Sutureless repair with TachoComb sheets for oozing type postinfarction cardiac rupture

Left ventricular free-wall rupture is a well recognized complication of myocardial infarction and a frequent cause of death. The appropriate surgical management varies significantly depending on the condition of the tear and the presence of concomitant lesions. We present a case of oozing type postinfarction cardiac rupture that was treated successfully by a sutureless patch technique using a fibrin tissue-adhesive collagen fleece (TachoComb [Torii Pharmaceutical, Tokyo, Japan]). This represents a quick, effective, and safe option for dealing with oozing type myocardial rupture due to myocardial infarction.     

Unsuspected gallbladder carcinoma after laparoscopic cholecystectomy

Background/Purpose Many cases have been reported of disastrous port-site recurrence after laparoscopic cholecystectomy (LC) revealed unsuspected gallbladder carcinoma (GBC). Some investigators have reported that the prognosis of patients after LC showed unsuspected GBC is not worsened by laparoscopic procedures. We retrospectively reviewed our cases and the literature to reconfirm the intrinsic risks of LC for unsuspected GBC. Methods Of 1663 patients who underwent LC from January 1991 to December 2003 in a single institution, 9 (0.54%) with unsuspected GBC were reviewed. Results These 9 patients consisted of 5 men and 4 women, whose ages ranged from 58 to 87 years, with a median age of 73 years. Two patients with a pT1a tumor (limited to mucosa) and 2 patients with a pT1b tumor (muscle layer) underwent no further operation. The remaining 5 patients with a pT2 tumor (subserosa) underwent further operations with lymph node dissection. Five patients (2 patients with pT1b and 3 patients with pT2) developed recurrence and all of them died within a median period of 19 months (range 14–37 months) after LC. The causes of death were bone metastases in 1 patient (pT2), local recurrence in 2 patients (pT1b and pT2), and peritoneal metastasis in 2 patients (one elderly patient with pT1b who underwent laparoscopic common bile duct exploration, and one patient with pT2 in whom the cystic duct was damaged during surgery). Four patients (2 with pT1 and 2 with pT2) have been doing well with a median follow-up of 39.5 months (range 12–99 months) after LC. Conclusions Surgeons should always prevent bile spillage during LC and when removing the resected gallbladder. When laparoscopic common bile duct exploration is planned, especially for elderly women, surgeons should also bear in mind the increasing possibility of unsuspected GBC.     

Correlation of CD133, OCT4, and SOX2 in Rectal Cancer and Their Association with Distant Recurrence After Chemoradiotherapy

Background  

Cancer stem cells are associated with metastatic potential, treatment resistance, and poor patient prognosis. Distant recurrence remains the major cause of mortality in rectal cancer patients with preoperative chemoradiotherapy (CRT). We investigated the role of three stem cell markers (CD133, OCT4, and SOX2) in rectal cancer and evaluated the association between these gene levels and clinical outcome in rectal cancer patients with preoperative CRT.     

Airway compression by the ascending aorta due to a thin thoracic cage

An 89-year-old woman with dyspnea and disturbed consciousness due to hypoventilation was admitted to our hospital. Chest radiography showed no abnormal shadow, but she was intubated for deteriorated hypoventilation. Bronchoscopy demonstrated obstruction of the left main bronchus at the carina. Computed tomography (CT) showed neither a mass lesion in the mediastinum nor an aortic aneurysm, but compression of the airway by the ascending aorta was observed. It was thought that the patient’s thin thoracic cage was unable to support the weight of the ascending aorta, which consequently compressed the left main bronchus. After inserting stents into both main bronchi, the patient’s consciousness improved, and respirator support was withdrawn. In aged, bedridden, thin patients with hypopnea or recurrent airway infection, CT and bronchoscopy should be performed to investigate airway patency.     

Leg Anterior Compartment Syndrome Following Ankle Arthroscopy After Maisonneuve Fracture

We report a case of leg anterior compartment syndrome following ankle arthroscopy after Maisonneuve fracture. A 21-year-old football player sprained his left ankle. Plain radiography of his left ankle showed a lateral dislocation of the talus without obvious fractures. Plain radiography of his left lower extremity showed a spiral fracture of the proximal fibula approximately one third distal to the fibular head. According to these findings, we diagnosed this fracture as a Maisonneuve fracture and treated it by ankle arthroscopy and drilling of the talar osteochondral injury followed by arthroscopic ankle visualization during syndesmosis screw fixation. Six hours after surgery, the patient complained of pain in the lower extremity. We diagnosed acute compartment syndrome and performed emergent fasciotomy. One year after surgery, he was able to fully participate in athletic activities. We consider ankle arthroscopy to be available for the treatment of ankle fracture with the suspected complication of an intra-articular disorder such as a Maisonneuve fracture. However, with this type of ankle fracture, there is a higher potential risk of acute compartment syndrome developing than with other types of ankle fractures. Therefore we suggest that surgeons guard against this complication.     

Respiratory-gated F-FDG PET/CT for the diagnosis of liver metastasis

Purpose

To ascertain the role of respiratory-gated PET/CT with ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) for accurate diagnosis of liver metastasis.

Materials and methods

Forty patients with suspected liver metastasis underwent conventional whole-body PET/CT scan initially, followed by respiratory-gated PET/CT scan covering the liver. Visual detectability (using a 5-point confidence scale), maximum standardized uptake value (SUVmax) and metabolic tumor volume (MTV) of hepatic metastatic lesions were assessed for three data sets including ordinary whole-body (WB) scan, and non-respiratory-gated (nRG) and respiratory-gated (RG) scans. Results of enhanced CT and/or MRI, or clinical and radiological follow-up were used for reference.

Results

Sixteen of the patients were found to have 53 metastatic lesions in the liver. Patient-based accuracy of WB, nRG, and RG was 92.5%, 95.0%, and 97.5%, respectively, with a lesion-based detection rate of 67.9%, 73.6%, and 73.6%, respectively. The average SUVmax of 34 liver metastatic lesions for WB, nRG, and RG was 6.60 ± 2.34, 7.19 ± 2.66, and 8.08 ± 3.24, respectively. SUVmax for RG was significantly higher than that for WB (p = 0.0069). The average MTV of these 40 lesions for the three protocols was 5.32 ± 4.78 cm³, 5.07 ± 4.73 cm³, and 4.73 ± 4.67 cm³, respectively. Among the three protocols, RG showed the best visual and quantitative evaluation for diagnosis of liver metastasis.

Conclusion

Respiratory-gated PET/CT allows more accurate identification of liver metastases than non-respiratory-gated PET/CT.     

Hemodynamic and catecholamine responses during tracheal intubation using a lightwand device (Trachlight) in elderly patients with hypertension

Purpose.Tracheal intubation using a lightwand device (Trachlight) should minimize hemodynamic change by avoiding direct-vision laryngoscopy. We evaluated hemodynamic and catecholamine responses during tracheal intubation using a Trachlight in elderly patients with hypertension.Methods.Twenty-six hypertensive patients aged over 65 years undergoing orthopedic surgery were randomly divided into two groups, group L (n = 13) and group T (n = 13). Anesthesia was induced with fentanyl (2g·kg^–1) and propofol (1.5mg·kg^–1), and then muscle relaxation was obtained with vecuronium (0.15mg·kg^–1). The trachea was intubated with either a Macintosh laryngoscope (group L) or a Trachlight (group T). Hemodynamics, plasma catecholamine concentrations, and arterial blood gases were measured before the induction of anesthesia (T0), before tracheal intubation (T1), immediately after tracheal intubation (T2), and 3min after tracheal intubation (T3).Results.The intubation time was shorter in group T than in group L (12.6 ± 1.7 vs 23.5 ± 2.9s, mean ± SE; P 0.01). Compared with the preinduction (T0) value, systolic blood pressure (SBP) showed a significant decrease at T1 and T3 in group L and at T1, T2, and T3 in group T. The heart rate (HR) and plasma norepinephrine (NE) concentration showed no change in either group throughout the time course, whereas the plasma epinephrine (E) concentration showed a significant decrease at T2 and T3 in both groups. The mean values of the rate-pressure product (RPP: HR × SBP) were less than 15 000 after tracheal intubation in both groups. There was no significant difference in hemodynamic or catecholamine responses between groups at any point. No patient had ischemic ST-T changes in either group.Conclusion.A lightwand has no advantage over a laryngoscope in terms of hemodynamic and plasma catecholamine responses to tracheal intubation in elderly patients with hypertension, despite a shorter intubation time.     

Development of a therapeutic adenoviral vector for cholangiocarcinoma combining tumor-restricted gene expression and infectivity enhancement

Cholangiocarcinoma is an invasive malignancy that is most often unresectable upon diagnosis and unresponsive to chemotherapy and radiation. While adenoviral gene therapy has shown promise in treating many tumors, systemic toxicity and low tumor transduction efficiency have hampered its application in many gastrointestinal cancers. To overcome these difficulties, we have constructed an adenoviral vector utilizing a tumor-specific promoter (TSP) for selective transgene expression and a vector with an RGD-motif in the fiber-knob region for infectivity enhancement. In seeking a TSP for cholangiocarcinoma, Secretory Leukoprotease Inhibitor, Midkine, Gastrin Releasing Peptide, VEGF, Cox-2M, and Cox-2L promoters were configures in adenoviral vectors, and evaluated in cholangiocarcinoma cells lines (Oz and SkChA-1). Luciferase assays demonstrated that Cox-2 promoters (M and L) showed the highest promoter activity, with Cox-2M appearing slightly stronger than Cox-2L. Infectivity enhanced vectors with RGD-motif in the fiber-knob region were also constructed with the luciferase transgene driven by a CMV control and the Cox-2M and Cox-2L promoters. Subsequent luciferase assays comparing the unmodified vectors to the RGD-modified versions demonstrated higher levels of luciferase activity than the RGD-infected cells. This paradigm was then applied to a therapeutic HSV-TK/GCV model by constructing RGD-enhanced HSV-TK vectors driven by Cox-2M and Cox-2L promoters. In vitro cytocidal effect analysis confirmed that the RGD-modified, cox-2 (M and L) driven vectors showed a stronger cytocidal effect upon gancyclovir administration than the vectors with wild-type fiber. The Cox-2 promoter demonstrates a favorable selectivity profile for cholangiocarcinoma, and RGD-modification further enhances transduction efficiency. This combination has potential to overcome the obstacles to clinical application of adenoviral gene therapy in cholangiocarcinoma. Presented at the Forty-Third Annual Meeting of The Society for Surgery of The Alimentary Tract, San Francisco, California, May 19–22, 2002 (oral presentation).     

Autosynchronized systolic unloading during left ventricular assist with a centrifugal pump

OBJECTIVES: The purpose of this study was to investigate how the inflow cannulation site of the left ventricular assist system with a centrifugal pump would influence cardiac function on failing heart models. METHODS: In 10 sheep, a left ventricular assist system was instituted by an outflow cannula in the descending aorta, two inflow cannulas in the left atrium and the left ventricle, and connecting those cannulas to a magnetically suspended centrifugal pump. A conductance catheter and a tipped micromanometer for monitoring the pressure-volume loop were also inserted into the left ventricle. Myocardial oxygen consumption was directly measured. Heart failure was induced by injection of microspheres into the left main coronary artery. The assist rate was varied from 0% to 100% at each inflow cannulation site. RESULTS: The pump flow with left ventricular cannulation increased during the systolic phase and decreased during the diastolic phase, whereas it was constant with left atrial cannulation. Ejection fraction with left atrial cannulation decreased as the assist rate increased, whereas that with left ventricular cannulation was maintained up to 75% assist. The external work with left atrial cannulation decreased gradually as the assist rate increased, whereas the external work with left ventricular cannulation did not decrease until the assist rate reached 75%. The myocardial oxygen consumption in both cannulations decreased proportionally as the assist rate increased; they were significantly less with left ventricular cannulation at the 100% assist rate than with left atrial cannulation. CONCLUSION: Left ventricular cannulation during left ventricular assistance maintains ejection fraction and effectively reduces oxygen consumption.     

Clinicoanatomical studies on the dorsal subsegmental bile duct of the right anterior superior segment of the human liver

BACKGROUND: The dorsal subsegmental intrahepatic bile duct in the right anterior superior segment (B8c) sometimes joins the posterior sectorial duct. In such cases it can be misidentified as the right posterior superior segmental duct (B7). However, there are no published studies on the confluent pattern of B8c. MATERIALS AND METHODS: We studied B8c in the resected liver of 107 patients (65 with bile duct carcinoma and 42 with gallbladder carcinoma) who had undergone right hepatectomy or more extensive right-sided liver resection. RESULTS: B8c was identified in all cases. It joined the right posterior sectorial duct or B7 in 18 cases (16.8%). In 12 cases B8c joined independently the posterior sectorial duct or B7. In 6 cases B8c joined the posterior sectorial duct after making the common duct with the lateral subsegmental duct in the anterior superior or anterior inferior segment (B8b or B5c). CONCLUSIONS: B8c does not join the anterior sectorial bile duct in every sixth case.