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Background: Although recent studies described important roles for carbonic anhydrase (CA) XII in epithelial carcinogenesis and tumor behavior, a consensus has not yet been reached regarding its clinicopathological significance in esophageal squamous cell carcinoma (ESCC). In the present study, we investigated its prognostic significance in ESCC., Materials and Methods: An immunohistochemical analysis was performed on 70 primary tumor samples obtained from ESCC patients who underwent esophagectomy, and the relationships between the expression of CA XII and various clinicopathological features or prognosis were analyzed., Results: Immunohistochemical staining showed that CA XII was primarily found in the cell membranes of carcinoma cells. Although the expression of CA XII was related to the pT category, it had no prognostic impact. We then examined the expression of CA XII according to the pT category. In pT2-3 ESCC, the 3-year survival rate of patients with the high grade expression of CA XII (29.1 %) was significantly lower than that of patients with the low grade expression of CA XII (70.3 %). Furthermore, a multivariate analysis demonstrated that the expression of CA XII was one of the most important independent prognostic factors following radical esophagectomy in pT2-3 ESCC., Conclusion: These results suggest that the expression of CA XII may be a valuable prognostic factor for patients with advanced ESCC. The results of the present study provide an insight into the role of CA XII as a biomarker in ESCC.

Aim: To evaluate discrepancies between biopsy and resected specimens using the Japanese Classification of Gastric Carcinoma (JCGC) and tumor-node-metastasis (TNM) classification., Methods: A total of 376 consecutive paired samples from biopsy and resected gastric specimens, which were derived from curative gastrectomy for gastric cancer between 2008 and 2011, were retrospectively analyzed., Results: (1) Discrepancies in the histologic type were observed between biopsy and resected specimens; 11.7% (44/376) in the JCGC and 18.1% (68/376) in TNM. In specimens diagnosed as the differentiated type from biopsy specimens, 14.4% (28/195) in the JCGC and 41.1% (67/163) in TNM were finally diagnosed as the undifferentiated type from resected specimens; and (2) the incidence of mixed-type gastric cancer was significantly higher in specimens with discrepancies than in those without in both the JCGC and TNM (both P < 0.0001); 93.2% (41/44) of specimens with discrepancies in the JCGC and 97.1% (66/68) of specimens with discrepancies in TNM were mixed-type gastric cancers., Conclusion: Mixed-type gastric cancer was associated with a high incidence of histologic discrepancies between biopsy and resected specimens in both the JCGC and TNM definitions. Care should be taken in deciding treatments based on diagnosis of the histologic type for mixed-type gastric cancer from biopsy specimens.

Background/aim: Although laparoscopy-assisted gastrectomy (LAG) is widely used for the treatment of gastric cancer, its safety and feasibility for elderly patients remains controversial. We herein examined the impact of age on the early surgical outcomes of LAG with suprapancreatic nodal dissection for elderly patients with clinical stage I gastric cancer., Patients and Methods: This retrospective study included 292 patients undergoing LAG with suprapancreatic nodal dissection for clinical stage I gastric cancer. We divided patients into an elderly group (age ≥ 75 years; n=55) and non-elderly group (age <75 years; n=237). Preoperative conditions, operative findings and postoperative outcomes, including complications, were compared between these two groups., Results: The elderly group had a higher incidence of co-morbidities (61.8%) and lower forced expiratory volume in 1 second/forced vital capacity (74.8%). Preoperative levels of hemoglobin (Hb) and serum albumin (Alb), as well as the total lymphocyte count (TLC) were lower in the elderly group (p<0.001, <0.001 and =0.018, respectively). No significant differences were observed in intraoperative findings between the two groups. The incidence of overall and surgical complications in the elderly group (21.8% and 14.5%, respectively) did not significantly differ from those in the non-elderly group. The frequency of non-surgical complications in the elderly group (9.1%) was significantly higher (p =0.018), whereas no critical complications or mortality were observed. No significant differences were noted in the severity of complications or hospital courses between the groups., Conclusion: LAG with suprapancreatic nodal dissection appears to be safe and feasible for elderly patients with clinical stage I gastric cancer., (Copyright© 2015 International Institute of Anticancer Research (Dr. John G. Delinassios), All rights reserved.)

The role of the inhibitor of apoptosis (IAP) family members in tumor necrosis factor-α (TNF-α)-induced apoptosis of human gastric cancer MKN28 cells was explored. TNF-α induced up-regulation of cIAP2, whereas cycloheximide (CHX) induced down-regulation of XIAP and survivin. Degradation of cIAP1 and XIAP, but not survivin, was accelerated by co-treatment of cells with TNF-α and CHX, and TNF-α-induced up-regulation of cIAP2 was inhibited by BMS-345541 (NF-κB inhibitor). Treatment of MKN28 cells with TNF-α plus CHX induced degradation of survivin and activation of caspase-8 and -3, followed by degradation of cIAP1 and XIAP and apoptosis. Proteasome inhibitors (MG132 and epoxomicin) suppressed TNF-α plus CHX-induced degradation of survivin, cIAP1, and XIAP as well as apoptosis. A caspase inhibitor (z-VAD-fmk) suppressed TNF-α plus CHX-induced apoptosis, but allowed degradation of survivin, cIAP1 and XIAP. TNF-α receptor 1 and 2 were expressed on MKN28 cells. The magnitude of apoptosis induced by TNF-α plus BMS-345541 was much less than that induced by TNF-α plus CHX. These findings suggest that TNF-α plus CHX-induced apoptosis of gastric cancer MKN28 cells may be caused by accelerated degradation of the IAP family members (survivin, cIAP1, and XIAP), in addition to inhibition of NF-κB-dependent synthesis of anti-apoptotic molecules., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objective: In the emergency department, it is sometimes difficult to differentiate heart failure (HF) from other diseases (e.g., respiratory diseases) in patients who develop dyspnea. The plasma B-type natriuretic peptide (BNP) levels increase in patients with HF, and various levels are associated with specific New York Heart Association classes. Although the diagnosis of HF should not be made based only on the plasma BNP levels, the identification of a cut-off value for BNP to diagnose HF would be helpful., Methods: Patients admitted to the emergency department of our hospital with dyspnea between January 2010 and December 2011 were retrospectively reviewed. The patients whose estimated glomerular filtration rate was less than 30 mL/min/1.73 m(2) were excluded. Patients were divided into two groups: those with HF (n=131) and those without HF (n=138). The cut-off value for BNP was determined by the receiver-operating characteristic curve., Results: The area under the curve of this curve was 0.934. The optimal cut-off point for detection of HF was 234 pg/mL. The sensitivity and specificity were 87.0% and 85.5%, respectively. The fifth and 95th percentiles of the HF group were 132.2 and 2,420.8 pg/mL, respectively. Those of the non-HF group were 9.7 and 430.2 pg/mL, respectively., Conclusion: Our study suggests that a plasma BNP level cut-off value of 234 pg/mL can be used to detect HF in the emergency department.

The patient was a 53-year-old man whose chief complaint was dysphagia. Pretreatment examination revealed 2 types of locally advanced esophageal squamous cell carcinoma at the middle to lower thoracic esophagus. A computed tomography (CT) scan showed a bulky primary tumor suspicious of aortic invasion and cardiac lymph node metastasis. The pretreatment diagnosis was cT4N2M0, cStageIVa. After induction chemotherapy with 5-fluorouracil (5-FU) and cisplatin (CDDP) (the FP regimen) according to the JCOG9907 regimen, subtotal esophagectomy and 2-field lymphadenectomy with retrosternal stomach roll reconstruction were performed. Intraoperatively, the primary tumor showed extensive and firm adhesion to the aortic wall. The postoperative diagnosis was pT4N0M0, pStageIII, RM1. Postoperative chemoradiotherapy (65 Gy+FP) was performed for the residual tumor at the aortic wall. The patient is alive without recurrences 4 years and 6 months after the esophagectomy. Downstaging of the tumor with induction chemotherapy and effective local control with surgery and postoperative chemoradiotherapy may have contributed to the patient's long-term survival. For multimodal treatment of cT4 esophageal cancer, an effective combination of chemotherapy, surgery, and chemoradiotherapy is essential to improve the treatment outcome.

Esophageal cancer (EC) is often associated with multiple primary cancers, and the frequency of EC in patients with a history of metachronous primary cancers (HMPC) was reported as 7.8%. The clinical characteristics of these cases have not yet been elucidated in detail. Therefore, we analyzed 36 EC patients with HMPC among 370 cases that underwent curative resection in our hospital between 1996 and 2013. The most frequent HMPC was gastric cancer (36.1%). The group with HMPC was significantly older than the group without HMPC, whereas no significant differences were observed in other background factors. The stomach was used for reconstruction more frequently reconstructed in the group without HMPC (p<.05). No significant differences were observed in surgical complications between the 2 groups (p=0.283). The 5-year overall survival rates were similar between the groups. The safety of surgery for and prognosis of EC patients with HMPC were similar to those of EC patients without HMPC; therefore, curative surgery should be considered for EC patients with HMPC.

Prospective randomized controlled studies have indicated that endoscopic placement of self-expandable metal stents (SEMSs)is an effective treatment option for patients with malignant gastric outlet obstruction (GOO). We report a case of effective palliation of gastric cancer-related jejunum stricture with a SEMS. A7 7-year-old woman, who had previously undergone partial remnant gastrectomy and Roux-en-Y reconstruction, was diagnosed with abdominal recurrence of gastric cancer. After a 4 month observation period, which the patient opted for with informed consent, recurrent vomiting and loss of appetite ensued. Computed tomography (CT) and upper gastrointestinal series (UGI) examinations revealed a single intestinal stenosis caused by a recurrent tumor. Endoscopic placement of a SEMS palliated this intestinal obstruction, and her oral intake improved (GOOSS score improved from 0 to 3). Upper gastrointestinal series verified that the SEMS maintained its lumen 3 months after the procedure. Endoscopic treatment with a SEMS can be more effective for malignant intestinal stenosis caused by abdominal recurrence of gastric cancer, especially when it is difficult to laparotomy adhesion derived previous operation or peritonitis carcinomatosa. Further studies may be needed to clarify the clinical benefits of stent placement for patients with abdominal recurrence of gastric cancer.

The patient was a 48-year-old woman who was diagnosed with early gastric cancer during a long-term follow-up period for Gardner syndrome. Subtotal colectomy for colon leiomyoma was performed when the patient was 22 years old. Partial resection of the ileum was performed for ileum leiomyoma at the age of 27. Total resection of the remaining colon with ileostomy was performed for a pelvic desmoid tumor at the age of 40. In addition, resection of a desmoid tumor of the abdominal wall was performed 8 times in the 25 years since the first operation. During the follow-up for gastric polyps associated with Gardner syndrome, gastric cancer was detected from biopsy specimens of a wide range of the fundus polyps. Endoscopic resection was considered not to be applicable because of the extensive nature of the lesion. Total gastrectomy was also considered not to be applicable because of concerns about short bowel syndrome due to intestinal reconstruction. Therefore, proximal gastrectomy with esophagogastric anastomosis was performed. The pathological diagnosis was 0-IIa, 70 × 44 mm, tub1, m, ly0, v0, n0, PM (-), DM (-), stageIA. The postoperative course was uneventful, and the patient was discharged on postoperative day (POD) 16. We speculate that long-term survival of patients with Gardner syndrome without severe short bowel syndrome might result in carcinogenesis of gastric polyps.

Herein, we report 9 patients who underwent esophagectomy after endoscopic submucosal dissection (ESD) between April 2003 and December 2013. All patients were men, with a mean age of 65 years. En bloc ESD was performed, and no complications arose in any patient. The mean surgical time of esophagectomy was 323 minutes, and mean blood loss was 295 mL. Postoperative complications were present in 5 patients(anastomotic leakage in 3, pulmonary complications in 2, and recurrent laryngeal nerve palsy in 1). In a patient diagnosed with pT1b-SM1 disease after ESD, a residual tumor(pT1a-MM, N0) was detected after esophagectomy. In another patient diagnosed with pT1b-SM2 disease, lymph node metastasis was detected after esophagectomy. In all patients, curative resection was performed, and no recurrences have been observed to date. This highlights the importance of additional esophagectomy after ESD for patients with pT1b disease. Esophagectomy after ESD can be considered a valid treatment because it provides high curative rates with acceptable safety.

The patient in this case study was a 71-year-old male who underwent distal esophagectomy with gastric tube reconstruction via a posterior mediastinal route for esophageal cancer 12 years previously. An endoscopy revealed a hypopharyngeal tumor in the right piriform fossa, and the histopathological diagnosis, based on a biopsy sample, was squamous cell carcinoma. Preoperative angiography of the right gastroepiploic artery revealed poor blood flow in the remnant esophagus. First, the adhesion of the gastric tube to the surrounding tissue was dissected via a right thoracotomy. Then, the gastric tube was raised using a cervical approach, and total pharyngolaryngoesophagectomy with free jejunal transfer was performed. The patient was discharged 28 days after the operation without complications. We report a patient with hypopharyngeal cancer who had previously undergone distal esophagectomy with gastric tube reconstruction via a posterior mediastinal route upon whom we successfully performed a total pharyngolaryngoesophagectomy with free jejunal transfer. In such a case, it is important to carefully decide the surgical approach in order to prevent anastomotic leakage.

Background: Laparoscopy-assisted total gastrectomy (LATG) is commonly performed for early gastric cancer (EGC) in the upper stomach; however, the incidence of anastomotic complications remains high, and postoperative nutritional status is not satisfactory. This study aimed to evaluate the feasibility and nutritional impact of a novel surgical procedure, laparoscopy-assisted subtotal gastrectomy (LAsTG)., Methods: This was a retrospective study of 167 patients with EGC in the upper stomach. Of these, 57 patients underwent LAsTG, while 110 patients underwent LATG. Postoperative change in body weight, and serum concentration of albumin (Alb) and total protein (TP) were compared between the LAsTG and LATG groups. Analysis of covariance (ANCOVA) was used to assess the influence of potential confounding factors., Results: Frequency of anastomotic complications was significantly higher in the LATG group (16.3 %) than in the LAsTG group (5.3 %, P = 0.040). Postoperative recovery of body weight at 12 months after surgery was significantly better in the LAsTG group (89.8 ± 1.4 %) than in the LATG group (82.1 ± 1.0 %, P < 0.001). By ANCOVA, adjusted mean differences of Alb and TP at 12 months after surgery between the LAsTG and LATG groups were 0.226 g/dl (95 % CI 0.141-0.312; P < 0.001) and 0.380 g/dl (95 % CI 0.265-0.495; P < 0.001); thus, the surgical procedure was significantly associated with the postoperative Alb and TP levels., Conclusions: LAsTG could be a better choice than LATG for EGC in the upper stomach as a result of improvements in the incidence of anastomotic complications and postoperative nutritional status.

Background: xCT is a component of the cysteine/glutamate transporter, which plays a key role in glutathione synthesis. The objectives of the present study were to investigate the role of xCT in the regulation of genes involved in cell cycle progression and the clinicopathological significance of its expression in esophageal squamous cell carcinoma (ESCC)., Methods: xCT expression in human ESCC cell lines was analyzed by Western blotting and immunofluorescent staining. Knockdown experiments were conducted with xCT siRNA, and the effect on cell cycle was analyzed. The cells' gene expression profiles were analyzed by microarray analysis. An immunohistochemical analysis of 70 primary tumor samples obtained from ESCC patients that had undergone esophagectomy was performed., Results: xCT was highly expressed in TE13 and KYSE170 cells. In these cells, the knockdown of xCT using siRNA inhibited G1-S phase progression. Microarray analysis identified 1652 genes whose expression levels in TE13 cells were altered by the knockdown of xCT. Pathway analysis showed that the top-ranked canonical pathway was the G1/S checkpoint regulation pathway, which involves TP53INP1, CDKN1A, CyclinD1/cdk4, and E2F5. Immunohistochemical staining showed that xCT is mainly found in the nuclei of carcinoma cells, and that its expression is an independent prognostic factor., Conclusions: These observations suggest that the expression of xCT in ESCC cells might affect the G1/S checkpoint and impact on the prognosis of ESCC patients. As a result, we have a deeper understanding of the role played by xCT as a mediator and/or biomarker in ESCC.

Background: It is difficult to determine preoperatively whether upper/middle thoracic lymphadenectomy is necessary in patients with adenocarcinoma of the esophagogastric junction (AEG) or lower esophageal squamous cell carcinoma (ESCC). Here, we investigated whether stratification based on the location of the proximal end of the tumor, as assessed using preoperative computed tomography (CT) images, would be useful for predicting upper/middle thoracic lymph node involvement for AEG and lower ESCC., Methods: A total of 142 patients with AEG and lower ESCC treated by R0-1 surgical resection via a thoracotomy was retrospectively investigated. The location of the proximal end of the tumor in comparison with the vena cava foramen (VCF) was decided by inspecting preoperative CT images and then correlated with upper/middle thoracic lymph node involvement., Results: The incidence of upper/middle thoracic lymph node involvement was low in AEG and ESCC tumors having proximal ends below the VCF (0 %, 0 of 13, and 5.9 %, 1 of 17, for AEG and ESCC, respectively). In contrast, when the tumors' proximal ends were above the VCF, patients had higher frequencies of upper/middle thoracic lymph node involvement (36.4 %, 8 of 22, and 37.8 %, 34 of 90, for AEG and ESCC, respectively). Multivariate analysis showed that the location of the proximal end of the tumor is an independent risk factor related to upper/middle thoracic lymph node involvement (odds ratio 14.3, 95 % confidence interval 1.76-111, p = 0.013), whereas other clinical factors (cT, cN, tumor length, and histologic types) are not., Conclusions: This manner of stratification using preoperative CT images could be useful in deciding the extent of thoracic lymphadenectomy in both AEG and ESCC.

Background: Postoperative complications such as anastomotic leakage were reported to be a major independent prognostic factor for long-term survival in gastrointestinal malignancies. This study sought to clarify the prognostic significance of postoperative inflammatory complications specifically for patients with gastric cancer., Methods: This study included 1,395 patients who underwent curative resection for gastric cancer from 2005 to 2008. Complications were evaluated according to the Clavien-Dindo classification. Overall survival (OS) and disease-specific mortality (DSM) were compared between complication and no-complication groups. Presence of complications was modeled by the Cox proportional hazard model for OS and the Fine and Gray competing risk regression model for DSM to assess the correlation between complication and prognosis., Results: The median follow-up time was 3.1 years. Two hundred seven patients (14.8 %) had complications of grade 2 or higher. Of 131 patients who died within this period, 87 died of gastric cancer. The 3-year OS in the complication group was 84.1 % compared to 93.1 % in the no-complication group (P < 0.0001). The cumulative incidence of DSM was also significantly worse in patients with complications (P < 0.0001). Multivariate analysis identified the same significant increasing risk of complication for both OS (hazard ratio 1.88; 95 % confidence interval 1.26-2.80) and DSM (hazard ratio 1.90; 95 % confidence interval 1.19-3.02)., Conclusions: Postoperative complications that can cause prolonged inflammation have an obvious impact not only on the OS but also on the DSM of patients with gastric cancer even if the tumor is resected curatively.

The objectives of the present study were to investigate the role of K-Cl cotransporter 3 (KCC3) in the regulation of cellular invasion and the clinicopathological significance of its expression in esophageal squamous cell carcinoma (ESCC). Immunohistochemical analysis performed on 70 primary tumor samples obtained from ESCC patients showed that KCC3 was primarily found in the cytoplasm of carcinoma cells. Although the expression of KCC3 in the main tumor (MT) was related to several clinicopathological features, such as the pT and pN categories, it had no prognostic impact. KCC3 expression scores were compared between the MT and cancer nest (CN), and the survival rate of patients with a CN > MT score was lower than that of patients with a CN ≤ MT score. In addition, the survival rate of patients in whom KCC3 was expressed in the invasive front of tumor was lower than that of the patients without it. Furthermore, multivariate analysis demonstrated that the expression of KCC3 in the invasive front was one of the most important independent prognostic factors. The depletion of KCC3 using siRNAs inhibited cell migration and invasion in human ESCC cell lines. These results suggest that the expression of KCC3 in ESCC may affect cellular invasion and be related to a worse prognosis in patients with ESCC.

The aim of the present study was to determine the efficacy of a hypotonic treatment for peritoneal dissemination from gastric cancer cells using an in vivo model. We firstly evaluated the toxicity of a peritoneal injection of distilled water (DW) (2 mL for 3 days) in mice. Macroscopic and microscopic examinations revealed that the peritoneal injection of DW did not severely damage the abdominal organs of these mice. MKN45 gastric cancer cells preincubated with NaCl buffer or DW for 20 minutes in vitro were then intraperitoneally injected into nude mice, and the development of dissemination nodules was analyzed. The total number, weight, and volume of the dissemination nodules were significantly decreased by the DW preincubation. We then determined whether the peritoneal injection of DW inhibited the establishment of peritoneal dissemination. After a peritoneal injection of MKN45 cells into nude mice, NaCl buffer or DW was injected into the abdominal cavity for 3 days. The total volume of dissemination nodules was significantly lower in DW-injected mice than in NaCl-injected mice. In conclusion, we demonstrated the safeness of a peritoneal injection of DW. Furthermore, the development of dissemination nodules from gastric cancer cells was prevented by a preincubation with or peritoneal injection of DW.

Background: Adaptor proteins, with multimodular structures, can participate in the regulation of various cellular functions. A novel adaptor protein XB130 has been implicated as a substrate and regulator of tyrosine kinase-mediated signaling and in controlling cell proliferation and apoptosis in thyroid and lung cancer cells. However, its expression and role in gastrointestinal cancer have not been investigated. We sought to determine the role of XB130 in cell cycle progression of esophageal squamous cell carcinoma (ESCC) cells and to examine its expression and effects on the prognosis of patients with ESCC., Methods: Expression of XB130 in human ESCC cell lines was analyzed by Western blot testing and immunofluorescent staining. Knockdown experiments with XB130 small interfering RNA (siRNA) were conducted, and the effect on cell cycle progression was analyzed. Immunohistochemistry of XB130 for 52 primary tumor samples obtained from patients with ESCC undergoing esophagectomy was performed., Results: XB130 was highly expressed in TE2, TE5, and TE9 cells. In these cells, knockdown of XB130 with siRNA inhibited G1-S phase progression and increased the expression of p21, the cyclin-dependent kinase inhibitor. Immunohistochemistry showed that 71.2% of the patients expressed XB130 in the nuclei and/or cytoplasm of the ESCC cells. Further, nuclear expression of XB130 was an independent prognostic factor of postoperative survival., Conclusions: These observations suggest that the expression of XB130 in ESCC cells may affect cell cycle progression and impact prognosis of patients with ESCC. A deeper understanding of XB130 as a mediator and/or biomarker in ESCC is needed.

Background: Cancer cells that are exfoliated into the peritoneal cavity during surgery are viable and have the potential to produce peritoneal recurrence. Although peritoneal lavage with distilled water is applied in some cancer surgeries to kill tumor cells, there is no consensus regarding the optimal methodology and its effects., Methods: Three human gastric cancer cell lines, MKN28, MKN45, and Kato-III, were exposed to distilled water, and the resultant morphologic changes were observed using a microscope. Analysis of cell volume changes was performed using a flow cytometer. To investigate the cytocidal effects of the water, re-incubation of the cells was performed after exposing them to hypotonic solution. Additionally, the effects of 5-nitro-2-3-phenylpropylamino)-benzoic acid (NPPB), a Cl(-) channel blocker, and R(+)-[(dihydroindenyl)oxy] alkanoic acid (DIOA), a blocker of the K(+)/Cl(-) co-transporter, on the cells during their exposure to hypotonic solution were analyzed., Results: After the cells had been exposed to the distilled water, a rapid increase in cell volume occurred followed by cell rupture. In the MKN45 and Kato-III cells, treatment with NPPB increased cell volume by inhibiting regulatory volume decrease and enhanced the cytocidal effects of the hypotonic solution, whereas no such effects were observed in the MKN28 cells. On the other hand, treatment of the MKN28 cells with DIOA inhibited RVD and enhanced the cytocidal effects of hypotonic shock., Conclusion: These findings support the efficacy of peritoneal lavage with distilled water during surgery for gastric cancer and suggest that the regulation of Cl(-) transport enhances the cytocidal effects of hypotonic shock., (Copyright © 2012 Elsevier Inc. All rights reserved.)

The Carpentier-Edwards PERIMOUNT (CEP) Magna (Edwards Lifesciences, Irvine, CA, USA) is a newly developed bioprosthesis with an improved cuff design that allows its implantation into the smaller aortic annulus. We evaluated the hemodynamic performance of the CEP Magna for smaller aortic annulus cases. Patients who underwent aortic valve replacement for aortic stenosis receiving a Magna 19 mm (n = 13), were compared with a standard CEP (n = 19). In the 19-mm series, the real annular size was significantly smaller in the Magna than the standard (21.1 ± 0.8 vs. 19.8 ± 0.8 mm, p = 0.007). The Magna was significantly superior with respect to effective orifice area index (EOAI) at postoperative 3 months; however, no significant difference was seen in other factors (peak pressure gradient, left ventricular mass index, ejection fraction). At postoperative 3 months, despite the lack of statistical significance, the incidence of patient-prosthesis mismatch (PPM) was lower with the Magna. Using the same label size, the Magna can be implanted in a smaller aortic annulus with performance comparable with or better than hemodynamic performance with the standard CEP. The Magna is a useful prosthesis for the small aortic annular patient.

This study aimed to investigate cytocidal effects of hypotonic shock on esophageal squamous cell carcinoma (ESCC) cell lines, and to apply pleural lavage with distilled water to surgery for ESCC. Three human ESCC cell lines, TE5, TE9 and KYSE170 were exposed to distilled water, and morphological changes in ESCC cells were closely observed under a differential interference contrast microscope connected to a high-speed digital video camera. Further, serial cell volume changes after hypotonic shock were measured using a high-resolution flow cytometer. To investigate the cytocidal effects of hypotonic shock on ESCC cells, re-incubation of ESCC cells was performed after hypotonic shock. Additionally, the effects of 5-nitro-2-(3-phenylpropylamino)-benzoic acid (NPPB), a Cl- channel blocker, during hypotonic shock were analyzed. Video recordings by high-speed digital camera demonstrated that hypotonic shock with distilled water induced cell swelling followed by cell rupture. Measurements of cell volume changes using a high-resolution flow cytometer indicated that severe hypotonicity with distilled water increased broken fragments of ESCC cells within 5 min. Re-incubation experiments demonstrated cytocidal effects of hypotonic shock on ESCC cells. Treatment of cells with NPPB increased cell volumes by the inhibition of regulatory volume decrease, which is observed during hypotonic shock, and enhanced cytocidal effects. These findings demonstrated the cytocidal effects of hypotonic shock on ESCC cells, and clearly support the efficacy of pleural lavage with distilled water during surgery for ESCC.

Background: The present study estimated survival benefits from lymph node dissection at the splenic hilus in advanced proximal gastric cancer patients who underwent total gastrectomy with simultaneous splenectomy, and then determined patient subgroups that received relatively high survival benefits from splenectomy., Methods: A total of 280 patients with advanced proximal gastric cancer who underwent curative total gastrectomy with simultaneous splenectomy were retrospectively analyzed. Patients with primary tumors directly invading the spleen or pancreas and those with gross metastases to the para-aortic nodes, as determined by intraoperative diagnosis, were excluded from analyses. The index of estimated benefit from lymph node dissection at the splenic hilus by splenectomy was calculated for each clinicopathological factor by multiplying the incidence of splenic hilar metastasis by the 5-year survival rate of patients with metastasis to that nodal station., Results: Thirty patients (10.7%) showed lymph node metastasis at the splenic hilus, and the 5-year survival rate of these patients was 51.3% (overall index 5.49). The index was relatively high in patient subgroups with tumors localized on the greater curvature (19.4) and Borrmann type 4 cancers (12.9), while relatively low in subgroups with encircling tumors (1.62) and tumors invading adjacent organs other than the spleen and pancreas (0)., Conclusion: Patients with tumors localized on the greater curvature and Borrmann type 4 cancers might obtain relatively high survival benefits from lymph node dissection at the splenic hilus by splenectomy.

Background: This study aimed to assess treatment outcome and factors influencing survival after lymph node recurrence of thoracic esophageal squamous cell carcinoma (SCC) after curative resection., Methods: A total of 207 patients who underwent curative resection of thoracic esophageal SCC between March 1999 and March 2009 were retrospectively analyzed. Of these, lymph node recurrence was observed in 45 (21.7%) patients. Twenty-nine patients received intensive treatment (radiation therapy, chemoradiotherapy, or lymphadenectomy) directed at recurrent nodes, 9 patients received chemotherapy, and 7 patients received best supportive care (BSC). Treatment outcome and prognostic factors of these patients were investigated., Results: Patients who received intensive treatment had significantly higher survival rates after recurrence than those who received chemotherapy or BSC (P = 0.0049 and 0.0004, respectively). In univariate analysis of survival after recurrence, the number of recurrent nodes (a single node or multiple nodes), the region of recurrent nodes (limited to a single region or extended to multiple regions), and the presence of simultaneous organ recurrence (present or absent) were prognostic factors (P = 0.0004, 0.0017, and <0.0001, respectively). Multivariate analysis demonstrated that the region of recurrent nodes and simultaneous organ recurrence were independent prognostic factors (P = 0.0396 and 0.0006, respectively)., Conclusions: Our findings suggest that the region of recurrent nodes (limited to a single region or extended to multiple regions) and simultaneous organ recurrence are factors influencing survival after lymph node recurrence of thoracic esophageal SCC after curative resection.

Background/aims: Although routine postoperative follow-up is generally performed for early detection of recurrences, there is no evidence that the periodic follow-up improves survival in patients with gastric cancers. This study aimed to assess the prognostic impact of cancer-related symptomatic status during postoperative followup in gastric cancer patients., Methodology: A total of 81 gastric cancer patients, who developed recurrences after curative surgery, were retrospectively evaluated for clinicopathological findings with regard to the relationship to cancer-related symptoms at the time recurrences were diagnosed., Results: Undifferentiated tumor type, advanced T-stage (T3/4) and peritoneal recurrence were more common in symptomatic patients groups, whereas differentiated tumor type and both locoregional and hematogenous recurrences were more common in asymptomatic patients (p = 0.02, 0.03 and 0.03, respectively). Disease-free survival showed that there were no significant differences between the asymptomatic and symptomatic patient group. However, the post-recurrence survival in patient with symptoms was significantly worse than that in those without symptoms (p < 0.01)., Conclusions: Cancer-related symptomatic status at the time recurrences are diagnosed might provide prognostic information predicting post-recurrence survival. However, we have to conclude that even intensive follow-up did not contribute to the early detection of recurrences in patients with gastric cancers.

A 73-year-old woman was referred for treatment of left atrial (LA) myxoma. At surgery, a myxoma was attached to the left atrial side of the fossa ovalis in the atrial septum by a stalk and was transmurally excised with a margin of the atrial septum. The atrial septum was closed without any prosthetic materials under mild to moderate tension. Although she was asymptomatic, postoperative transesophageal echocardiography (TEE) revealed an abnormal cavity, containing heterogeneous echogenesity without blood flow, in the posterior LA wall. Magnetic resonance imaging (MRI) demonstrated a mass without significant enhancement. It was considered to be an intramural hematoma, and the diagnosis of LA dissection was made. Follow-up echocardiography showed disappearance of the dissected lumen without surgical intervention. Both TEE and MRI are useful for the correct diagnosis of an LA dissection; and surgical intervention, entry closure or internal drainage, may not always be necessary in the absence of a hemodynamic compromise with an LA dissection.

Thanks to recent advances of therapeutic devices, the less invasive surgical explorations such as endoscopic submucosal resection( ESD) and laparoscopic surgery have widely gained an acceptance and become more common. During laparoscopic partial gastrectomy for submucosal tumor such as gastrointestinal stromal tumor (GIST) of the stomach, it is important to avoid an excessive surgical resection of the gastric wall, which causes a deformity of the stomach and has a potential risk to decrease oral intake. We report here a successfully treated case without any deformity of the stomach and complications using laparoscopic and endoscopic cooperative surgery (LECS) for intraluminal type of GIST. LECS is a recently developed procedure and it enables us to resect a tumor with minimum surgical margin. This procedure could be applicable for clinically benign tumor, and it is effective especially for tumors located near esophagogastric junction or pyloric ring of the stomach.

Background/aim: This study was designed to investigate the clinical significance of lymphangiogenic vascular endothelial growth factors C and D, and chemokine receptor CCR7 in the lymphatic spread of gastric cancer., Patients and Methods: The expressions of VEGF-C and -D, and CCR7 were examined in 82 gastric tumors showing a discrepancy between the degree of lymphatic invasion (Ly) and the status of lymph node metastasis (N) (Ly+N-: 72, and Ly-N+: 10 patients)., Results: High expression of VEGF-C and -D, and CCR7 was present in 88%, 63% and 67% of cases, respectively. The VEGF-C expression was significantly higher in Ly+N- than Ly-N+ (p<0.05), but VEGF-D and CCR7 were not. CCR7 expression was a prognostic factor in the Ly+N- subgroup (p<0.05), but VEGF-C and -D were not., Conclusion: VEGF-C and -D and CCR7 may play critical roles in lymphatic invasion in primary tumors. CCR7 expression should provide prognostic information in node-negative gastric cancer patients showing lymphatic invasion.

Background: Calcium-channel blockers (CCBs) are highly effective in suppressing coronary spasm and are widely used as the standard therapy for coronary spastic angina, but it is unclear if CCB treatment completely suppresses the symptoms., Methods and Results: The clinical course of the symptoms caused by coronary spasm was investigated in patients taking CCBs: 90 patients were evaluated and 80 patients were followed. The mean follow-up period was 1,796+/-1,169 days. There were no cardiac deaths, but 3 patients were admitted to the hospital, 1 because of the onset of non-Q wave myocardial infarction and 2 because of repeat anginal attacks. In those 2 patients, medical therapy was discontinued at their discretion. In the follow-up analysis, we found that the incidence of symptoms caused by repeat anginal attacks was 37.0% (27/73) in the first year and was increasing every year., Conclusions: CCBs are strongly recommended for improving the prognosis of coronary spasm, but in many cases they do not suppress completely symptoms.

We report a case of spontaneous splenic rupture (SSR) caused by a Bacillus species (sp.) infection. A 36-year-old man on warfarin therapy since an aortic valve replacement at the age of 13 was admitted to our hospital with a 3-week history of a high fever. He had been asymptomatic until 4 months previously, when he suffered a cerebral embolism despite adequate oral anticoagulation. Abdominal computed tomography revealed splenic infarctions, which resulted in splenic rupture 2 days later. After embolization of the splenic artery, splenectomy was successfully performed. Pathologic examination revealed splenic infarction, resulting from septic emboli, with associated rupture of the splenic capsule, but no abscess was found. Bacillus sp. was isolated from cultures of arterial blood preoperatively, and the excised splenic specimens, postoperatively. In addition to rupture of the suppurating intrasplenic vessels with hematoma formation, the anticoagulant therapy possibly contributed to distension of the intrasplenic hematoma.

We report a case of a 64-year-old female patient who underwent a right lobectomy of the liver (including total resection of the caudate lobe), dissection of the group 2 lymph nodes, left hepaticojejunostomy (Roux-en-Y fashion), and reconstruction of the portal vein (end-to-end anastomosis between the main portal vein and the left portal branch) for treatment of hepatic hilar bile duct cancer in 1996. In 2001, the anastomotic site of the hepaticojejunostomy was dissected and re-anastomosed due to gastrointestinal bleeding caused by variceal rupture in the jejunal loop. In 2006, splenectomy was performed for recurrence of gastrointestinal bleeding due to another variceal rupture in the jejunal loop. Portal venography performed perioperatively showed a decrease in portal blood flow into the liver via the jejunal varices and an increase in portal blood flow into the liver via the left gastric vein. She had two jejunal variceal ruptures at five-year intervals after extrahepatic portal obstruction and underwent successful treatments.

Background: Patients with congestive heart failure (CHF) are often re-hospitalized, worsening both their quality of life and prognosis. Although renal dysfunction reportedly increases the risk of CHF, the association between renal dysfunction and re-hospitalization for CHF remains unclear., Methods and Results: Patients with CHF and decreased renal function were reviewed. The estimated glomerular filtration rate (GFR) was calculated with the Modification of Diet in Renal Disease equation. Patients with decreased renal function (estimated GFR on admission <45 ml .min(-1) . 1.73 m(-2)) were re-hospitalized more frequently than were patients with preserved renal function (estimated GFR on admission >or=45). Patients with decreased renal function were older and had higher rates of anemia, worsening renal function during hospitalization, and previous hospitalization for CHF. Independent predictors of re-hospitalization for CHF identified with multivariate analysis were age, previous hospitalization for CHF, decreased renal function, and non-use of an angiotensin-converting enzyme inhibitor or angiotensin-receptor blocker., Conclusions: Renal dysfunction is an independent predictor of re-hospitalization for CHF, so careful follow-up is needed, even after discharge.

We report a case of double cancer of the cystic duct and gallbladder associated with low junction of the cystic duct. A 73-year-old woman was admitted to the hospital complaining of upper abdominal pain. Endoscopic retrograde cholangiography showed a stenotic lesion in the lower common bile duct and no visualization of the cystic duct or gallbladder. Enhanced computed tomography revealed a heterogeneously enhanced tumorous lesion around the lower bile duct in the pancreatic head. A diagnosis of cancer arising from the cystic duct that entered the lower part of the common hepatic duct was made by intraductal ultrasonography, which showed an intraluminal protruding lesion in the cystic duct. Isolated gallbladder cancer was also diagnosed, by abdominal computed tomography. She underwent pancreaticoduodenectomy with dissection of regional lymph nodes. Histological examination revealed moderately differentiated adenocarcinoma of the cystic duct and well-differentiated adenocarcinoma of the gallbladder. Double cancer of the cystic duct and gallbladder is extremely rare, and this case also suggests a relationship between a low junction of the cystic duct and neoplasm in the biliary tract.

Background: Acute myocardial infarction (MI) sometimes occurs without painful symptoms and in such cases, prognosis is worsened by delays in diagnosis and revascularization. Renal insufficiency induces many types of neuropathy, but the relation between renal insufficiency and painless MI remains unclear., Methods and Results: Patients with MI and elevated creatine kinase levels were retrospectively analyzed. Renal insufficiency (serum creatinine concentration > or =1.5 mg/dl) and other characteristics (age, sex, body mass index, hypertension, smoking, diabetes mellitus, dyslipidemia, history of stroke, previous MI, hemodialysis, and atrial fibrillation) were compared between patients who had MI with painful symptoms (painful MI, n=131) and patients who had MI without painful symptoms (painless MI, n=18). Other variables compared were the time from symptom onset to admission, peak creatine kinase concentration, Killip class, site of MI, emergency coronary angiography, postprocedural Thrombolysis In Myocardial Infarction grade III flow, and in-hospital death. Univariate analysis identified older age, renal insufficiency, and previous MI as predictors of painless MI. Patients with painless MI showed higher rates of Killip class > or =II and in-hospital death and a longer time from symptom onset to admission. However, multivariate analysis identified only renal insufficiency as an independent predictor of painless MI., Conclusions: MI without painful symptoms frequently develops in patients who have renal insufficiency, so the possibility of painless MI should be evaluated in such patients to ensure early diagnosis and treatment.

Four cases are described of acute subdural hematoma that occurred after valve replacement in patients receiving anticoagulant therapy. All four patients experienced rapid deterioration of consciousness or neurological dysfunction, to varying degrees, between two and 42 days after valve replacement; emergency brain computed tomography scanning demonstrated the presence of subdural hematoma. The neurological problems were completely resolved by removal and drainage of the hematoma in three patients, while conservative management was performed with no aggravation of neurological symptoms in the fourth patient.

Background: Leaflet opening angles of ATS valves in vivo tend to be less than those reported by the manufacturer, and there is a wide variation in opening angles even among valves of the same size., Methods: Leaflet movement of aortic ATS valves was evaluated by cineradiography in 77 patients. The mean period from valve replacement to cineradiography was 40.2 months, and during that period, the ATS valve was replaced due to prosthetic valve obstruction in 1 of the 77 patients., Results: In 76 patients with a normally functioning ATS valve, the mean opening angle of 19-mm valves (66.3 degrees +/- 2.3 degrees) was significantly less (p < 0.0001) than that of ATS valves 21 mm or larger (72.2 degrees +/- 3.8 degrees in 21-mm, 72.4 degrees +/- 2.8 degrees in 23-mm, and 72.8 degrees +/- 2.9 degrees in 25-mm valves). No significant differences were found in the opening angles of ATS valves 21 mm or larger, and the opening angles exceeded 65 degrees in all 69 patients with valves in this category. In one case of obstruction in a 21-mm valve, the opening angle was 57.5 degrees. The closing angle was 24.9 degrees +/- 1.3 degrees, which corresponded well with the manufacturer's in vitro data., Conclusions: The opening angle in the 19-mm ATS aortic valve is significantly less than that in valves 21 mm or larger, and an opening angle of less than 65 degrees probably indicates prosthetic valve obstruction in aortic ATS valves sized 21 mm or larger.

We report four long-term survivors after valve replacement with a Starr-Edwards (S-E) mitral caged-disk valve. A model 6520 disk valve, size 3M, had been used in all of the four patients. Of the four patients, three underwent replacement of the disk valves 23, 24, and 26 years after mitral valve replacement (MVR), respectively. A pacemaker was implanted in the remaining patient 33 years after MVR. The S-E disk valves were considered hemodynamically slightly stenotic compared with modern bileaflet valves. No disk wear was detected in any of the three explanted valves, and in the remaining patient, a noninvasive evaluation of the disk showed that it was functioning normally. These results suggest the favorable long-term durability of the S-E disk valve.

This report describes 3 aged patients undergoing emergent surgery who refused elective operation for a thoracic aortic aneurysm because of freedom from symptoms attributable to the aneurysm at the time of presentation. A 77-year-old woman with a thoracoabdominal aneurysm 57 mm in diameter at presentation had recurrent hemoptysis 12 months later. A 78-year-old man with a saccular type distal arch aneurysm 64 mm in diameter at presentation was transported with shock and hemothorax 27 months later. Another 82-year-old man with a saccular type distal arch aneurysm 60 mm in diameter at presentation was admitted with severe chest and back pain 36 months later. All of them underwent tube graft replacements of the aneurysm urgently and were discharged on foot. Aged patients with life-threatening events should not be denied surgical intervention because of excessive operative mortality and morbidity, even if they had previously refused elective surgery.

Surgery for thoracic aortic aneurysm (TAA) in patients 75 years and older is a high risk, but data for their natural history are not available. In the present study the subjects were 62 patients with TAA aged on average 78 years (range, 75-85 years) enrolled between August 1994 and December 2001: 20 operatively treated patients (OPE) and 42 medically managed patients (MED). All of them had been included in the indication for TAA surgery at the time of consultation. Hospital mortality rates and survival rates (Kaplan-Meier method) were compared among emergency OPE, elective OPE, and MED. There were 136 total patient-years of follow-up. Actuarial survival in MED (ie, the natural history) was 83% at 1 year after consultation and 41% at 3 years. Hospital mortality rates in emergency and elective OPE were 27% (3/11) and 0% (0/9), respectively (p=0.22), and the corresponding 3-year survival rates were 44% and 83% (p=0.019). Actuarial survival in elective OPE was higher than that in MED (p=0.022), but that of emergency OPE was similar to that for MED (p=0.17). Patients aged 75 years and older with TAA should undergo an elective operation if the aneurysm diameter is larger than 6 cm and if the patient is asymptomatic and in good anatomicosurgical, physical, and social condition.

Forty octogenarians (OCTO) undergoing a variety of cardiac and thoracic aortic surgeries using cardiopulmonary bypass (CPB) between 1994 and 2002 were retrospectively studied. The results were compared with those of high-risk younger patients aged less than 60 years (YOUNG) (n=89). All patients had an expected operative mortality of EuroSCORE 5 and over. The EuroSCORE score was 9.9+/-3.3 (range, 5-18) in the OCTO group and 6.8+/-2.3 (range, 5-16) in the YOUNG patients (p<0.0001). There were 4 (10%) and 10 (11%) hospital deaths, respectively (p>0.99). Major postoperative complications occurred in 50% of the OCTO and 36% of the YOUNG patients (p=0.17). There were 10 and 7 late deaths, respectively. Actuarial survival including hospital death was significantly lower in the OCTO group than in the YOUNG (p=0.033). Actuarial survival was significantly higher in female octogenarians than in male (p=0.046). The overall 3-year survival rate was 88+/-8% and 64+/-11%, respectively. Multivariate analysis showed that predictors of late death were male gender (p=0.0005) and a high EuroSCORE (p=0.0010). Cardiac and thoracic aortic surgery using CPB can be performed in octogenarians with an acceptable hospital mortality rate and gratifying medium-term survival results.

The risk factors and the outcome of stroke in thoracic aortic surgery were studied in 127 patients (86 males, 41 females), aged 18 to 84 years (mean, 64 years), operated on between September 1994 and December 2000. There were 29 operations on the ascending aorta, 63 arch, 29 descending, 5 thoracoabdominal, and 1 extraanatomical bypass. Perioperative stroke occurred in 15 patients (12%). The risk factors for stroke were identified as preexisting chronic renal failure and femoral arterial cannulation. Hospital death occurred in 4 of the 15 cases (27%) of stroke and 7 of the 112 cases (6%) without stroke (p < 0.05). There were 18 late deaths during a mean follow-up period of 3.2 years (range, 1 month to 7.2 years). The 3-year survival rates were 43 +/- 14% in the stroke patients and 85 +/- 4% in the other patients. Actuarial survival, including during hospitalization, was lower in the stroke patients than in the other patients not only among those 70 years or older but also among all the patients (both p < 0.0001). Stroke occurring in thoracic aortic surgery is thus an important risk factor for early and late mortality, particularly in patients 70 years or older.

Background: We reviewed our clinical experience with primary cardiac tumors, attempting to clarify the surgical management of these rare entities., Methods: Between October 1978 and November 1999, we experienced 60 surgical cases of primary cardiac tumors. There were 23 male and 37 female patients (age range, 7 months to 84 years). Tumors included the following 3 groups: myxomas (n=49), nonmyxoma benign tumors (n=3), and malignant tumors (n=8). We reviewed the presenting symptoms, diagnostic data, anatomical findings, and surgical techniques, and evaluated the surgical RESULTS. Late follow-up was 95% complete (mean follow-up, 7.7+/-7.1 years)., Results: Tumors produced obstructive, embolic, and/or constitutional symptoms in most cases. Generally, echocardiography alone gave sufficient information for operation. Full-thickness excision was performed in 42 patients with myxoma. Complete excision was achieved in all of the nonmyxoma benign tumors and in none of the malignancies. Early mortalities in the 3 groups were 8.2% (4/49), 0% (0/3), and 12.5% (1/8), respectively. Late mortalities were 9.5% (4/42), 0% (0/3), and 100% (7/7), respectively. One patient with myxoma had recurrence, the cause of which was likely to be inadequate resection. The late deaths in patients with malignancies were due to metastasis or local recurrence., Conclusions: Benign tumors are generally curable if surgically excised. Preoperative refractory cardiac dysfunction or embolism should be avoided by the accurate evaluation on echocardiography. The prognosis of malignant tumors is poor if they are only debulked. However, aggressive surgery that can palliate obstruction and allow time for adjuvant therapy should be carried out.

This retrospective analysis was performed to determine the early and late outcome in patients 70 years and older undergoing aortic valve replacement (AVR). From October 1994 to May 2001, 49 patients (24 men and 25 women, age 70 to 88 years [mean 74 +/- 4.6 years]) underwent primary AVR with or without concomitant procedures. Twenty-one received mechanical valves and 28 bioprostheses. Age was different between both groups: 72 +/- 2.3 years (mechanical) and 76 +/- 5.1 years (bioprosthetic) (p = 0.0005). Aortic stenosis was present in 25 patients (51%). Follow-up was 100% complete at a mean follow-up of 2.9 years (range 0.3-6.5 years). Overall hospital mortality was 4.1% (2/49). There were no postoperative complications in 24% of patients. Postoperative hospital stay or hospital survival was 27 +/- 13 days. Survival at 3 and 5 years was 89 +/- 5% and 80 +/- 7%, respectively. Three late deaths were due to noncardiac causes and 1 each had a cardiac or valve-related cause (thromboembolism). Other valve-related complications such as anticoagulant-related hemorrhage, perivalvular leak, endocarditis, prosthetic valve failure, and reoperation were not noted in any of the 49 patients. The actuarial survival curve was similar in each group of bioprosthetic versus mechanical and septuagenarians versus octogenarians. Under the selection criteria for AVR currently applied in our hospital, geriatric patients showed a satisfactory early outcome and medium-term survival benefit.

Biocompatibility of a new type of heparin-coated cardiopulmonary bypass equipment, the Bioline, was evaluated in coronary artery bypass surgery cases. The heparin-coated (H) group (n = 15; Quadrox Bioline oxygenator/reservior and Carmeda BioMedicus BP-80 centrifugal pump) was compared with the nonheparin-coated (N) group (n = 12; uncoated, otherwise similar oxygenator, centrifugal pump, tubing, and filter set). Both groups used full systemic heparinization. The peak values of neutrophil elastase, C3a, IL-6, and IL-8 at 2 h after cardiopulmonary bypass (CPB), and C3a levels at the end of CPB and at 2 h after CPB were significantly reduced in the H group compared with those of the N group. However, no statistically significant intergroup differences were observed in thrombin-antithrombin complex, D-dimer, beta-thromboglobulin, or platelet factor-4. No significant differences were observed in hemostasis time, postoperative 12 h blood loss, required amount of blood transfusion, or intubation time. In conclusion, the Bioline demonstrated partially improved biocompatibility, in terms of leukocyte and complement activation, and proinflammatory cytokine production. However, it did not improve platelet activation, coagulation, or fibrinolysis cascade under full systemic heparinization. As a result, the clinical beneficial impact seemed to be the minimum.

A 49-year-old patient with end-stage dilated cardiomyopathy underwent implantation of a left ventricular assist system (LVAS). Although the systemic circulation seemed to be improved, the serum total bilirubin (Tbili) level increased sharply in the early postoperative period (preoperative Tbili, 5.7 mg/dl; postoperative day 3, 33.6 mg/dl). Plasma exchange (PE) was performed 7 times from postoperative day 4, and the Tbili level decreased to 16.3 mg/dl by postoperative day 11. Thereafter, serum Tbili normalized concomitant with improved circulatory condition. The cause of the hyperbilirubinemia was considered to be temporary right ventricular dysfunction or hepatic sinusoid endothelial dysfunction. The liver function was recoverable, so PE had been effective in this case. Unfortunately, the patient suffered a midbrain infarction and ultimately died. From this experience, PE is recommended if it is judged that liver function can be preserved and circulation is adequate, but its implementation should not be delayed. It is essential that LVAS is implanted before damage occurs to end-organ function and thus prevent hyperbilirubinemia.

A case of a 65-year-old woman who had a quadricuspid aortic valve associated with aortic regurgitation is reported. The patient had severe aortic regurgitation and four equally divided aortic cusps. The valve abnormality was detected by a transesophageal echo and an aortography. The incomplete aortic valve was excised and replaced by a St. Jude Medical prosthesis. Although this case had no coronary abnormality, a coronary displacement is often reported in quadricuspid aortic valve cases. In order to perform an operation safely, accurate information which is obtained by a non-invasive examination of the transesoph-ageal echo is quite valuable as it can indicate the need for further preoperative examinations of the coronary arteries.