Midterm results of stent-graft repair of acute and chronic aortic dissection with descending tear: the complication-specific approach

BACKGROUND: Endovascular stent-graft placement for the treatment of patients with aortic dissection is emerging as an attractive alternative to conventional cardiac operations. However, there has been no report of longer-term follow-up. The purpose of this study is to describe our midterm results with endovascular stent-graft repair for the treatment of patients with aortic dissections. METHODS: Thirty-eight patients with aortic dissections with descending tears were treated with endovascular stent-grafting. Ten patients had acute type A, 14 patients had acute type B, and 14 patients had chronic type B dissection. Stent grafts fabricated from expanded polytetrafluoroethylene-covered Z stents were placed to close entry tears in all patients through the delivery systems introduced from the femoral or the iliac arteries. RESULTS: Two patients with complicated acute type B dissection, who would have required surgical intervention, died within 30 days of the procedure, although no other patients died within the same period. There were no late deaths during the mean follow-up period of 27 months. Early and late complication rates were 33% and 36%, respectively, in patients with acute dissection, whereas rates were 4% and 0% (P <.05 vs patients with acute dissection) in patients with chronic dissection. CONCLUSIONS: Entry closure with endovascular stent-graft placement may be a safe and effective method for the treatment of patients with aortic dissection. It could be an alternative to conventional surgical intervention in selected patients with chronic dissection. However, strict patient selection and close follow-up seem mandatory in patients with acute dissection receiving Z stent-based stent-grafts. Stent-graft repair should be delayed for acute type B dissection without complications.     

Diagnosis of esophageal cancer using positron emission tomography

Fluorodeoxyglucose positron emission tomography (FDG-PET) is more accurate than computed tomography (CT) for evaluating lymph node metastases and for N staging, but less accurate than combined CT and endoscopic ultrasonography (EUS). Lymph nodes located adjacent to the primary lesion tend to be false negatives. We consider that combined FDG-PET and EUS is the most accurate for the detection of lymph node metastasis in esophageal cancer. FDG-PET is also more accurate than CT for detecting distant metastases and improves the detection of stage IV disease compared with the conventional staging modalities. For the diagnosis of recurrence except for perianastomotic recurrence, FDG-PET provides additional information and is more sensitive than conventional work-ups. FDGPET is a valuable tool for the noninvasive assessment of tumor response after neoadjuvant therapy. 11C-methionine (MET) is another tracer for PET that can be used to assess the metabolism of amino acids, since MET accumulates in esophageal malignant tumors. Choline-PET is more accurate than FDG-PET for the detection of mediastinal lymph node metastases.     

Carpal tunnel syndrome grading system in rheumatoid arthritis

The grading system of Hashizume and Hirooka for carpal tunnel syndrome (CTS) was modified to refine the system for surgical treatment selection for specific subsets of CTS in patients with rheumatoid arthritis (RA). The grading system uses clinical signs and symptoms of CTS, including pain indications, to identify surgical subsets of patients to facilitate treatment selection. Retrospective analysis of the system included radiographic and electromyographic findings. Twenty-nine hands of 21 adult patients with CTS in RA were graded in the current study. Eight hands with mild synovitis received conservative treatment only. Endoscopic carpal tunnel release (ECTR), using Okutsu's universal subcutaneous endoscopic system with a clear cannula, was performed in 11 hands with moderate synovitis. Open carpal tunnel release (OCTR) combined with flexor tenosynovectomy was performed in 9 hands with severe synovitis. One more hand required OCTR after ECTR when malignant RA was diagnosed. Clinical results, evaluated using Kelly's criteria, were: excellent in 19 hands, good in 5, fair in 4, and poor in the 1 patient with malignant RA. Clinical symptoms of CTS improved in all but the latter patient. Although the sample size in the current study is small, the results appear to warrant further study to determine the clinical utility of the grading system. Received: April 2, 2001 / Accepted: November 1, 2001     

Treatment of bone and soft tissue sarcomas of the hand and wrist

We studied 13 consecutive patients with bone and soft tissue sarcomas of the hand and wrist. Chondrosarcoma, Ewing's sarcoma, synovial sarcoma and epithelioid sarcoma were the most frequent histological diagnoses. Limb-sparing surgery was performed in ten patients but eventually three patients required an amputation. Surgical margins were wide in nine patients and marginal in four. Adjuvant therapy for nine patients consisted of chemotherapy in five and chemotherapy with radiation in four. Local recurrence occurred in two patients with epithelioid sarcoma. There was no significant relationship between surgical margin and local recurrence. Distant metastasis occurred in four patients. The 5-year survival rate was 66%. The mean functional score was 87%. Our study indicates that treatment consisting of resection of these tumours with either a wide margin or a marginal margin followed by adjuvant radiation appeared to be safe and resulted in an acceptable degree of limb function except in the patients with epithelioid sarcoma.     

Current status of hip bone densitometry in Japan: a nationwide survey

Hip fracture greatly impairs quality of life in patients with osteoporosis. Measurement of bone mineral density (BMD) in the hip, which is closely related to fracture risk, is therefore diagnostically important. Furthermore, since in some elderly individuals lumbar BMD may be overestimated because of vertebral fracture or spondylosis deformans, measurement of hip BMD is also important. However, hip BMD is unlikely to be measured as often as lumbar BMD in Japan. A questionnaire survey was conducted to determine how many institutions measure hip BMD. A total of 861 institutions responded to the survey, 596 (69%) of which performed hip bone densitometry. The number of such institutions per million population was calculated to be 4.7. Measurement of hip BMD was more frequent in university hospitals than in general hospitals, clinics, and non-medical institutions. Furthermore, 298 (51%) of 590 institutions measured hip BMD in more than 75% of all bone densitometry examinees. This is the first report on the current status of utilization of hip bone densitometry in Japan.     

Primary thymic adenocarcinoma coexisting with type AB thymoma: a rare case with long-term survival

Thymic carcinoma is a rare tumor. The most common histological subtype is squamous cell carcinoma, and only a few cases of thymic adenocarcinoma have been reported. A case of papillary adenocarcinoma of thymic origin that coexisted with type AB thymoma as a separate nodule is presented herein. The patient was found to have an abnormal mediastinal shadow on chest X-ray. A computed tomography scan revealed a round, 6.5-cm-diameter mass in the right anterior mediastinum. The preoperative diagnosis was thymoma, and thymothymectomy was performed. On pathological examination, two tumors, which were diagnosed as papillary adenocarcinoma and type AB thymoma, respectively, were present in the thymus without any connection with each other. The patient has been alive without any signs of recurrence for 11 years after surgery. We diagnosed the adenocarcinoma in this case was a primary thymic carcinoma.     

Anesthetic management for pneumonectomy in a patient with cardiac amyloidosis

Cardiac amyloidosis may cause restrictive cardiomyopathy associated with heart failure, conduction disorder and ischemic heart disease. Therefore, patients with amyloidosis require careful hemodynamic monitoring in perioperative period. A 63-year-old man with cardiac amyloidosis was scheduled for pneumonectomy. His transthoracic echocardiography assessment showed a hypertrophic interventricular septum and slight decreased ejection fraction of 55%, but left ventricular (LV) diastolic function was decreased. Pulse Doppler for mitral valve inflow showed that the early peak velocity/atrial peak velocity (E/A) ratio was 0.9, the deceleration time (DT) was 163 msec and the early diastolic mitral annular tissue velocity (E') was 4 cm x sec(-1). These data suggested a pseudonormalization state. We performed careful monitoring using arterial pressure-based cardiac output (APCO), central venous oxygen saturation (ScvO2) and transesophageal echocardiography. There were no severe complications such as circulatory collapse and arrhythmia in the perioperative period.     

A case of paracecal hernia

A 63-year-old male patient suddenly suffered right lower abdominal pain. The patient had tenderness and rebound tenderness at the right lower abdomen. Marked small bowel dilatation and an intestinal obstruction were evident upon abdominal X-ray and abdominal computed tomography (CT) imaging. CT imaging also revealed a dilated small bowel cluster in a wrapped round shape in the right lower abdomen. The cecum and the ascending colon were displaced inward. Strangulation in the ileocecal region was suspected, and emergency surgery was performed. A part of the small bowel was incarcerated within the retrocecal recess, and the intestinal tract was strangulated in the hernia orifice, by which paracecal hernia was diagnosed. The strangulated intestinal tract was repositioned, and the orifice to the hernia was closed. Paracecal hernia is a rare disease; an internal hernia should always be considered in patients with ileus without a history of surgery.     

Repair of an Abdominal Aortic Aneurysm with a Remarkably Dilated Meandering Artery: Report of a Case

A 73-year-old man on dialysis for chronic renal dysfunction was referred to our hospital for surgical treatment of an abdominal aortic aneurysm (AAA). Preoperative angiography showed a remarkably developed meandering artery branching from the inferior mesenteric artery (IMA). The superior mesenteric and celiac arteries were occluded at the origin, and all blood flow to the abdominal organs was apparently supplied by collateral circulation from the IMA. Considering the risk of mesenteric ischemia after aortic clamping in conjunction during surgery, we used a perfusion catheter with a 12-F balloon to create a shunt to the IMA from the subclavian artery. The operation was successful and the patient recovered uneventfully. We describe this surgical procedure for its effectiveness in preventing postoperative mesenteric ischemia in a rare case of an AAA with complex branching lesions.