Open heart surgery without blood transfusion for cyanotic congenital cardiac defects

Between November 1994 and January 1997, 42 cases of cyanotic congenital cardiac defects underwent definitive surgery at Matsudo Municipal Hospital. We evaluated 30 cases, each weighing from 7 to 20 kg. The procedures were performed at the age of 9 months to 6 years (mean age—2.4 years). The body weights were 7.7 to 20 kg (mean weight—11.4 kg). The preoperative diagnoses were Tetralogy of Fallot (TOF) in 19 cases, Fontan candidates in 6 and the others in 5. We classified them into 3 groups; Group Abstract—15 cases were completed with non-blood transfusion, Group B—8 cases used only plasma protein fraction and Group C—7 cases used blood transfusion. Cardiopulmonary bypass (CPB) system is a semi-closed circuit and priming volume is 400 to 600 ml. There is no difference among the 3 groups in operative age, body weight, opeartion time, CPB time, aortic cross clamp time, bleeding and postoperative state. The same results were obtained in minimum base excess and urine output during CPB and the changes of hematocrit and total protein. In Groups A and B, CPB blood was retruned to the patient as soon as possible after CPB was weaned, but in Group C, blood transfusion was performed without the return of CPB blood. In all groups, hemodynamics were stable. Retrospectively, it is thought that blood transfusion was not necessary in Group C and the use of the plamsa protein fraction was not needed in Group B. In conclusion, the open heart surgery can be performed safely without blood transfusion for cyanotic congenital cardiac defects.     

Intraductal papillary mucinous tumor of the pancreas associated with autosomal dominant polycystic kidney disease

A 43-year-old male with a history of autosomal dominant polycystic kidney disease (ADPKD) was admitted to our center with severe abdominal pain and was diagnosed with acute pancreatitis. CT showed multiple cysts in the liver and both kidneys along with ADPKD and a cystic mass, 4 cm in diameter, in the pancreatic head. The main pancreatic duct was dilated to 1 cm in diameter. The patient was diagnosed with acute pancreatitis due to intraductal papillary mucinous tumor (IPMT), and pancreatoduodenectomy was performed. Histologic examination revealed a multiloculated cystic tumor filled with mucin in the head of the pancreas. Microscopically, the tumor was diagnosed as adenocarcinoma and was found to have invaded the main pancreatic duct. Although, in addition to our case, only seven cases with association between ADPKD and malignant neoplasms have been reported, five of these cases had neoplasms arising from the pancreas. Therefore, we suggest that some genetic interactions may exist between ADPKD and pancreatic carcinogenesis.     

Paraparesis associated with ruptured anterior cerebral artery territory aneurysms

BACKGROUND: Paraparesis is a rare but characteristic manifestation of ruptured anterior communicating artery or anterior cerebral artery (ACA) aneurysms, but the pathogenesis remains unclear. This study investigated the neuroimaging and clinical features of patients with such paraparesis to evaluate possible causes. METHODS: Nine of 178 patients with ruptured anterior communicating artery or ACA aneurysms presented with paraparesis among 462 patients with subarachnoid hemorrhage (SAH) admitted between May 1996 and November 2001. Diffusion-weighted magnetic resonance (MR) imaging was performed within 48 hours of the onset of SAH in 4 of these 9 patients. The clinical course and neuroimaging studies of these 4 patients were retrospectively reviewed. RESULTS: Diffusion-weighted MR imaging revealed -intensity areas in the medial aspects of the bilateral frontal lobes, which were supplied by the ACAs and distal to the aneurysms, in all 4 patients. These high-intensity lesions had normal to subnormal values of apparent diffusion coefficient (ADC). Most of the high-intensity lesions recovered and did not result in the final lesions regardless of the ADC values, but some lesions with subnormal ADC values resulted in cerebral infarction. Paraparesis was transient and almost completely resolved in 3 patients. CONCLUSIONS: Diffusion-weighted MR imaging detected primary brain damage in the ACA territories caused by acute SAH, which was compatible with the clinical paraparesis. Primary brain damage caused by SAH may include 3 types of lesions: reversible with normal ADC value, reversible with subnormal ADC value, and irreversible with subnormal ADC value.     

Accumulation of Excess Visceral Fat Is a Risk Factor for Pancreatic Fistula Formation After Total Gastrectomy

Background  The effect of obesity on gastrectomy in patients with gastric cancer is controversial. The degree of abdominal fat increases the technical difficulty of abdominal surgery. This study examined the effect of visceral fat on total gastrectomy and risk factors associated with the formation of pancreatic fistula. Methods  Between February 2001 and April 2007, 191 patients with gastric cancer underwent total gastrectomy. The visceral fat area (VFA) was calculated from computed tomography (CT) scans taken at the level of the umbilicus using FatScan Software. Patients were divided into high- (≥100 cm², n = 52) and low-VFA groups (<100 cm², n = 139), and also into high- (≥25 kg/m², n = 47) and low-BMI groups (<25 kg/m², n = 144). Results  Blood loss and incidence of pancreatic fistula were significantly higher in the high- than low-VFA group. However, only blood loss was significantly different between the high- and low-BMI groups. VFA, blood loss, and splenectomy were identified as significant risk factors for pancreatic fistula formation on univariate analysis, and multivariate logistic regression analysis of these factors identified VFA (p = 0.0001) and splenectomy (p = 0.0014) as significant predictors of pancreatic fistula. Conclusions  VFA is a better indicator for pancreatic fistula formation after total gastrectomy than is BMI. Lymph node dissection must be performed carefully, especially in patients with visceral fat accumulation during total gastrectomy with splenectomy.     

Subcutaneous Peroneus Longus Tendon Rupture Associated with OS Peroneum Fracture

We report a rare case of subcutaneous peroneus longus tendon rupture associated with os peroneum fracture. Three dimensional computed tomographic scan was useful to understand this disorder. We treated the patient with excision of fractured os peroneum and tenodesis of the proximal stump of the ruptured peroneus longus tendon to the lateral aspect of the calcaneus.

Key points

• In order to understand a rare case of subcutaneous peroneus longus tendon rupture associated with os peroneum fracture, three dimensional computed tomographic scan was useful.
• The patient was treated with excision of fractured os peroneum and tenodesis of the proximal stump of the ruptured peroneus longus tendon to the lateral aspect of the calcaneus.

Key words: Os peroneum, fracture, rupture, peroneus longus tendon.     

CD133 Expression at the Metastatic Site Predicts Patients’ Outcome in Colorectal Cancer with Synchronous Liver Metastasis

Background

CD133 is a transmembrane protein that is proposed to be a stem cell marker of colorectal cancer (CRC); however, the correlation between CD133 expression and survival of CRC patients with liver metastasis has not been fully examined.

Methods

CD133 expression was evaluated immunohistochemically, both in primary tumors and synchronous liver metastases of 88 consecutive CRC patients, as well as recurrent lesions in the remnant liver of 27 of these 88 patients. The relationship between CD133 expression and clinicopathological characteristics, recurrence-free survival, and overall survival (OS) was analyzed.

Results

CD133 expression in liver metastases (mCD133) was detected in 50 of 88 patients (56.8 %), and had significant correlation with CD133 expression in primary lesions (pCD133) (p < 0.001). CD133 expression in liver recurrent lesions (recCD133) also had a significant correlation with mCD133 (p < 0.001). mCD133+ patients had significantly longer disease-free survival (p = 0.043) and OS (p = 0.014) than mCD133? patients. In addition, mCD133+ patients had a significantly lower rate of extrahepatic recurrence (p < 0.001).

Conclusions

Patients without CD133 expression in liver metastasis had significantly shorter survival, perhaps because mCD133? patients had a significantly higher rate of extrahepatic recurrence.

     

Comparison of laparoscopy-assisted and open pylorus-preserving pancreaticoduodenectomy for periampullary disease

Background

Although many reports have described laparoscopic pancreatic surgery, pancreaticoduodenectomy (PD) has not been widely accepted. The present study aimed to compare laparoscopy-assisted and open pylorus-preserving pancreaticoduodenectomy (PPPD) to investigate the feasibility, safety, and tumor clearance.

Methods

Fifteen patients with periampullary disease underwent laparoscopy-assisted PPPD, in which resection was performed laparoscopically and the reconstruction was performed through a small midline incision. These patients were compared with 15 patients who, during the same period, underwent conventional open PPPD.

Results

Mean operative time and mean blood loss were similar between groups. No significant differences in the incidence of complications or hospital stay were noted between groups. Surgical margin and number of lymph nodes found in the resected specimen did not differ between groups.

Conclusions

Laparoscopy-assisted PPPD is on the same level with conventional open surgery in terms of perioperative outcomes or treatment efficacy.     

Effect of substituting allogenic blood transfusion with autologous blood transfusion on outcomes after radical oesophagectomy for cancer.

BACKGROUND: The oncologic benefit of avoiding allogenic blood transfusion in oesophageal cancer resection has not been studied. METHODS: The medical records of 68 patients (Auto group) who underwent a potentially curative oesophageal cancer resection without allogenic blood transfusion from 1996 to 1999 receiving 800 g of autologous blood donated preoperatively, and 97 patients (Allo group) who underwent the same operation with allogenic blood transfusion from 1990 to 1995 were compared. RESULTS: There were no differences in age, gender, stage of disease, number of retrieved nodes, or perioperative hemoglobin concentration between the two groups. The survival of the 45 patients with nodal involvement in the Auto group was better than that of the 59 patients in the Allo group (p=0.0435), and the survival of the 35 patients with T3 or T4 lesions in the Auto group was better than that of the 61 patients in the Allo group (p=0.0408). According to logistic regression analysis, allogenic blood transfusion correlated with tumour recurrence in patients with either nodal involvement or a T3-4 lesion. The natural killer cell activity remained higher in the Auto group than in the Allo group (p<0.05). CONCLUSION: Avoidance of allogenic blood transfusion favorably effected the survival of patients with oesophageal cancer at risk for recurrence.     

Use of a modified Dumon stent for postoperative bronchopleural fistula

This report describes a case of a postoperative bronchopleural fistula successfully managed with a modified Dumon stent. Surgical interventions for the bronchopleural fistula with empyema were subsequently avoided. Dumon stent is an acceptable option for the treatment of postoperative bronchopleural fistulas.     

Lack of correlation between results of ABO-incompatible living kidney transplantation and anti-ABO blood type antibody titers under our current immunosuppression

In this study, we examined the impact of preoperative anti-A/B antibody titers on the results of ABO-incompatible living kidney transplantation (LKT). In all, 167 recipients underwent ABO-incompatible LKT at our institution between 1989 and 2002. These patients were subdivided into those transplanted under cyclosporine with azathioprine or mizoribine (Group 1, n=78) and those transplanted under tacrolimus or mycophenolate mofetil (Group 2, n=89). Overall patient survival at 5 and 10 years was 93.8% and 88.0%, respectively. Overall graft survival at 5 and 10 years was 76.9% and 55.9%, respectively. Graft survival in the patients with anti-A/B IgG titers over 1:128 was significantly lower in group 1, whereas no significant correlation between the anti-A/B IgG titers and graft survival was found in group 2. In conclusion, no correlation between anti-A/B antibody titers and the results of ABO-incompatible LKT was seen after tacrolimus or mycophenolate mofetil application.