Surgical treatment of a sigmoid volvulus associated with megacolon: report of a case.

Sigmoid volvulus occurring concomitantly with megacolon is an uncommon cause of bowel obstruction, and various approaches to treatment have been proposed. We report herein a case of sigmoid volvulus with megacolon that was successfully treated by elective surgery following endoscopic reduction during the same hospital stay. A 70-year-old woman was admitted to our hospital with abdominal pain, distension, and severe constipation. Physical examination, plain abdominal X-ray, and barium enema confirmed a sigmoid volvulus and further examinations revealed concomitant megacolon. An elective sigmoid colectomy was performed following successful endoscopic decompression. The postoperative course was uneventful and there was no residual colonic dysmotility. Histologically, no aganglionic tissue was observed in the resected specimen.

Two-stage operation for multiple aneurysms of the thoracic aorta, abdominal aorta, and left common iliac artery in an octogenarian.

Multiple aortic aneurysms are well described in the surgical literature. However, there are many problems related to surgical treatment of elderly patients with such aneurysms. This report presents the case, an octogenarian with multiple aortic aneurysms that were successfully treated by graft replacement. An 82-year-old man with a descending aortic aneurysm was referred to our institution for surgery. In addition to the previously diagnosed aneurysm, computed tomography and aortography showed an abdominal aortic aneurysm and a left common iliac aneurysm. Since the patient was an elderly man with chronic obstructive pulmonary disease, a two-stage operation was performed. The abdominal aortic aneurysm and left common iliac aneurysm were resected first due to the risk of thromboembolism from the abdominal aortic aneurysm during surgery involving replacement of the descending aorta under femoro-femoral (F-F) bypass. Fifty-two days after the first operation, a second operation was performed to repair the descending aortic aneurysm. The postoperative course was uneventful. Angiography after the operation showed satisfactory replacement of the multiple aortic aneurysms. The patient was discharged 25 days after the second operation.

A new devised skirted elephant trunk technique.

A simple and effective new elephant trunk technique was devised and applied to two patients with a successful result. In advance before the operation, an arch graft with a skirted elephant trunk was made. This was done by inserting a smaller, 22 mm diameter sized graft into the arch graft at the distal end and suturing it so as to leave a skirt extending over the smaller graft. This configuration facilitates the distal anastomosis and effectively shortens anastomotic time.

Surgical treatment of traumatic aneurysm of the ascending aorta.

Traumatic aneurysm of the ascending aorta is a rare event. This case describes a patient with such an aneurysm, resulting from injuries received in a motorcycle accident. The patient was admitted to the emergency room of a local hospital complaining of chest pain, and was subsequently referred to our institution. On admission, a chest x-ray showed mediastinal widening. Computed tomography and aortography revealed an ascending aortic aneurysm and contusion of the upper lobe of the right lung. Due to concerns about bleeding from the lung contusion, surgery was delayed for one week. During surgery, intimal tears were detected at two sites in the ascending aorta. The wall of the ascending aorta was subsequently resected and a prosthetic graft inserted. The postoperative period was uneventful and a postoperative aortogram showed that the graft had molded well.

Successful treatment of bilateral deep femoral aneurysms and multiple iliac aneurysms associated with severe aortic valve disease: report of a case.

We report herein the case of a patient in whom aneurysms of the bilateral deep femoral arteries (DFA) and multiple iliac aneurysms associated with severe aortic valve disease were successfully treated by a two-staged operation. The patient was a 74-year-old man who had dense calcification of the ascending aorta and aortic arch. Prior to aortic valve replacement (AVR), the aneurysms of the DFA and internal iliac arteries were resected. The terminal end of the abdominal aorta and bilateral common iliac arteries were then reconstructed with a Y graft to be used as a possible alternative arterial input route in place of the ascending aorta for extracorporeal circulation during the AVR. The inferior mesenteric artery (IMA) was well developed, and the external iliac arteries and their branches were preserved at aneurysmectomy. Postoperatively, there was no ischemia of the pelvic organs or the hip muscles. The AVR was subsequently performed 5 weeks after the first operation, and the patient was discharged after an uneventful postoperative course.

A ruptured syphilitic descending thoracic aortic aneurysm. The characteristic findings on computed tomography for the etiological diagnosis of aneurysm.

We report the case of a 72-year-old man with a ruptured syphilitic descending thoracic aneurysm who underwent an emergency operation and successful graft replacement. Preoperative physical examination showed a pulsative mass on the left back. Preoperative computed tomography showed bone destruction in the TH6 to TH10 thoracic vertebrae and ribs and penetration (or rupture) of the aneurysm into the subcutaneous tissue. During the period of preoperative evaluations, free wall rupture of the aneurysm occurred and emergency operation for graft replacement was performed. The microscopical examination of the aneurysmal wall revealed the syphilitic changes. In literature, the vertebral destruction by atherosclerotic aneurysm is usually located at the TH12 to L3 of vertebral bodies. From the findings of this patient and a study of existing literature, we concluded that the finding of vertebral bone beyond TH12 to L3 region on CT examination of the aneurysm could be a etiological characteristic finding for syphilitic aortic aneurysm.

Improvement in esophageal varices and liver histology postoperatively in Budd-Chiari syndrome.

BACKGROUND: In the past 17 years, 32 patients with Budd-Chiari syndrome were treated by reconstruction of the occluded inferior vena cava and reopening of the hepatic veins under femoro-femoral normothermic extracorporeal partial bypass. The mean follow-up was 8 years (range, 1.5 to 17 years). METHODS: To evaluate the benefits of our operative procedure, we compared the preoperative, early postoperative, and late postoperative endoscopic appearance of the esophageal varices and the histologic findings of the liver tissue obtained intraoperatively and at a later date. RESULTS: The esophageal varices found preoperatively in 29 patients (90.6%) had disappeared in 7 patients by the time of discharge, and in 2 patients they disappeared 4 to 7 years after surgery. In the remaining 20 patients, the grade of the esophageal varices was reduced markedly. Histologic examination of the liver showed cirrhosis in 22 patients, fibrosis in 9 patients, and severe congestion in 1 patient. Inspection of the liver in the late postoperative period (in 10 patients) showed improvement in centrilobular congestion and no increase in interlobular fibrosis. CONCLUSIONS: Gradual and steady improvement of esophageal varices and hepatic fibrosis can be achieved after our operative procedure.

[A case report of surgical treatment of constrictive pericarditis with coronary artery disease].

We performed the concomitant operation for constrictive pericarditis and coronary artery disease in an octogenarian. A 82-year-old male was hospitalized with dyspnea, edema of the lower extremities and pleural effusion on chest X-ray film. Cardiac catheterization revealed constrictive pericarditis and 75% stenosis of left anterior descending artery. Extensive pericardiectomy was performed including posterior wall of left ventricle and left atrium under the beating heart by using femoro-femoral partial bypass. Single CABG with a saphenous vein graft was performed following pericardiectomy. Postoperative cardiac catheterization showed good recovery of hemodynamics and patency of the bypass graft. Postoperative course was uneventful. The patient was discharged on twenty fifth postoperative day.

[Clinical experience with normothermic selective cerebral perfusion during graft replacement of ascending-arch-descending aortic aneurysms with annuloaortic ectasia].

We treated three cases of ascending-arch-descending aortic aneurysm with annuloaortic ectasia by performing graft replacement. The patients included a 34 year old female, a 34 year old male and a 42 year old male. In one case the aneurysm was atherosclerotic and of type I and II + IIIb dissection in the other two cases. During the operation we were able to utilize normothermic selective cerebral perfusion during construction of the left common carotid artery. Specially, normothermic partial F-F bypass and normothermic selective cerebral perfusion to the left common carotid artery were used during graft replacement from the descending aorta to the left common carotid artery. This was followed by regular hypothermic total ECC and hypothermic cerebral selective perfusion during subsequent graft replacement of the innominate artery and a modified Bentall's operation. This new protocol in which normothermic cerebral perfusion is utilized during the procedure on the left common carotid artery and hypothermic perfusion is utilized only during the subsequent procedure on the innominate artery permits significant shortening of the cardiac arrest time and cerebral perfusion time compared with when only hypothermic perfusion is used. This significant shortening contains obvious benefits in the areas of cardiac and brain protection.

[Intraosseous meningioma associated with lung cancer: a case of multiple neoplasms].

Intraosseous tumor was found in a 63 year old male patient with lung cancer during metastatic work-up study. Plain skull X-ray film showed a large osteolytic lesion in the left temporo-parietal bone. Bone and Ga scintigrams revealed an increased activity in this lesion. CT scan demonstrated an isodense lentiform configuration, which was homogeneously enhanced with contrast medium. It was iso-intense in T1, and high-intense in T2 and proton weighted MR images. The tumor was removed en bloc with surrounding normal bone. The attached dura was markedly thickened, but there was no tumor infiltration. Histological diagnosis was transitional meningioma with psammoma body. Postoperatively he was transferred back to Okinawa Hospital and right lower lobectomy was performed for the lung tumor. Histological diagnosis was well-differentiated adenocarcinoma. We examined immunohistochemically p53 protein expression, but p53 immunoactivity was observed in neither tumor. Multiple neoplasms associated with brain tumor are relatively rare, but the incidence will increase in the future as the diagnostic work-up develops. Pathological diagnosis will give us the decisive opportunity for proper treatment. It is to be stressed that, in multiple neoplasms, care should be taken to avoid misdiagnosis of metastasis.