Reoperation of tetralogy of Fallot for the transannular patch neo-intimal stenosis: a case report]

A 3-year-old male patient underwent right ventricular outflow tract reconstruction with a glutaraldehyde-preserved equine pericardium for tetralogy of Fallot. Because of progressive severe pulmonary restenosis with over systemic right ventricular pressure, tricuspid regurgitation, and abnormal high echoic shadow in the distal main pulmonary artery on echocardiogram, he required reoperation a year after the first correction. In the reoperative findings, the pseudointima was thickened heavily and detached from glutaraldehyde-preserved equine pericardial patch. The patch was removed and the right ventricular outflow was reconstructed widely to the pulmonary bifurcation with porcine pericardial patch again. Patho-histological findings showed foreign body giant cells and macrophages in the pseudointima. Four years after the reoperation, echocardiogram shows 41 mmHg for the right ventricular pressure and 22 mmHg for the pressure gradient of right ventricular outflow tract, and the patient is doing well now.     

Anterior screw fixation combined with posterior interlaminar fusion for fracture of axis: report of two cases

Two cases of axis fracture are reported. Traffic accidents were the cause of injury in both cases. The odontoid process was dislocated anterolaterally with fracture of the lateral mass of the axis in both cases. In Case 1 good alignment of the atlas and axis could not be maintained even with a Halo-vest. The case 2 patient with spinal cord compression caused by dislocation of the axis was referred to our hospital 8 weeks after the accident. Both cases were surgically treated in a similar fashion. Because of the lateral mass fracture and lateral displacement of the atlas relative to the axis, posterior screw fixation with interlaminar fixation (Magerl) was thought to carry a risk of causing damage to the vertebral artery. Because of this, anterior screw fixation combined with posterior wiring was conducted. First, the odontoid process was fixed anteriorly by a screw because it was able to be placed back in good alignment while the patient was in the supine position. Then, the posterior C1-2 interlaminar wiring with iliac bone graft was added. Rigid fixation was obtained without any complication. Various kinds of fixation, such as posterior interlaminar wiring, odontoid screw fixation and Magerl's fixation, have been reported for the treatment of unstable axis fracture. Among them Magerl's method has been regarded as the most stable. When it is not applicable, combination of the first two methods can be an alternative way of treatment for this odontoid process fracture.     

Mediastinal lymph node involvement as the initial manifestation of occult thyroid cancer in the surgical treatment of lung cancer: Report of a case

A 63-year-old man was referred to our institute for the treatment of squamous cell carcinoma of the upper lobe of his right lung. A right upper lobectomy of the lung was performed with a mediastinal lymph node dissection. The postoperative pathological examination of the dissected specimens revealed one of the superior mediastinal lymph nodes to be morbid with micrometastasis of occult thyroid cancer, while no node involvement was seen due to lung cancer. A right lobectomy of the thyroid gland with a modified radical neck dissection was done 4 years later after the confirmation of the absence of any recurrent sign of lung cancer. In the resected specimen, papillary thyroid microcarcinoma was observed with several intraglandular metastases and right regional lymph node involvement. Eight months later, a new primary lung cancer developed in the left lung, and a left upper lobectomy of the lung with a mediastinal lymph node dissection was performed. At that time, the absence of mediastinal lymph node metastasis from lung cancer or thyroid cancer was confirmed. Mediastinal lymph node involvement as the initial manifestation of occult thyroid cancer in surgical treatment for lung cancer is rare, but it is important to be aware of the possibility of incidentally detecting occult thyroid cancer in surgical dissections in this area for lung cancer. The appropriate surgical treatment should be determined while carefully considering the prognosis of the lung cancer as well as that of any coexisting malignancy.     

Superior biocompatibility of heparin-bonded circuits in pediatric cardiopulmonary bypass.

BACKGROUND: Heparin bonding of pediatric cardiopulmonary bypass circuits may decrease activation of blood compartments as inflammatory responses. We studied the biocompatibility of heparin-bonded circuits in infant cardiac surgery. METHODS: Twenty-four infants undergoing elective cardiac surgery were randomly assigned to either a nonheparin-bonded control circuit (n = 12) or a fully heparin-bonded circuit (n = 12) including membrane oxygenator, reservoir, and all tubing. Blood samples were used to identify differences in complement activation and cytokine release between groups during and after cardiopulmonary bypass. The postbypass oxygenation index was also compared. RESULTS: The C3 activation product in the heparin-bonded group was significantly lower during (p < 0.01) and just after (p < 0.05) cardiopulmonary bypass. No statistically significant difference in C4 activation products was observed. Lower interleukin-6 and tumor necrosis factor-alpha were found immediately after cardiopulmonary bypass (p < 0.05) and a higher mean postbypass oxygenation index was also seen (p < 0.05) in the heparin-bonded group. CONCLUSION: We found that a heparin-bonded cardiopulmonary bypass circuit reduced inflammatory response and improved oxygenation in pediatric cardiac surgery. These results suggest that the superior biocompatibility of the bonded circuit may reduce pulmonary complications.     

Arterial stiffness in predialysis patients with uremia

BACKGROUND: Hemodialysis patients have advanced arterial wall stiffening as shown by increased aortic pulse wave velocity (PWV), an independent predictor of cardiovascular mortality. We compared aortic PWV of uremic patients before starting hemodialysis treatment with that of patients on maintenance hemodialysis. METHODS: The subjects were 71 patients with end-stage renal disease (ESRD) before starting hemodialysis (predialysis group), 144 patients on maintenance hemodialysis, and 140 healthy control subjects. These three groups were all nondiabetic and comparable in age and gender. RESULTS: The hemodialysis group had greater aortic PWV than the healthy subjects, and the predialysis patients showed a still higher value than the hemodialysis group. Multiple regression analysis in the total subjects revealed that the presence of renal failure was significantly associated with increased aortic PWV independent of age, gender, blood pressure, body mass index, smoking, high-density lipoprotein (HDL) and nonhigh-density lipoprotein (non-HDL) cholesterol levels. In contrast, hemodialysis was associated with decreased aortic PWV independent of renal failure and the other factors. Further analyses in the combined uremic patients again indicated the favorable impact of hemodialysis on aortic PWV independent of the classical risk factors, use of antihypertensive medications, including angiotensin-converting enzyme inhibitors and calcium channel blockers, hematocrit, serum calcium, phosphorus, parathyroid hormone levels, and the use of calcium carbonate. Insulin resistance using homeostasis model assessment (HOMA-IR) was associated with increased aortic PWV. CONCLUSION: Aortic stiffening was present in uremic patients before starting hemodialysis treatment and no adverse effect of hemodialysis was observed, suggesting the important roles of renal failure and/or metabolic alterations secondary to renal failure in arterial stiffness in patients with uremia.     

Anesthetic management for cleft palate plasty in a patient with Pierre-Robin syndrome

A girl (15 months-old) with Pierre-Robin Syndrome was scheduled for cleft palate plasty. She had a past history of difficulty feeding, mild airway obstruction during sleeping and mental retardation. After induction of anesthesia with an inhalational anesthetic technique, conventional tracheal intubation was impossible. We introduced a laryngeal mask airway (LMA) and successfully intubated through the LMA. After extubation of the tracheal tube, she developed upper airway obstruction with arterial desaturation. We ventilated her lungs in the lateral position with an inhalation of epinephrine and injection of methylprednisolone. Airway obstruction then improved gradually. In this case, LMA was a valuable device as a guide for the tracheal intubation. Because airway obstruction after extubation is a common complication in a patient with Pierre-Robin syndrome, we need to observe the patient closely.     

Ultrasonographic evaluation of small nodules in the peripheral lung during video-assisted thoracic surgery (VATS).

OBJECTIVE: We examined the possibility of intraoperative ultrasonography during video-assisted thoracic surgery (VATS) to localize and make a qualitative diagnosis of small peripheral pulmonary nodules. METHODS: Ultrasonography during VATS and conventional thoractomy was performed on 25 and 18 nodules, respectively, all which were localized in the peripheral lung, were less than 30 mm in diameter and for which there was no definitive diagnosis. RESULTS: All 25 nodules, including 10 invisible but palpable and three both invisible and non-palpable, could be localized by ultrasonography during VATS. If nodules were located less than 15 mm from the pleural surface, ultrasonography during VATS could detect nodules 10 mm or less in diameter. The rate of malignant tumors among 11 of 12 pulmonary nodules (91.6%) showing both heterogeneous and ill-defined patterns was significantly higher than 6 of 16 nodules (37.5%) showing both homogeneous and well-defined patterns on ultrasonography. CONCLUSIONS: Our study suggested that ultrasonography during VATS is useful for the detection of peripheral pulmonary nodules, even when they are not identified on video images or palpation, and may enable a differential diagnosis between malignant and non-malignant lesions.     

Non-viral in vivo thrombomodulin gene transfer prevents early loss of thromboresistance of grafted veins.

OBJECTIVE: Immediate loss of thrombomodulin activity in the endothelium of vein grafts has been demonstrated during 90 min exposure to arterial circulation; this loss of activity is ascribed as an important cause of early thrombosis. Conventional ex vivo gene transfection after vein harvest cannot cover this acute period immediately after implantation. We have established a highly efficient non-viral gene therapy protocol utilizing modified transferrin receptor-facilitated gene transfer. Using this technique, we examined whether in vivo thrombomodulin gene therapy, directed to the endothelium of rat veins 2 days prior to grafting, may prevent thromboresistance impairment of vein grafts under simulated arterial circulation. METHODS: Abdomen of SD rat was opened and cationic liposome:transferrin:thrombomodulin gene complexes or the vector without DNAs were applied to the inferior vena cava of rats while blood flow was reduced by proximal and distal clamping. After 2 days, the transfected veins were harvested and thrombomodulin expression and thromboresistance properties determined before and after exposure to an artificial circuit. RESULTS: The trial of gene transfection using variable doses of DNAs confirmed that 7.5 microg of total DNAs was the most efficient quantity for thrombomodulin gene transfection to IVCs, although accompanying an increase of gene expression in other downstream organs. By transfection of the thrombomodulin gene in IVCs, the generation capacity of activated protein C in venous endothelium increased three-fold compared with veins treated with vector alone (P<0.01). Under simulated arterial circulation, perfusion of veins treated with vector alone decreased thrombomodulin activity to 36% of preperfused levels (P<0.01), whereas transfected grafts preserved the activity at normal vein endothelium levels even after perfusion. Consequently, the increase in endothelial thrombin activity induced by simulated arterial circulation was markedly attenuated in transfected veins (P<0.01), while immunohistochemistry confirmed the preservation of endothelial lining. CONCLUSIONS: Transferrin receptor-facilitated in vivo gene transfer to the inferior vena cava resulted in sufficient thrombomodulin gene expression immediately after graft implantation and subsequent maintenance of thromboresistance even after exposure to arterial pressure. Although further studies are needed, the present results suggest the possibility of gene therapy targeting acute phases of vein graft disease.     

Anaplastic and meningothelial meningiomas in a single tumor: A “dedifferentiated meningioma”?

The patient was a 74‐year‐old man, who developed progressive cognitive impairment and gait instability. Neuroradiological examination demonstrated a large and predominantly extra‐axial tumor spreading over the bilateral frontal base, indicative of olfactory groove meningioma. The greater part of the resected tumor consisted of a dense, patternless proliferation of large, round or polygonal cells, and compactly fascicular growth of spindle cells. Tumor cells showed markedly anaplastic cytological features. In small areas of the tumor, a typical meningothelial meningioma showing no cellular atypism was found. Both tumor components were closely juxtaposed and no pathological features of an intermediate grade (atypical meningioma) were noted. Shortly after the operation, the patient developed a local recurrence of the tumor and multiple metastases to the cerebrum, bone and skin. Anaplastic meningioma is a rare, highly malignant neoplasm which arises de novo or as a result of the progressive transformation of a low‐grade meningioma. The coexistence of anaplastic and low‐grade components in a single meningeal tumor has been rarely reported. This dimorphic appearance is reminiscent of “dedifferentiation”, a phenomenon infrequently seen in various mesenchymal and salivary gland neoplasms. We think that the term “dedifferentiated meningioma” can be appropriately applied to tumors such as that reported herein.     

A dumon stent inserted for bronchial stenosis causing a left bronchopericardial fistula: Report of a case

We present herein the case of a 59-year-old man in whom a Dumon stent, inserted as treatment for stenosis of the left main bronchus, caused a left bronchopericardial fistula. The patient initially presented with severe dyspnea caused by main bronchial stenosis of unknown origin for which a Dumon stent was inserted at a local hospital. The Dumon stent migrated to the endobronchus through the stenosis of the left main bronchus a few days later, and his dyspnea remained unresolved. He was subsequently referred to our department 6 months later, where a left pneumonectomy under supportive cardiopulmonary bypass through the femoral artery and vein was performed, and a postoperative pathological diagnosis of bronchial leiomyosarcoma was made. For this rare group of malignant tumors, early diagnosis permits complete surgical resection of the mass and offers the best prognosis. Excision of the tumor should be performed under cardiopulmonary bypass through the femoral vessels when a risk of sudden rupture of the pulmonary artery or vein exists for any reason.