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Objective We previously reported the noninferiority of paravertebral block (PVB) to epidural block. In this study, we assessed whether PVB via an intrathoracic approach was also safe for the patients ineligible for epidural block because of, for example, anticoagulation or antiplatelet therapy.

症例は55歳，女性．意識消失発作にて，精査が施行された．頭蓋内病変は認められず，24時間ホルター心電図にて2:1高度房室ブロックが認められた．そのため，意識消失はAdams-Stokes発作と診断され，ペースメーカー（Pacemaker:PM）植込み術の予定となった．しかし，金属アレルギーの既往があったため，外来にて金属パッチテストを施行した．PMに使用されている金属にアレルギーは認められなかったが，予防的にPM本体をpolytetrafluoroethylene（PTFE）シート（ゴアテックスシート®）にて被覆し，植込み術を行った．植込み後12カ月が経過したが，PM植込み部のトラブルは生じていない．PMアレルギーのためPM植込み部の皮膚炎を繰り返す症例に対し，PTFEシートを使用した報告はいくつかある．今回われわれは，予防的PTFEシート被覆にてPM植込み部トラブルを回避した，金属アレルギーの1症例を経験したため，報告する．

Background and study aims: The optimal method of perioperative management of antiplatelet agents during endoscopic procedures that carry a high risk of bleeding is still controversial. The aim of this study was to evaluate the safety of continuing aspirin treatment during these procedures in an Asian population. Patients and methods: A multicenter, prospective, observational cohort study was conducted at six high volume endoscopy centers in Japan. The study included patients at high risk of thromboembolism who were regularly taking antiplatelet agents (e. g. thienopyridine derivatives and aspirin). Enrolled patients continued their aspirin therapy, and underwent endoscopic procedures that had a high risk of bleeding for treatment of lesions in the upper and lower gastrointestinal tracts. The primary end point was the rate of major bleeding complications after endoscopic procedures. Results: The study was terminated in accordance with predetermined safety criteria because 7 of 28 consecutive patients experienced major bleeding complications (25.0 %; 95 % confidence interval 10.7 % – 44.9 %). All major bleeding complications occurred following endoscopic submucosal dissection (ESD; 6 stomach, 1 colon). Univariate analysis showed that postoperative administration of thienopyridine derivatives was the only significant factor associated with postoperative bleeding (P = 0.01). Subanalysis of gastric ESD (23 lesions in 19 patients) confirmed that the administration of thienopyridine derivatives (P = 0.01) and that of multiple agents (P = 0.02) were the significant factors. All bleeding complications (postoperative day 11.2 ± 3.5) occurred after resuming thienopyridine derivative therapy postoperatively (postoperative day 2.3 ± 2.4). Conclusion: In Asian patients taking thienopyridine derivatives with aspirin, cautious postoperative care is necessary for those undergoing endoscopic procedures that are associated with a high risk of bleeding, especially gastric ESD. Continuation of aspirin alone during these endoscopic procedures may be acceptable. Study registration: UMIN000009176.

Intracranial arterial dissection is considered to be not a rare disease recently, but the natural history of this disease is not well known yet. In this study, we analyzed the serial changes of angiographical or MRI/MRA finding and the long-term outcome to clarify the treatment strategy in patients with non-hemorrhagic intracranial arterial dissection. Among 120 consecutive patients with arterial dissection of the vertebrobasilar system, 44 (37%) presented with ischemia and/or headache. Ages ranged from 27 to 77 years (mean: 49.3+/-11.0 years). Thirty-nine patients were managed conservatively and an antiplatelet agent was given in 10 because of history of myocardial or brain ischemia. Only 5 were treated surgically because the lesion had been enlarged or extended on the follow-up study. The vertebral artery was most commonly affected. On the initial angiographical or MRI/MRA finding, fusiform dilatation (43%) was the most frequent finding, followed by pearl and string sign (32%). In the serial changes of the findings, no change (43%) was most common, followed by improvement (37%). Among 39 patients who presented with ischemia, 8 (21%) had subsequent symptoms (ischemia in 7, subarachnoid hemorrhage in 1). Recurrence tended to occur more frequently in the antiplatelet group. The follow-up period ranged from 1 to 17 years (mean: 5.8+/-4.1 years). The long-term outcomes were generally favorable. Thirty-three patients (85%) recovered well and 3 died among the 39 conservatively managed patients. Four of 5 patients achieved good recovery and returned to work in the surgically treated group. In addition, the outcomes in the antiplatelet group did not differ significantly from those without the above agents. These results were quite similar to those in the nationwide study, and suggest that conservative treatment, mainly the control of high blood pressure, is the first choice in the non-hemorrhagic arterial dissection of the vertebrobasilar system and that antiplatelet or anticoagulant therapy might not be indicated in the patient with ischemia. Furthermore, the surgical indication for this disease remains controversial, and the study of a larger number of patients is indispensable to clarify this issue.

We studied the bleeding risk during latency period after gamma knife surgery (GKS) for small (3 cm or less) cerebral arteriovenous malformations (AVMs). We analyzed 720 cases with a natural history and 100 cases with GKS. The incidence of bleeding was calculated from the data of the former cases according to the history of bleeding and their age and was compared with the actual number obtained from the latter. The estimated incidence of bleeding was 1.6 for unruptured AVMs and 5.5 for ruptured AVMs, whereas the actual incidence of bleeding was 2 for unruptured and 0 for ruptured. The difference was statistically significant in the ruptured but was not significant in the unruptured. These results lead us to conclude that the bleeding risk during latency period after GKS for small AVMs is almost the same in the unruptured, but is decreased in the ruptured.

肩・鎖骨などの整形外科的手術で固定に用いる鋼線の術後の移動・迷入はまれな合併症であると言われているが我々は2例の胸腔内迷入症例を経験したので報告する.症例1は34年前に左胸鎖関節脱臼のため固定術を受けた56歳男性で, 他病で入院した際の胸部X線検査にて縦隔内に存在する金属性異物を指摘された.胸部CTでは前縦隔内大動脈弓部の前方に位置していたため, 胸腔鏡下摘出術を行った.症例2は右鎖骨骨折に対して経皮的整復固定術を受けた71歳女性で, 3ヵ月後に発熱のため撮影した胸部X線写真にて, キルシュナー鋼線 (2本) の移動を認めた.先端がそれぞれ肺実質内と縦隔内の血管の間に達していたため右開胸にて除去した.心血管系の損傷を起こして死亡した症例の報告もあり, 固定用鋼線の移動・迷入が確認された場合には症状の有無にかかわらず早期の摘出術が必要である.

To decide optimal treatment for various cerebral arteriovenous malformations (AVMs) is a highly complex issue. We retrospectively examined the clinical course of 24 cases of AVMs in reference to angiographic features, and performed clinical decision analysis to develop a logical therapeutic strategy. Annual bleeding rate was calculated in each group with specific angioarchitecture. The average bleeding rate was estimated at 3.2% per year. The rate was higher in the group with more hazardous angioarchitectures: 8.6% with intranidal aneurysm, and 5.5% with venous stenosis, respectively. Decision analysis demonstrated that Spetzler grade III AVM patients of 56 years or younger can expect better results from surgery than from conservative treatment. In grade IV, those of 48 years or younger can also expect better results from surgery. Because bleeding tends to develop more frequently in patients with intranidal aneurysm, older patients with this angioarchitecture (grade III: up to 70 years, grade IV: up to 60 years) can still expect better results from surgery. Clinical decision analysis is a helpful approach to plan a logical therapeutic strategy for AVMs.

The indication of preventive surgery for patients who harbor asymptomatic unruptured intracranial aneurysms remains controversial. To evaluate the benefit of this treatment, we investigated the management outcome in 128 patients with 157 unruptured aneurysms. Surgery was planned in patients 70 years old or younger without serious systemic complications. A total of 77 patients underwent surgery including four endovascular interventions, and conservative management was chosen in 51 patients. There was no mortality and 6.5% morbidity as postoperative results, and no complication was found after endovascular treatment. Among the patients in conservative management, four patients suffered from subsequent rupture during the total follow-up period of 148 person-years. The annual rupture rate was estimated at 2.7%. According to the clinical decision analysis based on our data, preventive surgery is beneficial for a Japanese 70 years old or younger. However, the expected utility decreases if the rupture rate is set at 0.5% or 0.05%, posing a doubt about the benefit of the surgery. Decision analysis provides an aid for logical and objective choice in the management of unruptured aneurysms. The actual risk of rupture has a major impact on decision making in therapeutic strategy.

症例は79歳男性.腹部大動脈瘤手術後9年目に間歌性下血を呈し精査中に, Y型人工血管置換部中枢側に約6cmの腹部大動脈瘤の再発を認めた.下血症状は消失し, I型人工血管術を施行した.腹部大動脈と腸管との間に瘻孔はなかったが,術後4日目に再度間欺性の下血症状が出現し,術後8日目には大量下血によるショック症状を呈し緊急開腹手術となった.骨盤腔内の癒着した小腸を剥離すると,Y型人工血管左脚の吻合部から約2cm離れた部位に外腸骨動脈瘤腸管瘻があり,手術にて救命できた.動脈瘤腸管瘻は下血の原因としては稀であるが,術前診断が困難であるだけでなく,手術時期が遅れると致死的となる.腹部大動脈瘤術後9年目に間歌性下血で発症したことで,診断に苦慮したが,早期診断のためには本疾患も念頭に置き精査する必要があると思われる.

症例は58歳女性.検診で胸部X線写真で異常陰影を指摘され当院受診した.胸部CT検査, MRI検査で巨大な心膜嚢腫を疑われた.胸腔鏡下に嚢胞内貯留液を吸引することで容易に巨大嚢腫を切除できた.嚢腫は心膜と連結していたが交通はなく,病理組織学的診断は心膜嚢腫であった.心膜嚢腫は比較的稀な疾患であるが,本症例の如く嚢胞液中の腫瘍マーカー (CA19-9, CA125) が異常高値を示した巨大な心膜嚢腫を胸腔鏡下に切除した症例の報告はない.心膜嚢腫は悪性化の報告もあり,積極的な外科的切除が望ましいと考えているが,胸腔鏡下手術は術中の病理学的検査で確定診断が得られ,嚢腫内容液の吸引することで容易に心膜から剥離切除でき理想的な治療法と考える.

The natural history of intracranial arterial dissection is not well known yet, so that adequate treatment is still controversial for this disease. We conducted this study to elucidate the clinical features and the long-term outcome of the conservatively managed patients with the intracranial arterial dissection and subarachnoid hemorrhage in the vertebrobasilar system. Twenty-five patients were conservatively managed (only control of high blood pressure, no antiplatelet nor anticoagulant), whereas 64 underwent surgery, including intravascular surgery. The reasons for the conservative treatment were: anatomical problems in 11, poor clinical state in 9, and treatment strategy in 5. In the retrospective analysis, age, clinical severity, location of the dissection, and angiographical findings did not differ between the 2 groups. The incidence of the history of arterial hypertension and the rate of rebleeding were significantly higher in the conservative group. In the conservative group, the follow-up period ranged from 0.5 to 14 years (mean=6.4 years). The most common finding on serial angiogram was no change on the initial one, followed by improvement. As for outcome, 13 patients died of rebleeding or vasospasm in the acute stage. The long-term outcome in the remaining 12 was favorable: Eleven made good recovery. These results suggest that the long-term outcome in the ruptured vertebrobasilar arterial dissection might be favorable, if the patients overcome the various problems in the acute stage.

Object. The purpose of this study was to delineate the long-term natural history of hemorrhagic moyamoya disease (MMD).Methods. A retrospective review was conducted among 42 patients suffering from hemorrhagic MMD who had been treated conservatively without bypass surgery. The group included four patients who had undergone indirect bypass surgery after an episode of rebleeding. The follow-up period averaged 80.6 months. The clinical features of the first bleeding episode and repeated bleeding episodes were analyzed to determine the risk factors of rebleeding and poor outcome.Intraventricular hemorrhage with or without intracerebral hemorrhage was a dominant finding on computerized tomography scans during the first bleeding episode in 29 cases (69%). During the follow-up period, 14 patients experienced a second episode of bleeding, which occurred 10 years or longer after the original hemorrhage in five cases (35.7%). The annual rebleeding rate was 7.09%/person/year. The second bleeding episode was characterized by a change in which hemisphere bleeding occurred in three cases (21.4%) and by the type of bleeding in seven cases (50%). After rebleeding the rate of good recovery fell from 45.5% to 21.4% and the mortality rate rose from 6.8% to 28.6%. Rebleeding and patient age were statistically significant risk factors of poor outcome. All four patients in whom there was indirect revascularization after the second bleeding episode experienced a repeated bleeding episode within 8 years.Conclusions. The occurrence of rebleeding a long time after the first hemorrhagic episode was not uncommon. Furthermore, the change in which hemisphere and the type of bleeding that occurred after the first episode suggested the difficulty encountered in the prevention of repeated hemorrhage.

Non-traumatic intracranial arterial dissection has been accepted as a unique entity of 'cerebral infarction in otherwise healthy young adults', and is particularly prevalent in Western countries. A recent data collection and analysis have revealed additional clinical features. The nationwide study in Japan conducted in 1996 has provided new information on the natural history and current treatment of intracranial dissecting aneurysms in Japan. The incidence of symptomatic dissection was found to be much higher in the vertebrobasilar system than in the carotid system. The mean age of the patients was 51.3 years. Patients with carotid lesions were younger (mean 43.8 years). The male/female ratio was 2: 1. Fifty-eight percent of patients presented with subarachnoid hemorrhage. Recurrence was more frequent in patients with subarachnoid hemorrhage (14%) than in patients with no hemorrhage (4.2%). Common radiological findings were dilatation, 'pearl and string' sign and narrowing of the affected artery. Surgical treatment involved a variety of procedures including proximal occlusion, entrapment, wrapping and endovascular embolization. Patients with subarachnoid hemorrhage (61%) underwent surgical treatment more frequently than patients with no hemorrhage (17%). Good recovery was achieved in 64% of all patients. Outcome was better in patients with no subarachnoid hemorrhage compared with those with hemorrhage.

BACKGROUND Two cases of intracavernous internal carotid artery aneurysm with unusual clinical findings are reported. The pathomechanism and clinical significance are discussed. CASE DESCRIPTION The first patient was a 49-year-old woman who presented with 6th nerve palsy and Horner's syndrome caused by a posteriorly located intracavernous aneurysm. The symptoms improved gradually in proportion to the size of the aneurysm. The second patient was a 69-year-old woman with isolated oculomotor superior division palsy caused by an anteriorly located large aneurysm. CONCLUSION In the first case, a local aneurysmal compression at both the 6th nerve and the sympathetic fibers sent from the plexus on the intracavernous internal carotid artery is the most probable explanation. In the second case, the aneurysm might have selectively compressed the superior division of the oculomotor nerve at the anterior cavernous sinus. Clinical recognition of these syndromes results in a better diagnostic orientation. The authors discuss the pertinent anatomy and pathophysiology of the lesions because these findings are rarely seen clinically or in the literature.

The aim of this study was to estimate the results of abdominal aortic aneurysm (AAA) repair with or without coronary artery disease (CAD), retospectively. We studied the incidence of associated CAD among 47 consecutive patients operated upon for AAA, excluding ruptured aneurysms. The screening of CAD was routinely performed by coronary angiography. More than 50% luminal stenosis of the major coronary artery was judged positive for CAD. Twenty-five of the 47 patients (53%) had CAD of 25 patients, 14 patients were subjected to pharmacotherapy, and 11 were indicated coronary revasculization. Nine of those patients underwent successful PTCA prior to surgery. The remaining two patients were considered to be unsuitable for PTCA and underwent coronary bypass grafting before AAA repair. There was no operative mortality or perioperative myocardiac infarction during and after the repair of AAA. This study seggests that AAA repair with CAD could be performed saflely by means of the detailed preoperative evalution and that PTCA or CABG should be approached aggressively in cases with CAD prior to AAA repair.

A 46-year-old female presented with decreased bilateral visual acuity due to an unruptured non-thrombosed giant aneurysm arising from the left internal carotid artery. After admission, acute thrombosis of the aneurysm occurred spontaneously. Her consciousness and visual acuity temporarily worsened. Serial T2-weighted magnetic resonance (MR) imaging showed the size of the low intensity area near the orifice increased, and the aneurysm ruptured thereafter. Trapping of the aneurysm with a high-flow bypass was performed. Serial MR imaging findings clearly demonstrated the intraluminal structure of the thrombosed giant aneurysm. The aneurysm grew in size after thrombosis. The enlarging signal-void area on T2-weighted MR images were indicative of aneurysmal rupture. MR imaging is quite helpful to evaluate the changes of intraluminal thrombosis and size in giant aneurysms.

A retrospective study was conducted to determine the angioarchitecture related to hemorrhage in patients with cerebral arteriovenous malformations (AVMs), who underwent conservative treatment and long-term follow-up. The average observation period was 9.3 years, and the annual bleeding rate was estimated at 3.6%. In all cases angiographic findings were reviewed in detail. The average AVM grade by Spetzler-Martin was 3.5. Higher bleeding rate was observed in large AVM (5.4%) compared with small (2.1%) or medium AVM (2.9%). Deep venous drainage (8.6%/year) was strongly correlated to hemorrhage. Concerning location of nidus, hemorrhage was frequently found in insular, callosal, and cerebellar AVMs. Venous ectasia, feeder aneurysm, and external carotid supply were commonly demonstrated on angiograms. Comparison of annual bleeding rate revealed that AVMs with intranidal aneurysm (8.5%) and venous stenosis (5.5%) had a high propensity to hemorrhage. Therapeutic strategy should be focused on these potentially hazardous lesions by the use of endovascular embolization or stereotactic radiosurgery, even if surgical resection is not indicated.

We have experienced a case of infection of an artificial vessel due to acute appendicitis in a 50-year-old man. The patent had undergone an abdominal arota-right femoral artery bypass operation using an artificial vessel in 1990. In 1995, he developed suppurative gonarthritis of the right lower limb, femoral osteomyelitis, and inflammation of the gastrocnemius and femoral muscles. These symptomas were improved by chemotherapy and incision drainage, though the etiology was unknown. In 1997, occlusion of the artificial vessel and suppurative lesions in the peripheral dorsal region of the foot and 3rd toe occurred, and a removal of the artificial vessel was conducted on November 8. On November 10, pus and intestinal juice like material flowed out from the wound. CT revealed gas in the retroperitoneal space, and a laparotomy was performed with a suspicion of perforation of the intestine. During operation the necrosed appendix, abscess formation and small bowel perforation were confirmed, and an appendectomy and a partial resection of the small intestine were carried out. Histologically, the appendix presented gangrenous appendicitis that might cause infection and occlusion of the artifical vessel. After the operation the inflammation was alleviated. There have been no signs of recurrence, and the patient is doing well.

Objective We propose a modification to the currently prevailing grading systems in patients with subarachnoid hemorrhage. The changes will make them correlate more strongly with the surgical results. Methods The relationship between preoperative clinical grades and management outcome was retrospectively investigated in a series of 304 patients with ruptured cerebral aneurysms on the anterior circle of Willis. Preoperatively, every patient was evaluated with the Hunt and Kosnik grading system, the World Federation of Neurological Surgeons Scale, and the Glasgow Coma Scale. All the patients underwent surgical treatment on the aneurysms within 72 hours of the first onset of symptoms. Hyperdynamic therapy was performed after the surgery was evaluated with the Glasgow Outcome Scale. Results In the Hunt and Kosnik system, the outcome was significantly different between the patients with Grades II and III and those with Grades III and IV, but there was no significant difference among the adjacent grades except between patients with Glasgow Coma Scale scores of 13 and 14. The outcome of oriented patients was significantly better than that of confused patients. Neither eye opening nor presence of focal deficit was a significant prognostic factor. Conclusion To grade patients with subarachnoid hemorrhage objectively, three responses should be recorded separately in the Glasgow Coma Scale score. Patients with confused verbal responses should be graded lower than those who are oriented, even when they have the same total score.

We report the successful surgical treatment of a rare case of chronic expanding hematoma in the pericardial cavity that developed into a very large mass over a long period. The patient, who had a history of cardiac surgery for a double-outlet right ventricle 14 years previously and for tricuspid regurgitation 8 years ago, noticed a slowly growing mass near the left atrium and ventricle 5 years ago. The mass, which confirmed a diagnosis of chronic expanding hematoma, was resected by left thoracotomy.

Tracheal disruption due to blunt chest trauma is relatively rare but often fetal. Further improvement in life-saving strategy is expected. Here two cases of tracheal disruption due to a traffic accident with different clinical course are reported on. Case I: A 35-year-old woman manifested tension pneumothorax immediately after the injury to develop dyspnea. Emergency operation was carried out within 4 hours after the injury. Tracheoplastic procedure was able to save the patient's life. Case II: A 58-year-old man had a completed atelectasis of the left lung due to encapsulated tracheal disruption three weeks after a traffic accident and was also successfully treated by tracheoplastic procedure. It should be emphasized that early diagnosis and primary repair are important in the treatment of tracheal distruption due to blunt chest trauma.

Background and Aims: Although there are guidelines for the management of antithrombotic agents during the periendoscopic period, gaps between various guidelines create a confusing situation in daily clinical practice. The purpose of this study was to examine the current management of antithrombotic agents during the periendoscopic period in Japan. Methods: This is a prospective cohort study in 12 high-volume endoscopy centers in Japan. A total of 970 outpatients receiving antithrombotic agents underwent endoscopies (705 esophagogastroduodenoscopies and 265 colonoscopies) with or without invasive procedures. Main outcome measures are adverse events in these patients. Results: Need for cessation of antithrombotics before endoscopy was mostly determined by non-gastroenterologists (51%) who are unfamiliar with the Japan Gastroenterological Endoscopy Society (JGES) guideline, although cessation periods after endoscopy for most patients were determined by endoscopists (78%). Consequently, most patients underwent endoscopy without cessation (25%) or after a cessation period of 6–7 days (33%), indicating low permeation of the JGES guideline in Japan. Among 970 patients, two patients experienced major complications that may be related to thromboembolic events or gastrointestinal bleeding (95% confidence interval [CI]: 0–0.7%). One of these patients died due to sudden onset ventricular tachycardia. Invasive procedures, including 40 biopsies and two mucosal resections, were performed in 42 patients without cessation of antithrombotics, and no patients experienced major complications (95% CI: 0–8.4%). Conclusions: This study revealed a conflicting clinical environment due to absence of a unified guideline in Japan. Further accumulation of data is mandatory to establish a unified guideline based upon solid evidence.

We report a relatively rare surgical treatment for two cases of inflammatory pseudotumors of the lung. In case 1, a 52-year-old male with a history of left chest pain was admitted to our hospital for an abnormal nodule with an irregular margin that was detected in the left upper lung field. The nodule, measuring 15 mm in diameter, was larger than the one observed six months earlier, which had been removed by a thoracoscopic resection. In case 2, a 64-year-old female with a history of chronic cough and hemoptysis was admitted to our hospital, and an abnormal nodule with pleural indentation was detected in the lower left lung field. The nodule, measuring 8 mm in diameter, was also removed by a thoracoscopic resection. In both cases, the histologic examination enabled us to diagnose the lesion as an inflammatory pseudotumor. In general, it is very difficult to differentiate inflammatory pseudotumors from malignant tumors of the lung. The best treatment for inflammatory pseudotumors is usually early and complete surgical resection, since it can lead to improved survival. Therefore, we consider thoracoscopy-aided surgery to be less invasive and more useful than other surgical methods in the diagnosis and treatment of inflammatory pseudotumor of the lung.

J Thorac Cardiovasc Surg 1998;115:945-7

Circulatory support using both intraaortic balloon pumping (IABP) and percutaneous cardiopulmonary support (PCPS) can improve general hemodynamics; however, sometimes brain damage occurs caused by hypoperfusion. Such cerebral hypoperfusion is likely to be caused by PCPS when applying the conventional femoral cannulation. We have developed a new IABP catheter which incorporates a conduit for PCPS with an outlet at the catheter tip, the goal of which is the improvement of cerebral perfusion. The hemodynamic characteristics of this new IABP catheter were compared with those of the conventional combination of IABP and PCPS. Studies were performed by mock test using a pulsatile artificial heart. A polyvinyl chloride tube acted as the aorta with 2 branches at the proximal and distal portions representing the upper and lower portions of the body. The IABP balloon was positioned between the 2 branches, and changes in flow at the 2 branches were examined at varying PCPS flow rates. Flow in the proximal branch using the new device was greater than it was using the conventional PCPS device. We conclude that cerebral perfusion could be improved with the use of this new special IABP catheter.

Endovascular embolization of the middle meningeal artery was performed in two cases of refractory chronic subdural haematoma (CSDH) after repeated burr hole and irrigation surgeries. The embolization prevented expansion of the CSDH in both cases, and the haematoma disappeared completely in one case. The expansion of CSDH is considered to result from repeated bleeding from the macrocapillaries on the haematoma capsule. Embolization of the middle meningeal artery appears to be useful to eliminate the blood supply to this structure.

A 19-year-old woman with a history of drug addiction suffered from sepsis and heart failure. Blood culture was positive for Streptococcus viridans. An operation was indicated because the echocardiography showed massive vegetation on the anterior leaflet of the tricuspid valve and severe regurgitation even though the endocarditis was healed with drug therapy. At operation all of the anterior leaflet of the tricuspid valve was resected with the vegetation. Using the technique of cusp commissuroplasty, the disrupted commissure was reconstructed by approximating the septal and posterior cusps at the level of their normal closure, forming a zone of apposition by using a single stitch. Leaflet apposition resulted in a defect between the apposed leaflets and the tricuspid annulus, which was patched with autologous pericardium. The tricuspid valve was reconstructed to function as a unicommissural bicuspid valve. The patient was stable during the follow-up period of two years without any medical treatment.

A multilocular-cystic and cavernous, retroperitoneal tumor was found in a 40-year-old man whose past medical history was unremarkable. On admission, he complained of a large and still growing intra-abdominal mass associated with dull pain and a low-grade fever. Laboratory findings revealed leukocytosis and C-reactive protein elevation, compatible with inflammation of the tumor. Percutaneous aspiration of the tumor was performed under transabdominal ultrasonographic guidance, and continuous drainage of fluid from within the tumor ameliorated his symptoms. From preoperative examinations, including radiological imaging, fluid aspiration, and endoscopy with biopsy, a diagnosis of retroperitoneal lymphangioma was made. Laparotomy revealed extensive adhesions between the tumor and both the duodenum and the pancreatic head. A pancreaticoduodenectomy was therefore performed. At 3-year follow-up, there was no sign of recurrence. Retroperitoneal lymphangioma is an uncommon disorder, and the cavernous type is extremely rare. The duodenal lesion was an important feature of the present case, and endoscopic biopsy of this lesion facilitated precise preoperative diagnosis of retroperitoneal lymphangioma.

Background and Objective: To further understand the precise process of the tumor cell degeneration after photodynamic therapy (PDT), laser hyperthermic therapy (LH), and combined treatments using an Nd:YAG laser. It is important to examine initial morphological alteration of tumor cells after these treatments. Study Design/Materials and Methods: In this study, nude mice bearing HeLa cell tumors were treated with PDT, LH, and combined treatments of the two. Tumor tissues obtained immediately after these treatments were analyzed using electron microscopy and morphometry. Results: In the combined treatments, which produced more severe effects on tumor cells, morphological features of apoptosis such as cytoplasmic condensation, blebs, and apoptotic bodies appeared in the cells, although the typical alteration in the nuclear chromatin was not seen. Conclusion: Cytoplasmic alterations may proceed more rapidly than nuclear alterations in the cellular degeneration induced by the single or combined treatments of PDT and LH.

Postnephrectomy renal arteriovenous fistula (AVF) with an aneurysmal lesion is a rare clinical entity that may cause high-output heart failure. In this report, we describe the case of a 68-year-old man who had undergone nephrectomy for renal tuberculosis 43 years previously, in whom an acquired large renal AVF presenting as an aneurysm caused congestive cardiac failure. We also discuss the hemodynamic, hormonogenic (human arterial natriuretic polypeptide; hANP), and radiographic findings before and after surgery for the AVF. The AVF with an aneurysmal lesion was clearly visualized by three-dimensional-computerized tomographic (CT) scanning, and proximal ligation of the renal artery was followed by an uneventful recovery. This procedure can produce good results when a fistula is too large to allow safe embolization and when excision would be hazardous due to inflammation surrounding the fistula.

This study was conducted to determine risk factors for poor outcome in the natural history of arteriovenous malformation (AVM). We statistically analysed the correlation between clinical or angiographical findings and clinical outcomes for 55 cases of untreated AVM. Subsequent haemorrhage from AVMs was the only significant risk factor for poor outcome (P< 0.0001). The odds ratio was 44.56 with a 95% confidence interval (CI) from 4.80 to 413.90. Risk factors for subsequent haemorrhage from AVMs were also determined. The size (P = 0.0483) and location (P = 0.0147) of an AVM were significant risk factors for subsequent haemorrhage. The odds ratios were 3.97 with a 95% CI from 1.18 to 13.33 and 3.89 with a 95% CI from 1.10 to 13.72, respectively. AVMs of more than 60 mm, and deep or infratentorial AVMs had more chance of subsequent haemorrhage, and hence of a poor outcome. We propose using an aggressive multidisciplinary approach to treating these AVMs.

Aims. To assess seroprevalence of human immunodeficiency virus (HIV), hepatitis C virus, injecting drug use, unsafe sexual behaviours, self-mutilation and tattoos in patients attending a drug and alcohol treatment centre in Japan. Design. Cross-sectional survey. Setting. The work was carried out at the National Sanitarium of Shimousa, Chiba, Japan, a 32-bed inpatient centre specializing in drug and alcohol treatment. Measurements. Laboratory analyses for HIV antibody, hepatitis C antibody, hepatitis B antigen and antibody; questionnaires for history of sexual activities, needle and syringe use; physical examination with assessment of self-amputated finger joints, tattoos, scars from lacerations and cigarette burns. Findings. No patients tested positive for anti-HIV. The seroprevalence of anti-HCV positives was 53.8% of methamphetamine-dependent patients, 18.4% of solvent-dependent patients and 5.6% of alcohol-dependent patients. Past needle sharing was reported by 82.1% of methamphetamine-dependent patients, 18.4% of solvent-dependent patients and 5.6% of alcohol-dependent patients. A history of syringe sharing was reported by 87.2% of methamphetamine-dependent patients. More than two-thirds of all patients reported contact with commercial sex workers. Casual sexual contacts were more common among solvent and methamphetamine-dependent patients than those dependent on alcohol. Tattoos and cigarette burns were more common among methamphetamine and solvent-dependent patients than among alcohol-dependent patients. Among the methamphetamine-dependent patients, 20.5% reported self-amputated finger joints compared with none in the other patient groups. Conclusions. HCV prevalence is a significant problem among methamphetamine users in Japan, probably because of a high rate of needle and/or syringe sharing. Although HIV infection is currently negligible, the very high rate of needle and syringe sharing could give rise to a significant increase in the HIV rate among drug users in the future.

A 70-year-old male with aortic regurgitation, chronic atrial fibrillation (Af) and chronic aortic dissection of the aortic arch was treated simultaneously. We found a limited dissection in front of aortic arch during operation. We performed total arch replacement using a branched prosthesis and aortic valve replacement, in addition to a modified left atrial isolation for chronic Af under the aid of extracorporeal circulation, and selective cerebral perfusion. Left atrial isolation is a simpler procedure than maze procedure and left side maze procedure for eliminating Af. This simple procedure makes possible a simultaneous extended operation for complicated aortic and cardiac disease even in an elderly patient.

Background. We have devised a simple surgical procedure to be performed on the posterior wall of the left atrium for the treatment of chronic atrial fibrillation (AF) associated with mitral valve disease. The effectiveness of this procedure for serial mitral valve operations was then evaluated. We postulated that chronic AF associated with mitral valve disease could be attributable to a distended left atrium. The refractory period of the distended left atrium was significantly shorter in the left posterior atrial wall, especially at the base of the left atrial appendage and at the orifice of the left posterior pulmonary vein. We hypothesized that the left posterior atrial wall with its shorter fibrillatory cycle length would act as a driver for maintaining the AF, and therefore, surgical ablation of this critical area in the left atrium could terminate the chronic AF. Methods. The surgical patients were divided into two groups. In group 1 (control group), 15 patients with chronic AF were operated on by the mitral valve procedure only. In group 2, 36 patients underwent this procedure in combination with a concomitant mitral valve operation. The disappearance rate of the AF was estimated by electrocardiography, and atrial function was estimated by transthoracic and transesophageal echocardiography. Results. The chronic AF had been reduced significantly or eliminated at discharge in 4 of 15 patients (26.7%) in the group 1, versus 31 of 36 patients (86%) in group 2 (p < 0.05). In group 2, 29 of the 31 patients (94%) whose AF had disappeared recovered the atrial kick of their right atrium, and 21 patients (22/31; 71%) recovered the atrial kick of their left atrium. Conclusions. Surgical ablation of the posterior wall of the left atrium was effective in the treatment of chronic AF associated with mitral valve disease. This simple procedure could restore a sinus rhythm and also recovered atrial systolic function. We conclude that the left atrium may act as a driver for sustaining AF in mitral valve disease.

A man who underwent tricuspid and mitral valve replacement with bioprostheses at 45 years of age required a second double valve replacement at 50, a third tricuspid valve replacement for enterococcal endocarditis at 57, and a third mitral valve replacement for relapsing enterococcal endocarditis at the age of 60. Recurrent Enterococcus faecalis prosthetic valve endocarditis was thought to be due to colon polyps causing intermittent infection.