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Objective: This study tested to see if trehalose, a cytoprotective disaccharide, protects against spinal cord ischemia in a rabbit model., Methods: The infrarenal aorta was mobilized in four groups of 10 rabbits. In groups I, II, and III, it was clamped proximally and distally for 20 minutes. In group I, the clamped aorta was infused at 2.5 L/min for 2 hours with lactated Ringer's (LR) solution. In group II, the clamped aorta was infused with 5% trehalose in LR. LR was administered intravenously (2.0 mL/min) in groups I and II starting 30 minutes before clamping. In group III, 5% trehalose in LR was infused intravenously only. Group IV was a sham-operated control group without aortic clamping. At 8, 24, and 48 hours after reperfusion, hind limb function was scored using the Tarlov score (paralysis = 0, perceptible joint movement = 1, good joint movement but unable to stand = 2, able to walk = 3, normal = 4). Histologic analysis and electron microscopy were performed on anterior horn cells., Results: The Tarlov scores in groups I, II, and III were, respectively, 1.1 ± 1.4, 3.5 ± 0.5, and 2.9 ± 0.9 at 8 hours; 0.8 ± 1.2, 3.9 ± 0.3, and 2.9 ± 0.9 at 24 hours; and 0.6 ± 0.7, 3.9 ± 0.3, and 2.7 ± 0.9 at 48 hours after reperfusion. Group IV scores were normal (4 ± 0) at all assessments. These scores were higher in groups II and III than in group I (P < .01) at all assessments. Scores at 24 and 48 hours were higher in group II than in group III (P < .05). In group III, delayed paraparesis developed in one rabbit at 24 hours and in two more at 48 hours. Histopathologic analysis showed the number of normal neurons was higher in groups II (P < .0001), III (P = .006), and IV (P < .0001) vs group I. Electron microscopy confirmed preserved neuronal cell ultrastructure in rabbits with normal limb function., Conclusions: Transaortic trehalose infusion was protective against paraplegia, whereas intravenous trehalose reduced spinal cord ischemia. This study was preliminary and further studies are needed., (Copyright © 2014 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

A 57-year-old Japanese man presented with massive right pleural effusion, and a huge tumor arising in the pleural cavity was detected by chest computed tomography. A thoracoscopic tumor biopsy revealed that the tumor protruded extensively into the pleural cavity, and its gross appearance was cystic and glossy. Microscopically, the tumor cells were rounded and epithelioid in shape. Prominent and abundant myxoid stroma was also present together with an inflammatory infiltrate, and the tumor was anaplastic lymphoma kinase (ALK)-immunopositive. Fluorescence in situ hybridization revealed that the Ran-binding protein 2-ALK fusion gene was present. Taken together, these findings supported the diagnosis of epithelioid inflammatory myofibroblastic sarcoma (EIMS), which is a variant of an inflammatory myofibrobrastic tumor. This is the first reported case of an EIMS arising in the pleural cavity.

Background: Postoperative infection is one of the most frequently observed complications after lung resection and should be addressed in perioperative management. This study evaluated the clinical significance of chest tube tip culture relevant to postoperative infection., Methods: From September 2002 to December 2011, 1,438 patients who underwent lung cancer operations in Shizuoka Cancer Center Hospital were evaluated. Postoperative infections, including surgical site infection, postoperative pneumonia, and postoperative empyema without fistula, were defined as those occurring within 30 days of thoracotomy., Results: Postoperative infections developed in 84 of the 1,438 patients (5.8%), including 42 (2.9%) with surgical site infection, 36 (2.5%) with pneumonia, and 13 (0.9%) with empyema. The sensitivity, specificity, and positive predictive value of chest tube tip culture were 23%, 98%, and 41.3%, respectively. Multivariate analysis demonstrated that the independent risk factors associated with the development of postoperative infections were coexisting diabetes mellitus and positive chest tube tip culture. Positive chest tube tip culture was the only independent risk factor associated with surgical site infection. The independent risk factors associated with postoperative pneumonia were age 70 years or older, coexisting diabetes mellitus, and positive chest tube tip culture. Finally, positive chest tube tip culture was the only independent risk factor associated with postoperative empyema., Conclusions: Positive chest tube tip culture strongly predicts postoperative infections in lung cancer surgery and necessitates careful observation in the perioperative period., (Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Purpose: Interstitial lung disease (ILD) is associated with primary lung cancer and an increased risk of postoperative acute exacerbation (AE). Although the preoperative factors associated with AE of ILD are well described, there is little information about the postoperative factors. Thus, the present study focuses on the postoperative management of chest-tube drainage associated with AE of ILD., Methods: We conducted a retrospective chart study of 1,309 patients with lung cancer, who underwent pulmonary resection at Shizuoka Cancer Center between September 2002 and January 2011. ILD was diagnosed by chest computed tomography (CT) findings in 95 patients. After the exclusion of 6 patients with a history of pneumonectomy, the subjects of this study were 8 patients who suffered AE after surgery (AE group) and 81 patients (non-AE group) who did not. We investigated the clinicopathological findings and postoperative management of chest-tube drainage in the two groups., Results: The clinicopathological findings of the two groups did not differ significantly. The chest tubes could not be removed before postoperative day 5 because of pleural effusion in 5 patients (62.5 %) from the AE group and 12 patients (14.8 %) from the non-AE group (P = 0.0040)., Conclusions: The postoperative volume draining from the chest-tube is an important sign of AE of ILD.

Background: The efficacy of postoperative adjuvant cisplatin (CDDP)-based chemotherapy, such as the combination of CDDP and vinorelbine (VNR), has been established for surgically resected non-small-cell lung cancer (NSCLC). However, the optimal treatment schedule and dosage for CDDP and VNR are unknown. We evaluated patient compliance with and the safety of adjuvant chemotherapy of CDDP at 80 mg/m(2) administered on day 1 plus VNR at 25 mg/m(2) administered on days 1 and 8, every 3 weeks., Methods: Medical records of 100 surgically resected NSCLC patients, treated with a combination of CDDP and VNR at the Shizuoka Cancer Center between February 2006 and October 2011, were retrospectively reviewed., Results: Eighty-three (83%) patients completed the planned 4 cycles of CDDP plus VNR and 59 (59%) received the planned doses. Sixty-eight percent of the patients experienced a decreased neutrophil count (grade 3/4 toxicity); 1%, a decreased platelet count; and 4%, febrile neutropenia. No treatment-related deaths were noted in this study. Univariate analysis of the factors influencing patient compliance with this adjuvant chemotherapy showed that neither patient characteristics nor surgical procedure was significantly associated., Conclusions: Our results indicated that adjuvant chemotherapy with CDDP at 80 mg/m(2) administered on day 1 plus VNR at 25 mg/m(2) administered on days 1 and 8, every 3 weeks, was feasible for surgically resected NSCLC cases., (Copyright © 2012 The Japanese Respiratory Society. Published by Elsevier B.V. All rights reserved.)

Calcifying tumor of the pleura is a rare benign tumor, similar to the calcifying fibrous pseudotumor originally described in the subcutaneous and deep soft tissues of the extremities, trunk, and neck. Calcifying tumors of the pleura have also been reported infrequently as disseminated lesions. Here we report a case of disseminated calcifying tumor of the pleura, with some new findings obtained in this study, and review the literature of disseminated calcifying tumor of the pleura.

Previous studies have indicated that high-dose intravenous edaravone (3-10mg/kg) protects against ischemic spinal cord injury. This study examined whether direct injection of low-dose edaravone into the clamped segment of the aorta prevents ischemic spinal cord injury. Spinal cord ischemia was induced in rabbits by aortic clamping below the renal artery and above the aortic bifurcation for 15min at normothermia. In groups A and B, 3 and 1mg/kg of edaravone, respectively, was injected into the clamped segment of the aorta immediately following aortic clamping. In group C, saline was injected. Neurological function was assessed at 8, 24, and 48hr and 7 days after reperfusion with Tarlov criteria. The spinal cord was histologically examined at 7 days with hematoxylin-eosin staining and in situ terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end labeling (TUNEL) staining. The Tarlov score remained grade 4 throughout the period in groups A and B, whereas it dropped to grade 0 or 1 at 7 days in group C, significantly higher in the former two groups. The number of intact motor neurons was significantly greater in groups A and B with less necrotic motor neurons than in group C. There was no significant difference in terms of spinal cord protection between groups A and B. There was no TUNEL-positive neuron in any group, indicating the absence of apoptosis. Low-dose intra-aortic edaravone injection prevents immediate neuronal injury by reducing neuronal cell damage in the early stage as well as delayed neuronal injury at 7 days.

Background: Perfluoro-octyl bromide (PFOB), one of the perfluorochemical oxygen transporters, improved postischemic cardiac dysfunctions. Also norepinephrine (NE) is one of the important inducible factors on reperfusion arrhythmias (ventricular fibrillation [VF]). We used these methods to evaluate the relationship between PFOB emulsion and NE release on reperfusion arrhythmias., Materials and Methods: The perfusion of isolated guinea pig hearts was employed: each of four groups of 6-7 hearts were used with Krebs-Henseleit solution (KHS) as control, and KHS with 5%, 15%, or 30% PFOB emulsion. The hearts were perfused in a constant pressure Langendorff model, stabilized for 30 min, followed by 30 min preischemia, then 30 min ischemia and 45 min reperfusion at normothermia., Results: PFOB emulsion dose-dependently limited VF and inhibited NE release in reperfusion. Only 30% PFOB emulsion showed the significant improvement of VF (p=0.05). In hemodynamic parameters, only 5% PFOB emulsion showed a significant decrease in reperfusion, but there was no difference in coronary flow rate (CFR). No differences among the four groups were demonstrated in cardiac oxygen metabolic parameters., Conclusions: It was most likely that a high concentration of PFOB emulsion attenuated reperfusion arrhythmia by decreasing NE release.

Purpose: Under myocardial reperfusion conditions, hemoglobin (Hb)-based artificial blood showed effectiveness for post-ischemic dysfunction. However, there are no studies about the effects of this product on reperfusion arrhythmias (ventricular fibrillation, VF) associated with norepinephrine (NE) release. This study was to evaluate the effects of the timing of the administration of pegylated liposomal Hb (LHb, P(50)=40-45 mmHg, 1 mg/mL) on NE release and VF., Materials and Methods: Isolated guinea pig hearts (n=6 in each group) were randomly divided into four groups in Krebs-Henseleit solution being supplemented or not with LHb as follows: pre-ischemia (PRE), reperfusion (REP), or PRE+REP groups. The hearts were perfused for 30 min (preischemic period) and then subjected to 30 min of global ischemia, followed by 30 min of reperfusion with a normothermic Langendorff apparatus at 30 mm Hg aortic pressure in a constant pressure model., Results: No differences were documented among the four groups in heart rate, left ventricular-developed pressure, or coronary flow rate. However, the REP group significantly decreased the duration of VF and NE release, but it did not inhibit the incidence of VF., Conclusion: These results suggest that the administration of LHb, especially with the timing of reperfusion, might prevent reperfusion arrhythmias linked to the inhibition of NE release.

Endothelin (ET)-1 is an endogenous vasoconstrictor which modulates norepinephrine (NE) release in myocardial ischemia reperfusion. Recent studies have demonstrated the pro- or anti-arrhythmic effects in reperfusion. The present studies were undertaken to test the hypothesis that ET receptors located in sympathetic nerve terminals modulate NE release associated with reperfusion arrhythmias (ventricular fibrillation; VF). Immunohistochemical studies showed that both ETA and ETB receptors exist in the sympathetic nerve varicosities, which were stained positive for tyrosine hydroxylase (TH) in the left ventricular wall in guinea pigs. Isolated guinea pig hearts were subjected to 20 min of normothermic global ischemia followed by 30 min reperfusion. Exogenously applied ET-1 (0.1 and 1 nM) dose-dependently increased NE release and the duration of VF, but these responses were significantly suppressed with the Na(+)/H(+) exchanger inhibitor, 5-(N-ethyl-N-isopropyl)-amiloride (10 microM). The ETA receptor antagonist (BQ123, 1 microM) and nonselective ET receptor antagonist (PD142893, 1 microM) significantly attenuated NE release and VF, whereas the ETB receptor antagonist (BQ788,300 nM) markedly elevated NE release but did not affect VF. These studies provide the first evidence that both ETA and ETB receptors, located in the sympathetic nerve varicosities, modulate NE release, at least in part, in association with reperfusion arrhythmias.

Fosfomycin (FOM), a drug with unique mechanism of action against bacteria, was prospectively compared with cefmetazole (CMZ) and flomoxef (FMOX) to assess its effectiveness in preventing postoperative infections after upper gastroenterological and hepatobiliary surgery. FOM (2g/dose), CMZ (1 g/dose), or FMOX (lg/dose) was infused intravenously 2-3 times daily for basically 4 days including the day of surgery in order to examine whether or not infections would develop after surgery. According to the analysis results of 162 cases, efficacy in preventing infection was 86.8% for FOM, 73.1% for CMZ and 83.3% for FMOX, showing no significant differences among the 3 groups. Thus FOM was considered as efficacious as CMZ or FMOX in prophylaxis against postoperative infections. There were no adverse reactions in the FOM or CMZ group, but 3 cases of adverse reactions occurred in the FMOX group. Based on the above results, the usefulness of FOM for prophylaxis against postoperative infections has been confirmed. At present, the first- and second-generation cephems are most frequently used for prophylaxis against postoperative infections. In order to prevent an increase of resistant strains due to inappropriate use of these drugs, FOM, having no cross resistance with currently used drugs, is a promising candidate for prophylaxis against postoperative infections.

Purpose: The purpose of the present study was to evaluate the stability of a high-porosity expanded polytetrafluoroethylene (ePTFE) graft, which has been shown to possess excellent biocompatibility and tissue integration., Methods: The graft used in the present study was a high-porosity ePTFE graft , which had an average internodal distance of approximately 60 microm and a random node architecture with tortuous path channels extending from the outer to the inner surface. Eleven beagle dogs (each group n = 3 or 4) weighing 10-12 kg were used. The graft, with a 6 mm inside diameter and a 30-40 mm length, was implanted into the canine abdominal aorta and retrieved after 2-80 weeks. The deformation of the graft was evaluated by conventional computed tomography (CT). The radial tensile strength, longitudinal tensile strength, and suture retention strength of the graft were measured after 2-80 weeks., Results: CT studies showed no anastomotic aneurysm or deformation of the graft. Physical tests demonstrated no significant deterioration in suture retention strength, radial tensile strength or longitudinal tensile strength for periods ranging from 2-80 weeks compared to pre-implantation grafts., Conclusion: The graft possesses adequate stability that ensures safe and effective clinical use.

The aim of this study was to anatomically verify echo-guided identification of key lumbar arteries supplying blood to the spinal cord and to examine whether changes in nerve root motion could be used for detecting malperfusion following aortic cross-clamping. In two beagle dogs, nerve root motion was monitored through the intervertebral disc using transesophageal echocardiography. Communications between each lumbar artery and the spinal vasculature were assessed by echogenic signals in the spinal cord following saline injection into each lumbar artery. Nerve root motion immediately disappeared after clamping the aorta and recovered as soon as it was declamped. These changes were induced specifically by clamping the aorta at the first lumbar level. The changes were instantaneous and may be beneficial because of minimal ischemic insult of the spinal cord. In dog #1, the result of the saline injection test was anatomically verified with the presence of a spinal branch. However, in dog #2 echogenic signals appeared in the muscles as well as in the spinal artery. A morphological study showed no spinal branch of the lumbar artery but only an indistinct artery in the intervertebral foramen. These findings probably account for those cases in humans where there is unsuccessful visualization of the Adamkiewicz artery by angiography. Consequently, the above two assessments identified the key artery. Cessation of nerve root motion following segmental clamping of the aorta and echogenic signals in the spinal cord following saline injection into a lumbar artery may represent the key artery with respect to hemodynamics and perfusion, respectively.

Background: Although hemodilution is usually utilized during cardiopulmonary bypass (CPB), hemodilution can cause adverse effects such as hypotension and hypoxia. The purpose of this study was to evaluate a novel perfluoro-octyl bromide (PFOB) emulsion, one of perfluorochemicals (PFCs) emulsions, administered during hemodilution CPB., Methods: Fifteen dogs were subjected to CPB for 2 hours under mild hypothermia. Animals were divided into three groups; control group, hemodilution group and PFOB group. During the experiment, hemodynamics, complete blood count and blood chemistry were monitored. In addition, serum complement titer (CH50), bradykinin and histamine concentrations were also measured., Results: Heart rate (HR) was markedly elevated in the hemodilution groups (p<0.05). Mean arterial pressure (MAP) did not change in the three groups. White blood cell (WBC) and platelet (PLT) count did not significantly differ among the three groups. Plasma lactate concentration was markedly elevated only in hemodilution group during late phase of CPB (p<0.05). In the hemodilution group, CH50, bradykinin and histamine, were markedly elevated during the CPB and just after CPB (p<0.05)., Conclusions: The present study demonstrated possible benefits of the new PFC emulsion during cardiac surgery by counteracting the adverse effects of hemodilution during CPB.

Although identification of the key artery that perfuses the spinal cord is essential to avoid occurrence of paraplegia after surgery on the thoracoabdominal aorta, reliable and noncomplicated measures are not yet available. A new method of determining it by using echocardiography with a saline injection into the lumbar artery was evaluated for feasibility and adequacy in a canine model. In two mongrel dogs, the abdominal aorta was opened and saline was directly injected into the lumbar arteries while the spinal cord was visualized by echocardiography through the intervertebral disc. When the echogenic or Doppler signal was detected in the spinal cord, the particular lumbar artery was determined as "positive", or as "negative" when the signal was not detected. After the dog was sacrificed, red resin was injected into the "positive" arteries and blue resin into the "negative" arteries. In the extracted spinal cord, the anterior and posterior spinal arteries were filled with red resin, rather than with blue resin, to indicate that the key arteries were correctly identified. There were multiple "positive" arteries, which were mainly located on the left side and accounted for approximately one-third of the entire lumbar arteries. The "negative" arteries mainly perfused the muscles around the vertebra. Injected resin came out of the adjacent lumbar arteries of the same category, suggesting that communication is present among the positive arteries, but independently of that among the negative arteries. Echo-guided identification of key arteries is technically feasible and correctly determines the key arteries in this preliminary canine model.

The performance of cardiac surgical procedures via median sternotomy in a patient with a tracheostomy can result in difficult problems, such as mediastinitis, stoma necrosis or inadequate operative exposure. We present a case of successful treatment for aortic valve regurgitation in a patient with a tracheostomy using a T-shaped sternotomy instead of a usual median sternotomy. This approach permitted adequate surgical exposure for cardiopulmonary bypass and aortic valve replacement. After surgery, the patient had a good clinical course without any complications and he was discharged on the 65th postoperative day. We consider this procedure to be applicable in consideration of the favorable results obtained.

We report a 58-year-old male treated with surgical drainage by mediansternotomy using a pedicled omental flap for descending necrotizing mediastinitis (DNM). The patient recovered from DNM after five months of mechanical respiratory support. In deciding upon the most appropriate surgical approach for mediastinal drainage, the level of infection is a good landmark and should be investigated by CT scan. We also review the 43 cases of successful surgical treatment of DNM reported since 1989 in Japan, including our own patient, who were diagnosed with DNM by CT scan according to the classification proposed by Endo et al., and discuss the most appropriate surgical approach for mediastinitis based on the literature. In the treatment of DNM localized to the upper mediastinal space above the carina, a transcervical approach may be appropriate. In diffuse DNM extending into the lower anterior mediastinum, a mediansternotomy or a thoracotomy may be useful, and in diffuse DNM extending into both the anterior and posterior lower mediastinum, a thoracotomy may be the best approach for debridement of the lower posterior mediastinum, in addition to early complete debridement of the entire cervical area.

We report a rare successful surgical repair of a common atrium (CA) with mild tricuspid valve (TV) regurgitation due to valvular annulus enlargement in a 39-year-old man, who had a complete atrial septum defect (ASD) without the characteristic of an endocardial cushion defect. The left-to-right shunt ratio was 85 percent and the Qp/Qs was 6.7 due to the CA. Left ventriculogram revealed no evidence of typical goose-neck deformity and no mitral valve regurgitation. The operation consisted of making a new atrial septum with an autologous pericardial patch and tricuspid annuloplasty (DeVega) using extracorporeal circulation. There was no evidence of a cleft on the anterior leaflet of the mitral valve or the septal leaflet of the TV. The postoperative echocardiogram showed no residual shunt flow through a new atrial septum and no TV regurgitation, and atrioventricular (AV) dissociation did not occur. We consider this procedure to be widely applicable in consideration of the favorable results obtained after surgical treatment.

Yohimbine, an alpha(2)-adrenoceptor antagonist, has been reported to protect hypoxic myocardium and inhibit carrier-mediated norepinephrine (NE) release and reperfusion arrhythmias (ventricular fibrillation; VF) in normothermic ischemia. In heart surgery, mild hypothermic (tepid) cardioplegia has been reported to reduce metabolic demand and permit immediate recovery of cardiac function. Therefore, we determined the effect of yohimbine on NE release and reperfusion arrhythmias in isolated perfused guinea pig hearts of tepid temperature (32 degrees C) ischemia model. Stepwise increase of global ischemia period (20, 40, and 60 min) induced a progressive increase of NE release and duration of VF. Neuronal uptake 1 inhibitor desipramine (100 nM) and Na(+)-H(+) exchanger inhibitor 5-N-ethyl-N-isopropyl-amiloride (10 microM) decreased NE and VF in 60-min hypothermic ischemia. This indicated that NE release induced by protracted tepid ischemia was due to carrier-mediated release. Yohimbine (1 microM) markedly reduced NE release and VF (p < 0.01 versus control) and 5-bromo-N-(4,5-dihydro-1H-imidazol-2-yl)-6-quinoxalinamine [UK 14,304 (UK); 10 microM], an alpha(2)-adrenoceptor agonist, increased NE release and VF (p < 0.01 versus control). Yohimbine (1 microM) prevented the potentiated effect of UK (10 microM) in hypothermia (p < 0.01 versus UK). Our findings indicate that presynaptic reduction of carrier-mediated NE release seems to be one of the most important factors controlling reperfusion arrhythmias, and alpha(2)-adrenoceptor blockade by yohimbine (1 microM) in tepid ischemia may contribute to effective myocardial protection in terms of NE release and reperfusion arrhythmia.

A 42-year-old man was admitted to another hospital complaining of acute abdominal pain that was induced by eating. Abdominal computed tomography and selective angiography revealed an intimal flap separating true and false lumens that was located 3 cm from the origin of the superior mesenteric artery (SMA). Emergency surgery was performed because of the sudden recurrence of diffuse abdominal pain after eating and abdominal aorta-SMA bypass grafting was done using a radial artery graft. Postoperative angiography revealed that the graft showed good patency. The postoperative course was uneventful and abdominal pain no longer occurred after eating. This excellent result was achieved by early diagnosis using CT scanning and angiography plus an aggressive surgical repair with a radial artery bypass graft for isolated dissection of the superior mesenteric artery.

A 53-year-old man crashed his motorcycle into a vehicle and was transported to our hospital by ambulance after about 30 min. Echocardiography revealed cardiac tamponade. Pericardiocentesis was immediately performed using a 5 Fr catheter via the subxiphoid approach and the results suggested cardiac injury. Surgery was commenced via median sternotomy about 2.5 hours after the accident. Patients with cardiac rupture who reach hospital alive can be saved by rapid transport, early detection, and early surgery. In particular, rapid echocardiography and pericardiocentesis via the subxiphoid approach under ultrasonic guidance are easy and helpful methods of making a diagnosis and achieving hemodynamic improvement prior to surgical intervention.

Spontaneous and isolated dissection of the limb arteries without involvement of the aorta is extremely rare. We present a 36-year-old male who has 95% tapering stenosis and dissection of the left external iliac artery with abrupt onset with total thrombosis in the false lumen until the level of the inguinal ligament. We also suggest that endovascular stent graft placement is a useful treatment for isolated arterial dissections prior to operation in consideration of the technical ease and safety of guiding intravascular ultrasound like in this case.