Pneumomediastinum is a frequent but minor complication during esophageal endoscopic submucosal dissection.

BACKGROUND AND STUDY AIM: Esophageal perforation caused by endoscopic submucosal dissection (ESD) induces serious pneumomediastinum. In the absence of endoscopically detected perforation, postprocedural pneumomediastinum may occur. The aim of this study was to evaluate the association between the clinical factors/courses and pneumomediastinum revealed by chest computed tomography (CT) with special reference to an exposed muscle layer during esophageal ESD. PATIENTS AND METHODS: A total of 58 patients undergoing ESD for esophageal neoplasms between February 2003 and June 2007 also underwent both chest radiography and chest CT within 1 hour after ESD. We studied the association between findings on CT scan and tumor-related and technical factors of esophageal ESD by uni- and multivariate analyses. We also analyzed the clinical factors/courses experienced by all patients. RESULTS: Pneumomediastinum was detected in 18 / 58 patients (31 %) by chest CT compared with only 1 / 58 patients (1.7 %) by chest radiography. ESD-induced exposure of the muscular layer (32 patients) was the only significant factor for pneumomediastinum (18 / 32; P < 0.0001). Clinical factors such as fever, white blood cell count, and C-reactive protein were significantly increased in the group positive for both endoscopically exposed muscular layer and pneumomediastinum (+/+, n = 18) compared with the (-/-) group (n = 26) in the early phase (day 1) after ESD. However, these factors did not affect the length of the fasting period or the length of hospital stay. CONCLUSIONS: In esophageal ESD, pneumomediastinum detected by chest CT only does not cause clinically significant complication. Endoscopic muscle exposure during ESD is a significant risk factor for pneumomediastinum, which causes mild inflammation in the early post-ESD phase.

[Survival of 2 years and 7 months with 5'-DFUR treatment in a patient with peritoneal gastric cancer recurrence].

A 79-year-old male patient with peritoneal recurrence of gastric cancer 1 year and 7 months after radical operation was treated by oral administration of 5'-DFUR. After the beginning of oral administration of 5'-DFUR, he survived 2 years and 7 months with a good performance status and without any adverse effects. A very limited number of cases with long survival by the oral administration of 5'-DFUR after peritoneal recurrence of gastric cancer have been reported. Of a total of 653.0 g of 5'-DFUR administrated, 436.8 g (66.9%) were given in a protocol consisting of daily oral 1,600 mg of 5'-DFUR for 7 consecutive days and 7 drug free days. This high-dose (1,053 mg/m2/day) and intermittent method of 5'-DFUR administration might have contributed to the long survival and good performance status of this patient.

Left internal thoracic artery harvesting in pleural symphyses under minimally invasive direct vision.

In minimally invasive direct coronary artery bypass grafting (MIDCAB), the internal thoracic artery (ITA) is harvested under a direct-vision or videothoracoscopic techniques. However, whatever the technique used, dense pleural adhesions hamper ITA harvesting. We describe the case of a patient who underwent MIDCAB 40 years after a pulmonary resection for tuberculosis. The parietal pleura adhered to the left lung so firmly that we could not enter the intrapleural cavity. Therefore, the ITA was harvested creating an extrapleural tunnel Although this approach resulted in more operating time and bleeding, an anastomosis between the ITA and left anterior descending coronary artery was performed successfully. We believe that MIDCAB can be carried out even in patients with dense pleural adhesions.

Total arch replacement using aortic arch branched grafts with the aid of antegrade selective cerebral perfusion.

BACKGROUND: We report our clinical experience with total arch replacement using aortic arch branched graft in an attempt to determine the independent predictors of both in-hospital mortality and neurologic outcome. METHODS: We studied 220 consecutive patients who underwent total arch replacement using aortic arch branched graft between May 1990 and June 1999. All operations were performed with the aid of hypothermic extracorporeal circulation, antegrade selective cerebral perfusion, and open distal anastomosis. RESULTS: The overall in-hospital mortality rate was 12.7%. Multivariable analysis showed independent determinants of in-hospital mortality to be chronic renal failure, long pump time, participation in early series, and shock. Postoperative permanent neurologic dysfunction was 3.3%. On multivariable analysis, old cerebral infarct and pump time were independent determinants of permanent neurologic dysfunction. The selective cerebral perfusion time had no significant influence on in-hospital mortality or neurologic outcome. The 5-year survival rate including in-hospital deaths was 79% +/- 6%. CONCLUSIONS: Selective cerebral perfusion allows increased ease of performance of total arch replacement, a complex and time-consuming procedure, and helps reduce periprocedural mortality and morbidity in patients with aortic arch aneurysm and those with acute aortic dissection.

Differences in gut integrity following abdominal surgery according to the magnitude of the surgical stress.

BACKGROUND: An increase in serum diamine oxidase (DAO) activity reflects intestinal mucosal damage. This was used to estimate the effect of surgical stress after elective abdominal surgery on gut integrity. METHODS: Patients with gastrointestinal tract cancers were placed in either group T (transthoracic esophagectomy for esophageal cancer, n = 9) or group L (laparotomy, n = 10). The serum DAO activity was measured pre-operatively, and on postoperative days 1, 3, and 8. RESULTS: Transthoracic esophagectomy was associated with a more extensive stress than the operations in group L, as measured by the intra-operative blood loss, the amount of blood transfused, and the operative time (P = 0.007, P = 0.0002, P = 0.0011, respectively). Following surgery, the serum DAO activity was decreased markedly in all patients in group T. In contrast, the activity was unchanged in group L (P = 0.04). CONCLUSIONS: The severity of the surgical insult plays a significant role in the decrease in serum DAO activity. These results suggest that surgical stress influences gut integrity following elective abdominal surgery.

Extended total arch replacement for acute type a aortic dissection: experience with seventy patients.

OBJECTIVE: We sought to report the clinical experience with extended total arch replacement for acute type A aortic dissection and to determine the factors that influence early mortality, late survival, and late reoperation. METHODS: Between December 1988 and August 1998, 70 patients underwent emergency graft replacement of both the ascending aorta and the total aortic arch for acute type A aortic dissection. All operations were performed with hypothermic extracorporeal circulation, selective cerebral perfusion for cerebral protection during aortic arch repair, and open distal anastomosis. Concomitant procedures included aortic valve resuspension in 18 patients, composite graft replacement in 10 patients, and coronary artery bypass grafting in 5 patients. RESULTS: The early mortality rate was 16% (11 of 70 patients). Multivariable analysis showed that renal-mesenteric ischemia and coronary artery bypass grafting were independent determinants for early death. Survival rates at 3 and 5 years postoperatively, including the early deaths, were 75% +/- 5% and 73% +/- 6%, respectively. Multivariable analysis showed that renal-mesenteric ischemia and en bloc repair were independent determinants for late death. Freedom from reoperation was 91% +/- 4% and 77% +/- 8% at 3 and 5 years, respectively. Multivariable analysis showed that anastomotic leakage was the only significant determinant for late reoperation. CONCLUSIONS: Extended total arch replacement for acute type A aortic dissection could be justified in properly selected patients.

The elephant trunk technique for type A dissection.

A modified elephant trunk technique that was used to treat acute type A dissection is described. This technique prevents leaks at the distal anastomosis and facilitates surgery on the aneurysmatic downstream aorta following total arch replacement. In addition, it allows closure of the primary intimal tear in patients with DeBakey type III retrograde dissection.

Enlargement of ulcer-like projections after repair of acute type A aortic dissection.

We treated two cases of enlargement of ulcer-like projections in the descending thoracic aorta, which were recognized after emergency graft replacement from the ascending aorta to the aortic arch for acute type A aortic dissection. The intimal tear, which was near the left subclavian artery, was resected during the initial operation. Graft replacement of the descending thoracic aorta was successful.

Isopower maps of the electrogastrogram (EGG) after total gastrectomy or total colectomy.

Isopower or topographic electrogastrograms (EGG) correspond to topographic electroencephalograms. Both project the topographic localizations of the spectral frequencies on the abdominal surface or scalp. This paper compares the pre-operative control isopower EGG maps with those of total gastrectomy or total colectomy. EGGs were recorded simultaneously at 27 locations on the epigastro-abdominal surface. Spectral analysis by the maximal entropy method (MEM) was performed and the ensemble means of pre-prandial and post-prandial spectra were calculated. The spectral frequencies were arbitrarily classified into five groups, 1 cycle per minute (cpm) (0-2.4 cpm), 3 cpm (2.5-4.9 cpm), 6 cpm (5.0-7.4 cpm), 8 cpm (7.5-9.9 cpm) and 10 cpm (10.0-12.9 cpm). Maximal power peaks in each spectral group, and electrode locations which were expressed by x-y coordinates were the indicators for making the isopower EGG maps by using a contour map program. Thereafter, the maximal power spots or foci in each spectral group were determined. The pre-operative maximal power foci of the 1, 8 and 10 cpm groups were distributed rather evenly on the epigastro-abdominal surface. Those of the 3 and 6 cpm groups, mainly concentrated in the epigastric region, were absent in almost all patients who had undergone total gastrectomy. The infra-umbilical foci of the 3 and 6 cpm groups completely disappeared after total colectomy. The infra-umbilical foci of the 3 and 6 cpm groups (2.5-7.4) may reflect the colonic activities and the epigastric 3 cpm foci, the gastric activities. The pre-operative maximal power of the 3 cpm foci decreased significantly after total or sub-total gastrectomy.

Dedifferentiation of neoplastic cells in medullary thyroid carcinoma: report of a case.

We report herein the unusual case of a man who was diagnosed as having sporadic medullary thyroid carcinoma (MTC) at the age of 29 years, and subsequently followed up for a period of 18 years. A total thyroidectomy with radical neck dissection was initially performed, followed by a stable interval of 16 years with regional metastases. He then developed widely disseminated metastases resulting in death within 2 years at the age of 47 years. While the neoplastic tissue from localized metastases in the soft tissue of the neck expressed strong immunohistochemical positivity to calcitonin (CT), calcitonin gene-related peptide, carcinoembryonic antigen, neuron-specific enolase, and chromogranin A during the stable interval, extremely weakened immunoreactivity to those markers was observed in samples from the disseminated metastases in the subcutaneous tissue after his clinical deterioration. Furthermore, only a few neoplastic cells in specimens obtained at postmortem sampling exhibited a weak response to CT. Ultrastructurally, the characteristic secretory granules in the neoplastic cells decreased remarkably in number, consistent with the immunohistochemical findings. These granules also diminished in diameter and intracytoplasmic small lumina and intercellular clefts with microvilli, interpreted as an attribute of anaplastic thyroid carcinomas, were frequently observed in tissues obtained after his clinical deterioration or at postmortem sampling. These cytological changes might represent dedifferentiation of the neoplastic cells or the anaplastic transformation of MTC.

Impending rupture of the descending aorta by enlargement of the false lumen after graft replacement with the elephant trunk technique: report of a case.

We report herein a case of an impending rupture of the descending aorta caused by an enlargement of the false lumen after a graft replacement using the elephant trunk technique. The patient was a 51-year-old woman who had received a graft replacement of the ascending aorta for an acute Stanford type A aortic dissection 6 years previously. An enhanced computed tomographic scan and digital subtraction angiography revealed pseudoaneurysms at the proximal and distal anastomotic site, and a residual dissection of the aortic arch. A graft replacement of the ascending aorta to the aortic arch was performed with the distal site using the elephant trunk technique. Five days after the operation, massive bleeding from the drainage tube occurred. A chest enhanced computed tomographic scan suggested an impending rupture of the descending aorta caused by an enlargement of the false lumen. A graft replacement of the descending aorta was carried out. Postoperatively she had no complications, and digital subtraction angiography showed an excellent reconstruction of the thoracic aorta. One month after the second operation, she was discharged from hospital.

Successful surgical treatment of primary aorto-duodenal fistula associated with inflammatory abdominal aortic aneurysm: A case report.

We report a rare case of a 50-year-old woman with intermittent gastrointestinal (GI) bleeding and diagnosed as having primary aortoenteric fistula (PAEF) with inflammatory abdominal aortic aneurysm (IAAA). She was transferred to our institution with suspected PAEF as assessed by duodenoscopy and CT scan. As the patient was in shock due to massive GI-bleeding two days after admission, we performed an emergency laparotomy. The fistula was closed and the aneurysm replaced by a Woven Dacron Graft with an inter-positioning omental flap. A high index of suspicion is the most important diagnostic aid to prevent overlooking this often fatal disease.

A single-stage operation for bicuspid aortic valve, annulo-aortic ectasia, hypoplastic aortic arch, and coarctation of the aorta: A case report.

The patient was an 18-year-old man who had been diagnosed as having a bicuspid aortic valve and dilatation of the ascending aorta six years previously. As he grew up, aneurysmal change of the ascending aorta and hypertension in the upper body gradually progressed. Preoperative evaluation showed annulo-aortic ectasia and the following congenital abnormalities: bicuspid aortic valve, hypoplastic aortic arch, and coarctation of the aorta. Composite graft replacement and extended total aortic arch replacement were carried out.

Selective visceral and renal perfusion in thoracoabdominal aneurysm repair.

OBJECTIVE: Whether or not selective visceral and renal perfusion during thoracoabdominal aortic aneurysm (TAAA) repair has a protective effect on visceral and renal function remains unknown. The aim of this study was to clarify if selective perfusion has such an effect. METHODS: From May 1982 to December 1997, 82 consecutive patients underwent TAAA repair. Patients receiving hypothermic circulatory arrest or cooling of the kidney using Ringer's lactate solution were excluded, thus 73 patients were enrolled into this study. They were divided into three groups: those in whom selective visceral and renal perfusion was performed using a roller pump (n = 41), those in whom it was performed using a centrifugal pump with a reduced heparin regimen (n = 22) and those who underwent simple aortic clamping alone (n = 10). RESULTS: Serum creatinine, total bilirubin and alanine aminotransferase levels were elevated postoperatively in patients undergoing simple cross-clamp repair, but remained almost within normal limits in patients undergoing TAAA repair with selective visceral and renal perfusion. Urine output was more in selective perfused patients than in non-perfused patients. Renal dysfunction, defined by requirement of hemodialysis or by a serum level of creatinine above 3 mg/dl, occurred in four patients (10%) of the roller pump group and in two patients (9%) of the centrifugal pump group, while in four patients (40%) of the simple cross-clamping group. CONCLUSION: Our experience suggests that selective visceral and renal perfusion has a protective effect on hepato-renal function during TAAA repair.

[Surgical management for acute aortic dissection with organ ischemia].

In a series of one hundred and one cases of surgical treatment for acute aortic dissection between January 1986 and September 1997, we evaluated 29 cases presenting with organ ischemia. These consisted of 23 cases of acute type A dissection (type A) and 6 cases of type B dissection (type B). Organ ischemia was diagnosed by (1) aortography, (2) a retrospective review of the history and (3) physical examination or laboratory data. The 23 surgical cases of acute type A dissection consisted of, coronary ischemia 8 cases, cerebral and spinal cord ischemia 9 cases, intestinal ischemia 3 cases, lower extremities ischemia 10 cases, and plural organs ischemia 8 cases. In the 6 cases of acute type B, we noted 4 intestinal ischemias and 2 lower extremities ischemias. The operative mortality rates when subdivided according to ischemic organ were: coronary ischemia 50%, cerebral and spinal cord ischemia 11%, intestinal ischemia type A 33%, type B 50%, and lower extremities ischemia type A 33%, type B 0%. The operative mortality rates, especially for patients presenting with acute myocardial infarction or intestinal ischemia, were relatively high. In cases of acute aortic dissection when organ ischemia occurred, we believed that it was necessary to perform early thoracic aortic repair and reconstruction of the ischemic organ.

Total aortic replacement for aortitis syndrome: report of a case.

We report herein the case of a 35-year-old woman who was administered steroid therapy based on a diagnosis of aortitis syndrome. Despite this treatment, the symptoms of cardiac failure gradually progressed, and she was referred to our hospital to undergo surgery. Preoperative evaluations revealed a large aneurysm extending from the ascending aorta to the thoracoabdominal aorta. A two-staged total aortic replacement was carried out and postoperative digital subtraction angiography showed excellent reconstruction of the entire aorta.

Do the level of nodal disease according to the TNM classification and the number of involved cervical nodes reflect prognosis in patients with differentiated carcinoma of the thyroid gland?

BACKGROUND AND OBJECTIVES: The importance of nodal involvement as a prognostic factor in differentiated carcinoma of the thyroid gland remains controversial. We therefore attempted to confirm the prognostic factors in differentiated thyroid carcinoma, with special reference to nodal status. PATIENTS AND METHODS: A total of 139 patients with differentiated thyroid cancer followed for 2-27 years, with a median follow-up of 7 years were studied. All patients underwent surgical resection, either subtotal, total, or lobectomy, with modified radical neck dissection. Survival was calculated using the Kaplan-Meier method. RESULTS: Ten (7%) patients have died from thyroid cancer. Adverse prognostic factors included age >45 years (P=0.0120), the presence of distant metastases (P=0.0006), and TNM stage (P=0.0002). The number of lymph nodes dissected ranged from 6 to 92, with an average of 26. Lymph node metastases were found in 102 (73%) patients. There was no difference in survival according to the level of nodal disease by the TNM classification. Furthermore, the number of cervical lymph nodes involved had no effect on the survival. CONCLUSION: Our results suggest that the presence of histologically confirmed lymph node metastases is not an important prognostic factor in patients with differentiated thyroid carcinoma.

[Operative results and long-term prognosis of type A acute aortic dissection].

Between 1983 and 1997, we operated upon 91 patients with type A acute aortic dissection. The dissection was localized in 22 patients and extensive in 69 patients. All patients underwent graft replacement and 61 (67%) patients underwent simultaneous replacement of ascending aorta and total aortic arch. The hospital mortality rate were 9% for the localized dissection and 21% for the extensive dissection. The actuarial survival rates in patients with localized dissection at 5 and at 10 years was 91% and 76%, whereas those in patients with extensive dissection at 5 and at 10 years was 68% and 62%. The freedom from dissection related death or reoperation in operative survivors with localized dissection at 5 and at 10 years was 100% and 83%, whereas those in patients with extensive dissection at 5 and at 10 years was 78% and 56%. The simultaneous replacement of ascending aorta and total aortic arch in patients with extensive dissection was effective to obliteration of the distal false channel, although this extended procedure has to be carefully adopted in high risk patients with associated complications such as acute dissection organ ischemia.