Evaluation of sodium intake for the prediction of cardiovascular events in Japanese high-risk patients: the ESPRIT Study.

The optimal level of sodium intake remains controversial, and the effects on a broad range of cardiovascular (CV) conditions remain unknown. The Evaluation of sodium intake for the prediction of cardiovascular events in Japanese high-risk patients (ESPRIT) is a prospective observational study designed to investigate whether sodium intake assessed by spot urine testing is associated with adverse CV events. A total of 520 patients who visited our cardiology clinic with various cardiovascular risk profiles were included. Sodium intake was estimated by spot urine testing at the time of entry, and the measurement was repeated at least every 6 months during follow-up. The primary endpoint was composed of (1) hospitalization due to heart failure, (2) acute coronary syndrome, (3) cerebrovascular events, and (4) documented CV deaths. The secondary endpoint was all-cause mortality. During the median follow-up period of 5.2 years, there were 105 composite CV events (3.9%/year), including 60 hospitalizations due to heart failure, 9 acute coronary syndromes, 21 cerebrovascular events, 15 CV deaths, and 26 cases of all-cause mortality. The average sodium excretion (from a median of 14 measurements) during the follow-up period was 3.52 ± 0.67 g/day. After adjustment for age, sex, and body weight, higher sodium excretion ( ≥ 4.0 g/day) was associated with composite CV events (hazard ratio 1.79, confidence interval 1.01-3.15 compared with the reference value of 3.0-3.49 g/day) but not all-cause mortality. The ESPRIT study showed that high sodium excretion (≥ 4.0 g/day) was associated with the predefined composite CV events (UMIN ID: UMIN000005419).

Importance of pericardial fat in the formation of complex fractionated atrial electrogram region in atrial fibrillation.

BACKGROUND/OBJECTIVES: Pericardial fat (PF) and complex fractionated atrial electrogram (CFAE) are both associated with atrial fibrillation (AF). Therefore, we examined the relation between PF and CFAE area in AF. METHODS: The study population included 120 control patients without AF and 120 patients with AF (80 paroxysmal AF and 40 persistent AF) who underwent catheter ablation. Total cardiac PF volume, representing all adipose tissue within the pericardial sac, was measured by contrast-enhanced computed tomography. The location and distribution of CFAE region were identified by left atrial endocardial mapping using a three-dimensional mapping system. We analyzed the significance of total cardiac PF volume and total area of CFAE region on AF, persistence of AF from paroxysmal to persistent form, and the relation between total cardiac PF volume and total CFAE area. We also evaluated the regional distribution of PF volume and CFAE area in five areas of the left atrium (LA). RESULTS: Total cardiac PF volume correlated with AF (odds ratio [OR]: 1.024, p<0.001). Total cardiac PF volume and total CFAE area were both independently associated with persistence of AF (OR: 1.018, p=0.018, OR: 1.144, p=0.002, respectively). Multivariate linear regression analysis identified total cardiac PF volume as a significant and independent determinant of total CFAE area (r=0.488, p<0.001). Furthermore, regional PF volume correlated with local CFAE area in an each LA area. CONCLUSIONS: PF volume correlated significantly with CFAE area in patients with AF. This finding suggests that PF is directly related to the progression of CFAE area and promotes the pathogenic process of AF.

Simple technique for gasless transumbilical single-incisional laparoscopic-assisted appendectomy.

PURPOSE: Single-incision laparoscopic surgery has recently received more attention. We developed a novel simple technique of gasless transumbilical single-incisional laparoscopic-assisted appendectomy (TUSILAA) and retrospectively analyzed our initial experience. METHODS: TUSILAA has been attempted in 50 consecutive patients with acute appendicitis. The vertical incision through the umbilicus was used for laparoscopic access and the abdominal wall was lifted by a Kent retractor set system. RESULTS: Our technique was successful in 45 out of 50 (90 %) patients. The median operating time was 59 min (range 35-140). The median length of postoperative hospital stay was 4 days (range 2-12). None of the cases were converted to open appendectomy. There were no perioperative surgical complications. CONCLUSIONS: Our novel technique, gasless TUSILAA, is safe and feasible with acceptable operative time and excellent cosmetic result. Furthermore, this procedure has the advantage of cost-effectiveness since any disposable instruments including trocars, staplers, or expensive devices are not required. Therefore, this could be used as the first-choice surgical procedure for selected patients with uncomplicated acute appendicitis.

A defect of the abdominal wall with intestinal fistulas after the repair of incisional hernia using Composix Kugel Patch.

INTRODUCTION: In the present paper, we show a rare case of the large abdominal wall defect and enterocutaneous fistulas after the tension free repair using prostheses for incisional hernia. PRESENTATION OF CASE: The patient, a 70-year-old man, had a history of a hemicolectomy for a perforating colon cancer, complicated by a large incisional hernia that was closed primarily but recurred. Three years later, the hernia was repaired at the time of a second colectomy using a Composix Kugel Patch. His course was complicated by a chronic postoperative wound infection with eventual development of enterocutaneous fistulas. The patient was successfully treated with extirpation of the prosthesis, resection of the fistulized bowel, and placement of a tensor fasciae latae myocutaneous flap. DISCUSSION: Enterocutaneous fistulas are a known complication of incisional hernia repairs using prostheses. Additional clinical data are required to confirm the safety and efficacy of this procedure as it becomes more widely adopted. CONCLUSION: Extirpation of the prosthesis should be performed without delay to prevent serious complications. Reconstruction with a tensor fasciae latae myocutaneous flap was useful for the large abdominal wall defect.

Predicting early cancer-related deaths after curative esophagectomy for esophageal cancer.

Esophagectomy is the primary treatment for esophageal cancers, but a few patients still suffer from early recurrence and die within one year after surgery. The aim of this study was to identify preoperative predictive risk factors for early cancer-related deaths after curative esophagectomy for esophageal squamous cell carcinoma. The records of 200 consecutive patients with esophageal cancer who underwent esophagectomy between 1990 and 2009 were retrospectively reviewed. The preoperative clinical characteristics of the remaining 32 patients who died of cancer within one year were compared with those of 168 patients who survived for more than one year postsurgery. The most frequent cause of death was lymph node recurrence followed by local recurrence and lung metastases. A tumor size 60 mm or greater and lymph node metastases in two fields on preoperative imaging were identified as prognostic factors on multivariate analysis. The one-year survival rate and median survival time of patients with both these risk factors were 40 per cent and 12 months, respectively. Aggressive additional treatment may be needed if both a tumor size 60 mm or greater and lymph node metastases in two fields are found during diagnostic imaging before esophagectomy for esophageal squamous cell carcinoma.

The prognostic nutritional index predicts long-term outcomes of gastric cancer patients independent of tumor stage.

PURPOSE: The aim of this study was to investigate the impact of the prognostic nutritional index (PNI) on the long-term outcomes in gastric cancer patients. METHODS: This study reviewed the medical records of 548 patients with gastric cancer who underwent gastrectomy. The PNI was calculated as 10 × serum albumin (g/dl) + 0.005 × total lymphocyte count (per mm(3)). The receiver operating characteristic (ROC) curve analysis was performed to determine the cutoff value of the PNI. The multivariate analysis was performed to identify the prognostic factors. RESULTS: The mean PNI was significantly lower in patients with T3-T4 tumors (P < 0.001) and lymph node metastasis (P < 0.001) than in those without such factors. Patients who had a postoperative complication had a lower mean PNI than those without (P = 0.023). When the ROC curve analysis was performed, the optimal cutoff value of the PNI for predicting the 5-year survival was 48. In the multivariate analysis, a low PNI was an independent predictor for poor overall survival (P < 0.001). In the subgroup analysis, the overall and relapse-free survival rates were significantly lower in the PNI-low group than in the PNI-high group among patients with stage I and stage III disease. CONCLUSIONS: The PNI is a simple and useful marker for predicting the long-term outcomes of gastric cancer patients independent of the tumor stage. Based on our results, we suggest that the PNI should be included in the routine assessment of gastric cancer patients.

Postoperative functional evaluation after pylorus-preserving nearly-total gastrectomy with jejunal interposition for gastric cancer.

BACKGROUND/AIMS: Pylorus-preserving nearly-total gastrectomy (PPNTG) for gastric cancer is based on the principle that the operation prevents the rapid gastric emptying and reflux that occurs after traditional gastrectomy. In this study, we evaluate the postoperative functional status of patients undergoing PPNTG in comparison with total gastrectomy with Roux-en-Y reconstruction (TG-RY). METHODOLOGY: Ninety-six patients with gastric cancer underwent PPNTG or TG-RY at Nara Medical University Hospital. Short-term outcomes were analyzed retrospectively through medical records from hospitalization. Long-term outcomes were evaluated via questionnaires concerning postoperative function. RESULTS: Of the 96 cases, 32 underwent PPNTG and 64 underwent TG-RY. There were no significant differences in operation time, intraoperative blood loss, postoperative complications, or length of stay. Forty-eight patients responded to the questionnaire (PPNTG: 18, TG-RY: 30). The incidence of general malaise, headaches, chest pain, heartburn and cold sweats was significantly lower in the PPNTG group. Nutritional assessment revealed no differences between the groups. CONCLUSIONS: For gastric cancer of the proximal stomach, PPNTG is a safe alternative to TG-RY, and improves patients' long-term quality of life.

Surgical outcomes for cancer at the gastroesophageal junction.

The aim of this study was to evaluate the clinicopathological characteristics and prognostic factors of cancer at the gastroesophageal junction (GEJ) whose center is situated at a site within 2 cm above and below the junction. This retrospective study included 90 patients with cancer at the GEJ, including 58 with adenocarcinoma (ADC) and 32 with squamous cell carcinoma (SCC). ADC tumors were larger in size than SCC tumors. ADC and SCC at the GEJ showed a similar distribution of the pattern of lymphatic spread. The rate of lower mediastinal lymph node metastasis was approximately 20 per cent, which is similar to the nodes along the celiac artery and the nodes along the common hepatic artery. The overall survival rates were similar between the groups. The presence of five or more lymph node metastases was an independent prognostic factor according to a multivariate analysis. When two or more lymph nodes larger than 10 mm were detected preoperatively, five or more lymph node metastases were proven by histology in most cases. The most frequent sites of recurrence of ADC and SCC were the peritoneum and lymph nodes, respectively. Aggressive additional treatment may be needed if two or more lymph nodes are seen on preoperative imaging.

Risk factors for esophagojejunal anastomotic leakage after elective gastrectomy for gastric cancer.

OBJECTIVE: The aim of this study was to investigate the correlation between intraoperative anastomotic troubles and the incidence of esophagojejunal anastomotic leakage (EJAL), and to identify risk factors for EJAL after elective gastrectomy for gastric cancer. METHODS: This study reviewed the medical and surgical records of 327 patients who underwent elective gastrectomy followed by esophagojejunostomy. A multivariate analysis was performed to determine the risk factors for EJAL. RESULTS: An EJAL occurred in 19 patients (5.8 %). A multivariate analysis demonstrated that hemoglobin A1c ≥7.0 % (p < 0.01), chronic renal failure (p < 0.01), proximal gastrectomy (p < 0.05), and anastomotic trouble during construction of the esophagojejunostomy (p < 0.01) were independent predictors for EJAL. Anastomotic trouble during construction of esophagojejunostomy occurred in 20 patients (6.1 %), and EJAL occurred in 6 of these 20 patients (30 %). Four of ten patients (40 %) in whom an incomplete anastomosis was repaired by suturing during surgery had an EJAL, while none of seven patients who underwent re-anastomosis had this complication. CONCLUSIONS: EJAL is strongly associated with intraoperative technical errors. To reduce this complication, proper anastomotic techniques are required. Re-anastomosis should be performed when an incomplete anastomosis is discovered during surgery.

[A case report of advanced gastric cancer with peritoneal dissemination effectively treated by combination chemotherapy of S-1 and docetaxel].

The present patient was a 69-year-old male diagnosed as gastric cancer with peritoneal dissemination by staging laparoscopy. He was treated with chemotherapy using S-1 (120 mg/body/day) and docetaxel (70 mg/body/day 1) administered for 2 weeks, followed by one drug-free week in three-week courses. After 4 courses of treatment, the primary tumor regressed, but only slightly. Because of an adverse event, we continued with a lower dose. After 4 more courses of treatment, the primary tumor and dissemination were undetectable on abdominal CT scan but were endoscopically detected. The patient has been followed on an outpatient basis without surgical treatment for 2 years.

Risk factors for surgical site infections after elective gastrectomy.

OBJECTIVE: The aim of this study was to identify the risk factors for surgical site infections (SSIs) after elective gastrectomy. METHODS: This study reviewed the medical records of 842 patients who underwent elective gastrectomy. Multivariate analyses were performed to determine the risk factors for SSIs. RESULTS: Superficial incisional, deep incisional, and organ/space SSIs were detected in 50 (5.9%) patients, 2 (0.2%) patients, and 90 (10.7%) patients, respectively. A multivariate analysis demonstrated that female gender (p = 0.0332) and allogenic blood transfusion (p = 0.0266) were independent predictors for superficial incisional SSIs, while a male gender (p = 0.0355), corticosteroid therapy (p = 0.037), total gastrectomy (p < 0.0001), and a duration of operation ≥300 min (p = 0.0062) were independent predictors for organ/space SSIs. The median length of postoperative hospital stay was significantly longer in patients with organ/space SSIs in comparison to those without SSIs (p < 0.0001) and with superficial incisional SSIs (p < 0.0001). The patients with organ/space SSIs had a significantly higher re-operation rate in comparison to those without SSIs (p < 0.0001). CONCLUSIONS: The risk factors both for incisional SSIs and for organ/space SSIs are strongly associated with surgical results. Meticulous surgical techniques are therefore required to prevent SSIs.

Potential association of Helicobacter cinaedi with atrial arrhythmias and atherosclerosis.

Helicobacter cinaedi has been increasingly recognized as an emerging pathogen. Reports of recurrent bacteremia and isolation of H. cinaedi organisms from a patient with myopericarditis led us to postulate that H. cinaedi is associated with chronic inflammatory cardiovascular diseases such as atrial arrhythmias and atherosclerosis. To assess any association of H. cinaedi with atrial arrhythmias, a retrospective case-control study of patients attending Kumamoto University Hospital from 2005 to 2009 was performed. The arrhythmia status of these patients was determined from their electrocardiography and electrophysiological studies. Multiple logistic regression analysis was used to identify independent risk factors. In a comparison of case patients (n= 132) with control subjects (n= 137), H. cinaedi seropositivity was identified as an independent risk factor for atrial arrhythmia (odds ratio, 5.13; 95% confidence interval, 3.0-8.7; P < 0.001). There were no significant differences, however, between these two groups with respect to anti-H. pylori IgG concentrations, anti-Chlamydophila pneumoniae IgG concentrations, and other studied variables. IgG concentrations against H. cinaedi and H. pylori were inversely correlated, which suggests cross-immunity between these two bacteria. Also, to explore any association of H. cinaedi with atherosclerosis, immunohistochemical analysis of atherosclerotic aortic tissues collected post mortem from nine patients was performed. Immunohistochemistry of atherosclerotic aortic tissues from all nine patients detected H. cinaedi antigens inside CD68(+) macrophages. These findings provide the first evidence, to our knowledge, of a possible association of H. cinaedi with atrial arrhythmias and atherosclerosis.

Intrathoracic hernia of a retrosternal colonic graft after esophagectomy: report of a case.

We report a case of intrathoracic herniation of the colonic interposition pulled up through the retrosternal space after subtotal esophagectomy for esophageal cancer. The patient, a 68-year-old man, presented with progressive dysphagia about 1 year after this operation. We performed left thoracotomy and laparotomy, which revealed the reconstructed colon herniating into the left thoracic cavity through a large defect in the left mediastinal pleura. The redundant colon was resected, and the colonic graft was shortened and straightened. We concluded that the defect in the mediastinal pleura and colonic redundancy had permitted the colonic graft to herniate into the left thoracic cavity.

Prognostic significance of splenic hilar nodal involvement in proximal third gastric carcinoma.

BACKGROUND/AIMS: The utility of prophylactic splenectomy in patients with proximal third gastric carcinoma is controversial. In this study, we investigated the significance of nodal involvement in the splenic hilum and the impact of splenectomy. METHODOLOGY: A total of 129 patients who underwent D2 radical resection with splenectomy for gastric carcinoma involving the upper portion of the stomach were analyzed. RESULTS: Lymph node metastasis at the splenic hilum was found in 21 (16.3%) of 129 cases. Multivariate analysis revealed that the number of metastatic lymph nodes was an independent risk factor for lymph node metastasis at the splenic hilum. The 5-year survival rate for patients with lymph node metastasis at the splenic hilum was 17.9%. There were significant differences in survival among patients grouped according to the extent of extraperigastric nodal involvement. While nodal involvement in the splenic hilum was found to be an independent prognostic factor, the number of metastatic lymph nodes was not. CONCLUSIONS: The prognosis of patients with lymph node metastasis at the splenic hilum was significantly poorer compared to that for patients with metastases in the other extraperigastric nodes. Furthermore, prophylactic splenectomy appears not to improve survival of patients with proximal third gastric carcinoma.

Improvement effect on endothelial function in patients with congestive heart failure treated with cardiac resynchronization therapy.

BACKGROUND AND PURPOSE: Cardiac resynchronization therapy (CRT) is a beneficial strategy to improve severe cardiac dysfunction in patients with congestive heart failure (CHF). The improvement of endothelial function in CHF patients treated with CRT is reflected in the mortality risk reduction. However the precise mechanisms of the relationship between CRT and vascular endothelial function have not been well discussed. METHODS AND SUBJECTS: Twenty-two severe consecutive CHF patients associated with dilated cardiomyopathy [New York Heart Association (NYHA) class 3.3 ± 0.5, left ventricular ejection fraction (LVEF) 24.4 ± 5.9%] were included in this study. We evaluated endothelial function, measured by reactive hyperemia peripheral arterial tonometry (RH-PAT), between optimal medical therapy alone group (medical therapy group: n = 10) and CRT group (n = 12) at the study enrolment and 12 weeks later. Furthermore we analyzed the association between the RH-PAT and cardiac function. ESSENTIAL RESULTS: Both therapies significantly and equally improved NYHA class, LVEF, end-diastolic left ventricular dimension and plasma levels of brain natriuretic peptide (BNP). CRT significantly increased RH-PAT index (medical therapy group: 1.5 ± 0.2 to 1.5 ± 0.3, p = 0.824; CRT group: 1.4 ± 0.2 to 1.7 ± 0.4, p = 0.003) and cardiac output (medical therapy group: 3.3 ± 1.1 to 3.5 ± 1.0, p = 0.600; CRT group: 2.7 ± 0.6 to 4.3 ± 1.5, p = 0.001), compared to the medical therapy group. There was significant positive correlation between the change in RH-PAT index and cardiac output (r = 0.600, p = 0.003). CONCLUSIONS: CRT significantly improved endothelial function through the improvement of cardiac output in CHF patients, compared to optimal medical therapy.

Analysis of the mechanisms initiating random wave propagation at the onset of atrial fibrillation using noncontact mapping: role of complex fractionated electrogram region.

BACKGROUND: The complex fractionated atrial electrogram (CFAE) region has been suggested to contribute to the maintenance of atrial fibrillation (AF), but its role for the initiation of AF has not been clarified. OBJECTIVE: We analyzed the mechanisms of the initiation of random reentrant wave propagation at AF onset, especially in relation to CFAE region. METHODS: Endocardial mapping of the left atrium using a 3-dimensional noncontact mapping system was performed in 19 patients. RESULTS: Thirty-two spontaneous AF onset episodes, which were initiated by the focal repetitive discharges (9 ± 9 beats), deriving from the pulmonary veins (PV) (n = 17) and from non-PV CFAE regions (n = 15) were observed. The coupling intervals of the focal discharges that initiated AF (AF-D) were significantly shorter than those that did not initiate AF (non-AF-D) (179 ± 33 ms vs. 217 ± 45 ms, P = .0005). After the AF-D, localized conduction blocks occurred in the CFAE region. Subsequently, the waves propagated to the remainder of the atrium, accompanying the anchored activation around the localized conduction block lines in the CFAE regions. Left atrial activation times of AF-D were significantly longer than those of non-AF-D (151 ± 35 ms vs. 83 ± 17 ms, P < .0001). These longer activation times after AF-D enabled the waves to reenter the previously blocked CFAE region from the opposite direction, and thus the meandering reentrant wave propagation was initiated. CONCLUSION: Unidirectional conduction block in the CFAE region and subsequent prolonged left atrial activation time following short coupled premature discharge were the underlying mechanisms of AF initiation, suggesting the importance of the CFAE region as the substrate for AF onset.

Radiofrequency energy induced ventricular fibrillation in a case of idiopathic premature ventricular contraction originating from the left ventricular papillary muscle.

A 15-year-old boy without structural heart disease was admitted for the treatment of frequent episodes of premature ventricular contractions (PVCs). Left ventricular mapping revealed that the origin of PVC was at the posterior papillary muscle. Diastolic small potentials were observed during sinus rhythm with a constant interval following QRS beats. This potential eventually coupled with the ventricular myocardium, resulting in the generation of PVC, and thus preceded QRS by 31 msec. Catheter ablation to this site induced non-sustained ventricular tachycardia, followed by transient ventricular fibrillation. Repeated application of radiofrequency energy eliminated PVC accompanied by the split of the diastolic potential.

Multiple forms of atypical atrioventricular nodal reentrant tachycardia with different right- and left-sided retrograde slow pathways.

A 56-year-old man was admitted for the treatment of supraventricular tachycardia. After successful ablation of the left concealed accessory pathway, four fast-slow forms of atrioventricular nodal reentrant tachycardia associated with different right- and left-sided retrograde slow pathways were induced. The locations of retrograde slow pathway were observed at the left inferior paraseptum, left mid-septum, right inferior paraseptum, and coronary sinus ostium, respectively. These retrograde slow pathways formed the integral limb of each tachycardia because conduction block of each slow pathway by catheter ablation was associated with the termination of tachycardia or abrupt change in the atrial activation sequence.

Catheter ablation of multiple focal atrial tachycardias originating from the tricuspid annulus using non-contact mapping system.

We describe an 81-year-old man with multiple focal atrial tachycardias (ATs) originating from the tricuspid annulus. Non-contact mapping showed 3 incessant ATs, originating from the vicinity of His bundle region, inferior portion of coronary sinus ostium, and coronary sinus ostium, and 2 premature atrial contractions (PACs) originating from the tricuspid annulus in the 5 o'clock position and 6 o'clock position in the left anterior oblique view. Radiofrequency energy application to these 5 sites successfully eliminated the ATs and PACs. The patient has remained free from ATs or any symptoms without medication during the 16-month follow-up period. Non-contact mapping was useful in identifying the multiple AT origins, especially even if the tachycardia origin shifted occasionally or the tachycardia was non-sustained.