "Triton" tumor developing in the thyroid. Although malignant "Triton" tumors have often been known to develop in cases of neurofibromatosis, Von Recklinghausen's disease, this patient showed no clinical evidence of that disease. Total thyroidectomy including left standard radical neck dissection was followed by postoperative irradiation to the neck. Despite this, local and distant metastases developed four months after treatment and the recurrent foci did not respond to chemotherapy or irradiation. The clinical course of this case mimicked that of anaplastic carcinoma of the thyroid and interestingly, a minimal lesion of papillary adenocarcinoma was found to exist concurrently in the thyroid gland of this patient.

A 46 year old woman was admitted to our institute in June, 1987 with an attack of asthma, as well as remittent fever and leukocytosis accompanied by hypereosinophilia. She was found to have melena from an unknown source upon gastrointestinal examination. Four low-density areas were found in the liver on computed tomography and one of the intrahepatic foci formed a large extrahepatic abscess communicating with the intrahepatic duct on tubography. Resection of the four hepatic segments, including the large abscess, and cholecystectomy were performed. Healed necrotizing arteritis was histopathologically observed in the resected liver specimen, with the four low-density areas on CT scan having all been necrotic foci. One of them formed an intrahepatic biliary fistula and rupture of a hepatic aneurysm into a biliary duct was found to be the cause of melena. Although eosinophil infiltration and extravascular granuloma were not observed, a diagnosis of allergic granulomatous angiitis was made from the characteristic clinical course, systemic vasculitis and peripheral blood eosinophilia. To the best of our knowledge, this is the first report of intrahepatic duct perforation most probably being caused by hepatic aneurysm rupture in a patient with allergic granulomatous angiitis.

A rupture of the ascending aorta which occurred in a woman on the 13th postoperative day following a right upper lobectomy with mediastinal lymph node dissection for lung cancer is reported herein. Fortunately, the patient was rescued from a cardiac tamponade and hemothorax by emergency operation. The operative findings suggested a traumatic rupture of the aorta, however, lymph node dissection of the mediastinum could not be excluded as a possible cause. Therefore, careful mediastinal lymph node dissection should be carefully performed in operations for lung cancer.

Based on the findings that the enhancement of serum alpha 2-macroglobulin (A2M) is associated with the occurrence of infectious complications following surgery in patients with esophageal cancer, we examined possible factors which could contribute to the alterations of serum acute phase protein levels in patients with this disease. A multiple linear regression analysis was made for 71 patients with esophageal cancer and 58 with gastric cancer. In patients with esophageal cancer, protein calorie malnutrition (PCM) and age factors more strongly contributed to the alteration of 6 acute phase protein levels than did the malignant tumor when compared to those with gastric acner. PCM was negatively associated with A2M levels while it was positively associated with alpha 1-acidglycoprotein (A1AG) and haptoglobin (Hp) levels. Age did not contribute to the A2M levels but did have a negative effect on the Hp, ceruloplasmin (Cp) and fibronectin (Fn) levels. On the other hand, the malignant tumor was positively related only to the A1AG levels. Since none of these factors contributed to the elevation of A2M levels, it is suggested that the presence of chronic infection might be a factor contributing to the A2M increase which was associated with the occurrence of postoperative infectious complications in patients with this disease.

A new method of hernioplasty for adult groin hernias centering on repair of the transversalis fascia was assessed by a questionnaire conducted every five years on adult patients who had received the above operation. The efficacy of this method was evaluated in terms of the postoperative quality of life and prevention of recurrence of groin hernias. Over the last 9 years, 834 adult patients with 921 groin hernias, including bilateral lesions, have undergone the above procedure and overall, favorable results were obtained, with only one case of recurrence (0.1 per cent) being reported. Contralateral herniation, which has been often reported following Bassini's or Hatakoshi's method, was found in only one of our patients although the number of patients who complained of pain in the operated region was comparatively high, being 51 cases or 11.4 per cent.

A 30 year old female was admitted with right upper abdominal pain and fever. Ultrasonography and computed tomography revealed a large cystic mass in the right lobe of the liver, and aspiration bacteriology was negative. A right hepatic lobectomy was performed for a suspected cystadenocarcinoma, however, the tumor was histologically diagnosed as a hemangiopericytoma with prominent venous invasion. The patient died within a short time of multiple pulmonary metastases. Primary hepatic hemangiopericytoma is extremely rare, and according to our research, this is only the 4th case reported in the literature.

A case of Crohn's enterocolitis associated with diffuse tracheo-bronchitis is presented herein. Although respiratory tract involvement in Crohn's disease is extremely rare, our review of the world literature revealed several common clinical pathologic features. These features include a productive cough with chest X-ray films which are normal except for some peripheral involvement. Bronchoscopy, however, shows diffuse inflammation of the trachea and bronchi with widely scattered whitish lesions while biopsy reveals a granulomatous infiltration of inflammatory cells. This tracheobronchitis typically responds well to treatment with prednisone.