[Zasshi] [Journal]. Nihon Kyobu Geka Gakkai最新文献

Forty-one patients suffered initial relapses with brain metastasis after surgery for non-small lung cancer at our hospital between 1978 and 1995. These patients were a total of 8.4% of all cases of surgical removal, and had an average relapse period of 8.6 months +/- 8.0 months after surgery on the primary lesions. Of these, surgical removal of metastasized lesions was performed on 18 patients (43%), in which the 5-year post-operative survival rate was 35.7%, and the median survival time was good at 28 months. It was found that the survival period was significantly extended in the group whose relapse period was less than one year after surgery on the primary lesions, and in the group who received cranial irradiation post-operatively on the metastasized brain lesion. Following surgery on the metastasized lesion, second relapses occurred in nine patients, and six patients suffered from second relapses in the brain, of which four did not receive cranial irradiation post-operatively. Cases of radiotherapy in patients of 70 years of age or more frequently manifested post-radiotherapy subacute neuropathy. From the above, it is thought that the following procedures should be adopted: 1. Periodic examination for brain metastasis during the 24 months following surgery for non-small cell lung carcinoma for purposes of early detection; 2. in cases where brain metastasis is detected, if no metastasis is identified in other organs, a policy of surgical removal should be adopted where possible; and, 3. in cases of 70 years of age or less following surgery on the metastasized lesion, cranial irradiation should be considered.

A 68-year-old man presented to another hospital with progressive shortness of breath, dry cough, and systemic edema. A chest X-ray, echocardiogram, and chest CT showed a mediastinal mass and massive pericardial effusion. His symptoms improved after the treatment for heart failure. The pericardial effusion was bloody. In that, malignant cell wasn't proved. Thoracotomy was performed to diagnose the mediastinal tumor and to extirpate it. Pathological diagnosis after operation was thymoma with direct invasion to pericardium and tunica externa of aorta. Thymomas are routinely asymptomatic for prolonged periods of time. Symptomatic pericardial tamponade as initial manifestation due to a thymoma with a massive pericardial effusion is uncommon.

To prevent the atheroembolic complications such as brain infarction due to the manipulation of atherosclerotic ascending aorta during cardiac surgery, the ascending aorta of 55 patients including 6 emergencies (mean age: 67.7 +/- 6.9 years, valvular disease: n = 12, ischemic heart disease only or combined with valvular disease: n = 43) were evaluated with intraoperative echography as a routine, to enable a proper placement of the cannulae, clamp etc. Irregular elevated lesions into the aortic lumen from the intima were identified in 7 patients (13%, mean age: 71.0 +/- 6.9 years) of ischemic heart disease, which included 2 emergent cases. Arch cannulation was employed in 3 patients with wide-spread lesions on the posterior wall and femoral cannulation was done in 1 patient with wide-spread lesions on the anterior wall. Two of these patients received CABG with in situ arterial conduits under ventricular fibrillation, and the other 2 patients received CABG with aortic cross clamping at the lesion-free site during proximal anastomosis of vein grafts (single clamp technique). Two patients with localized lesion were done CABG with partial aortic clamping and one of them had cerebral infarction during the operation. We recognized that manipulation of the ascending aorta has to be done with a meticulous care and well away from the diseased site. In another patient with localized lesion, the arch cannulation and the single clamp technique were used 2 cm away from that lesion. The brain infarcted patient completely recovered without any sequelae and the others also had no atheroembolic complications. Although calcified lesions on CT were correlated with atheromatous lesions on echogram (p = 0.004), these atheromatous plaques were not detected by enhanced CT, except in only one patient. For screening of the atherosclerosis of ascending aorta, the CT examination was not so effective and the intraoperative echography was the most sensitive and could be easily accomplished. In conclusion, in order to prevent the atheroembolism that might occur due to the improper manipulation of the diseased ascending aorta during usual procedures, surgical strategies have to be modified according to the position, extent and quality of the atherosclerotic lesions, diagnosed by intraoperative echoscanning of the aorta.

Three years after myocardial infarction, a 60-year-old man had congestive heart failure caused by left ventricular aneurysm with mitral regurgitation. He underwent the following concomitant operations: (1) patch reconstruction for a left ventricular aneurysm and (2) mitral plasty for a torn chordate and mitral regurgitation by using valvuloplasty, a shortening chordae and a prosthetic ring. A postoperative examination indicated that his cardiac function had markedly improved.

A 33-year-old male was transferred to our hospital because of coldness, numbness and pain in his right arm. Chest X-ray showed abnormal first ribs on both sides that were attached to the second ribs below the clavicles. Angiogram revealed an aneurysm of right subclavian artery, thrombus in the aneurysm and embolism to the brachial artery. Thrombectomy using a Fogarty catheter was done and the radial pulse recovered. Surgical resection of the abnormal first rib and thrombectomy was performed, because ischemic symptoms recurred in spite of anticoagulation and antiplatelet therapy. Acute arterial occlusion in patients with thoracic outlet syndrome is rare. The literature on arterial complications of thoracic outlet syndrome is reviewed.

We report a neonatal case of one-stage repair for transposition of the great arteries with intact ventricular septum (TGA with IVS) and coarctation of the aorta (CoA). The surgery was performed at 27 days of age when the patient, a male, weighed 3408 g. Preoperative cardiac catheterization and angiography confirmed the diagnosis of TGA with IVS, CoA, atrial septal defect, patent ductus arteriosus, persistent left superior vena cava, left sided juxta-positioning of appendages and dextrocardia. The procedure was simultaneous subclavian flap aortoplasty through a left thoracotomy and an arterial switch operation through a median sternotomy. The patient's postoperative course was uneventful and he has grown well. Postoperative cardiac catheterization revealed mild pulmonary stenosis (pressure gradient of 19 mmHg between the right ventricle and the pulmonary artery) and mild aortic arch kinking from the arterial switch maneuver. One-stage repair, the combination of subclavian flap aortoplasty and arterial switch operation, provides a good clinical result in this complex malformation.

Recently much interests have focused on the imbalance between the release of thromboxane A2 (TXA2) and prostaglandin I2 (PGI2), which may contribute to the development of pulmonary vascular injury. TXB2 has potents of platelet aggregation and vasoconstriction, while PGI2 has against in its activities. We investigated the effect of new PGI2 analogue (ONO-1301), which is a novel prostacyclin mimetic with inhibitory activity against thromboxane synthetase, on the early graft function in canine left single lung allotransplantation model. 19 donor dogs were divided into three groups. Seven dogs were comprised control group and received heparin administration (400 Unit/kg) before pulmonary arterial flushing with 50 ml/kg of 4 degrees C low potassium dextran glucose (LPDG) solution. Each six dogs were comprised I2-10 and I2-50 groups respectively, with receiving a 10-minute infusion of ONO-1301 (10 micrograms/kg/min) before flushing. The pulmonary cold preservation was performed with LPDG solution at 4 degrees C for 18 hours. After left single lung transplantation, in control group, saline solution was administered to the recipient for 10 minutes encompassing the reperfusion process (starting from 5 minutes prior to reperfusion). In I2-10 group, the ONO-1301 (10 micrograms/kg/min) was administered in the same manner. In I2-50 group, the ONO-1301 was administered from the same timing as I2-10 group, but for 50 minutes. The recipient dogs were observed for 6 hours after ligation of the right pulmonary artery and bronchus. We measured the transplanted lung function, including arterial blood gas and pulmonary hemodynamics, and plasma 6-keto-PGF1 alpha, TXB2 and lipid peroxide levels of left atrial blood. Pulmonary histological investigation was performed after preservation and sacrifice the recipient dog. All recipient dogs were survived for observation period. I2 groups provided significantly better gas exchange and pulmonary hemodynamics than control group. The 6-keto-PGF alpha levels in control group peaked after an early rise in TXB2 levels, and reached maximum at one hour after contra-lateral ligations. These prostanoid release levels rose again at 6 hours. While in I2 groups, the levels of them were significantly lower compared with control group. Histological examination of the transplanted lung after assessment, revealed disruption of alveoli forced by pulmonary edema in control group. In contrast, there was minimal fluid extravasation without alveolar disruption in both I2-10 and I2-50 groups. There were no significant differences between I2-10 and I2-50 groups. Although it dose not protect the implanted lung completely from developing edema, the ONO-1301 administration (10 micrograms/kg/min) to the donor and the recipient resulted in prevention of TXA2 and PGI2 release and improvement of the respiratory function and pulmonary hemodynamics after reperfusion. We conclude that it seems beneficial to administer the ONO-1301 to the donor and the

An animal study was designed to examine whether the viability of asphyxiated cadaver hearts in situ could be extended by the verapamil pretreatment. Verapamil was administered separately at a dose of 0.1 (n = 9), 1.0 (n = 9), or 10 mg/kg (n = 16) to male adult Sprague-Dawley rats (440-500 g) 15 minutes prior to asphyxiation to death. Verapamil was not administered in control rats (n = 9). All dead rats were left at room temperature for 30 minutes followed by excision of their hearts and washout of coronary vascular beds with a cold University of Wisconsin solution. After simple cold storage for 30 minutes, hearts were reperfused on an isolated working rat heart apparatus in a nonworking mode with modified Krebs-Henseleit buffer for 60 minutes. After 30 minutes of the subsequent working mode, hemodynamics were measured and the hearts were perfused with 3% glutaraldehyde for the ultrastructural examination using electron microscopy. The hearts of the 10 mg/kg group were irreversibly contracted (0/16 vs. 8/9 in control hearts, p < 0.0001) during reperfusion, and most of them could make a pressure enough to keep a working mode (14/16 vs. 1/9 in control hearts, p = 0.0003). Satisfactory results were not found with 0.1 and 1.0 mg/kg verapamil groups. In ultrastructural examination, coronary vessels after preservation were dilated in the 10 mg/kg group, whereas were not dilated enough to washout of the red blood cells by the solution in controls. Irreversible changes of myocytes after reperfusion such as contraction bands and amorphous densities were presented in controls, but not in the 10 mg/kg group. Verapamil pretreatment before cardiac arrest may contribute to preserve cadaver hearts with dilating the coronary vessels and probably preventing the calcium influx into cardiomyocytes during ischemia and reperfusion. Verapamil provides dose-dependent extension of viability of non-beating donor hearts in situ.

A case of "aggressive fibromatosis" which appeared in posterior mediastinum is reported. A 50-year-old woman was admitted to our hospital with right shoulder pain. The tumor surrounded the right vertebral artery and infiltrated into the right sympathetic nerve, brachial plexus and muscle tissue. It was suspected of neurogenic tumor by percutaneous needle biopsy. Removal of the tumor and partial resection of the invaded vertebral artery and brachial plexus were made in Aug. 10, 1996. In postoperative examination, the tumor was 6.2 x 6.5 x 4.5 cm in size and diagnosed pathologically as "aggressive fibromatosis". Postoperative course was uneventful, but Horner's symptoms and motor disturbances of IV, V, fingers of the right hand were slightly occurred. Radiotherapy of 60 Gy was done after operation. There is no recurrence to date 17 months after surgery. As for the character of this disease, it seldom metastasizes, but grows infiltratively and the recurrence after operation is an important problem. In particular, the neck and the head are important because surgical margin is not provided enough, anatomically. Therefore, chemotherapy or radiotherapy after operation is needed. In this case, radiotherapy was done after operation. So, there is not the recurrence and passes to date 17 months after surgery. But, follow-up of long terms is necessary because it may recur after postoperative therapies.

After resection of a non-invasive thymoma, two metastatic lung tumors were found in the left upper lobe and the left lower lobe. There were differences in tumor doubling time (TDT) and invasion between the metastatic tumor in the lower lobe and the one in the upper lobe. The TDTs of the tumors were 834.1 days and 328.3 days, and the tumor of the left lower lobe invaded the left lateral basal segmental bronchus (B9). The differences in the two tumors were determined by pathological findings and nuclear DNA pattern. Pathologically, the resected thymoma and both of the metastatic tumors were mixed type, which consisted of epithelial cells and lymphocytes. But by epithelium form, the resected thymoma and the tumor in the lower lobe were classified as cortex type, and only the slow growing tumor in the upper lobe contained a spindle-cell component. The DNA pattern of the resected thymoma was aneuploid and the two metastatic tumors were diploid. As this case is very interesting clinically and pathologically, we reported it.