Study in three different types of cardiopulmonary bypass on arterial ketone body ratio: its prognostic implication and participation of body temperature

The aim of this study was to investigate the change of hepatic metabolic activity presented by the ketone body ratio (AKBR) during and after cardiopulmonary bypass (CPB) and to evaluate the prognostic value. AKBR were measured in 20 cases of coronary aortic bypass grafting using moderate hypothermic CPB (group M), ten cases of aortic arch surgery using deep hypothermia with selective cerebral perfusion (DHSCP) with an open technique (group D) and 15 cases of descending thoracic aortic replacement using partial CPB (group N). AKBR decreased significantly in all groups 5 min after CPB compared with the value before CPB. There was a significant difference in AKBR 1 h after CPB among the three groups and AKBR returned to the prebypass value in group N (group M, 0.32 +/- 0.16; group D, 0.14 +/- 0.04; group N, 0.48 +/- 0.14; P < 0.0001). AKBR rose significantly after the discontinuation of CPB compared with the value during CPB and returned to the prebypass value in groups M and D. The patients who underwent DHSCP with an open technique had a value of AKBR below 0.2, but liver function still recovered normally. The value of AKBR correlated with temperature significantly and a very low level of AKBR below 0.2 was observed during core cooling to 20 degrees C without negative prognostic implications. AKBR decreased 5 min after CPB in group N which suggested decreased hepatic perfusion at an early stage of partial CPB. The prognostic implication of AKBR during CPB is whether low level AKBR recovers or not.     

A case of thoracic disc herniation with sudden onset paraplegia on toilet straining: case report

Thoracic disc herniation is less common rather than cervical or lumbar herniation. Cases of sudden onset without trauma are especially rare. Generally, the neurological onset of disc herniation is caused by mechanical cord compression due to a protruded disc, and its onset is usually gradual. Ischemia is also considered as a factor of neurological onset. We report a case of a 78-year-old male with sudden paraplegia while straining at the toilet. T2 weighted MR image on admission showed mild disc protrusion at the level of Th8-9 and intramedullary high signal intensity below the Th8-9 level. We speculate that Valsalva-like maneuver had led to the congestion of vertebral venous plexus or compression of the anterior spinal artery, and spinal ischemia occurred.     

Combination of Obesity with Hyperglycemia is a Risk Factor for the Presence of Vertebral Fractures in Type 2 Diabetic Men

Although patients with type 2 diabetes show no bone mineral density (BMD) reduction, fracture risks are known to increase. It is unclear why the patients have an increased risk of fracture despite sufficient BMD. We investigated the relationships of body mass index (BMI), HbA_1c, and urinary C-peptide (uC-peptide) versus BMD, bone metabolic markers, serum adiponectin, and prevalent vertebral fracture (VF). A total of 163 Japanese type 2 diabetic men were consecutively recruited, and radiographic and biochemical data were collected. BMI was positively correlated with BMD at the whole body, lumbar spine, and femoral neck (P < 0.05) and negatively correlated with osteocalcin and urinary N-terminal cross-linked telopeptide of type-I collagen (uNTX) (P < 0.01). HbA_1c was negatively correlated with osteocalcin (P < 0.01) but not BMD at any site. Subjects were classified into four groups based on BMI and HbA_1c (group LL BMI < 24 and HbA_1c < 9, group LH BMI < 24 and HbA_1c ≧ 9, group HL BMI ≧ 24 and HbA_1c < 9, group HH BMI ≧ 24 and HbA_1c ≧ 9). Serum adiponectin, osteocalcin, and uNTX were lower and the incidence of VF was higher despite sufficient BMD in the HH group. Multivariate logistic regression analysis adjusted for age, duration of diabetes, uC-peptide, and estimated glomerular filtration rate showed that the HH group was associated with the presence of a VF and multiple VFs (odds ratio [OR] = 3.056, 95% confidence interval [CI] 1.031–9.056, P = 0.0439, and OR = 5.415, 95% CI 1.126–26.040, P = 0.0350, respectively). Combination of obesity with hyperglycemia was a risk factor for VF despite sufficient BMD in diabetic men.     

Endovascular stent grafting of the descending thoracic aorta after arch repair in acute type A dissection

An endovascular stent graft was successfully deployed to the primary entry site in the proximal descending thoracic aorta after total aortic arch replacement using the "elephant trunk" technique in acute type A aortic dissection. The residual false lumen of the descending aorta was thrombosed completely after stent grafting. The elephant trunk was feasible for a proximal landing zone for stent grafting of the descending aorta. Stent grafting in combination with aortic arch replacement was a safe and effective procedure, and may be an alternative choice in carefully selected patients with type A aortic dissection.     

Prediction of the response to chemoradiation and prognosis in oesophageal squamous cancer

BACKGROUND: The sensitivity of cancer cells to chemotherapy and radiation therapy depends on various biological properties. This study investigated the expression of p53, CDC25B and metallothionein (MT), and evaluated their clinical significance in chemoradiation therapy (CRT) for oesophageal squamous cell carcinoma.METHODS: The expression of p53, CDC25B and MT was evaluated by immunohistochemistry using biopsy specimens taken before CRT for 77 patients with oesophageal squamous cell carcinoma, and correlated with the pathological effects of CRT and survival.RESULTS: p53-positive tumours and MT-positive tumours had a poor response to CRT, whereas tumours with strong CDC25B expression were associated with a good response. When each patient was scored for the presence of the three biological factors, there was a strong correlation between the sensitivity score and the pathological effect of CRT (P < 0.001), and a (non-significant) difference in the 5-year survival rate between patients with a high score and those with a low score (67 versus 34 per cent respectively; P = 0.12).CONCLUSION: The combined evaluation of p53, CDC25B and MT may help to identify patients with advanced oesophageal squamous cell carcinoma who will benefit from preoperative CRT.     

Axonal supercharging technique using reverse end-to-side neurorrhaphy in peripheral nerve repair: an experimental study in the rat model

OBJECT: In an attempt to improve peripheral nerve repair, the influence of the addition of reverse end-to-side neurorrhaphy for an injured peripheral nerve was investigated in the rat sciatic nerve transection model. METHODS: Twelve Sprague-Dawley rats were divided into two groups (six rats in each group). In Group I, the right sciatic nerve was cut at a point distal to the gluteal notch and repaired using end-to-end neurorrhaphy with four 10-0 nylon epineurial sutures. In Group II, after performing the same procedure as in Group I, the left sciatic nerve was cut distally and passed through a subcutaneous tunnel to the right side. The proximal stump of the left sciatic nerve was coapted to the epineurial window of the right sciatic nerve distal to the injured point in an end-to-side fashion using 10-0 nylon epineurial sutures. The effects were evaluated using analgesimeter recordings for the hind paw, electrophysiological tests, measurement of the muscle contraction force, a double-labeling technique, weight measurement and histological examination of the gastrocnemius muscle, histological examination of the bilateral sciatic nerves, and immunofluorescent staining. RESULTS: Results from the many tests used to evaluate the reverse end-to-side neurorrhaphy technique indicated that functional recovery of the denervated target organs was promoted by axonal augmentation. CONCLUSIONS: The reverse end-to-side neurorrhaphy technique could be useful in peripheral nerve repair.     

Bladder-Sparing Extended Resection of Locally Advanced Rectal Cancer Involving the Prostate and Seminal Vesicles

Purpose Total pelvic exenteration (TPE) is the standard procedure for locally advanced rectal cancer involving the prostate and seminal vesicles. We evaluated the feasibility of bladder-sparing surgery as an alternative to TPE. Methods Eleven patients with advanced primary or recurrent rectal cancer involving the prostate or seminal vesicles, or both, underwent bladder-sparing extended colorectal resection with radical prostatectomy. The procedures performed were abdominoperineal resection (APR) with prostatectomy (n = 6), colorectal resection using intersphincteric resection combined with prostatectomy (n = 4), and abdominoperineal tumor resection with prostatectomy (n = 1). Local control and urinary and anal function were evaluated postoperatively. Results Cysto-urethral anastomosis (CUA) was performed in seven patients and catheter-cystostomy was performed in four patients. Coloanal or colo-anal canal anastomosis was also performed in four patients. There was no mortality, and the morbidity rate was 38%. All patients underwent complete resection with negative surgical margins. After a median follow-up period of 26 months there was no sign of local recurrence, and ten patients were alive without disease, although distant metastases were found in three patients. Five patients had satisfactory voiding function after CUA, and three had satisfactory evacuation after intersphincteric resection (ISR). Conclusion These bladder-sparing procedures allow conservative surgery to be performed in selected patients with advanced rectal cancer involving the prostate or seminal vesicles, without compromising local control.     

Experience of coronary artery bypass grafting on the beating heart with right heart bypass; 3 cases of octogenarian

Right heart bypass (RHB) yields more stable hemodynamics by increasing left ventricular preload and collapse right ventricular chamber during the displacement of the heart on beating heart coronary artery bypass grafting (CABG). Recently beating heart CABG gaining popularity, and the indications for CABG have increasingly expanded to elderly person. Using RHB while exposing posterior branches by displacing the beating heart, we have attempted to make total revascularization in beating heart CABG. We performed beating heart CABG with RHB in 3 cases of octogenarian. All patients had left main trunk lesion and needed revascularization of posterior vessels. Introduction of RHB enabled us to approach to posterior target vessels in better exposure and under greater hemodynamic stability. All three patients had no complications postoperatively. Strictly speaking CABG with RHB is not off-pump CABG, but RHB system does not include either artificial lung or manipulation of the aorta. Therefore we think it is very effective support system which enables multiple coronary revascularization for elderly person.     

Preoperative concurrent chemotherapy and radiation therapy followed by surgery for esophageal cancer.

Currently, the most promising strategy to improve the prognosis of advanced esophageal cancer is preoperative chemoradiation (CRT) followed by surgery. The superiority of CRT over radiation therapy alone has been demonstrated by several randomized studies. Many phase II studies of CRT followed by surgery have shown that the pathologic complete response (CR) rate ranges from 17 to 40%, and the median survival time (MST) is 12 to 31.3 months. Five randomized trials have compared preoperative CRT followed by surgery with surgery alone for resectable esophageal cancer, and four of them did not find any significant survival benefit for the combined treatment group. There are several issues in interpreting these findings, such as the quality of the surgery, the accuracy of the preoperative staging, the statistical power and design of the trials. Until comprehensive evaluation can be done, the standard therapy for resectable esophageal cancer should be considered to be surgery alone. The histological response in the resected specimen correlates well with the prognosis. Patients with pathologic CR display significantly better survival than those with microscopic residual cancer cells in the resected specimens. These findings suggest that more potent regimens leading to higher pathologic CR rates should improve the prognosis. Chemotherapy or radiation therapy sensitivity testing needs to be established. If accurate prediction of the response is possible prior to therapy, non-responders can be excluded. Cell cycle-related genes, apoptosis-related genes, and drug metabolizing genes have been investigated in many pilot studies and need to be evaluated by large-scale clinical studies. At present, pathologic CR can not be accurately diagnosed before surgery. Endoscopic biopsy is also unreliable for the diagnosis. In the future, new diagnostic tools such as positron emission tomography scanning, a sensitivity test or molecular markers may enable accurate diagnosis of pathologic CR to guide the choice of treatment strategies for individual patients.     

Upper extremity deep vein thrombosis treated by a filter in the superior vena cava placed intraoperatively to allow safe esophageal surgery: Report of a case

Upper extremity deep vein thrombosis (UEDVT) is an infrequent but dangerous vascular event, especially for patients undergoing thoracic surgery. However, there is no standard perioperative management to reduce the risk of pulmonary thromboembolism in such patients. We describe how we performed successful esophagectomy in a patient with UEDVT treated by placing a filter in the superior vena cava during surgery.