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Survival and prognostic factors were analysed in patients who had undergone surgical resection with curative intention with the aim of identifying groups of patient with stage III and IV gallbladder cancer on the TNM classification who might benefit from surgery.Thirty-seven patients with advanced gallbladder cancer were studied, the cumulative survival rate for each group was calculated for each pTNM factor.The 5-year survival rates in the stage III patients were 83.3%, while those for the stage IVA patients were 46.2%, and those for the stage IVB patients 16.7%.In patients with invasion of adjacent organs, including the liver and gastrointestinal tract, and rated as pT3 or pT4, extended surgery excising the invaded tissue may be justified. In patients with pN2 lymph-node metastasis, even without adjacent organ invasion, radical surgery may not achieve a good outcome.

Total hepatic vascular exclusion and venovenous bypass are frequently used surgical procedures when concomitant resection of the inferior vena cava is required during surgery of liver cancer involving the retrohepatic inferior vena cava close to the hepatic veins. However, the duration of total hepatic vascular exclusion is limited due to the risk of hepatic ischemia. Three patients presented with severely compressed inferior vena cava and/or hepatic veins due to liver cancer. The surgical procedure involved initial taping of the inferior vena cava just below the hepatic veins by extrahepatic division and taping of the hepatic veins. After taping the inferior vena cava, hepatectomy with caval resection was performed by simply clamping the retrohepatic inferior vena cava, without the need for total hepatic vascular exclusion or venovenous bypass. In all patients the retrohepatic inferior vena cava were safely replaced with a prosthetic graft under stable hemodynamics. Duration of the inferior vena cava clamping was 31, 66, 75 minutes, respectively. No graft-related complications occurred, but 2 of the 3 patients showed temporal renal dysfunction associated with renal congestion postoperatively. The surgical procedure described herein is effective for the treatment of retrohepatic inferior vena cava in some patients. However, when the case is complicated by chronic nephropathy or simultaneous nephrectomy is required, venovenous bypass should be performed.

A total of 18 patients (13: colon cancer, 5: gastric cancer) with multiple liver metastases (H3) underwent hepatic arterial infusion chemotherapy (HAI) using an implanted arterial port with portable syringe pumps in our outpatient clinic. Clinical perspective: overall response rate was 22.2% (CR: 1 case, PR: 3 cases (1 case: hepatectomy after HAI), NC: 12 cases, PD: 2 cases), however, 7 of 12 cases of NC were long NC (more than 6 months). No major complications with HAI were experienced. Patient Perspective: After HAI in our outpatient clinic, the 50% survival was 341 days, 50% hospital free days were 319 days and home stay rate was 92.9%. Societal Perspective: cost and hospital stay days were significantly reduced. Home anti-cancer chemotherapy using HAI for gastrointestinal cancer patients with multiple liver metastases was safe and efficient from the viewpoint of medical outcomes.

Criteria for selection of patients for portal vein embolization (PVE) before major hepatectomy for advanced-stage hepatocellular carcinoma (HCC) have not been clarified in detail. This study was aimed at defining those benefiting from this therapy in a retrospective fashion.Firstly, to determine liver functional criteria for applying this approach 26 patients with stage III (17 patients) or IV (9 patients) disease, who underwent major hepatectomies after PVE, were divided into those without major complications (20 patients) and a postoperative liver failure group (6 patients). Clinical, analytical, and hemodynamic parameters obtained before and after PVE were compared between the groups. Secondly, to define the application of this approach with regard to tumor progression survival rates of patients were also obtained, taking into account factors which affect tumor development, i.e. lesion size, intrahepatic metastasis and vascular invasion.With regard to liver function 4 nonindications were obtained: (1) a portal pressure measured right after PVE25 cm H(2)O; (2) post-PVE serum hyaluronate200 ng/ml; (3) pre-PVE serum cholinesterase150 U/l; (4) post-PVE serum cholinesterase150 U/l. In view of the tumor progression in patients with HCCs featuring intrahepatic metastasis spread to more than 3 segments (IM3) 1-, 3- and 5-year survival rates were low (42.9, 28.6 and 0%) with a statistical significance, compared to those in patients with intrahepatic metastasis limited in the same lobe (76.9, 46.2 and 24.6%).When laboratory data fulfill 3 or more of the criteria, the extent of hepatic resection may have to be carefully reconsidered. Patients with HCCs featuring IM3 intrahepatic metastasis may not benefit from the aggressive approach described here.

Sixteen patients who involved in chest wall disease underwent major chest wall resection between April 1995 and January 1999. The underlying diseases were 6 recurrence of breast cancers, 4 direct invasion by primary lung cancer, 2 metastatic chest wall tumor, one direct invasion by metastatic lung tumor, one direct invasion by metastatic mediastinal tumor, one radio-induced-necrosis of the chest wall, and one chest wall infection. In 9 patients, the thoracic cage reconstruction was performed using double sheets of absorbable mesh (Dexon mesh), cross string sutures and autologous ribs grafts. None of the patients had major respiratory failure and chest wall unstability. No late complications including infections, pains, recurrence and others related to reconstruction materials have been observed.

Effectiveness and present problems of video-assisted thoracic surgery (VATS) for metastatic lung tumor were investigated by comparing 14 cases (16 operations) of VATS with 16 cases (19 operations) of conventional thoracotomy during the same period. VATS was favorably selected in the solitary metastasis. The cases who had small tumor diameter less than 3 cm and shorter distance from viseral pluera to the tumor surface than tumor diameter were advantageous for only thoracoscopic procedure to do the safe and sure resection. Regarding to the tumor number, we detected another tumor intraoperatively in 2 of 16 cases (12.5%) of VATS and 6 of 19 cases (31.6%) of thoracotomy. Multiple metastases had the tendency to have the differences of the tumor number between preoperation and intraoperation. Prognosis is very good until now, but the recurrence rate was high (64.5%) and one case had the recurrence at the surgical margin. VATS for metastatic tumor is very effective, but it is important not to hesitate to do the mini-thoracotomy and convert to conventional thoracotomy for safe and sure resection.

The c-erbB-2 proto-oncogene encodes a transmembrane protein which is highly homologous to epidermal growth factor receptor. Overexpression of this c-erbB-2 protein has been reported in many human carcinomas, including breast carcinoma. However, there have been few studies of the expression of c-erbB-2 in cholangiocarcinoma and hepatolithiasis, a condition occasionally associated with cholangiocarcinoma.In this study, we evaluated immunoreactivity for the c-erbB-2 protein in human cholangiocarcinomas (n = 47), hepatolithiasis (n = 20), fetal livers (n = 36) and normal adult livers (n = 6). In normal adult livers and fetal livers, expression of c-erbB-2 protein could not be detected in hepatocytes or intrahepatic biliary cells. In hepatolithiasis, there was overexpression of c-erbB-2 in 15/20 (75%). The expression was found with a membranous pattern on the proliferated intrahepatic bile ducts and proliferated intrahepatic peribiliary glands around the bile ducts containing stones. Hepatocytes were negative for c-erbB-2 protein. Moreover, the biliary cell expression of the c-erbB-2 protein correlated significantly with Ki67 labelling index. On the other hand, aberrant expression of c-erbB-2 was found in 33/47 (70%) cholangiocarcinomas. The c-erbB-2 expression in cholangiocarcinomas did not correlate with Ki67 labelling index or p53 expression.These results indicate that aberrant expression of c-erbB-2 protein is found in cholangiocarcinoma and also in noncancerous biliary proliferative lesions such as hepatolithiasis. These findings also suggest that c-erbB-2 oncogene participates not only in cholangiocarcinogenesis but also in biliary cell proliferation in non-neoplastic conditions.

From 1995 to 1996, we performed aortic arch replacement using antegrade cerebral perfusion under deep hypothermia in 7 patients, in whom 4 cases accompanied with cardiac lesion which treated simultaneously and 3 cases had abdominal aortic aneurysm. We compared the surgical results between cases with (group II, n = 4) and without (group I, n = 3) combined cardiovascular lesion. There is no difference between two groups in the cerebral perfusion time and the amount of bleeding and blood transfusion. The cardiac ischemic time and bypass time were insignificantly longer in group II than in group I. We experienced no early death and no cardiac and brain complication in both groups. Three cases with abdominal aortic aneurysm had two-staged operation successfully after arch surgery within a half year. In conclusion, we successfully treated aortic arch aneurysm even in patients combined with other cardiovascular lesion as well as in patients without that.

A 63-year-old woman with papillary thyroid carcinoma showed increased TSH values (measured by two-site immunometric assay kit). X-ray and endocrinological examinations did not prove the coexistence of pituitary neoplasm. TSH values which were measured by using an another TSH assay system (TSH RIABEAD II assay kit) revealed normal range. Measured TSH values were reduced by adding mouse IgG into serum. These findings suggest that substances in serum, which can link reagent mouse antibody in the assay system, may give falsely increased TSH values. We should be aware that two-site immunometric assay may give falsely increased hormone values due to the appearance of substances against anti-animal antibodies in serum.

We report a case of simultaneous occurrence of medullary carcinoma and papillary carcinoma of the thyroid in the same thyroid gland. Immunoreactivity of calcitonin, carcinoembryonic antigen, neuron specific enolase and thyroglobulin made a sharp distinction between both neoplasms of the thyroid. It appears reasonable to consider that simultaneous occurrence of medullary carcinoma and papillary carcinoma of the thyroid in this case does not have embryological or genetical significance.

Autotransfusion of the shed mediastinal blood after cardiac operations was performed in 20 cases (ATS group). Safety and efficacy of the autotransfusion were studied comparing with the 10 cases without autotransfusion (control group). A 65.1 +/- 17.1% of bleeding volume within 24 hours after surgery was autotransfused in the ATS group. The ATS group received 1,396 +/- 1,674 ml of the banked blood compared with 780 +/- 1,194 ml for the control group. There was no significant difference between two groups in regard to saving the banked blood. Hematological and biochemical studies after surgery in the ATS and control groups revealed that CPK, BUN and creatinine of the ATS group were significantly higher than those of the control group, although these changes were transitory and trivial. However, prothrombin time of the ATS group was lower than that of control group, so there may be the possibility that this technique itself increases the hemorrhage. Since the cardiotomy filter was obstructed with clots in cases of massive bleeding, shed mediastinal blood may not be fully defibrinogenated in the cases with massive bleeding. These results lead to the following conclusions: autotransfusion of the shed mediastinal blood after cardiac operations is a safe method, but the efficacy of it is doubtful.

Cardiac surgeons have hesitated to perform valvuloplasty for MR caused by elongated or ruptured chordae of the anterior leaflet (AL) of the mitral valve. We experienced three cases of successful chordal reconstruction (CR) to the AL last year. Two of them were due to elongation of all chordae tendineae to the AL. Four CRs, one chordal shortening, cleft closure and ring annuloplasty (AP) were performed in one case, and 8 CRs to the AL, two to the posterior leaflet, commissural closure and ring AP in another. In the third case 2 CRs combined with Reed's AP, closure of ASD and tricuspid AP were performed. The MR disappeared in one case and improved to grade I in others postoperatively. NYHA classes improved from class III or IV to I or II postoperatively. The MRs have not increased 6 to 12 months after the surgery. The CR with PTFE suture enabled to do the valvuloplasty for the chordal abnormalities of the AL without valve resection. This technique seems to be adequate for repairing a major prolapse of the AL caused by multiple chordal abnormalities.

The effects of pulsatile and nonpulsatile flow during cardiopulmonary bypass (CPB) with of centrifugal pump (Sarns) and membrane oxygenator, on blood cells, hemodynamics, and hormonal response were studied. In the pulsatile group (group P) in which pulsatile flow was generated by centrifugal pump and a 20 Fr arterial cannula was used, hemolysis and reduction of platelet count during CPB were more marked than in the nonpulsatile group (group NP), in which the same type of circuit was used. When the 20 Fr arterial cannula was replaced with a 24 Fr cannula (group Pc), the rate of hemolysis during CPB was significantly reduced compared with that in group P (p less than 0.05). The rate of rise in plasma free hemoglobin from 10 to 70 minutes CPB in group Pc was 15.0 mg/dl/hr, this value did not exceed that in either group NP or in group Pr, in which a roller pump rather than centrifugal pump was used to generate pulsatile flow. These findings show that pulsatile CPB with a centrifugal pump produces no deleterious hematologic effect in clinical use. The rise in the level of angiotensin II in group P was significantly smaller than that in group NP (p less than 0.05), and the rise in plasma renin activity and levels of angiotensin I, adrenalin and noradrenaline were smaller than those in group NP, although these differences were no significance. These findings indicate that the centrifugal pump generates pulsatile flow effectively, although not so effectively as to prevent the rise in peripheral vascular resistance. During CPB, there was no change in levels of thyroid hormones, including free T3, free T4 and reverse T3, in either pulsatile groups P and Pc or nonpulsatile group. TSH level in group Pc was significantly elevated in contrast with that in the nonpulsatile group (p less than 0.05), in which no change in TSH level was seen. It is suggested that pulsatile perfusion using a centrifugal pump might maintain sufficient hypothalamic-pituitary function to permit secretion of TSH in response to various stimuli.

The clinical profiles of 15 patients with acute pulmonary embolism (APE) were analysed. The most common symptoms of APE were tachypnea and tachycardia with sudden onset. Both PO2 and PCO2 had decreased in almost all patients (mean PO2: 50 mmHg, PCO2: 30 mmHg). Chest roentgenogram (X-P) revealed hyperlucency of the lung field, prominence of proximal pulmonary artery and cardiac enlargement. ECG showed SI QIII TIII and ST-T changes in half of the cases. These changes, however, disappeared within 4 days in most patients. Lung scan and digital subtraction pulmonary angiography were useful for the diagnosis. Sixty percent of patients recovered only by medical therapy, and embolectomy was performed in only two patients. Fifty-three percent of patients were, however, considered to be candidates for the embolectomy, and half of them died because of ineffective medical therapy. From these results we concluded that the combination of severe hypoxemia and hypocapnia with abnormal chest X-P can be used for a diagnostic or therapeutic decision. If a patient has those findings, pulmonary angiography is recommended together with thrombolytic therapy. If a large embolus is detected, embolectomy is mandatory. The need for surgical therapy for APE is greater than we had imagined.

A 60-year-old patient with rupture of the papillary muscle combined with free wall rupture secondary to myocardial infarction is described. Transesophageal echocardiography was useful in making the diagnosis. Surgery was performed 2 days after the onset of acute myocardial infarction, and patch reinforcement of the ruptured wall and mitral valve replacement were effective. Only one case of this type of double rupture has been reported, and this is the first case to have been repaired surgically. It may be unusual for double rupture to occur because the first rupture decreases wall stress to less than the normal level.

A 47-year-old man with ventricular septal perforation (VSP) was repaired successfully. His preoperative examinations revealed Hegglin like syndrome with fixed and split second heart sound due to early closure of aortic valve (QT-Q II A = 58 ms), and bidirectional shunt through the VSP. These abnormal phenomena occurred due to shortening of left ventricular ejection time and prolongation of right ventricular ejection time, and were completely abolished after the operation.

In order to clarify the differences of left ventricular mechanics between chronic aortic and mitral regurgitation (AR and MR), 23 patients with AR and 17 patients with MR were studied by noninvasive techniques. There were no differences between two types of regurgitation in R/Th, LV dimension, LVEDVI, PWTd, LV mass I and mean blood pressure. However, the peak systolic wall stress (PSWS), ESVI and systolic blood pressure (sBP) of AR were significantly higher than that of MR. One month after valve replacement (VR), in AR all parameters decreased significantly expect increased PWTd. But in MR, blood pressure, LV systolic size and LV mass I were unchanged, although LVDd, LVEDVI, PSWS and R/Th decreased significantly. These results indicates that high PSWS in AR is diminished effectively after AVR by both effects of reduction of LV volume and sBP, although in MR, as a sBP is kept in low level, a drop of PSWS after MVR occurs only due to reduction of volume. Therefore, systolic function after MVR for MR with impaired myocardium may be more destroyed by relatively high afterload as it is difficult to diminish the volume, even if LV function was kept relatively in good condition before operation.

To evaluate the narrowing of the left ventricular outflow tract (LVOT) during systole caused by a rigid mitral prosthesis, the geometric relationship between the prosthesis (or the mitral annulus) and the left ventricular base (LVB) was studied in five patients with mechanical mitral valve prostheses and eight normal subjects. The images of the mitral valve annulus (MVA) and the LVOT orifice reconstructed in three dimensions were projected on the plane of the LV base. Calculating the areas of these projected images (i.e., those for MVA [Sm], LVOT orifice [So], the LVB [Sb; Sb = Sm + So]), the MVA-LVB ratio (Sm/Sb) was determined. In the normal subject, the MVA-LVB ratio was nearly constant during systole (59 +/- 5% at 0 msec and 62 +/- 7% at 300 msec, respectively), whereas in the patients with prostheses, the ratio increased from 61 +/- 4% (0 msec) to 69 +/- 4% (300 msec). The increase in MVA-LVB ratio reduces the proportionate share of LVOT orifice in relation to the total LVB. The ideal mitral valve prosthesis should be flexible at the annulus to attain good performance in LVB dynamics.

A variety of clinical variables and physiological parameters have been discussed in relation to postoperative survival and symptoms in aortic regurgitation (AR). Many of them have been derived from left ventricular morphology and functions, but there has been no parameter from aortic functions. As the heart is united with the aortic tree to form a circulatory system and both heart and aorta affect each other, aortic functions also have an important prognostic value after aortic valve replacement (AVR). This study was performed to clarify the participation of aortic functions in determining the prognosis after AVR. Fifteen consecutive patients undergoing isolated AVR for AR were evaluated. Twenty-one preoperative hemodynamic and dimensional variables of both heart and aorta were analyzed to determine the risk factors for early postoperative morbidity. These variables were obtained from chest X-ray film, electrocardiogram, echocardiogram, cine-aorto-ventriculogram and pressure manometries. All patients were divided in two groups according to the postoperative course. Group I composed of 10 patients took relatively smooth postoperative course, except two patients suffering from cardiac tamponade. Group II composed of 5 patients suffered from low cardiac output syndrome (LOS) and/or dangerous arrhythmias postoperatively. Two out of them died of uncontrollable ventricular arrhythmias. There were no statistic differences between two groups in the factors derived from preoperative examinations, i.e. CTR, LVDsI, PWT, R/Th, %FS, EDVI, EF, CI, LVEDP, etc. Mean aortic compliance of group II, (3.8 +/- 2.1) X 10(-4) mmHg-1, was, however, significantly lower than that of group I, (21.7 +/- 4.8) X 10(-4) mmHg-1, (p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Progressive left ventricular hypertrophy was observed following operations in which long bypasses were inserted from the ascending aorta to the abdominal aorta for aneurysm exclusion in cases of thoracic aortic aneurysm. This effect was not observed after operations in which there was grafting with a short prosthesis for abdominal aortic aneurysm, wrapping and trans-section of the dissecing aneurysm. Clinical and experimental studies of the hemodynamic aspects suggest that the left ventricular hypertrophy was caused by an increase in systolic blood pressure at the aortic root due to the low distensibility of the long graft, a decrease in the Windkessel effect by exclusion of the proximal aorta and energy loss by turbulence formation of the proximal anastomotic area. Therefore, the distensibility or compliance at the long prosthesis seems to be very important in cases with long grafts of the aorta.

Two surgical cases of acute pulmonary embolism with severe cardiocirculatory impairment were reported. In the first case, emergent open pulmonary embolectomy with cardiopulmonary bypass was not effective, and multiple and organized emboli were indicative. In the second case, complete pulmonary thromboembolectomy was accomplished under extracorporeal circulation with remarkable hemodynamic improvement. It was suggested that urgent pulmonary angiography was necessary for definitive diagnosis and medical treatment, and that indications for pulmonary embolectomy included all patients with massive emboli in the main branches of the pulmonary artery. Monitoring of pulmonary arterial pressure was important to assess the effect of thrombolytic therapy, and the system of emergent cardiopulmonary bypass was required for immediate and effective cardiopulmonary resuscitation.

Left ventricular posterior wall movement in 20 patients with mitral stenosis (MS) was measured using M-mode echocardiogram in order to evaluate the improvement of myocardial function after open mitral commissurotomy (OMC) and compared between the cases with (10 patients) and without (10 patients) papilloplasty. The maximum left ventricular end-diastolic posterior wall velocity (LVPEVdmax) was increased from 71 +/- 12 to 90 +/- 16 mm/s in OMC patients (p less than 0.01) and from 59 +/- 19 to 101 +/- 28 mm/s in OMC + P patients (p less than 0.001). The maximum left ventricular systolic posterior wall velocity (LVPWVsmax) showed an increase from 51 +/- 9 to 62 +/- 10 mm/s in OMC patients (p less than 0.02) and from 48 +/- 10 to 69 +/- 8 mm/s in the OMC + P group (p less than 0.001). The mean LVPWVs increased from 35 +/- 8 to 48 +/- 8 mm/s in the OMC + P group (p less than 0.01). These parameters correlate fairly well with stroke volume index (SVI), ejection fraction (EF), and fractional shortening (FS) derived from internal LV dimensions. Thus, the posterior wall movement may prove to be useful as an index for evaluating the improvement of LV function after OMC.

As a result of improvement in intraoperative and postoperative management, severe aortic valve disease can be cured by operation, however, late cardiogenic sudden death after aortic valve replacement (AVR) has been existed as one of the important unsolved problem. This report is aimed to predict the risk factors influencing the postoperative prognosis of severe aortic valve disease. Twenty-three cases with aortic regurgitation (AR) and 20 cases with aortic stenosis (AS) were selected by postoperative period over 12 months. In 18 AR cases with normal coronary artery substantiated by selective coronary angiography, cross sectional area index of left ventricular wall (CSAI) and ST depression in left chest leads of electrocardiogram correlated well as the CSAI increased, so decreased the ST segment. This shows the increment of CSAI leads left ventricular endocardial ischemia. By means of introduction of this indicator, 23 AR and 20 AS patients were divided into two groups as group C-I having CSAI over 20 cm2/m2 and group C-II under 20 cm2/m2. Left ventricular ejection fraction (EF) was selected as an predictive indicator of left ventricular function. As same as CSAI, AVR cases were divided into two groups as group E-I having EF under 50% and E-II over 50%. Each group was compared concerning with the complication rate of postoperative low cardiac output syndrome (LOS) and late cardiogenic sudden death. In C-I group of AR, 55% cases accompanied with LOS, 18% died due to LOS and 18% died suddenly from late cardiogenic cause, however, none of cases in C-II group had these complications.(ABSTRACT TRUNCATED AT 250 WORDS)