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The K+ channel opener nicorandil is a hybrid compound that contains nitrate in its structure. It has been reported that nicorandil can relax vascular tissue in vitro via a mechanism that involves activation of KATP channels and stimulation of soluble guanylyl cyclase. However, it is not known whether the increase of cGMP levels occurs through an elevation of nitric oxide (NO). The aim of the present study was to determine whether NO release was a direct effect of nicorandil. We reported here that nicorandil did not generate NO using ozone chemiluminescence detection methods in human or rat liver microsomes (P450-rich fractions) with addition of NADPH. However, nicorandil elevated cGMP levels in rat liver, aorta, and human coronary smooth muscle cells in vitro. The elevation was not inhibited by the NO trapping agent carboxy-2-phenyl-4,4,5,5-tetramethyl-imidazoline-1-oxyl-3-oxide (carboxy-PTIO). These results suggest that nicorandil elevates cGMP without NO generation. Keywords:: nicorandil, nitric oxide (NO), cGMP, P450

Background Early outcomes of off-pump coronary artery bypass grafting have been documented by numerous studies. However, there have been few reports concerning midterm outcomes after off-pump coronary artery bypass grafting. Methods We retrospectively reviewed the records of 602 consecutive patients (24.8% female) who underwent isolated off-pump coronary artery bypass grafting between April 2001 and July 2004. Mean age was 66.7 ± 9.3 years. Mean Canadian Cardiovascular Society score was 2.5 ± 0.9. Early postoperative angiograms were evaluated during the same period of hospitalization. Midterm outcomes, including overall patient survival, freedom from cardiac death, and freedom from the combined endpoint of cardiac events, were evaluated. Results The average number of distal anastomoses per patient was 3.6 ± 1.4. The average operation time was 286.1 ± 72.1 minutes. Long segmental reconstruction of the left anterior descending coronary artery was performed in 218 patients (36.2%). Total arterial grafting was performed in 466 patients (77.4%). Thirty-day mortality was 0.5%. Overall patency rate for all grafts and anastomoses was 97.5% and 97.6%, respectively. Mean follow-up time was 2.9 ± 1.0 years. Cumulative patient survival at 5 years was 87.9% ± 2.4%. Freedom from cardiac death was 97.7% ± 0.6% at 5 years. Freedom from the combined endpoint of cardiac events was 83.8% ± 2.3% at 5 years. Conclusions Early and midterm outcomes after off-pump coronary artery bypass grafting have acceptable mortality and cardiac events rates, with favorable early graft patency rates.

The aim of this retrospective study was to detect the risk factors for in-hospital mortality after surgery for active prosthetic valve endocarditis ( PVE). We reviewed 35 operations for active PVE, including 6 cases of early PVE. Seven patients were New York Heart Association (NYHA) functional class IV. Preoperative mechanical ventilation was necessary in 3 patients, 1 patient required intra-aortic balloon pumping, and another needed percutaneous cardiopulmonary support. Preoperatively, cerebrovascular events were observed in 13 patients, annular abscess in 12, and perivalvular leakage in 14. Valve replacement was performed in 24 patients and aortic root replacement in 11. Annular reconstruction was required in 18 patients. There were 6 hospital deaths (17.1%). The results of risk factor analysis showed that early PVE, NYHA functional class IV, and preoperative mechanical ventilation were independent risk factors for in-hospital death after surgery. In conclusion, surgical treatment of PVE should be performed before hemodynamic deterioration.

Esophageal anastomotic leakage is one of the most fatal complications after esophagectomy and increases the hospitalization length. We aimed to identify a convenient clinical marker of anastomotic leakage in the early postoperative period.In total, 108 patients who underwent esophagectomy were retrospectively screened, and 96 were used to validate the overall results. All 108 patients underwent physical examinations and determination of their white blood cell count, C-reactive protein level, platelet count, fibrinogen level, fibrin degradation product level, and antithrombin III level until postoperative day 6.Anastomotic leakage occurred in 21 of the 108 patients (median detection, 8 days). The C-reactive protein level on postoperative day 3 and fibrinogen level on postoperative day 4 in the leakage group were significantly higher than those in the nonleakage group. Receiver operating characteristic curves for detection of anastomotic leakage were constructed; the cutoff value of C-reactive protein on postoperative day 3 was 8.62 mg/dL, and that of fibrinogen on postoperative day 4 was 712 mg/dL. Anastomotic leakage occurred in 23 of the 96 patients in the validation group. There was a significant difference between the leakage and nonleakage groups when the C-reactive protein threshold on postoperative day 3 was set at 8.62 mg/dL. However, there was no difference between the groups when the fibrinogen threshold on postoperative day 4 was set at 712 mg/dL.The C-reactive protein level on postoperative day 3 is a valuable predictor of anastomotic leakage after esophagectomy and might allow for earlier management of this complication.

A 67-year-old man was admitted to our hospital by ambulance after syncope due to complete A-V block. He had received surgical treatment for mycotic aneurysm of the right coronary artery 3 months before, with patch plasty of the right sinus of Valsalva and bypass grafting to the right coronary artery (RCA) as well as the left anterior descending branch. Computed tomography revealed pseudoaneurysm of the right Valsalva sinus of about 8 cm in diameter and a shunt flow to the right atrium. The previous bypass graft to RCA had been occluded due to compression by the aneurysm. As he was in a shock state, emergency operation was performed. Cardiopulmonary bypass was first established, and after the rectal temperature reached to 26 degrees centigrade, the chest was opened. The pseudoaneurysm burst out when the sternum was re-opened. Under circulatory arrest, the ascending aorta was clamped, and then the circulation was resumed. The previous bovine pericardium patch repairing the Valsalva sinus was detached due to infection, and mural thrombus and pus were observed in the aneurysm. At the bottom of the aneurysm, a fistula connected to the right atrium was found. Debridement around the aneurysm was performed as much as possible. The defect of the Valsalva sinus was repaired with a Dacron patch immersed in gentian violet. The postoperative course was uneventful without any recurrence of infection.

A 41-year-old man was shot three times with a custom-made handgun. There were six small round wounds on the surface from two bullets that went into the body and one bullet found in a wall behind the victim at the scene. The gunshot wound in the left supraclavicular region bled massively. He was transferred to our hospital and soon fell into shock. A chest radiogram showed right hemothorax. Resuscitation and blood transfusion were started, and right thoracic drainage was immediately undertaken. The left subclavicular region was incised, and bleeding from the left subclavian vein stopped. Right thoracotomy was done, and bleeding from the lung was controlled. Laparotomy was needed to look for the missing trajectory. Speculation regarding trajectories of bullets in patients with multiple thoracoabdominal gunshot wounds is difficult, and an emergent operation is often needed to control bleeding or to evaluate possible organ injury.

A 29-year-old female was admitted to our hospital complaining of severe dry cough and low-grade fever. A chest roentgenogram and a chest computed tomographic scan revealed a huge tumor and massive pleural effusion in the left pleural cavity. Pathological examination revealed spindle shaped malignant cells. SYT-SSX fusion gene transcripts were detected, so we diagnosed the tumor as a synovial sarcoma in the pleural cavity. After neoadjuvant chemotherapy we resected the tumor completely. A synovial sarcoma in the pleural cavity is extremely rare. To the best of our knowledge, this is the thirteenth case, and the first case to undergo neoadjuvant chemotherapy and complete resection. Because a synovial sarcoma in the pleural cavity has a poor prognosis and is characterized by a high incidence of recurrence, we must carefully follow up this patient.

We examined the expression of mucin core protein 1 (MUC1) immunohistochemically in 186 surgical specimens of histopathologically nonmucinous hepatocellular carcinoma (HCC) and compared the clinicopathological features in patients with MUC1-positive HCC (MUC1-positive group) with those in patients with MUC1-negative HCC (MUC1-negative group).MUC1 immunoreactively was present in 85 of the 186 HCCs. Of the clinicopathological variables examined, the serum concentration of alpha-fetoprotein, tumor differentiation, bile duct invasion, lymph node metastasis, and cytokeratin 19 expression exhibited significant associations with MUC1 expression. Although cumulative and tumor-free survival rates were not different between the two groups, the percentage of patients with first recurrence of HCC in distant organs (distant metastasis) within 2 years after surgery was significantly higher in the MUC1-positive group than in the MUC1-negative group (P = 0.0104). The risk ratio of MUC1 positivity for this type of distant metastasis was 3.156 (95% confidence interval, 1.064-9.358).In patients with MUC1-positive HCC, careful follow-up is necessary, not only for intrahepatic recurrence but also for distant metastasis, after the resection of primary HCC.

The purpose of this study was to analyze the clinical significance of serum Sialyl Lewisx (SLX) concentrations as a predictor of N2 disease in patients with non–small-cell lung cancer. The study included 272 patients with non–small-cell lung cancer who underwent pulmonary resection in our institution between January 1998 and December 2003. Of 272 patients, the serum concentrations of SLX were measured by using a commercially available radioimmunoassay kit. The 5-year survival rates of patients with concentrations of SLX > 38 U/mL and those with lower concentrations were 32% and 69%, respectively (P < .0001). The median serum concentration of SLX in patients with multilevel N2 or N3, single-level N2, and N0/1 disease were 44, 30, and 27 U/mL, respectively. The concentrations of serum SLX in patients with multilevel N2 disease were significantly higher than those in patients with single-level N2 or those with N0/1 disease (Mann-Whitney U-test; P < .0001). Although the sensitivity of SLX for identifying patients with non–small-cell lung cancer was only 24% in all patients, the sensitivity of SLX increased as the N-factor increased; the sensitivity of N0/1 disease was 15%, that of single-level N2 disease was 22%, and that of multilevel N2 or N3 disease was 71%. High serum concentrations of SLX predicted multilevel N2 disease and the associated poor outcome. Although the sensitivity of serum SLX is not acceptable for use as a screening tumor marker, we suggest that the serum concentration of SLX is useful as a staging marker to determine the strategy of treatment.

We describe an unusual case of a thoracic aortic aneurysm caused by Aspergillus. A 70-year-old man underwent prednisolone and Ara-C treatments for a myelodysplastic syndrome. Blood examination revealed pancytopenia. Under these treatments, an aneurysm presented at the distal aortic arch. He underwent resection of the aneurysm with a graft repair covered by a pedicled omentum flap, followed by prolonged administration of micafungin and itraconazole for a mycotic aneurysm. The postoperative course was favorable without complications. Serum C-reactive protein became negative and he was discharged 2 months after the surgery. However, 4 months after the surgery, he died from worsening of the myelodysplastic syndrome. The prognosis for patients with mycotic aneurysms is poor due to their immunocompetent condition arising from underlying diseases. Therefore, in addition to prompt treatment with antifungal agents combined with surgical debridement, control of the underlying disease is essential for improving the outcome.

Background— Multilineage developmental capacity of the CD34 + cells, especially into cardiomyocytes and smooth muscle cells (SMCs), is still controversial. In the present study we performed a series of experiments to prove our hypothesis that vasculogenesis and cardiomyogenesis after myocardial infarction (MI) may be dose-dependently enhanced after CD34 + cell transplantation. Methods and Results— Peripheral blood CD34 + cells were isolated from total mononuclear cells of patients with limb ischemia by apheresis after 5-day administration of granulocyte colony-stimulating factor. PBS and 1×10 3 (low), 1×10 5 (mid), or 5×10 5 (high) CD34 + cells were intramyocardially transplanted after ligation of the left anterior descending coronary artery of nude rats. Functional assessments with the use of echocardiography and a microtip conductance catheter at day 28 revealed dose-dependent preservation of left ventricular function by CD34 + cell transplantation. Necropsy examination disclosed dose-dependent augmentation of capillary density and dose-dependent inhibition of left ventricular fibrosis. Immunohistochemistry for human-specific brain natriuretic peptide demonstrated that human cardiomyocytes were dose-dependently observed in ischemic myocardium at day 28 (high, 2480±149; mid, 1860±141; low, 423±9; PBS, 0±0/mm 2 ; P Ulex europaeus lectin type 1 also revealed dose-dependent vasculogenesis by endothelial cell and SMC development after CD34 + cell transplantation. Reverse transcriptase–polymerase chain reaction indicated that human-specific gene expression of cardiomyocyte (brain natriuretic peptide, cardiac troponin-I, myosin heavy chain, and Nkx 2.5), SMC (smooth muscle actin and sm22α), and endothelial cell (CD31 and KDR) markers were dose-dependently augmented in MI tissue. Conclusions— Human CD34 + cell transplantation may have significant and dose-dependent potential for vasculogenesis and cardiomyogenesis with functional recovery from MI.

Organic nitrates, such as nitroglycerin (NTG), have been used to relieve the symptoms of angina pectoris. However, their biochemical mechanisms of action, particularly in relation to the development of tolerance, are incompletely defined. It has been reported that supplemental antioxidants such as vitamin E attenuate the development of nitrate tolerance. Therefore, we examined the role of vitamin E in the regulation of nitrate tolerance. Continuous NTG infusion induced nitrate tolerance in rats after 48 h, and vitamin E concentrations decreased in a time-dependent manner in tissues and plasma. Vitamin E supplementation (0.5 g/kg diet) maintained higher concentrations of vitamin E during NTG infusion. The onset and extent of the tolerance, estimated by the decrease in blood pressure following NTG bolus injection during the infusion of NTG, were accentuated in the vitamin E-deficient group. Vitamin E supplementation inhibited nitrate tolerance 48 h after NTG infusion. Cardiac P450 expression (CYP1A2) assessed by immunoblotting, markedly decreased 48 h after NTG administration in control rats. The supplementation of vitamin E significantly attenuated the decrease in P450. Treatment of NTG enhanced vascular superoxide production (L-012 chemiluminescence, DHE fluorescence). The peak of lipid peroxidation and free radical generation in the heart was reached before tolerance developed. In contrast, vitamin E-deficient hearts had lower P450 expression and higher free radical generation than control hearts. To evaluate other vitamin E-inhibitable mechanisms of nitrate tolerance, we studied the NO-cGMP pathway. NTG markedly reduced the vasodilator-stimulated phosphoprotein (VASP) serine 239 phosphorylation (specific substrate of cGMP-activated protein kinase I; cGK-I) in tolerant hearts. Vitamin E inhibited the depletion of pVASP. In conclusion, because continuous NTG infusion causes vitamin E depletion as well as nitrate tolerance, vitamin E deficiency may further accelerate nitrate tolerance via an increase in oxidative stress, the reduced bioconversion because of decreased P450 expression, and impairment of the NO/cGMP pathway in tolerant heart tissues.

Mesenchymal cells, primarily fibroblasts and myofibroblasts, are the principal matrix-producing cells during pulmonary fibrogenesis. Transforming growth factor (TGF)-beta signaling plays an important role in stimulating the expression of type I collagen of these cells. Bone morphogenetic protein (BMP)-7, a member of the TGF-beta superfamily, has been reported to oppose the fibrogenic activity of TGF-beta1. Here, we have addressed the effects of BMP-7 on the fibrogenic activity of pulmonary myofibroblasts. We first established cell lines from the lungs of transgenic mice harboring the COL1A2 upstream sequence fused to luciferase. They displayed a spindle shape and expressed vimentin and alpha-smooth muscle actin, but not E-cadherin. COL1A2 promoter activity was dose dependently induced by TGF-beta1, which was further augmented by adenoviral overexpression of Smad3, but was downregulated by Smad7. Under the identical condition, adenoviral overexpression of BMP-7 attenuated the TGF-beta1-dependent COL1A2 promoter activity. By immunocytochemistry, the ectopic expression of BMP-7 led to the nuclear localization of phospho-Smad1/5/8 and suppressed that of Smad3. BMP-7 suppressed the expression of mRNAs for COL1A2 and tissue inhibitor of metalloproteinase-2 while increasing those of inhibitors of differentiation (Id) 2 and 3. Ectopic expression of Id2 and Id3 was found to decrease the COL1A2 promoter activity. Finally, BMP-7 and Id2 decreased TGF-beta1-dependent collagen protein secretion. In conclusion, these data demonstrate that BMP-7 antagonizes the TGF-beta1-dependent fibrogenic activity of mouse pulmonary myofibroblastic cells by inducing Id2 and Id3.

Self-expandable metallic stent (EMS) placement has been the first choice for dysphagia because of the certainty over its safety, low invasiveness, and immediate efficacy. However, there still remain some problems in relation to the EMS placement site and anticancer therapies before and after EMS placement. Methods: Consecutive 78 patients in whom EMS was placed due to the unresectable malignant stricture in the esophagus or cardia from July 1995 to August 2003 in our department were studied. Results: Gastroesophageal reflux was found in 5 of 8 patients after placement of conventional EMS for the stricture in the gastroesophageal junction. Meanwhile, acid and bile reflux into the esophagus were not detected by pH and bilirubin monitoring, respectively, in 6 patients after placement of the EMS with an anti-reflux mechanism for the stricture in the gastroesophageal junction. The median survival period of all patients after EMS placement was 123 days. The median survival period of 7 patients with radiotherapy only after EMS placement was 138 days and that of 17 patients with radiotherapy before EMS placement was 60 days, which was shorter than that of the former (p

The failure of the vascular anastmoses is a devastating complication in free jejunum transplantation. We used color Doppler sonography to estimate blood flow in free jejunal grafts in 21 patients who underwent radical pharyngoesophagectomy. Fast Fourier transform (FFT) analysis of blood flow, the pulsatility index (PI) as a measure of peripheral vascular resistance, and thickening of the graft wall were evaluated for predictive value. The arterial wave patterns were classified into three types based on systolic–diastolic differences and magnitude of flow. Type I was physiologic flow, type III overtly pathologic, and type II intermediate. The three patients who required vascular reanastomoses intraoperatively had a type II pattern that degenerated to type III within 15 minutes. The PI increased to 3.5 to 4.5 over 1 hour. In the one patient who required retransplantation, the wave pattern became type III by 18 hours and had disappeared by 24 hours, at which point the PI could not be measured. Jejunal thickening increased from 1.0 mm to 5.0 mm after 24 hours, even in healthy grafts. Monitoring blood flow during the 24 hours after surgery is critical. A type III wave pattern or a PI >2.5 is an indication for reexploration. Doppler sonography offers a noninvasive way to measure blood flow in jejunal grafts semiquantitatively and can predict free jejunal graft failure.

症例は62歳男性. 主訴は咳嗽および両手関節痛. 末梢血液検査上, 好中球優位の白血球増多を認めたため, 血清G-CSF値を測定したところ98pg/ml と上昇していた. また胸部X線像上, 右肺下葉に径5cmの腫瘤陰影を認め, 気管支鏡下細胞診にて腺癌と診断された. 諸検査にてc-T2N0M0 stage IBと診断し右肺下葉切除術および縦隔リンパ節郭清術を施行した. 病期はp-T2N1M0 stage IIBであった. 切除標本の抗rhG-CSF抗体を用いた免疫組織化学染色は陰性であったが, 術後白血球数, 血清G-CSF値は正常化し, 関節炎症状も消失したため, 臨床経過よりG-CSF産生肺癌と診断した. 術後経過は良好で術後9ヵ月経過も関節炎症状を含め再発を認めていない. G-CSF産生肺癌の報告は近年増加しており, 自験例を含め本邦報告例92例の考察を加え報告する.

Ischemia-reperfusion injury is responsible for the morbidity associated with liver surgery under total vascular exclusion or after liver transplantation. Recently, it has been reported that mitochondrial K A T P channel openers have an effect on myocardial protection via a pharmacological preconditioning action. However, it remains unclear as to whether K A T P channel openers can reduce ischemia-reperfusion injury in the liver. The aim of this study was to determine the effects of the mitochondrial K A T P channel opener, nicorandil, on ischemia-reperfusion injury in the rat liver. Male Wistar rats were subjected to 73% ischemia for 45 minutes followed by 120 minutes of reperfusion. Nicorandil (3 mg/kg) was orally administered 60 minutes before hepatic ischemia. Nicorandil significantly decreased plasma levels of alanine aminotransferase and lactate dehydrogenase by about 50% and inhibited the remarkably increased TUNEL-positive hepatocytes after reperfusion. Some mediators associated with apoptosis were analyzed by Western blotting. Cytochrome-c and caspase-3 levels in the cytosol increased after reperfusion; nicorandil inhibited the release of cytochrome-c and activation of caspase-3. The expression of Bax and Bcl-2 was significantly increased after reperfusion, being slightly inhibited by the administration of nicorandil. These results suggest that the protective effects of nicorandil against hepatic ischemia-reperfusion injury correlate with the inhibition of mitochondrial cytochrome-c release and caspase-3 activation. These findings demonstrate that nicorandil may become a therapeutic drug for ischemia reperfusion-related liver injury.

Background. In organ transplantation, several immunosuppressants are currently used to control graft rejection. Clinically, no single immunosuppressive agent can completely prevent posttransplantation immunoreaction; thus, combination therapy is usually performed. Novel agents with more powerful immunosuppressive activity and less toxicity need to be developed. Methods. Lewis rat livers were orthotopically transplanted into Brown-Norway recipients. FK778 was administered orally from day 0 to day 6 to prevent acute rejection and from day 7 to day 13 to rescue ongoing rejection. To assess the combined effects, recipients were treated with intramuscular injection of FK506 and oral administration of FK778 from day 0 to day 6. Blood chemistry and histopathologic findings were measured to determine the patient's general condition and the graft condition. Allospecific antibodies were measured using enzyme-linked immunosorbent assays. The FK778 trough concentration was examined by using high-performance liquid chromatography. Results. The acute immune response was suppressed by FK778 alone in a dose-dependent manner. The optimal FK778 dosage was determined to be 20 mg/kg per day, because adverse effects (weight loss and intestinal bleeding) occurred at 30 mg/kg per day. FK778 treatment from day 7 to day 13 rescued liver grafts from ongoing rejection. The intramuscular FK506 (0.125 mg/kg per day) injection and the oral FK778 (20 mg/kg per day) gavages suppressed acute liver graft rejection effectively and maintained better graft condition compared with monotherapy. Conclusions. FK778 treatment effectively prevented acute rejection and rescued ongoing rejection after liver transplantation. The optimal dosage was determined to be 20 mg/kg per day. Combination therapy with FK506 was more beneficial than FK778 monotherapy.

Poly-2-methoxyethylacrylate (PMEA) is a new coating material, and several studies have revealed that PMEA-coated cardiopulmonary bypass (CPB) circuits have good biocompatibility. This study sought to compare this biocompatibility with those of heparin-coated and noncoated circuits.Forty-five patients undergoing coronary artery bypass grafting were randomly assigned to PMEA-coated (group P, n = 15), heparin-coated (group H, n = 15), or noncoated (group N, n = 15) circuit groups. Clinical data and the following markers were analyzed: (1) platelet preservation by number of platelets; (2) complement (C) activation by C3a and C4a levels; (3) inflammatory response by interleukin-6 (IL-6) and interleukin-8 (IL-8) levels.Platelet numbers were significantly preserved in group P compared with groups N and H. Postoperative blood loss did not differ among the groups. During CPB, C3a values were significantly lower in group H (536 +/- 145 ng/mL) than in group P (1,458 +/- 433 ng/mL, p0.01) and group N (1,815 +/- 845 ng/mL, p0.01). The C4a values did not differ 60 minutes after CPB initiation among the groups. The IL-6 and IL-8 levels were significantly lower in group P and group H than in group N.The PMEA coating was superior to heparin coating and noncoating in preserving platelets, and was equivalent to heparin coating in terms of the perioperative clinical course and inhibition of inflammatory cytokines, but slightly inferior in reducing complement activation.

Background The present study was designed to investigate whether orally administered benidipine and manidipine protect the myocardium from ischemia - reperfusion injury. Methods and Results Each drug (1, 3 or 10 mg/kg) was administered orally once daily for 1 week. The isolated rat heart model (Langendorff perfusion) was used, and each heart was subjected to global ischemia at 37°C for 40 min followed by reperfusion. Post-ischemic recovery of left ventricular (LV) function (measured as developed pressure (LVDP), dP/dt max and end-diastolic pressure) was compared with a control group. Creatine kinase (CK) leakage was also measured. Post-ischemic recovery of LVDP and LV dP/dt max were significantly increased by 3 mg/kg benidipine (LVDP: 87.5±10.1 vs 64.6±11.9%; LV dP/dt max: 97.8±10.4 vs 70.2±15.7%; p

Warfarin is widely used in clinical practice all over the world. We report a man in whom prominent eosinophilia appeared after the initiation of warfarin administration following aortic valve replacement. Laboratory data following the administration and discontinuation of warfarin suggested that this drug was responsible for the eosinophilia. It is important to recognize the possibility of warfarin-induced hypereosinophilia as a latent adverse effect even when there are no clinical signs or symptoms.

A 63-year-old woman successfully underwent a graft replacement of the retrohepatic inferior vena cava with a ringed polytetrafluoroethylene graft for primary leiomyosarcoma of the inferior vena cava (IVC). Although anticoagulant had been administered, a thrombus was found in the IVC just cranial of the downstream anastomosis 67 months after the operation. The patient remained free of symptoms, and she had no evidence of any tumor recurrence. She underwent a complete resection with a prosthetic reconstruction for leiomyosarcoma of the IVC and has since been able to enjoy a reasonably long-term survival. The occurrence of thrombosis must be kept in mind in the long-term follow-up of such cases.

Aneurysm of the membranous ventricular septum (AMS) is a congenital cardiac anomaly often associated with ventricular septal defect. This aneurysm usually pouches into the right side of the heart and remains intracardiac. An AMS that extends outside of the heart is rare. We report an unusual case of a giant extracardiac AMS diagnosed by transthoracic color flow Doppler echocardiography.

A 69-year–old man was referred to our department for surgical treatment of bilateral giant coronary artery aneurysms. He had no apparent clinical factors associated with atherosclerosis, such as diabetes mellitus, hyperlipidemia, or hypertension. Physical examination revealed no abnormalities. His medical history included malignant lymphoma that had been treated with chemotherapy and radiation therapy at the age of 60 years. He was also diagnosed with a plasma cell tumor in his tonsils at the age of 68 years. Just before treatment for this tumor, he developed sudden-onset myocardial infarction. Coronary angiography revealed 2 giant coronary aneurysms; one presented as a broad aneurysmal change of the right coronary artery (Figure 1A and Movie I in the online-only Data Supplement), and the other was located from the left main coronary artery to the left anterior descending artery (Figure 1B and Movie II in the online-only Data Supplement). On the basis of subsequent computed tomography, the maximum diameters of the right and left coronary aneurysms were 40 and 25 mm, respectively (Figure 2). Laboratory examination showed that the serum immunoglobulin …

A 41-year-old woman was evaluated because of elevated serum levels of the tumor markers CA19-9 and CA125. Whole-body examination revealed an intralobar pulmonary sequestration in the right lower lobe and bilateral cystic ovarian tumors (right: 20 mm, left: 60 mm in diameter, respectively). The left ovarian cyst was resected and diagnosed as an endometrioma. The right ovarian cyst was preserved because of its small size. However, the tumor marker levels remained elevated postoperatively. S10 segmentectomy of the right lung was subsequently performed. Immunohistochemical examination of the sequestrated lung demonstrated positive staining for CA19-9 in the bronchial and alveolar epithelia and mucus. After the pulmonary resection, the CA19-9 and CA125 levels decreased to their normal ranges.

Bicuspid aortic valve (BAV) is associated with an increased risk of aortic valve (AV) dysfunction, aortic dissection, and infective endocarditis. Therefore, its accurate diagnosis is critical. The morphological features of AVs are generally evaluated by transthoracic echocardiography (TTE) or transesophageal echocardiography (TEE), however, the difference in the diagnostic capability of these imaging modalities for detecting BAV remains unclear. Here, we compared these 2 methods to determine their accuracy, and to clarify each role in the diagnosis of BAV.This blind study evaluated 126 patients (age, 70.3 +/- 7.8 years) who subsequently underwent AV replacement. The number of AV cusps of each patient was estimated by TTE and TEE and compared to the number of AV written in the operative record. Patients with poor echocardiographic images were not excluded.Surgical findings showed 97 tricuspid AVs and 29 BAVs. The sensitivity, specificity, and accuracy for the diagnosis of BAV were 61%, 81%, and 77%, respectively, for TTE and 86%, 90%, and 89%, respectively, for TEE. The accuracy of TEE was significantly higher than that of TTE (p = 0.016). In non-calcified AVs, the accuracy of TTE was similar to that of TEE (96%, each) whereas in calcified AVs, TTE had a lower accuracy than TEE (72% vs 87%, p = 0.011). The feasibility was significantly higher for TEE than for TTE (98% vs 90%, p = 0.003).TEE provides higher accuracy and feasibility than TTE in the diagnosis of BAV, and it should therefore be indicated when morphological features of AVs cannot be evaluated by TTE.

We evaluated the preoperative and postoperative characteristics and prognosis of super-elderly patients with hepatocellular carcinoma (HCC). Four hundred and thirty-one patients who underwent hepatic resection for HCC were classified into three groups according to their age at the time of surgery: super-elderly (≥80 years; n = 20), elderly (70–80 years; n = 172) and younger (

Blunt traumatic injury to the innominate artery is relatively rare. We present the case of a 40-year-old woman who fell from a fourth-floor window and was transferred to our hospital with multiple injuries, hemodynamic shock, and disturbance of consciousness. Computed tomography with image reconstruction revealed transection of the innominate artery near its origin. Emergent surgery required establishment of cardiopulmonary bypass before sternotomy in preparation for uncontrollable hemorrhage. Proximal aortic arch replacement with a branch to the right axillary artery was successfully performed using circulatory arrest and selective cerebral perfusion.

Platypnea-orthodeoxia is a rare syndrome presenting with dyspnea and cyanosis induced by an upright position and relieved by recumbency. We report a patient with an excessively enlarged aortic root who had critical hypoxia due to a paradoxical shunt through the patent foramen ovale only when seated. The postural changes of the shunt, caused by changes in posture, were dynamically detected by transesophageal Doppler echocardiography. We believe that this syndrome should be considered when patients with aortic root dilatation present with inexplicable hypoxia, and that transesophageal Doppler echocardiography in the sitting position can be useful for detecting platypnea-orthodeoxia syndrome.

Objective: Radial artery suitability in coronary artery bypass grafting was assessed using duplex ultrasonography.Subjects and Methods: The vascular condition along the entire radial artery was scanned in 55 patients, measuring the internal diameter and mean flow velocity at the wrist (distally), after ulnar artery branching (proximally), and midway between these 2 points (medially). Distally along the radial and ulnar arteries, the mean flow velocity was determined before and after radial artery occlusion.Results: Atherosclerotic changes were detected in 4 patients. The internal diameter was 3.1 ± 0.4 mm proximally, 2.7 ± 0.3 mm medially, 2.4 ± 0.4 mm distally. The distal flow velocity was 0, and a reverse flow (peak velocity: 11.3 ± 6.0 cm/s) was observed after the occlusion test in patients with an intact palmar arch, their mean flow velocity, 21.1 ± 8.9 cm/s, and flow distally along the ulnar artery 58.0 ± 23.4 ml/min, were higher after the occlusion test than before it 14.7 ± 6.7 cm/s mean flow and 38.1 ± 15.9 ml/min distally. This was not observed in patients with an interrupted palmar arch. In 15 patients, radial arteries could not be used because of their small internal diameter, lack of a radial artery, poor vascular condition, or an interrupted palmar arch evaluated using duplex scanning.Conclusion: Reliable noninvasive assessment of radial artery anatomy and palmar arch continuity is thus possible using duplex ultrasonography.

OBJECTIVE—To provide better insights into the genesis of neointimal thickening in human vein grafts early after surgery. DESIGN—Retrospective study. SETTING—Tertiary referral centre. SUBJECTS—18 distal anastomotic sites of patent grafts, obtained at necropsy from eight patients who died over differing periods (ranging from two days to nine months) after the procedure. MAIN OUTCOME MEASURES—Immunohistochemical evaluation of smooth muscle cell phenotype modulation in relation to proliferative activity. RESULTS—The earliest changes are characterised by loss of surface lining endothelial cells and insudation of blood corpuscular elements admixed with fibrin-platelet thrombus. At sites of injury vimentin positive and actin negative spindle shaped cells appear in the intima, while the related pre-existent media shows focal absence of actin positive smooth muscle cells. Proliferative activity colocalises at these sites. With time distinct neointimal thickening occurs, associated with disappearance of proliferative activity and a phenotypic shift of the smooth muscle cells. CONCLUSIONS—The observation that luminal endothelial cell denudation, with insudation of the intima with blood elements, occurs in the very early stages suggests that these phenomena are responsible for the observed dedifferentiation of pre-existent smooth muscle cells, known to be a prerequisite for cell proliferation and the evolution of intimal thickening. It is likely, therefore, that platelet released growth factors play a pivotal role, which thus may provide a target for preventive pharmacological intervention. Keywords: smooth muscle cell proliferation; vein graft stenosis; platelet derived growth factor; platelet receptor inhibitors

Di(2-ethylhexyl) phthalate is an excellent plasticizer for polyvinyl chloride but a known endocrine disrupting chemical. To investigate whether tubing containing no diethylhexyl phthalate reduces the overall extraction of this plasticizer during cardiopulmonary bypass, 16 patients undergoing coronary artery bypass grafting were randomly divided into 2 groups of 8 each. Group A had tubing containing diethylhexyl phthalate in the circuit, and group B had no diethylhexyl phthalate in the tubing. The plasma diethylhexyl phthalate level at the end of cardiopulmonary bypass was significantly increased compared to before anesthesia in both groups (group A: 103 ± 60 to 2,094 ± 1,046 ng·mL−1; group B: 135 ± 60 to 472 ± 141 ng·mL−1), and it was significantly higher in group A than group B. This study demonstrates that using tubing free from diethylhexyl phthalate significantly reduces the release of this agent during cardiopulmonary bypass, which may minimize exposure to diethylhexyl phthalate.

Aneurysmal circumflex coronary artery (Cx) with fistulous connection to the coronary sinus is a rare clinical entity that usually remains asymptomatic until later in life, so the ideal therapeutic strategy is poorly defined. The timing of surgical treatment for asymptomatic patients is a big issue, and whether to leave or exclude the diffuse aneurysm in addition to ligation of the fistula is controversial, considering the native myocardial circulation. Complete surgical repair, including exclusion of a diffusely aneurysmal Cx and coronary revascularization to a graftable branch in the circumflex area combined with ligation of its fistula, is quite challenging and sometimes fatal because of a broad posterolateral myocardial infarction without revascularization caused by a lack of graftable branches. A case of diffuse aneurysmal Cx, which ruptured into the left atrium after surgical ligation of its fistulous connection to the coronary sinus, is presented. Simple ligation of the fistula, leaving a gigantic aneurysmal circumflex artery, is hazardous for later rupture and should be avoided. Therapeutic strategies for this complex disorder are discussed, including the optimal timing of surgical treatment. (Circ J 2007; 71: 1996 - 1998)

It is well known that activation of proteases in the lysosomes and cytosol is one of the mechanisms of ischemic injury. It might thus be beneficial to determine whether the addition of several clinically available protease inhibitors to a cardioplegic solution can improve its protective ability. Using an isolated working rat heart preparation, the effects of several protease inhibitors (serine protease inhibitors; nafamostat mesilate and gabexate mesilate, a thiol-protease inhibitor; NCO-700; and a urinary trypsin inhibitor, urinastatin) on the postischemic recovery of function and enzyme leakage were investigated in this study. These protease inhibitors were added to either the cardioplegic solution or reperfusion solution. The addition of each of the protease inhibitors, except urinastatin, to the cardioplegic solution improved the postischemic recovery of function and reduced enzyme leakage. The dose-response characteristics of these three protease inhibitors were bell shaped, and the optimal concentrations of nafamostat mesilate, gabexate mesilate, and NCO-700 were 5 µM, 100 µM, and 20 µM, respectively. In contrast to the results of the preischemic treatment study, the addition of any of the protease inhibitors to the perfusion medium during Langendorff reperfusion failed to improve the postischemic recovery of function and to reduce enzyme leakage. Surprisingly, the addition of NCO-700 to the reperfusion solution at a concentration of 5 µM or higher had rather harmful effects on both functional recovery and enzyme leakage. These findings suggest that serine and thiol proteases may play an important role in myocardial injury during ischemia, but not necessarily during reperfusion.

Transaortic stent grafting is an alternative method for treating distal arch aneurysms. Total arch grafts are too bulky to be inserted into a sheath catheter during usual stent grafting methods. An assembling method that uses a chain stitch enables the deployment of any type of stent graft into the distal aorta without the need for a sheath catheter. We describe how to safely assemble and use a branched arch stent graft. We consider this method to be beneficial in selected cases involving extensive distal arch aneurysms or in patients with highly calcified aortas.

To identify novel biomarkers for the diagnosis and prognosis of human primary lung squamous cell carcinoma (SCC), we compared the spectrum of proteins expressed in SCC and in the adjacent non-cancer tissue, using QSTAR Elite liquid chro- matography with tandem mass spectrometry (LC-MS/MS), coupled with iTRAQ technology. We identified 410 proteins differen- tially expressed in more than 75% of patients, and validated the expression of candidate target proteins by immunohistochemistry. Based on the results of LC-MS/MS, Ingenuity Pathway Analysis and immunohistochemical analyses, myristoylated alanine-rich C-kinase substrate (MARCKS) (upregulated 2.28-fold, p< 0.005) was selected as a potential biomarker of human lung SCC. In order to evaluate the association between patient prognosis and the expression of candidate biomarkers, univariate survival analysis was performed with disease-specific survival curves according to the Kaplan-Meier method, and differences in survival were assessed with the log-rank test. Immunohistochemical evaluation of MARCKS in 99 patients with lung SCC revealed a sig- nificant association between positive expression and poor prognosis compared with patients with negative expression (log-rank test; p = 0.024). These results indicate that MARCKS may represent a potential biomarker for the prognosis of primary lung SCC.

OBJECTIVES: In coronary artery bypass grafting (CABG), graft flow distal to a mild stenosis can compete with relatively preserved native flow through the stenosis and the competition can result in graft stenosis. In chronic total occlusion (CTO), coronary collateral circulation, which is essential to maintain myocardial viability distal to CTO, varies in extent among patients and the extent can be scored by Rentrop grade in coronary angiography. We investigated whether rich collateral circulation distal to CTO competes with distally anastomosed graft flow in association with Rentrop grade. METHODS: Of 666 patients who underwent CABG from January 2001 to December 2012, 70 patients whose left internal thoracic artery (ITA) was grafted distal to CTO in the left anterior descending artery (LAD) were divided into three groups: Poor collaterals (Rentrop grades 0 and 1, Group P, n= 22), Moderate collaterals (grade 2, Group M, n= 23) and Rich collaterals (grade 3, Group R, n= 25). The intraoperative measurements of mean graft flow (MGF) and pulsatility index (PI) of left ITA grafts, early graft patency and long-term clinical outcomes were compared. RESULTS: The MGF and PI of left ITA grafts differed significantly among the three groups (P= 0.025 and P= 0.046, respectively). Lower Rentrop grade was associated with preferable results of higher MGF and lower PI. The graft flow pattern in Group P showed a significantly higher MGF (P=0.020) and lower PI (P=0.041) than those in Group R. All early postoperative coronary angiograms showed patent left ITA grafts. Serial echocardiographic evaluations, survival rates and cardiac event-free rates were comparable with the follow-up of 5.00±3.11 years. CONCLUSIONS: Rich collateral circulation distal to CTO in LADs can potentially compete with graft flow, although the competition seems not to affect clinical outcomes probably due to the regression of collaterals surmounted by the graft flow. Rentrop grade is shown to certainly reflect the degree of collateral haemodynamic circulation distal to CTO and especially important to evaluate intraoperative graft flow appropriately, considering the possible phenomenon of graft flow competition.

To identify a useful biomarker for human lung squamous cell carcinoma (SCC), the expression of cytokeratin19 (CK19) in human SCC tissue was investigated. In addition, we examined the significance of CK19 expression levels by immunostaining and CYFRA21-1 levels in preoperative serum, and their correlation with the clinicopathologic features of human lung SCC.To identify proteins in cancerous and non-cancerous tissues for the diagnosis and prognosis of SCC, QSTAR Elite LC-MS/MS was used. Immunostaining for CK19 was classified as either "CK19-strong" or "CK19-weak". Correlations between prognosis and both CK19 expression in tumor tissues and serum concentrations of CYFRA 21-1 were analyzed in 107 cases of lung SCC.The upregulation of CK19 in human squamous cell carcinoma tissues was observed by LCMS/MS. The weak expression of CK19, as determined by immunostaining intensity, was a significant predictor of poorer disease-specific survival (p = 0.032). The prognosis was significantly poorer for patients with weak CK19 immunostaining in tumor tissues and a high serum concentration of CYFRA21-1 compared with the other groups (p = 0.003).The combination of weak CK19 expression and high serum CYFRA21-1 levels is a predictor of poorer prognosis for patients with human lung SCC.

We describe a case of coronary-subclavian steal syndrome in a 77-year-old man who presented with progressive coronary ischemia 8 years after coronary artery bypass grafting with an in-situ left internal thoracic artery graft. Coronary and left subclavian artery angiogram revealed completely patent internal thoracic artery graft and 90% stenosis in the proximal left subclavian artery. We performed axilloaxillary artery bypass using expanded polytetrafluoroethylene (ePTFE)[8 mm] graft. No coronary ischemia was noted postoperatively. Axillo-axillary artery bypass grafting was effective for coronary subclavian steal syndrome.

Background Radical segmentectomy has been performed for small-sized non-small cell lung cancer (NSCLC). However, underestimation of mediastinal lymph node metastasis in the absence of hilar or interlobar metastasis (skip N2) affects surgical strategy. Our aim was to investigate preoperative and intraoperative predictors of skip N2 in clinical stage (c-stage) IA NSCLC. Methods From 1998 to 2011, 279 patients (155 men and 124 women) with c-stage IA NSCLC (230 pN0, 17 pN1, 12 skip N2, 20 non-skip N2) underwent systematic lobectomy (R0 resection) at our institute. We compared preoperative serum concentrations of carcinoembryonic antigen, cytokeratin 19 fragment, sialyl Lewis X (SLX), and pre- and intraoperative clinicopathological features of pN0 and skip N2 patients. Receiver operator characteristic (ROC) curve analysis was performed to distinguish between the two patient groups. Results The 5-year survival rate of skip N2 patients was 78.6%, higher than that of non-skip N2 patients (44.9%), and not significantly different than that of pN0 (86.7%) or pN1 patients (82.4%). The mean serum SLX concentration in skip N2 patients (28.0 U/ml) was elevated compared to that in pN0 patients (22.9 U/ml). In ROC analysis of SLX, the area under the curve was 0.710, and the optimal cut-off value was 21.4 U/ml (sensitivity, 91.7%; specificity, 51.7%). In multivariate analysis, SLX was an independent predictor of skip N2 in patients with c-stage IA NSCLC (odds ratio, 9.43; p = 0.006). Conclusions Skip N2 metastasis is common in patients with c-stage IA NSCLC with high serum SLX, and lobectomy with complete dissection of hilar and mediastinal lymph nodes should remain the standard surgical procedure for these cases.

A 76-year-old woman with malignant rheumatic arthritis developed dysphagia and hoarseness secondary to an aberrant right subclavian artery aneurysm. We performed a hybrid endovascular repair with concomitant surgical treatment for the aberrant right subclavian artery aneurysm. One month after discharge, she was emergently admitted to our hospital because of chest pain and fever. We diagnosed aortoesophageal fistula and stent graft infection based on computed tomography, gallium scintigraphy, and esophagoscopy results. Esophagectomy, elimination of the infected stent graft, and muscle plombage were performed during several surgeries. However, she died of hemorrhagic shock secondary to an aortobronchial fistula.

We have treated a patient with polycystic kidney and liver disease with a coexisting cholangiocellular carcinoma surgically. Such treatment has not been reported in Japan so far, to the best of our knowledge. A 63-year-old man was admitted to the hospital because of obstructive jaundice. Imaging methods visualized a tumor of the porta hepatis and multiple cysts of the liver, kidney, and pancreas. The patient was diagnosed as having a cholangiocellular carcinoma with polycystic disease. Extended left lobectomy of the liver with reconstruction of the right hepatic artery and right hepaticojejunostomy was carried out. On and after 12th postoperative day, the patient had a fever and leukocytosis. A liver abscess was suspected, but we had difficulty in diagnosis, because the multiple liver cysts coexisted. Computed tomography done some days apart showed that the abscess changed while the cysts did not show any changes. If a patient with polycystic kidney and liver disease is treated by a surgical method that may increase a risk of liver abscesses, computed tomography should be done several times postoperatively to check the occurrence of this complication.

冠動脈バイパス術 (CABG) 後の遠隔期に発症した近位下行大動脈瘤に対し手術を施行した. 症例は61歳, 男性. CABG後8年を経過し, 冠動脈造影で静脈グラフトの閉塞を認め, 左前下行枝に吻合された左内胸動脈のみが開存していた. 瘤は左鎖骨下動脈分岐部直下に存在し, 瘤の中枢側遮断を要する手術手技は, 左内胸動脈の血流を障害するため不適当と判断した. そこで, 瘤への到達は前回手術の癒着を避けるために左第4肋間開胸で行い, 補助手段として中枢側大動脈遮断を要しない超低体温循環停止法を用いた. 大腿動静脈から送脱血管を挿入した体外循環下に全身冷却を行い, 脳波が平担化した時点 (直腸温24℃) で循環停止とし, 人工血管置換術を行った. 循環停止は17分, 体外循環時間は139分であった. 体外循環からの離脱は容易で, 術後の覚醒遅延もなく経過は良好であった.

The goal of this prospective study was to examine the effects of landiolol hydrochloride on prevention of atrial fibrillation and on hemodynamics in the acute postoperative phase after heart valve surgery. The subjects were 60 patients who underwent valve surgery at our hospital from April 2008 to July 2010. The patients were randomly divided into two groups: the landiolol group (30 patients) and the control (no landiolol) group (30 patients). In the landiolol group, continuous intravenous landiolol was initiated immediately on admission to the intensive care unit at a dose of 10 µg/kg/ minute. Occurrence of atrial fibrillation was compared between the groups over an observation period of 72 hours after surgery. Atrial fibrillation occurred in 6 patients (20%) in the landiolol group and 16 (53.3%) in the control group during the observation period. Landiolol hydrochloride significantly reduced the occurrence of atrial fibrillation in the acute postoperative phase after heart valve surgery. Heart rate was significantly decreased by landiolol, but aggravation of hemodynamics was not observed. These results suggest that landiolol is a useful drug for prevention of atrial fibrillation after valve surgery.

PURPOSE Few recent studies have examined the long-term outcomes after aortic valve replacement (AVR), and independent predictors for long-term survival and valve-related mortality have not been elucidated. METHODS From January 1993 to December 2009, 132 elderly patients (≥70 years old) with aortic stenosis underwent AVR in our hospital. The patients comprised 61 men and71 women with a mean age of 76.1 ± 3.7 years. Patients with acute or old myocardial infarction, mitral valve disease, and re-do surgery were not included in this study. Risk factors for late valve-related mortality were examined. RESULTS The 5-year freedom from valve-related mortality rate was 89.6%. The following significant independent risk factors for late valve-related mortality were identified:increase in the preoperative left ventricular mass index (hazard ratio, 1.10 [per 10 g/m(2)];p = 0.040); lack of sinus rhythm (hazard ratio, 7.11; p = 0.005); peak transvalvular pressure gradient of

This retrospective study aimed to determine the effect of simultaneous aortic valve replacement (AVR) and coronary artery bypass grafting (CABG) on operative outcomes and long-term survival in elderly patients with a high prevalence of comorbidity. One hundred and fifty-seven elderly patients (70 years old or older) undergoing isolated AVR (n = 120) or combined AVR/CABG (n = 37) were evaluated. Operative outcomes were compared between the two surgical groups. Long-term survival was also compared between the groups using the Kaplan–Meier method and long-rank (Mantel–Cox) test. Operative mortality was 0.8 % for the isolated AVR group and 5.4 % for the combined AVR/CABG group (p = 0.076). The length of the intensive care unit stay for the combined AVR/CABG group was significantly longer than that for the isolated AVR group (median: 40 vs. 21 h, p = 0.008). However, the occurrence rate of hospital complications, such as reoperation for bleeding, deep sternal infection, supra-ventricular arrhythmia, and neurological complications, was similar between the two groups. Actuarial survival at 3 and 5 years was 82.3 and 80.9 % for the isolated AVR group, and 88.3 and 73.0 % for the combined AVR/CABG group, respectively (p = 0.637). The satisfactory operative and long-term results in our study support a more aggressive simultaneous coronary revascularization combined with AVR for aortic valve stenosis in elderly patients.

We investigated the clinicopathological findings and outcome after surgery for hepatocellular carcinoma in patients without hepatitis B or C virus infection.Among 562 patients who underwent curative resection for hepatocellular carcinoma, the sera from 97 patients (B group) were positive for hepatitis B surface antigen alone, sera from 355 patients (C group) were positive for anti-hepatitis C virus antibody alone and sera from 104 patients (NBNC group) were negative for both hepatitis B surface antigen and anti-hepatitis C virus antibody. We compared the clinicopathological findings and postoperative outcomes in the 3 groups.The prevalence of diabetes mellitus, hypertension, hyperlipidemia and alcohol abuse were higher in the NBNC group than in the other groups. The prevalence of obesity was higher in the NBNC group than in the B group. Non-alcoholic steatohepatitis was detected in 16 NBNC patients. The tumor- free survival rate was higher in the NBNC group than in the C group.Obesity, diabetes mellitus, hypertension, hyperlipidemia, alcohol abuse and non-alcoholic steatohepatitis were the possible risk factors for hepatocellular carcinoma in the NBNC group. The patients in the NBNC group are expected to show a better outcome as compared to patients in the C group.

Wedge resection for tissue diagnosis of indeterminate lung tumors that is strongly suspected of being lung cancer, is sometimes difficult, and lobectomy, followed by a thorough pathological examination, is required. In the present report, four cases are presented, and the following indications, which have never been discussed before, are recommended for lobectomy without a pre-resectional diagnosis. First, where larger tumors are involved, and lobectomy is expected to result in a more favorable patient status and second, where the lesions are deeply located near major pulmonary vessels, or the patient is not a candidate for wedge resection or segmental resection. In each case, tolerance to surgery and detailed, informed consent for potentially complete resection are mandatory.