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Background Locally advanced gastric cancer with extensive lymph node metastasis is usually considered unresectable and so treated by chemotherapy. This trial explored the safety and efficacy of preoperative chemotherapy followed by extended surgery in the management of locally advanced gastric adenocarcinoma. Methods Patients with gastric cancer with extensive lymph node metastasis received two or three 28-day cycles of induction chemotherapy with irinotecan (70 mg/m2 on days 1 and 15) and cisplatin (80 mg/m2 on day 1), and then underwent gastrectomy with curative intent with D2 plus para-aortic lymphadenectomy. Primary endpoints were 3-year overall survival and incidence of treatment-related death. Results The study was terminated because of three treatment-related deaths when 55 patients had been enrolled (mortality rate above 5 per cent). Two deaths were due to myelosuppression and one to postoperative complications. Clinical response and R0 resection rates were 55 and 65 per cent respectively. The pathological response rate was 15 per cent. Median overall survival was 14·6 months and the 3-year survival rate 27 per cent. Conclusion This multimodal treatment of locally advanced gastric cancer provides reasonable 3-year survival compared with historical data, but at a considerable cost in terms of morbidity and mortality.

Maxacalcitol is a vitamin D analogue, which is administered intravenously for secondary hyperparathyroidism in dialysis patients as well as calcitriol. However, few dose-comparison clinical studies have been reported for these drugs. The present multicenter, randomized crossover study was conducted to determine the equivalence of maxacalcitol and calcitriol doses.Subjects comprised 31 patients on chronic hemodialysis with secondary hyperparathyroidism who had not received maxacalcitol or calcitriol in the previous 3 months. Patients were randomly divided into two groups, and maxacalcitol or calcitriol was administered in a crossover design for 12 weeks each. Maxacalcitol and calcitriol doses were adjusted based on serum levels of calcium and intact parathyroid hormone.After the 12-week maxacalcitol/calcitriol administration, there were no significant differences in levels of calcium (maxacalcitol 2.40+/-0.22 mmol/1 (9.6+/-0.9 mg/dl), calcitriol 2.42 + 0.25 mmol/l (9.7+/-1.0 mg/dl), p = 0.71), phosphate (maxacalcitol 1.97 + 0.42 mmol/l (6.1+/-1.3 mg/dl), calcitriol 2.00+/-0.48 mmol/l (6.2+/-1.5 mg/dl), p = 0.64), intact parathyroid hormone (maxacalcitol 267+/-169 pg/ml, calcitriol 343+/-195 pg/ml, p = 0.11) in serum or other bone-metabolic parameters such as serum alkaline phosphatase. The doses ofmaxacalcitol and calcitriol were 49.3+/-23.7 microg/month and 9.0+/-3.8 microg/month, respectively, and maxacalcitol : calcitriol dose ratio was 5.5: 1. No severe adverse reactions were seen for either maxacalcitol or calcitriol during the study period.Comparable therapeutic efficacy can be obtained in the treatment of secondary hyperparathyroidism using either maxacalcitol or calcitriol at a dose ratio of 5.5 : 1.

Perioperative mortality and morbidity in Japan from Jan. 1 to Dec. 31, were studied retrospectively. Committee on Operating Room Safety of Japanese Society of Anesthesiologists (JSA) sent confidential questionnaires to 774 Certified Training Hospitals of JSA and received answers from 60.2% of the hospitals. We analyzed their answers with a special reference to the age group. The total number of anesthetics available for this analysis was 732,788. All cases were divided in to 7 groups; group A(1 months), group B(12 months), group C(5 years), group D(18 years), group E (65 years), group F(85 years), and group G(85 years). The incidences of all critical events including cardiac arrest, severe hypotension, and severe hypoxemia were 168.14, 47.86, 24.63, 14.65, 28.43, 50.4, and 43.68 per 10,000 in patients with group A, B, C, D, E, F, and G, respectively. The overall mortality rate (death during anesthesia and within 7th postoperative day) were 74.10, 6.63, 3.30, 3.07, 4.82, 13.74, and 11.84 per 10,000 anesthetics in patients with group A, B, C, D, E, F, and G, respectively. The incidences of cardiac arrest were 54.15, 8.84, 5.08, 2.56, 4.84, 11.02, and 6.66 per 10,000 in patients with group A, B, C, D, E, F, and G, respectively. The mortality rates after cardiac arrest were 42.75, 2.95, 2.54, 1.70, 2.00, 6.56, and 5.18 in patients with group A, B, C, D, E, F, and G, respectively. The incidences of all critical events, the incidence of cardiac arrest, and the overall mortality rate were much higher in group A than other groups and lower in group D. Mortality and morbidity due to all kinds of causes including anesthetic management, intraoperative events, co-existing diseases, and operation were as follows. The incidence of all critical events attributable to co-existing disease were the highest in these four groups, and 94.04, 15.46, 7.87, 6.13, 7.26, 17.38, and 16.29 per 10,000 in patients with group A, B, C, D, E, F, and G, respectively. The incidences of all critical events attributable to anesthetic management were 31.35, 16.94, 4.60, 6.09, 10.77, and 14.07 per 10,000 in patients with group A, B, C, D, E, F, and G, respectively. The incidence of cardiac arrest in group A was much more attributable to co-existing disease and operation than other causes. The incidences of cardiac arrest attributable to anesthetic management were 0.00, 1.47, 0.25, 0.34, 0.83, 0.92, and 0.22 per 10,000 in patients with group A, B, C, D, E, F, and G, respectively. The mortality rates in these groups were 0.00, 0.00, 0.00, 0.17, 0.07, 0.05, and 1.48, and no death was found in cases under 5 years of age. The two cases of death in G group were due to too high anesthesia levels in spinal anesthesia. Other causes including overdose of anesthetics, toxic effect of local anesthetic, improper management of airway, and incompatible blood transfusion were preventable with the anesthesiologists' effort in protocol development and skilled assistance.

During the past 4 years, we have experienced a marked reduction in the incidence of esophageal anastomotic leakage and/or stricture coinciding with the use of a mechanical circular stapler for gastric cancer patients.We reviewed medical records of gastric cancer patients who underwent a total or proximal gastrectomy, and compared the leakage or stricture of stapled anastomosis with the hand-sewn anastomosis technique. A total of 390 esophageal anastomosis were performed between January 1978 and August 1997. Two types of mechanical circular staplers were used (EEA and CDH).Anastomotic leakage occurred in 13 (3.3%) of 390 cases; three (4.5%) of 66 cases with hand-sewn anastomosis, and 10 (3.1%) of 324 cases with stapled anastomosis (EEA: 4.5%, CDH: 0%). The anastomotic leakage rate was significantly lower in the CDH stapler group than in the EEA stapler group. Anastomotic stricture occurred in one (1.5%) of 66 cases of hand-sewn anastomosis, and 16 (4.9%) of 324 cases of stapled anastomosis (EEA: 5.9%, CDH: 2.9%). There were no significant differences in the stricture rate between the hand-sewn group and the stapler group.Stapling anastomosis using a CDH stapler led to a reduction in the incidence of anastomotic leakage. Surgeons must, however, continue to be aware of anastomotic stricture.

To establish the alteration in expression pattern of transforming growth factor (TGF)-betas and their receptors during repair of lens capsules after cataract surgery, we immunohistochemically located TGF-beta isoforms and their receptors in human lens capsules before and after cataract surgery.Ten post-cataract surgery capsular specimens were obtained during vitrectomy. Three sections of the anterior capsules were obtained during cataract surgery. A whole lens capsular bag immediately after lens extraction was obtained during vitrectomy. Cryosections of these specimens were processed for immunohistochemical analysis for TGF-beta1, TGF-beta2, TGF-beta3, TGF-beta receptor type I (TbetaR-I), type II (TbetaR-II) and type III (TbetaR-III), and were observed under light micros-copy.Lens epithelial cells (LECs) lining the inner surface of the anterior capsules exhibited immunoreactivity for TGF-beta2 and TbetaR-II. Immunoreactivity for TGF-beta1, -beta3, TbetaR-I and TbetaR-III was negative. In the whole capsular bag specimen, equatorial LECs were positive for TGF-beta1 and -beta2, but not for -beta3. In post-cataract surgery specimens, antibodies for each TGF-beta isoform labelled either the LECs or ECM accumulated on the capsules. Post-surgical LECs expressed TbetaR-I and TbetaR-II, and had also TbetaR-III in seven of the nine specimens examined.Expression pattern of TGF-beta s in quiescent LECs showed regional heterogeneity. Anterior LECs exhibited TGF-beta2 immunoreactivity, while equatorial LECs were positive for TGF-beta1 and -beta2. Quiescent LECs expressed TbetaR-II. LECs proliferating around IOLs expressed proteins of each TGF-beta isoform and each TbetaR. TGF-beta s were also localized in the ECM on capsules undergoing repair. TGF-beta3, TbetaR-I and TbetaR-III are up-regulated in LECs after cataract surgery.

Resection of hepatic arteries is often obligatory on resecting pancreatic, gastric and hepatobiliary malignancies. Hepatic artery reconstruction is required to preserve liver function and blood flow to the bile duct. We applied the gonadal vein to hepatic artery reconstruction.Hepatic artery reconstruction using a gonadal vein graft was performed in two patients: one with gallbladder cancer and the other with recurrent gastric cancer.The right ovarian vein, 2 mm in diameter and 4 cm in length, was grafted for reconstruction between the proper hepatic and the posterior hepatic artery in one patient who underwent modified central hepatic bisegmetectomy and common bile duct resection. The left spermatic vein, 3 mm in diameter and 6 cm in length, was grafted for reconstruction between the celiac artery and the right hepatic artery in the other, who underwent upper abdominal exenteration. The former graft was occluded due to tumor invasion at 4 months after surgery, the latter one was patent at 8 weeks after surgery.The gonadal vein had an ideal diameter and sufficient length to accomplish hepatic arterial reconstruction. The gonadal vein graft will be a new and preferable addition to the selection of an optimal graft for hepatic arterial reconstruction.

A 69 year-old man with a history of thoracoplastic surgery for pulmonary tuberculosis, who required a blood transfusion and subsequently tested positive for hepatitis C virus, developed a right hypochondrial mass, swelling of the lower extremities and malaise. A huge hepatocellular carcinoma invading the suprahepatic vena cava with tumor thrombi was diagnosed radiographically. An extended right hepatectomy with supra- to retrohepatic IVC resection was performed in an en bloc fashion using a centrifugal pump for hepatic vascular exclusion (HVE). The supra- to retrohepatic IVC was replaced with an expanded polytetrafluoroethylene (ePTFE) graft, 20 mm x 10 cm in size, and the left hepatic venous confluence was reconstructed. Twenty-one months after surgery, the patient is in good condition without recurrence of tumor.

The bed bath procedure consists of cleansing patients' body, passive position change, changing gown and making a bed. During the procedure, mixed venous desaturation was observed consistently in postoperative cardiac patients. We investigated the cause of the phenomenon in 22 patients undergoing cardiac surgery in their first postoperative day. The patients were breathing oxygen-enriched air via a Venturi mask. Cardiac index (CI), transluminal SvO2, arterial blood gas, Hb, DO2, VO2, FIO2, A-aDO2 and Qp/Qs were measured before and during the bed bath, while the patients were in the supine and left lateral position, respectively. Mean 8.5 +/- 1.5 minutes were required to complete the bed bath. During the bed bath, SvO2 decreased from 71 +/- 7% to 59 +/- 9% (P0.001), and returned to the baseline 6.5 +/- 7.4 minutes after the completion of the bed bath. VO2 increased markedly from 128 +/- 27 to 194 +/- 47 ml.min-1.m-2 (P0.001), while DO2 increased slightly from 480 +/- 91 to 513 +/- 110 ml.min-1.m-2 (P0.05). Among the determinants of DO2, CI increased slightly from 3.3 +/- 0.6 to 3.6 +/- 0.8 l.min-1.m-2, Hb remained unchanged and SaO2 decreased from 98.5 +/- 0.8 to 98.0 +/- 1.1%. FIO2 also decreased, while A-aDO2 and Qp/Qs remained unchanged. There was a negative correlation between VO2 change and SvO2 change, but no correlation between DO2 change and SvO2 change. There was a positive correlation between SaO2 change and SvO2 change, as well as between FIO2 change and SaO2 change. Therefore, the major cause of mixed venous desaturation was not the decreased DO2 or cardiopulmonary decompensation but the increased VO2 due to increased activity of the skeletal muscles. However, the decrease in SaO2 due to markedly increased O2 demand and the limited increase in CI might partially contribute to the marked decline in SvO2 through the limited increase in DO2.

Coagulation and fibrinolysis parameters were compared between two strategies of heparinization during cardiopulmonary bypass (CPB) in patients who underwent aortic surgery with deep hypothermic circulatory arrest (DHCA) and retrograde cerebral perfusion (RGCP) with aprotinin.From January 1994 to January 1996, 94 patients underwent aortic surgery with DHCA with aprotinin; replacement of the ascending aorta took place in 14 patients, arch in 69, and descending aorta in 11. Two million units of aprotinin was administrated in the priming of CPB, and 3 mg/kg heparin was given before CPB. During CPB, 49 patients had an additional 1 mg/kg/h heparin regardless of activated clotting time (ACT) [group A], whereas 45 patients had an additional 1 mg/kg/h heparin when ACT was less than 500 seconds [group B]. ACT, PT, aPTT, fibrinogen, AT-3, plasminogen, alpha2-PI (plasmin inhibitor), fibrin/fibrinogen degradation products (FDP), DD (D dimer), TAT (thrombin-antithrombin complex), PIC (plasmin-plasmin inhibitor complex), beta-TG (thromboglobulin), and PF-4 (platelet factor-4) were assayed. No difference was detected between the two groups regarding the duration of operation, CPB, aortic cross-clamping, DHCA, RGCP, and time from the end of CPB to admission to ICU. The heparin dose was greater in group A, but the protamine dose was similar. There was no difference in bleeding after perfusion or in ICU. Levels of TAT, fibrinogen, and DD were lower in group A. PIC, alpha-PI, and FDP value showed no difference. PF-4 and beta-TG were lower in group A, and the platelet count at the end of operation and the day after the operation was higher in group A.Platelets were better preserved and activation of the coagulation system during CPB was less severe in patients who had a regular additional constant heparin regimen irrespective of ACT in surgery for the aortic aneurysm with DHCA and aprotinin usage. An accurate monitoring system for heparinization is necessary to maintain appropriate anticoagulation during CPB in patients who are undergoing aortic surgery with DHCA using aprotinin.

The perioperative blood coagulation and fibrinolysis system in patients who underwent aortic surgery under deep hypothermic circulatory arrest with or without aprotinin usage was investigated.Of 112 patients who underwent aortic surgery between December 1993 and April 1995, 60 had repair under deep hypothermic circulatory arrest. Thirty-nine patients had 2 million U aprotinin in pump priming and had no additional aprotinin. There were 20 patients with aortic dissections and 17 with atherosclerotic aneurysms. Twenty-two patients had left thoracotomy, and 17 had midsternotomy. Surgery consisted of replacement of the ascending aorta in 9 patients, total arch replacement in 11, distal arch replacement in 11, replacement of the descending aorta in 3, and replacement of thoracoabdominal aorta in 5. The control group was 21 patients who underwent operation under deep hypothermic circulatory arrest and retrograde cerebral perfusion but without aprotinin. Blood coagulation and fibrinolysis tests, consisting of activated clotting time, prothrombin time, activated partial thromboplastin time, fibrinogen, antithrombin III, plasminogen, alpha 2-plasmin inhibitor, thrombin-antithrombin complex, plasmin inhibitor complex, fibrin degenerative products, and D-dimer complex, were performed at various stages of surgery, before heparin administration, after heparin, 60 minutes and 120 minutes after beginning of the extracorporeal circulation, 1 hour after protamine administration, and 6 hours after protamine. Statistical analysis was performed with Student's t test, chi 2 test, and ANOVA. The amount of bleeding after perfusion was less in the aprotinin group, and bleeding during first 24 hours in the intensive care unit was less. Blood examination revealed that prothrombin time was higher after cessation of cardiopulmonary bypass in the aprotinin group. Thrombin-antithrombin III complex and alpha 2-plasmin inhibitor were higher during and after bypass in the aprotinin group. There was no difference in activated clotting time, activated partial thromboplastin time, fibrinogen, antithrombin III, plasminogen, plasmin inhibitor complex, fibrin degenerative products, and D-dimer complex.Clinical advantages of hemostatic effects of low-dose aprotinin and no apparent deleterious effects were demonstrated in patients who underwent aortic surgery under deep hypothermic circulatory arrest with retrograde cerebral perfusion. However, blood coagulation and fibrinolytic studies revealed subclinical hypercoagulation. Therefore, and adequate dose of heparin is required during deep hypothermic circulatory arrest.

The maze procedure failed to abolish atrial fibrillation (AF) in 14% of patients with underlying organic cardiac lesions. Identification of contributing risk factors will improve results either by treatment of such factors or by avoidance of high-risk patients.We analyzed 192 consecutive patients with AF undergoing three variations of the maze procedure performed simultaneously with correction of valvular diseases (n = 165), congenital anomalies (n = 19), isolated AF (n = 7), and ischemic disease (n = 1). Twenty-six preoperative factors and two postoperative cardiac size parameters were analyzed by multivariate analyses between patients with successfully ablated AF (n = 165) and those who remained in AF (n = 27) after the maze procedure. Among all factors, postoperative left atrial dimension was the most potent in predisposing patients to persistent AF. Duration of AF left atrial dimension, and cardiothoracic ratio were identified as preoperative risk factors, whereas modifications of the maze procedure and pathogenesis and location of underlying disease failed to have a significant prognostic impact on rhythm after surgery. Individual risk analysis using the three preoperative variables revealed that left atrial size reduction to normalize its dimension played a pivotal role in determining rhythm after the maze procedure.Results favor earlier performance of the procedure before these risk factors develop, after which omission of the procedure or extensive left atrial plication may be appropriate. This requires further study.

Among patients who underwent reconstruction of the aortic root by Bentall-type procedure using a composite graft, we investigated patients who underwent reoperation for complications related to composite graft. We employed composite graft reconstruction of the aortic root in 155 patients for 16 years prior to December 1994. Annulo-aortic ectasia was observed in 112 patients, aortic dissection in 34, and aortitis without aneurysm formation in 9. The original Bentall procedure was performed in 36, the Cabrol method in 8, the interposition method in 26, and the Carrel patch method in 85 patients. Thirteen (8.4%) of these patients required reoperation for complications related to the composite graft. Three of 4 patients with graft infection early after surgery underwent reconstruction with composite graft, but died in the hospital. The remaining patient survived after combined treatment that included the graft washing with Iodine (Isozin) solution and omentopexy. Four patients developed pseudoaneurysm formation due to sutural insufficiency and 7 has prosthetic valve failure as late complications. Three of the 4 patients with pseudoaneurysm underwent reconstruction with a second composite graft by the interposition method, while one patient with aortitis required another reoperation. In the remaining one patient, the leak was directly close along with second aortic valve replacement. All prosthetic valves used in 7 patients with prosthetic valve failure were Ionescu-Shiley biological valves. Primary tissue failure was observed in 6 and prosthetic valve endocarditis in one patient. Second cardiac valve replacement using a mechanical valve was possible. All the patients who underwent late reoperation showed favorable results. Infection of the composite graft showed the poor prognosis, and prevention of infection is important. Sutural insufficiency at the anastomosed site can be prevented by appropriate surgical procedures such as reinforcing suture, but further countermeasures for sutural insufficiency were considered necessary for aortitis in conditions, such as Behcet's diseases.

The results of direct pulmonary embolectomy in 20 cases of pulmonary embolism treated in our facility from 1982 to May, 1995 was analyzed. The ages of the patients ranged from 25 to 72 years (mean: 46 years). The male-to-female ratio was 12:8. The 20 cases were divided into three groups based on the type of pulmonary embolism: Group I (4 cases of acute massive pulmonary thrombo-embolism). Group II (12 cases of chronic pulmonary thrombo-embolism) and Group III (4 cases of tumor embolism). In Group I, 2 patients developed shock and 2 developed severe right heart failure. Emergency thrombectomy using cardiopulmonary bypass succeeded in saving the lives of 3 patients in this group. In Group II, the preoperative NYHA grade was II in 1 case, III in 9 cases, and IV in 2 cases. The preoperative systolic pressure of the pulmonary artery ranged from 24 to 90 mmHg (mean: 74 mmHg). Surgery through a thoracotomy was carried out on 7 cases (on the right side in 4 cases on the left in 3 cases). Of these 7 patients, 2 died of heart failure and respiratory failure because thromboendarterectomy was inadequate. In another 2 patients, symptoms improved enough to allow them to resume their previous lives. The other three patients showed no change in their symptoms after surgery, but they could be discharged. The remaining 5 patients in Group II underwent surgery through the median approach. Deep hypothermia with circulatory arrest was used in the latter 4 of these 5 patients during surgery. 3 patients died during the perioperative period because adequate thromboendarterectomy was not possible and because their preoperative condition was very poor. 2 patients who were able to be performed adequate thromboendarterectomy showed good postoperative courses. Of the 4 patients in Group III, one patient survived 11 months after surgery, but the other 3 died during the preoperative period because very little embolus could be removed. These results allow us to conclude that the lives of patients with acute pulmonary thromboembolism can be saved by early detection and prompt surgery, but that management of chronic pulmonary thromboembolism involves difficulties in selecting surgical cases and in performing thromboendarterectomy.

One hundred twenty-eight valvular surgeries in patients over 70-year-old were reviewed (AVR:58, MVR:38, AVR and MVR: 11, mitral valvuloplasty (MVP): 11, AVR + MVP:11, mitral valvuloplasty (MVP): 11, AVR + MVP: 8, others: 2). Concomitant CABG was performed in 7, Maze in 6, TVR in 5 and Bentall in 3 cases. Early deaths occurred in 17 patients (13%). The early mortality was 5% in AVR, 21% MVR, 18% in AVR and MVR, 0% in MVP and 38% in AVR and MVP. Late death occurred in 16 patients. Forty-three percent of the late deaths were cardiac death. The actuarial survival at 10 years was around 50% in all groups. In the aortic position, a mechanical valve was implanted in 47 cases and a bioprosthetic valve was implanted in 33 cases. In the mitral position, the mechanical valve was implanted in 37 cases and the bioprosthetic valve was implanted in 12 cases. The event free rate after AVR at 10 years was 37% in patients with the mechanical valve (3 cerebral hemorrhage, 2 PVE, 1 thromboembolism and 1 sudden death) and 46% in patients with the bioprosthetic valve (2 PVE and 1 primary tissue failure). The event free rate after MVR at 10 years was 84% in patients with mechanical valves (1 perivalvular leak, 1 PVE and 1 sudden death) and 75% in patients with bioprosthetic valves (1 PVE and 1 sudden death). Between mechanical valve group and bioprosthesis group, no statistically significance was found in the event free curve after AVR nor MVR. There was no valve related event after MVP. Considering the better durability of bioprostheses in the aortic position than in the mitral position, the presence of atrial fibrillation and necessity of warfarin anticoagulation, we conclude that a choice of a bioprosthetic valve could be acceptable in the aortic position, but may not be recommended in the mitral position.

This report reviews our experience with single aortic and mitral valve replacement using the Carpentier-Edwards pericardial valve in a population younger than those of other reports.Between 1984 and 1993, 106 patients underwent single aortic or mitral valve replacement using a Carpentier-Edwards pericardial valve. There were 49 aortic and 57 mitral implants. The mean age was 56.7 +/- 14.3 years. The follow up was 100% complete; total follow up being 273.3 patient-years in the aortic (AVR) and 348.0 patient-years in the mitral valve replacement (MVR) group, with a mean of 5.6 and 6.1 years, respectively.The rates of thromboembolic complications for AVR and MVR were 0.37% and 0.58% per patient year respectively. There were no cases of non-structural dysfunction or anticoagulant-related hemorrhage. The incidences of prosthetic valve endocarditis for AVR and MVR were 0% and 0.86% per patient year respectively. Structural deterioration (calcification and sclerosis) occurred in one patient after AVR and in six patients after MVR, all younger than 60 years of age. Freedom from structural deterioration at five years and 10 years was 100% and 92.9% +/- 6.9% for AVR, and 100% and 76.9% +/- 8.6% for MVR.In conclusion, the Carpentier-Edwards aortic valve has a low incidence of valve-related complications at 10 years. Although late results of this valve in the mitral position were excellent in the elderly, leaflet degeneration is still a problem in patients under the age of 60 years.

The surgical procedures were reviewed based on the types of hypertrophied obstructive cardiomyopathy in 20 patients. The patients were classified in three groups: (1) Asymmetric septal hypertrophy (ASH), (2) Atypical or diffuse concentric hypertrophy (DIF), (3) Mid ventricular obstructive hypertrophy (MID). Among 11 patients with ASH, the ventricular septal myotomy (My) or the myotomy-myectomy (Mye) were performed in 9 patients and MVR was performed in 2 patients. Among 6 patients with DIF, My or Mye were performed in 4 and MVR was performed in 2. All three patients with MID were treated with MVR. The intraventricular systolic pressure gradient greater than 40 mmHg was still existent postoperatively in one ASH patient on whom Mye was performed and in 3 DIF patients on whom My or Mye were performed. The four patients had III degree mitral regurgitation preoperatively and were successfully treated. The postoperative NYHA functional class became II or less in all patients. For ASH, the My was effective in 9 patients except one earlier patient. For DIF, further consideration of surgical procedure might be required. For MID, a MVR is recommended.

To determine the short- and medium-term results of coronary artery bypass grafting (CABG) in dialysis patients, we analyzed a group of 14 patients with chronic renal failure who underwent CABG between May 1990 and October 1994. Two patients had concomitant valve repair for mitral regurgitation. Hospital mortality was 14% (2 out of 14). These two patients died of ileus due to ischemic colitis and agranulocytosis respectively. There was one late death from stroke. The four significant postoperative complications (morbidity 29%) were composed of two sternal dehiscence, one cardiac tamponade because of bleeding, and one perioperative myocardial infarction. Graft patency rate was 97% (34 out of 35 in 13 patients) within one month. Actuarial survival was 86% at one 1 to 3 years, and 43% at 3 and a half years. This rate is not significantly different from all dialysis patients, but night be better than dialysis patients with coronary artery disease who had not undergone CABG in the previous reports. Left ventricular size is larger in patients who died or who had significant complications in hospital than in patients with uneventful postoperative course. Cardiac arrest time, cardiopulmonary bypass time, chest tube output, and the amount of transfusion might be also related to mortality and morbidity though statistically not significant.

Hepatic tumors with elements of both hepatocellular and cholangiocellular carcinoma are occasionally encountered; however, the independent and simultaneous occurrence of different epithelial malignant tumors in different lobes is rare. This is a case report of resected double cancer in different lobes of the liver.A 73 year old Japanese man, with hepatic mass and a history of peritonitis and hepatitis, underwent laparotomy and hepatic resection of the posterior inferior and the left lateral segment, and cholecystectomy for cholecystlithiasis with left-sided gallbladder at our hospital in 1991.The tumor, located in the posterior inferior segment, a yellow-white, round, highly circumscribed mass with a thick capsule, was about 9.0 by 8.0 cm in size. The other tumor located in the left lateral segment, grayish-white on the cut section, was approximately 5.0 by 4.0 cm.In our case, it is unlikely the tumor in the right lobe metastasized to the left lobe and transformed into a different type. The two tumors showed clearly different microscopic features. Improved imaging will increase the frequency and number of double cancer diagnosis. This additional data may shed light on the pathogenesis and etiology of double cancer.

Between January 1978 and September 1992, 127 patients with isolated mitral regurgitation due to prolapse underwent mitral valve reconstruction. There were 74 men and 53 women whose mean age was 49.7 years, ranging from 16 to 74 years. Follow up was 99.2% complete and totaled 483.0 patient-years (mean: 3.8 years). One hundred and forty-eight procedures were carried out to repair the prolapses using four types of techniques: (1) leaflet plication in 97 patients; (2) artificial chordal replacement with polytetrafluoroethylene sutures in 30 patients; (3) chordal shortening in 16 patients; and (4) commissural imbrication in five patients. In order to repair the annular dilation, commissural plications were done in 75 and ring prostheses were implanted in 15 patients. There were one hospital and eight late deaths. One (cerebral infarction) of all deaths was related to the reconstructed mitral valve. There were 14 reoperations (11.0%) for recurrent mitral incompetence with a freedom from reoperation of 89.0% at five, and 81.1% at 10 years. There were four cases of thromboembolism (one fatal, three non-fatal) with freedom from thromboembolism of 96.7% at five, and 93.3% at 10 years. No endocarditis or hemorrhagic complications were noted. Linearized incidence of recurrent mitral regurgitation according to repair technique for the prolapse was 1.44%/pty in the leaflet plication series, 1.45%/pty with chordal replacement, 4.37%/pty after chordal shortening and 8.67%/pty following commissural imbrication. The linearized rate of failure in annuloplasty was 2.91%/pty after commissural plication and 1.74%/pty after ring annuloplasty. Statistically significant difference was confirmed only between leaflet plication and chordal shortening.(ABSTRACT TRUNCATED AT 250 WORDS)

Leakage around the coronary ostia continues to be the major complication of composite graft replacement of the ascending aorta and aortic valve. To reinforce coronary anastomosis and reduce the operating time, a new modification of the Bentall operation was developed. This procedure involves dissecting full-thickness coronary buttons while leaving the epicardium on the aortic wall and complete wrap of the composite graft by the tailored aortic wall (Carrel patch and inclusion technique). Since March 1983, this approach has been performed in 12 patients (group A) and other Bentall-type operations in 22 (group B). Time affected by haemostasis was 28 min less in group A than in B (P = 0.23). Blood loss and blood transfusion during surgery and hospitalization were significantly lower in group A than B. Significantly less leakage occurred in group A than in B. On the basis of these short-term results, the Carrel patch and inclusion technique is considered to be an accurate time- and blood-saving procedure.

The present study was carried out to find out whether or not peripheral blood T cell subsets predict the prognosis of a gastric cancer patient preoperatively. In this retrospective study, we used preoperative T cell subset data from 34 patients with advanced gastric cancer who had been treated by resection. T cell subsets were measured by single color flow cytometry before surgery. Multivariate analysis, using the Cox proportional hazard model, was adjusted to the CD3 cell count, disease stage, the CD16 cell count and the CD4/CD8 ratio, and suggested CD3 cell count (chi 2 = 4.95, P = 0.026) and disease stage (chi 2 = 9.32, P = 0.002) to be statistically the most independent prognostic factors. Using the hazard ratio, the relative risks of the worst versus the best prognosis were 24.3 for the CD3 cell count and 10 for disease stage. For patients with more than 1483 CD3 positive cells, a longer than average survival time can be expected. The prospective hazard ratio (lambda (t)/lambda 0(t)) of an arbitrary gastric cancer patient can be calculated using the following expression: log(e) (lambda (t)/lambda 0(t)) = -0.00127 (CD3 cell count-1483) +2.31186 (Stage-0.606), where Stage III is assigned a value of 0 and Stage IV a value of 1. The survival curve of an arbitrary gastric cancer patient can also be predicted.

Results of surgical treatment of atherosclerotic aneurysm of the distal aortic arch, reported to date, are not satisfactory. We recently analyzed the surgical results in 119 patients with this condition who were treated at our department. There were 104 males and 15 females, ranging in age from 38 to 81 years (mean: 66 years). The arch was reconstructed by total replacement in 29 cases, partial replacement in 49 cases, patch reconstruction in 34 cases and extra-anatomic bypass in 7 cases. The lesion was approached by median sternotomy in 75 cases, median sternotomy+left thoracotomy in 9 cases and left thoracotomy in 35 cases. In cases where median sternotomy was used, selective cerebral perfusion was generally employed as an auxiliary procedure. After surgery, cerebral complications were observed in 19 cases (16.0%). In 15 of these 19 cases, postoperative cerebral damage was attributed to atheromatous emboli. Twenty-six patients (21.8%) died in the hospital. Major causes of death included respiratory insufficiency, multiple organ failure and low cardiac output syndrome. To improve surgical results for this type of aneurysm, the operative procedure needs to be modified so that these postoperative complications are prevented. Especially it is essential to prevent intraoperative embolisms of brain and coronary arteries, and a reconstruction by total arch replacement with median sternotomy has improved recent surgical results.

In nine patients with central (thalamic) pain after stroke, X-CT, MRI, PET scan and intraoperative thalamic microrecordings were performed. The PET studies made use of Sokoloff's method with 18FDG and a steady-state method with C15O2-15O2. CT scan and MRI revealed definite thalamic damage (Th) in 3 cases, putaminal damage (Put) in 3 cases, combined damage (Th + Put) in one case, and cortical (parietal) damage in 2 cases. In patients with a subcortical lesion, the greater the severity of superficial pain, the higher was the relative value of regional cerebral glucose metabolism (rCMRGlu) as compared to oxygen metabolism (rCMRO2) in the cerebral cortex around the central sulcus on the damaged side. Also, in a case with combined (Th + Put) lesion, regional oxygen extraction ratio (rOEF) was increased in this area. Moreover, in another case, central pain disappeared after a small subcortical haemorrhage in the same structure. In all patients including those with a cortical lesion, rCMRGlu was decreased in the postero-lateral (sensory) thalamus on the invalued side. The possible role of the cerebral cortex around the central sulcus for the genesis of central pain is discussed.

To prevent aneurysm rupture, avoid pseudoaneurysm formation, and preserve intercostal arteries, a new procedure for repair of DeBakey type 3 dissecting aneurysm was developed. Since January 1977, 28 patients have undergone repair of type 3 dissecting aneurysm. Fifteen patients with type 3b underwent this new procedure (group 1) and 13 patients with type 3a dissecting aneurysm underwent segmental graft replacement (group 2). In group 1 a permanent axillofemoral bypass was placed on the right side. Next the intrathoracic false lumen was opened longitudinally, the entry was closed, and the aneurysmal wall was sutured around the true lumen as tightly as possible. The operative mortality rate was 20% in group 1 and 31% in group 2. One of 15 patients in group 1 died of operation-related causes, whereas three patients in group 2 died. There were six late deaths: three in group 1 and three in group 2. Paraplegia occurred in neither group 1 nor group 2. The mean diameter of the plicated descending aorta was 24.0 +/- 2.7 mm 3 months after surgery. No recurrence was detected in group 1. These results suggested that this new surgical technique for repair of type 3 dissection reduces the incidence of paraplegia and pseudoaneurysm formation.

Ten patients underwent open heart surgery for mitral valve after PTMC because of post PTMC MS (n = 4) and MR (n = 6) out of 150 patients undergoing PTMC in our hospital between June 1987 and October 1991. Intraoperative findings of 4 patients with residual mitral stenosis included severe thickening, stiffening and calcification on anterior and posterior leaflets, commissures and subvalvular apparatus. Mitral valve repair was possible in 2 and mitral valve replacement (MVR) was necessary in the other 2. In all 6 cases who massive mitral regurgitation after PTMC, in repairable tears in the mitral leaflets necessitated MVR. Since in these cases changes in the leaflets were less severe than those of the commissures or subvalvular apparatus, surgical repair could have been possible if open mitral commissurotomy (OMC) was done primarily. Patients selection for PTMC versus OMC based on precise morphological evaluation of mitral valve would reduce occurrence of massive MR resulting in surgical replacement.

Six tumor-associated antigens, cancer antigen 125 (CA125), tissue polypeptide antigen (TPA), ferritin (Fr), carcinoembryonic antigen (CEA), alpha fetoprotein (AFP), and sialyl Lex-i (SLX) were measured simultaneously for the early detection of ovarian cancer. To decrease the number of both false positive and false negative cases in the combination assay, statistical discrimination analysis employing the serum values for appropriate tumor markers has been studied with respect to ovarian cancer by the method of Mahalanobis' generalized distance. The new "ovarian cancer screening test" designed by us has been used in Shizuoka Prefecture since 1988, and 23,307 serum samples have been analyzed. One hundred twenty-seven of 165 ovarian cancer patients were suspected as having cancer by such clinical procedures as pelvic examination and/or ultrasonography, while in 150 patients cancer was detected by the statistical discrimination method. Thirty-one of 38 patients with ovarian cancer overlooked by the clinical procedures could be found by the statistical method. We conclude that clinical procedures and the statistical method can be complementary in detecting patients with this malignancy.

We have assessed the long-term prognosis about cardiac death of isolated coronary artery bypass surgery from 1972 to 1988 in 361 consecutive patients. The duration of follow-up were from 0.4 years to 14.6 (mean 5.7) years. Of the 361 study patients, the operative morality was 4.7% (17 patients) and 29 patients (8.0%) died during follow-up, 11 (3.0%) of which were from cardiac causes. Actuarial survival rate was 85.2% at 10 years after surgery. The 10 year-survival rate was similar for patients with single, double, triple vessel disease, and left main trunk disease (94.5%, 83.7%, 75.1% and 89.1%, respectively). For patients with and without old myocardial infarction, the 10 year-survival rate was significantly different (75.4% and 93.3%, respectively) (p less than 0.005). In order to detect which factors of preoperative cardiac function among cardiac index, LV end-diastolic pressure, LV end-diastolic volume index, LV end-systolic volume index, and LV ejection fraction influenced the long-term prognosis, multivariant regression analysis was performed. Only LV end-systolic volume index was a significant factor, and the discriminative point was 50 ml/m2. For patients with LV end-systolic volume index less than 50 ml/m2 and greater than or equal to 50 ml/m2, the 10 year-survival rate was significantly different (88.3% and 32.9%, respectively) (p less than 0.005). In conclusion, the most significant factor influencing longterm prognosis after coronary artery bypass surgery was left ventricular end-systolic volume, indicating the importance of preventing preoperative dilatation of left ventricle.

An application of MRI in functional stereotactic thalamotomy is presented. To estimate the individual anatomic variations of the thalamus prior to stereotactic thalamotomy, a special study using a proton density image that shows myeloarchitectonic features of the thalamus was performed. The proton density MRI was demonstrated to be very useful to determine the safest trajectory and tentative target point. However, as a detailed functional localization of the thalamic subnuclei cannot be yet obtained by MRI, the final target should be decided on the basis of electrophysiological findings.

In eight hundred eighty three patients with prior coronary bypass grafting (CABG), cardiac symptoms were recurred in 179 patients in late follow-up period (mean 5 +/- 2.8 years). Of 179 patients, 43 patients had PTCA eventually. In these, 57 times of angioplasties were attempted. Twenty-one lesions in venous bypass grafts and 50 in native coronary arteries were performed, respectively. The initial success rate per bypass graft and per stenosis of native coronary artery were 68% and 74%, respectively. Five patients had elective CABG following failed PTCA. There were no emergency CABG procedures required after unsuccessful PTCA. Intracoronary thrombolysis (ICT) were performed in 13 patients. In these, 15 ICT attempts were made. Nine lesions in venous bypass grafts, 9 for native coronary arteries, and 3 for both were attempted. The primary success rate per occlusion was 67%. Twenty reoperation were done. There was one hospital death and one late death due to congestive heart failure 4 years after the reoperation. In conclusion, invasive treatments in patients with prior CABG can be performed with satisfactory safety and good results. Therefore, invasive treatment should be considered in the patients with CABG if cardiac symptoms are disabling and angiographically suitable lesions are present in the native coronary arteries or vein grafts.

We have assessed the long-term results of heptagenerians after isolated coronary artery bypass surgery from 1979 to 1989 in 32 patients over 70 (mean 72) years old using actuarial techniques. In these patients, the long-term results could not be properly assessed because many other factors other than cardiac events influenced their survival. Accordingly, we compared our subjects with the general population matching the operative age and sex characteristics from life tables (= matched population). There was no operative mortality. The 5 year and 9 year survival rates were 93% and 31%. In the matched population, the 5 year and 9 year survival rates were 81% and 59%. The survival rate between the two groups was not significantly different. We concluded that the long-term results of coronary artery bypass surgery in patients over 70 years were similar to those of the matched population. Therefore, coronary artery bypass surgery should be offered to older patients for usual indications.

Circulating serum sialyl Tn (STN) antigen levels were measured in 89 patients with epithelial ovarian cancer. Survival at 5 years for patients with STN-negative (serum STN levels less than 50 U/ml) versus STN-positive tumors (serum STN levels greater than or equal to 50 U/ml) was 76.9% versus 10.8%, respectively (p less than 0.05). The overall survival probability was worse in patients with STN-positive sera. Percent progression-free survival at 5 years for patients with STN-negative versus STN-positive tumors was 51.9% versus 5.4%, respectively (p less than 0.05). The overall progression-free survival was shorter in patients with STN-positive sera. Multivariate regression analysis revealed that positive STN antigen level in sera is an independent predictor of poor prognosis in epithelial ovarian cancer.

Left ventricular assist systems (LVAS) can maintain the systemic circulation of patients with acute, profound heart failure. The assessment of natural heart (NH) function, however, is difficult in the clinical setting. The authors introduced a new index, heart rate-corrected ejection time/left atrial pressure (ETc/LAP) using echocardiography to evaluate NH function in 15 adult patients on the original LVAS for greater than 2 days. Bypass flow (BF) was gradually decreased according to the recovery of NH. Five patients were weaned from LVAS within 15 days, and LV function was well maintained (Group 1). Another six patients were weaned from LVAS within 21 days but died within 2 weeks (Group 2). The other four patients died on LVAS without recovery of NH (Group 3). In Group 1 patients, ejection time/pre-ejection period (ET/PEP) with LVAS assist increased continuously. In Groups 2 and 3, ET/PEP increased slowly and reached a plateau at approximately 10 days or remained low. Group 1 patients reached an ETc/LAP of 35 +/- 10 on LVAS within 7 days. Group 2 and Group 3 patient values were 18 +/- 2 (p less than 0.05) and 9 +/- 6 (p less than 0.01), respectively, on the seventh day. Based on these data, this new index provides an estimate of global NH function and a prediction of the probability of NH recovery.

In 15 patients with central pain (thalamic pain) after stroke, CT, PET scan and intraoperative thalamic microrecordings were performed. The results are considered together to evaluate a possible role of thalamic intralaminar nuclei in the genesis of central pain, especially of superficial pain. In the non-thalamic lesion group (deep pain dominant), thalamic background neural activity (BNA) was relatively high in Vim but low in CL. Conversely, in the thalamic lesion group (superficial pain dominant), thalamic BNA was higher in CL than in Vim, and markedly decreased in VC. In this group, regional cerebral oxygen consumption (rCMRO2) was relatively maintained, and regional oxygen extraction ratio (raOEF) and the relative value of regional cerebral glucose utilization (CMRGL), compared to rCMRO2, was increased in the cerebral cortex around the central sulcus. The genesis of superficial pain is discussed.

We evaluated the late results of coronary bypass grafting (CABG) in 85 patients. The patients were divided into two groups according to preoperative MI size estimated by the Selvester QRS score; 24 with MI size of larger than 20% of LV muscle (group A; average 28 +/- 11%), and 61 with MI size smaller than 20% (group B; average 10 +/- 9%). New York Heart Association classes of both groups following CABG improved significantly (from 2.8 +/- 0.7 to 1.3 +/- 0.4 in group A; p less than 0.01, from 2.5 +/- 0.6 to 1.2 +/- 0.5 in group B; p less than 0.01). There was higher incidence of serious ventricular arrhythmias in group A than in group B (83% vs. 21%, p less than 0.01). In Group A, LVEF and LVESVI did not improve following CABG (from 17 +/- 9 to 16 +/- 8 mmHg, from 39 +/- 15 to 40 +/- 15%, from 66 +/- 28 to 69 +/- 40 ml/M2), while in Group B, those improved significantly (from 13 +/- 6 to 11 +/- 5 mmHg; p less than 0.01, from 53 +/- 14 to 58 +/- 10%; p less than 0.01, from 39 +/- 23 to 32 +/- 14 ml/M2; p less than 0.05). The exercise-to-rest LVSWI ratios increased significantly following CABG in both groups (from 86 +/- 25 to 160 +/- 56% in group A; p less than 0.05, from 92 +/- 31 to 140 +/- 37% in group B; p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Five adult patients (pts) with age 15-67 (mean 43) received mechanical circulatory support with centrifugal pump (Biomedicus, BP-80, Sarns centrifugal pump) for postcardiotomy profound shock. Three pts underwent left ventricular support (LVS) alone, and the other 2 required biventricular support (BVS). Duration of the LVS ranged from 33 to 240 hours (mean 126 hours) and the right ventricular support 92, 120 hrs. Pump flow rate was 1.1 to 2.5 (mean 1.9) L/min/m2. Sixteen pumps were used and the pump exchange was performed 9 times in five pts and an average perfusion time per pump was 57 hrs. Two of 3 pts with LVS alone survived and one died of multiorgan failure associated with right heart dysfunction. In two pts with BVS, one survived and the other died of persistent low cardiac output early after pump removal. As the complication during mechanical support, bleeding was seen in 3 pts and cerebral infarction in one. Although centrifugal pump has potential limitation in antithrombogenicity and durability, this device provides a simple and effective mechanical circulatory support.

We reported a 65-year-old male with the history of both cerebral and myocardial infarctions. Simultaneous carotid endarterectomy and myocardial revascularization (coronary artery bypass grafting = CABG) were performed. Ascending aorta was severely calcified. CABG was performed without aortic cross clamp under systemic moderate hypothermia and elective ventricular fibrillation. The wean off from extracorporeal circulation was successful. The postoperative course was uneventful. We recommend the simultaneous revascularization for the carotid and coronary artery obstructive diseases. CABG under ventricular fibrillation without aortic cross clamp was useful and unhazardous in patients presenting calcified ascending aorta.

Although selective cerebral perfusion (SCP) might be an useful supportive method for aortic arch surgery, its optimal perfusion criteria has not been established. We studied the relationship between the oxygen saturation of superior vena cava or internal jugular vein (SvO2) and the perfusion hemodynamics during deep hypothermic (DH) SCP in twenty patients (pts) (type A dissection; 10, arch aneurysm; 10). SCP was accomplished by perfusion to the brachiocephalic trunk (BCT) and the left common carotid artery (LCC) using separate pumps. Cardiopulmonary bypass and DHSCP time were 128-312 (222 +/- 43, mean +/- SD) minutes and 25-214 (122 +/- 49) minutes, respectively. The cerebral perfusion pressures (CPP) monitored at the bilateral temporal arteries were 20-60 (47 +/- 9) mmHg and cerebral perfusion flow (CPF) was 0.28-0.7 (0.43 +/- 0.10) L/min/m2. The cerebral perfusion score (CPS) defined as CPP X CPF was 7-39 (20 +/- 8). SvO2 ranged from 79 to 99 (94 +/- 7)%. Two operative deaths were encountered from unrelated causes to SCP in both cases. Cerebral infarction occurred in one patient possibly form prolonged low perfusion with low SvO2. When the safety range of SvO2 in DHSCP was defined as greater than 90%, essential criteria to keep this range was CPP greater than 40 mmHg. In 13 out of 15 pts with SvO2 greater than 90%, CPS were above 15. In conclusion, optimal perfusion criteria for DHSCP was defined as CPP greater than 40 mmHg and CPS(CPP X CPF) greater than 15 considering adequate cerebral oxygen consumption.

Thirteen patients with successful or unsuccessful delayed sternal closure (DSC) after open heart surgery were reviewed. The indications of DSC were cardiac dilatation in 12 patients and intractable bleeding in one. Patients were divided into two groups as follows: Group A of 7 patients with mediastinum being sealed by prosthetic material, and Group B of 6 patients with primary skin closure by mobilized skin-flap. Postoperative complications and prognosis were compared between these two groups. There were 6 long term survivors. In group A, there were 4 deaths, 2 from low output syndrome (LOS) and 2 from sepsis due to mediastinitis. In group B, 2 died of LOS and 1 died of multiple organ failure, while no patients developed mediastinitis. In patients with unsuccessful DSC, mainly due to poor hemodynamics, there found no tendencies of decrease in CVP and LAP levels and no reduction in the amount of catecholamine dosage prior to attempted DSC. In conclusion, 1) mediastinal isolation with primary skin closure seemed more effective for preventing mediastinitis than coverage with prosthetic materials, 2) DSC was possible when there were hemodynamic improvements with decrease in CVP and LAP levels, and reduction in catecholamine dosage, and 3) plastic surgical technique was useful for primary skin closure.

Changes in blood coagulation and fibrinolysis were investigated in twenty seven patients with esophageal varices, who underwent endoscopic injection sclerotherapy (EIS) with 5% ethanolamine oleate with meglumine amidotrioate (EOMA), 1% Aethoxyskererol (AS) and pure ethanol. Changes in platelet aggregation between before and just after EIS were also investigated. Results obtained were as follows. 1) Remarkable changes in blood coagulation and fibrinolysis were observed in twenty patients, who underwent EIS by intravariceal injection combined with paravariceal injection. The patients showed significant change in factor XIa-alpha 1 antitrypsin complex as a result of destruction of the endothelium of varices, caused by the sclerosants. On the other hand, no significant changes were observed in seven patients, treated by paravariceal injection alone. 2) These changes were different from those observed in DIC because they were transient without bleeding tendency or multiple organ failures. 3) Paravariceal injection was suitable for EIS in the patients with very poor liver function. 4) Platelet aggregation was not elevated by EIS.

Ten patients with lung cancer and mediastinal tumor invading the mediastinal structures underwent replacement of superior vena cava (SVC) with ringed Gore-Tex to resect malignant tumors. In patients with lung cancer sleeve pneumonectomy (3 patients), sleeve lobectomy (1 patients) and tracheal resection (one patient) were performed simultaneously. By resection of the VCS system, invasive thymomas were able to be resected completely in 2 of 3 patients. In 2 patients with mediastinal tumors, one with metastatic testicular chorio carcinoma and one with malignant lymphoma of non-Hodgkin type, aggressive chemotherapy was followed by resection of the residual tumors including VCS. Except for one patient, there was no sign showing disturbance of the venous return in the VCS system in the 5 to 43 months' postoperative follow up period. We conclude that ringed Gore-Tex graft permits the extended operation for intrathoracic malignancies invading the mediastinal structures.

We applied kymo-two-dimensional (kymo-2-D) echoaortocardiography, which is capable of combining the structure motion and cardiac anatomy in a single picture, to examine two cases of aortic root dissection of DeBakey types I and II and a rare case of mycotic aneurysm of the aortic root. In aortic root dissection, the spread and course of false lumina were clearly visualized. In the case with two mycotic aneurysms of the aortic root, the anterior aneurysm into the interventricular septum was visualized as an echo-free area with an exaggerated motion of the left side of the interventricular septum. Thus kymo-2-D echoaortocardiography proved useful in diagnosing diseases involving the aortic root.

In 32 consecutive adult patients undergoing heart surgery, the induced diaphragmatic muscle action potential was measured. Phrenic nerve conduction disorder was defined as disappearance of muscle action potential (Edi) and conduction time (CT). Phrenic nerve conduction disorder was observed in 10 patients (31%); 8 patients on the left side and 2 patients on both sides. In non-conduction disorder group (22 patients), Edi and CT were measured. Edi of the right side decreased significantly from preoperative value of 705 +/- 318 microV to 445 +/- 285 microV at 1-3 days after operation (stage I) and to 559 +/- 314 microV at 7-10 days after operation (stage II) (p less than 0.05). CT of the right side prolonged significantly from 7.1 +/- 0.7 msec before operation to 7.44 +/- 0.97 msec at postoperative stage I and to 7.40 +/- 0.21 msec at postoperative stage II (p less than 0.05). For the left phrenic nerve, Edi showed significant (p less than 0.05) decrease from 803 +/- 338 microV before operation to 429 +/- 251 microV at the postoperative stage I and 620 +/- 350 microV at the postoperative stage II. In the conduction disorder group, incidence of atelectasis, diaphragm elevation and pleural effusion as documented by chest roentgenographic findings were higher than those of non-conduction disorder group (p less than 0.01). Moreover, the lowest temperature of the myocardium during operation was significantly (p less than 0.05) lower for conduction disorder group as compared to non-conduction disorder group. We believed that it is necessary to develop a innovative method for preventing the phrenic nerve from cold injury.

Anticancer chemotherapy with cisplatin (CDD) as the main drug (combined with adriamycin (ADM) and cyclophosphamide (CPM), PAC therapy) was performed on patients with ovarian cancer. Urinastatin (US) was concurrently administered to assess its effectiveness in preventing CDDP-induced nephrotoxicity. Twenty-two patients with gynecological malignant tumor were treated with PAC therapy, and of these, twelve concurrently received US. The ten who did not receive US served as the control. As a rule, one course of PAC therapy consisted of 50mg/m2 CDDP, 50mg/m2 ADM and 500mg/m2 CPM. Before the administration of CDDP, US 100,000 units was administered by I.V. drip infusion and after the administration, US 400,000 units was again administered by I.V. drip infusion at a speed of 100,000 to 200,000 units/hour. A total of approximately 3,500ml of fluids was administered I.V.. Each course of PAC therapy took 7 to 14 hours to complete. The control group underwent PAC therapy in a regimen not including US. As indexes of nephrotoxicity, serum levels of BUN, creatinine (Cr), and creatinine clearance (Ccr), and N-acetyl-beta-glucosaminidase (NAG), gamma-glutamyl transpeptidase (gamma-GTP), and arylamidase (AA) activity in the urine was determined before treatment and at days 1, 2, 3, 7, 14, and 21 after the initiation of PAC therapy. Changes in serum BUN, Cr, and Ccr levels after CDDP administration in the group with and the group without concurrent US were similar. Urinary gamma-GTP, AA, and NAG activity remained unchanged after CDDP administration in the group with concurrent US. In contrast, in the group without US, this urinary enzyme activity was transiently increased after CDDP administration.(ABSTRACT TRUNCATED AT 250 WORDS)