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O objetivo do trabalho foi avaliar a interação do herbicida tebuthiuron (Combine® 500 SC), com nematicidas carbofuram (Furadan® 350 SC) e benfuracarbe (Pottente®), aplicados no plantio da cultura da cana-de-açúcar (RB 867515). O experimento foi conduzido em casa de vegetação da Universidade Paranaense, em Umuarama – PR, no período de abril a agosto de 2014. Foi instalado em vasos com capacidade para 4,5 L, contendo uma planta por vaso, em delineamento inteiramente casualizado, com seis tratamentos e quatro repetições, sendo os tratamentos testemunha (T1), sem aplicação de produtos; aplicação isolada de carbofuran (T2); aplicação isolada de benfuracarbe (T3); aplicação isolada de tebuthiuron (T4); aplicação combinada de carbofuran e tebuthiuron (T5) e aplicação combinada de benfuracarbe e tebuthiuron (T6). O experimento foi submetido a duas avaliações, 45 e 90 dias após o plantio (DAP) sendo que na primeira, as variáveis avaliadas foram altura da parte aérea, número de folhas e número de plantas daninhas por vaso, e, na segunda, altura da parte aérea; número de folhas; número de plantas daninhas; massa fresca e seca da parte aérea; massa fresca do sistema radicular; população final total de nematoides por vaso, calculada pelo somatório de nematoides nas raízes e solo. Quanto ao número de folhas, o tratamento T4 demonstrou fitotoxicidade aos 45 DAP. Os tratamentos T3, T5 e T6 apresentaram as maiores massa fresca e seca da parte área da cana, demonstraram ausência de interação antagônica entre as combinações do herbicida com os nematicidas aos 90 DAP. Os tratamentos T3 e T5 foram eficientes no controle populacional de P. zeae.

Coagulopathy is still a frequent complication in the surgical treatment of acute aortic dissection. This study was designed to clarify the influence of acute aortic dissection on the clotting-fibrinolysis system and platelet function. From January 1993 to December 1994 21 patients with proven Stanford type B aortic dissection underwent a series of tests and procedures at our institution. There were 6 women and 15 men, aged 37–74 years (mean 62 years). All patients were admitted within 14 days of onset of dissection. No patient had complications requiring surgery and none died during the observation period. We observed a severe inflammatory reaction with activation of the clotting-fibrinolysis system immediately after onset of dissection. The platelet maximum aggregation rates were also decreased transiently after onset of the dissection. D-dimer values remained elevated throughout, the observation period. A rational approach to the surgical treatment of acute aortic dissection should involve coping with its activated clotting-fibrinolysis system and platelet dysfunction in addition to tissue friability.

The significant benefit of performing hepatic resection for hepatic metastases from colorectal primary cancers is well established; however, the effectiveness of dissection of the lymph nodes draining the liver remains uncertain. Herein, we report the case of a 52-year-old man who was found to have obstructive jaundice caused by lymphatic remetastasis from the hepatic metastasis of primary rectosigmoid cancer. He had previously undergone a high anterior resection for the rectosigmoid cancer, in April 1990, and a hepatic resection for metastasis was done in March 1994. When the hepatic resection was carried out, dissection of the regional lymph nodes of the liver (i.e., the nodes in the hepatoduodenal ligament) was not performed because no obvious metastatic nodes were identified. Three years after the hepatic resection, enlarged lymph nodes compressing the extrahepatic bile duct from outside were identified by cholangiography and computed tomography (CT). Because radiological studies were unable to determine the lesion capable of metastasizing to these nodes, they were diagnosed as remetastasized lymph nodes from the hepatic metastasis that had been resected 3 years earlier. The lymphatic remetastases were intractable to treatment, and the patient finally died of hepatic failure and malignant cachexia. This case serves to demonstrate that lymphatic dissection of the regional lymph nodes may need to be taken into consideration when resection of hepatic metastases from colorectal cancers is performed.

Objective: Human T lymphotropic virus type I infects CD4 + T cells and affects cell-mediated immunity. Cardiopulmonary bypass transiently alters lymphocyte subsets, resulting in a reduction in CD4 + T cells and an increase in CD8 + T cells. We proposed that cardiovascular operations and human T lymphotropic virus type I infection may act synergistically, resulting in serious damage to cell-mediated immunity. Methods: A total of 517 consecutive patients who were preoperatively screened for anti-human T lymphotropic virus type I antibody and underwent cardiovascular operations with cardiopulmonary bypass were enrolled in this study. Of the 517 patients, 82 (16%) had positive test results for anti-human T lymphotropic virus type I antibody. The surgical outcome of patients with positive and negative results for anti-human T lymphotropic virus type I antibody was analyzed retrospectively. Results: There was no difference between the 2 groups with respect to early mortality. Distribution of survival curve was also not significantly different ( P = .5; mean follow-up duration, 2.4 ± 1.8 years [range, 0-9.4 years] and 3.2 ± 2.8 years [range, 0-9.8 years]) in the groups with positive and negative antibody results, respectively). In particular, long-term follow-up did not reveal adult T-cell leukemia or human T lymphotropic virus type I–associated myelopathy, and occurrence of neoplasm did not differ between groups. Early infectious complication was, however, significantly higher in the group with positive antibody results than in the group with negative results ( P = .02). Logistic regression analysis revealed human T lymphotropic virus type I infection as a significant risk for this complication ( P = .04; odds ratio, 2.5; 95% confidence interval, 1.0-5.8). Conclusion: A combination of human T lymphotropic virus type I infection and cardiovascular operation is believed to increase the potential risk of infectious complications shortly after the operation. However, this synergistic effect seems to be transient and has little influence on long-term prognosis. (J Thorac Cardiovasc Surg 2000;120:699-706)

Objective: Organ malperfusion in aortic dissection can precipitate a serious condition. The strategy of treatment for it has been controversial. We have focused on the strategy and outcome of acute aortic dissection with organ malperfusion.Subjects and Methods: Between January 1995 and December 1998, 134 acute aortic dissection patients were admitted. There were 73 males (65.4+/−8.0 years old) and 61 females (66.7+/−7.4 years old). There were 83 patients of Stanford type A, and 51 patients of type B. Of them, 24 patients (17.9%) were complicated by organ malperfusion. The brain was affected in 4, the heart in 5, the spinal cord in 2, the liver in 1, the intestine in 1, the kidney in 4, and the lower extremities in 10 patients. Our management strategy for a patient with malperfusion in acute aortic dissection was that the antecedent operation was initially mandatory, and central grafting was secondarily considered.Results: Refusal of operation or lethal conditions excluded 8 of the 24 patients from operation. An antecedent operaiton was mandatory in eight of the remaining 16 patients. The overall mortality was 33.3% (8/24 patients), and operative mortality was 31.3% (5/16 patients) in the patients with malperfusion. The overall mortality was 11.8% (13/110 patients), and the operative mortality was 11.1% (9/81 patients) in the patients without malperfusion.Conclusion: Organ malperfusion is a major component in the management and treatment of acute aortic dissection. Only an appropriate strategy and therapy could result in a satisfactory outcome.

僧帽弁形成術中に生じた急性大動脈解離に対し上行大動脈置換術を施行した1例を報告する. 症例は74歳, 男性. 僧帽弁形成術の体外循環終了後, cardioplegia 針刺入部から出血が持続, 上行大動脈の膨隆, 色調変化が出現した. 経食道心エコーおよび術野からのエコーで上行大動脈から胸部下行大動脈の解離を確認し, 術中大動脈解離の診断を得た. ただちに体外循環を再開し, 超低体温, 循環停止下に上行大動脈置換を行った. 術後経過は順調で, 弓部, 下行大動脈の解離腔も血栓閉鎖していた. 術中大動脈解離は体外循環に伴う稀な合併症であるが, 病態は重篤であり, 迅速な診断と的確な処置が重要である.

症例は40歳女性. 心臓超音波検査で僧帽弁後尖に疣贅と僧帽弁閉鎖不全症を認め, 血液培養検査でSalmonella enteritidis が検出された. 各種抗生剤投与にもかかわらず炎症は寛解せず, 活動期の感染性心内膜炎であったが機械弁による僧帽弁置換術を施行した. 術後は胆道移行性のよい Fromoxef, Sulbactam を使用し良好な経過を得た. サルモネラ菌感染症による感染性心内膜炎は治療抵抗性のことが多く, 弁周囲へ炎症が及ぶ前に早期の外科治療が推奨される. 軽快後も胆嚢内に残存し慢性保菌者となる可能性があるので, 胆道移行性に優れた抗生剤を選択すべきである.

In 78-year-old woman with chronic liver disease, multiple tumors in the left hepatic lobe were disclosed during a periodic ultrasound examination. She had a history of local rectal resection for a 1.5cm carcinoid with invasion of the muscularis propria, in 1985. Under the diagnosis of hepatocellular carcinoma, she underwent a laparotomy in May, 1995. Considering her age and hepatic functional reserve, lateral segmentectomy with additional microwave coagulonecrotic therapy (MCN) was selected instead of left hepatectomy. Histological findings of the resected tumors showed a structure similar to that of the previous rectal carcinoid (trabecullar growth pattern, Soga type B), thus, the hepatic tumors were diagnosed as metastatic hepatic carcinoid from the rectal primary after 12 years of dormancy. Therefore a rectal carcinoid invasion of the muscularis propria, irrespective of size, should be treated carefully. The histological structure of the carcinoid might exhibit a slow-growing behavior. Since her postoperative course was uneventful and she is doing well two years and six months after operation, hepatectomy combined with MCN was the appropriate modality in this case.

To investigate whether the preoperative nutritional state influences the postoperative inflammatory reaction and immunity, we grouped patients whose postoperative nutritional support was performed by total parenteral nutrition into the good nutritional state group (group I) and the latent protein-calorie malnutrition suggested group (group II) based on the preoperative rapid turnover protein (RTP). Nutritional markers markedly decreased after surgery and recovered almost to preoperative levels on postoperative day (POD-) 7 in groups I and II. Nutritional markers on POD-7 in group II were significantly lower than those in group I (RTP, P < 0.001; albumin, P < 0.05). After surgery, levels of interleukin-6 (IL-6), C-reactive protein (CRP), and polymorphonuclear (PMN-) elastase were higher in group II than in group I (P < 0.01). In groups I and II, IL-6 and interleukin-8 (IL-8) rose before the remarkable elevation of CRP and PMN-elastase. In group I, all the nutritional markers showed a negative correlation with CRP and PMN-elastase. Further, a positive correlation was observed between IL-6 and CRP and between IL-8 and PMN-elastase. In conclusion, evaluation of the preoperative nutritional state appears to be very important for the prediction of postoperative complication.

1 To evaluate in vitro inhibitory effects of four types of histamine H2-receptor antagonist (H2-receptor antagonists), famotidine, roxatidine, cimetidine and ranitidine, on platelet function, we examined aggregating potency and P-selectin levels with agonist-induced aggregation. Ranitidine and cimetidine inhibited, in concentration of 0.35 mM, the secondary aggregation induced by 5 pM adenosine diphosphate (ADP), the aggregation induced by 1,g/mL collagen and 3 gM arachidonic acid. All of H2-receptor antagonists inhibited, in concentration of 1.4 mm, the aggregation induced by ADP, collagen and arachidonic acid. Ranitidine and cimetidine reduced markedly, in same concentration, P-selectin levels after induction of aggregation by 5 gm ADP, 1 ig/xmL collagen and 3 gM arachidonic acid. When classified by the strength of inhibitory action, ranitidine and cimetidine were strong, followed by famotidine and roxatidine. 2 It is considered that inhibitory effects of H.-receptor antagonists on platelet function are weaker than those of acetylsalicylic acid (ASA), since ASA inhibited platelet aggregation in concentration of 100 MM. 3 No relationship was observed between inhibitory effects of H2-receptor antagonists on platelet aggregation induced by above agonists and the presence or absence of imidazole ring in the chemical structure.

This study was designed to clarify the clinical characteristics and optimal management of patients who have acute aortic dissections accompanied by atherosclerotic (true) aortic aneurysm. Between January 1992 and August 1996, a total of 132 patients (Stanford type A/B = 72/60) had surgical repair or medical treatment of acute aortic dissection at our institution. Seventeen (type A/B: 5/12) of them had concurrent or previously repaired true thoracic or abdominal aortic aneurysms. There were 14 men and three women patients, ranging in age from 58 to 79 years with a mean of 70 years. Five patients developed type A dissections that affected preexisting true aneurysms located on the aortic arch (n=four) and infrarenal aorta (n=one). They all underwent emergency operations: four patients had total arch repair with resection of aortic arch aneurysms resulting in one death due to myocardial infarction, and the remaining one patient had a hemiarch repair that was followed by resection of an enlarged abdominal aortic aneurysm (AAA) 2 years later. Twelve patients developed type B dissections. Five of them had preexisting true aneurysms affected by dissection: there were three descending thoracic aortic aneurysms (DTAA) and two AAAs; rupture occurred in three patients (DTAA/AAA=one/two) while awaiting surgery. The other two patients successfully underwent emergency graft replacements of the descending thoracic aorta containing true aneurysm and dissection. No patient among the remaining seven with type B dissections, who had AAAs not affected by dissection, had an unfavorable outcome because of the presence of concurrent dissection and true aneurysm. The risk of rupture appears to be high in patients with an aortic segment where true aneurysm is affected by acute dissection. Hence, surgical repairs should be done on an emergency basis in those patients irrespective of the type of dissection.

From January 1992 through March 1997, 75 patients (DeBakey type I/II = 56/19) underwent a surgical repair of a type A acute dissection. The patients included 37 men and 38 women ranging in age from 23 to 83 years with a mean of 65 years. All patients were admitted to our hospital with a mean interval of 2.2 days from the episode of onset. The overall hospital mortality rate was 25% (19/75). There were three late deaths among the 56 patients discharged from the hospital. The actuarial survival rate for the patients surviving the operation was 87% at 5 years after repair. A subsequent aortic operation was necessary in 6 patients, while 3 other patients who had late aortic complications were put on medical therapy alone. As a result, the aortic event-free survival rate was 54% at 5 years. For a type I dissection the false lumen was completely thrombosed after repair in 34%. The descending thoracic aorta with a patent false lumen was markedly enlarged in proportion to the follow-up time. After a conservative approach to the aortic valve, all but one patient demonstrated an adequate valve function throughout this study period. This experience with a midterm follow-up showed an acceptable durability of the preserved aortic valve and a progressive enlargement of the persistent false lumen with a high rate of aortic complications. Hence, all patients with a type A dissection need a close follow-up to assess the aorta for complications of either recurrent or residual aneurysms and dissections.

His-bundle pacing gives a more physiological ventricular contraction in comparison to right ventricular apical pacing. However the problems of lead fixation and stability of long-term His-bundle pacing are yet unsolved. We used six adult beagles, in which a screw-in lead was anchored in the His-bundle region for observation of the pacing conditions and histopathologic changes of the conduction system over the course of 2 months. In the results, a satisfactory fixation was obtained using a conventional screw-in lead and no histological influence on the conduction system was observed. The pacing threshold at the time of implantation was 1.15 +/- 0.69 V (3.23 +/- 3.08 mA) in the pulse width of 0.5 ms. R wave amplitude, the impedance and slew rate were 7.28 +/- 2.04 mV, 409 +/- 102 Ohm, and 0.65 +/- 0.41 V/s, respectively. Two months later, these parameters changed to 2.83 +/- 1.06 V (10.4 +/- 5.71 mA), 5.63 +/- 1.62 mV, 310 +/- 71.3 Ohm, and 0.49 +/- 0.22 V/s, respectively. These results suggest the feasibility of clinical application of permanent His-bundle pacing.

慢性膿胸腔に扁平上皮癌が発生した稀な1例を経験した.症例は, 55歳の男性で膿胸発症から発癌までに19年と長期の膿胸罹患期間があり, 気管支瘻は認めなかったが, 皮膚瘻を伴っていた.膿胸腔側の肉眼所見で, 瘻孔周囲のやや赤い部分に扁平上皮化生の部分があり, 潰瘍状の部位に扁平上皮癌が散在しており, 扁平上皮癌の発生由来は, 膿胸腔の胸膜中皮化生と思われた.重層扁平上皮化生では, 10層以上の細胞が扁平上皮細胞への分化を示し, 個々の細胞は中等度の異型性を示していた.一方, 扁平上皮癌は, 充実性の胞巣を形成し胞巣中心部で角化を示す, いわゆる癌真珠を伴う高分化癌であった.また, 膿胸腔内面の胸膜は瀰慢性に肥厚していたが, 醸膿膜に明らかな腫瘤性病変はなく, 扁平上皮化生部分と癌組織部分が, 散在性にみられ, 腫瘍形態は散在性発育型であった.

症例は67歳の男性。約8年前に気づいた黒色の左鼠径部の皮疹が徐々に拡大, 潰瘍化してきたため, 1998年鹿児島大学病院皮膚科外来を受診した。潰瘍は24cm×9.5cmと下腹部ほぼ全体を占め, 潰瘍底には鼠径動脈が露出していた。また陰茎皮膚は象皮症を呈し, 排尿困難があった。潰瘍辺縁より行った皮膚生検で基底細胞癌の診断を得た。入院後に行った全身検索では他臓器への転移は見られなかった。露出動脈からの出血や陰茎の象皮症に対し, 血管置換術, 陰茎切断術及び尿路変更術を行った。潰瘍部には放射線療法及び植皮術を行い癌は完治した。

A 58-year-old man was admitted to the hospital because a huge abdominal tumor was found on ultrasonography (US) at a medical checkup. On physical examination, a movable, elastic soft mass with smooth surface was palpable on the left upper abdomen. The results of biochemical examination and the tumor markers, including CEA and CA 19-9, were nomal. Computed tomography (CT) and magnetic resonance imaging (MRI) disclosed a large cystic mass, measuring 9.0×13.0cm in size, which was located in posterior-lower portion of the stomach. Preoperative diagnosis was submucosal tumor of the stomach or a tumor arising from the greater omentum invading the gastric wall. A tatal extirpation of the tumor in combination with a partial resection of the involved gastric wall was performed. The extirpated tumor was 12.0×11.0×10.0cm in size, was entirely encapsulated, and composed of cystic and solid portions concomitantly.Histologically, it was leiomyoma originating in the omentum.Most of the tumors arising from the omentum have been proved malignant, such as leiomyosarcoma or leiomyoblastoma. Leiomyoma of the omentum is extremely rare, there have been only four cases including ours in the Japanese literature. Although, due to the absence of characteristic symptoms, it is difficult to make the preoperative diagnosis, US, CT and MRI are useful for the diagnosis.

全身性エリテマトーデスでの大血管病変の報告は稀である. 本疾患で23年の治療歴を持ち, 腹部大動脈瘤を発症した1例を経験した. 症例は49歳女性. 26歳時に全身性エリテマトーデスと診断され, ステロイド療法を開始され, 28歳時にループス腎炎と診断された. 内科外来通院中に腹部大動脈瘤を指摘され, 手術を行った. 動脈瘤は腎下型で最大径7cm, 長径8cm, 周囲との癒着はなかった. 動脈瘤壁は薄く, 一部石灰化し, 厚い壁在血栓を伴っていた. 直型人工血管で置換し, 術後経過良好で現在復職している. 動脈瘤壁の病理診断は動脈硬化性大動脈瘤であった. 全身性エリテマトーデス患者は炎症性疾患であるが, 動脈硬化が進行しやすいという側面も持っており, 比較的若年で動脈硬化性の大動脈疾患を発症する可能性があり, この点を念頭に置いた経過観察が必要である.

We report successful local resection for cancer of papilla of Vater in an 86-year-old woman. She was referred to our hospital because of right hypochondralgia. Abdominal ultrasonography and computed tomography showed marked dilatation of the common bile duct (CBD). Endoscopic retrograde cholangiography disclosed a small shadow defect in the terminal of the dilated CBD. Biopsy of the papilla revealed well-to-moderately differentiated adenocarcinoma. Considering her extreme old age and keeping in mind her quality of life after the operation, and the finding that the tumor was localized within the papilla and highly differentiated, we performed local resection. In addition, the intrapancreatic portion of the CBD and part of the main pancreatic duct (MPD) were further resected to secure a negative margin, confirmed by frozen section. The MPD was reapproximated to the duodenal mucosa and a choledocho-duodenostomy was performed for CBD reconstruction. Histopathological examination showed the tumor was papillary adenocarcinoma, 10 x 15 mm in size; there was no invasion beyond the sphincter of Oddi, it had partly infiltrated the CBD, but had not invaded to the pancreas or duodenum. The patient's postoperative course was not eventful and she has had good quality of life for the past 6 years since the operation, without any evidence of recurrence. Although radical pancreaticoduodenectomy is now the standard procedure in patients with malignant tumor of the papilla of Vater, local resection is a reasonable alternative for high-risk patients with highly differentiated, apparently localized carcinomas.

A 63-year-old man and a 49-year-old man who underwent PTMC eight years before were admitted in our hospital because of regurgitation and restenosis of the mitral valve. Both of them had ulcer like lesion on the anterior leaflet near the commissure of the mitral valve. These changes were made by PTMC and likely caused thrombosis. Long-term follow up data of PTMC is essential to chose the correct operative method for treating mitral stenosis.

Small bowel allograft rejection in large animals has yet to be well defined. There are no specific early signs of graft rejection. The present experiments were undertaken to compare acute small bowel allograft rejection in pigs with and without FK506 and also to examine the usefulness of mucosal biopsies. Thirty-six outbred Large-White pigs were divided into (1) group 1 (n = 9): nonimmunosuppressed recipients; (2) group 2 (n = 8): FK506-immunosuppressed recipients; (3) group 3 (n = 2): autotransplant controls; and (4) donors (n = 17). Orthotopic small bowel transplantations were performed with Thiry-Vella loops for daily biopsies. The survival rate of group 2 was significantly longer than that of group 1 (P0.05). One best survivor in group 2 was killed at postoperative day (POD) 365. Treatment by FK506 prevented rejection, but most of the pigs died of pneumonia. In group 1, rejection began on POD 3 and progressed to severe rejection rapidly within 7 days. In group 2, rejection began from POD 6 to POD 8, but either remained mild or spontaneously improved. The differences in the routine laboratory data and the tumor necrosis factor-alpha level were not evident between the groups. Histological studies of repeated graft biopsies are thus considered to be essential for detecting signs of graft rejection.

A 71-year-old woman with autoimmune hemolytic anemia underwent an emergency endocardial patch repair for ventricular septal perforation after acute myocardial infarction. Use of washed red blood cells was effective in averting hemolytic crisis throughout perioperative period. In spite of improvement of her hemodynamics, liver dysfunction which had been present preoperatively deteriorated after the operation. Finally she died of hepatic failure on the 21st postoperative day. Deterioration of liver function could not be associated with autoimmune hemolytic anemia. To date, little information is available concerning the influence of cardiopulmonary bypass on hemolysis in patients with autoimmune hemolytic anemia. Therefore, prudent management and use of washed red blood cells transfusion would prevent hemolytic aggravation even in open heart surgery.

We have studied influence of the age related factors on preoperative autologous donation (PAD) of blood in cardic surgery. PAD was undertaken in 246 cases of elective cardiac surgery by means of simple or leap-frog method, starting at approximately 4.5 weeks before operation. It provided 1726 ml of autologous blood storage on the average. Sorting the patients into three groups with age, leading surgical procedures were as follows: closure of the atrial septal defect (ASD) in teen 30s (group L, n = 51), aortic valve replacement (AVR) or mitral valve replacement (MVR) in 40s-50s (group M, n = 83) and 60s and over (group H, n = 112). Coronary artery bypass grafting (CABG) was more common in group H. Percent-freedom from allogeneic blood transfusion was 82.3% in group L, 80.7% in group M and 61.6% in group H, respectively (p0.05; L, M vs. H), donated blood volume in group H was significantly less than that of group M (p0.05, M: 1987 +/- 63, H: 1610 +/- 60 ml), because blood volume and hemoglobin level before donation tended to be less in group H. Each group did not differ in blood loss during and after operation, which showed a significant positive correlation with operation time and cardiopulmonary bypass (CPB) time. Comparing factors in ASD, CPB time was relatively long, and postoperative blood loss was significantly larger in group H (p0.05; L: 432 +/- 71 ml, M: 369 +/- 34 ml, H: 754 +/- 124 ml). This finding suggests that the secondary lesions in age ASD cases adversely affected hemostasis. As to AVR, MVR and CABG, there were no differences in these factors but donated blood volume among three groups. We conclude that elderly patient (60s and over) tends to necessitate allogeneic blood transfusion in cardiac surgery because of the insufficient PAD. Earlier commencement of PAD or concomitant application of erythropoietin will improve this situation.

Congenital cysts of the esophagus are relatively rare. We report two cases of congenital cyst arisen in the esophageal wall, together with a review of previous 97 cases in Japan in terms of the histopathological classification. A 70-year-old man was admitted to the hospital because of tarry stool (Case 1). Chest roentgenogram revealed a tumor shadow in the right cardiophrenic angle. The cyst located in the esophageal muscle layer was removed. The cyst wall was lined with ciliated columnar epithelium, and had some cartilage and a well-developed smooth muscle layer. Another patient was a 46-year-old man who was admitted because of dysphagia and arrythmia (Case 2). The cystic was located in the same place as that of case 1. The removed cyst was lined with squamouse epithelium and had double layers of smooth muscle without cartilage. Based on Arbona's criteria, the cyst in case 1 was diagnosed as bronchogenic cyst, and the cyst in case 2 was diagnosed as duplication cyst.

We evaluated a 68-year-old male patient with isolated levocardia without intracardiac anomaly. The patient's condition was complicated by the absence of the inferior vena cava, a lobulated spleen and sick sinus syndrome. Isolated levocardia without intracardiac anomaly is very rare and only 25 cases of this disease have been reported, to our knowledge. In general, it is accepted that cardiac rhythm disorder is frequently observed in cases of isolated levocardia and/or absence of inferior vena cava. However, there are few cases of isolated levocardia without intracardiac anomaly complicated by the absence of the inferior vena cava, a lobulated spleen and apparent sick sinus syndrome.

Simultaneous surgery was performed in 8 patients with malignant neoplasms complicated by cardiovascular diseases. The malignant neoplasms were lung cancer in 3 patients, colon cancer in 2, stomach cancer in 2, and liver cancer in 1. The complicating cardiovascular diseases were ischemic heart disease in 3, valvular heart disease in 2, abdominal aortic aneurysm in 2, and thoracic aortic aneurysm in 1. In the simultaneous operation, the first objective was improvement and maintenance of hemodynamics, and the radicality of the treatment for malignant neoplasms was pursued secondarily. However, operations for malignant neoplasms were performed first depending on the stage of the disease and the state of the surgical field. The approaches were obtained separately for prevention of infections except when both operations could be performed in the same operative field, and efforts were made to minimize the surgical insult especially in patients managed with an artificial heart-lung support. The surgical insult of simultaneous operation is considered to have been tolerable with the absence of prolonged operations, massive hemorrhage, or postoperative complications. All patients have been adequately rehabilitated, and all have been observed for a maximum of 54 months (mean 24 months) without signs of recurrence. From these results, simultaneous operation for malignant neoplasms and cardiovascular diseases is considered to be preferable if the neoplasms can be treated radically, and the patient is expected to tolerate the surgical insult.

We present a case of partial nodular transformation (PNT) of the liver in a 57-year-old man with a history of heavy drinking. On computed tomography, a low-density mass, measuring 3 cm in diameter, and associated with portal flow defect was visualized. Based on this finding and on the findings of other imaging studies, hepatic resection was performed because of suspected hepatocellular carcinoma. Pathology examination of the excised specimen showed small portal tracts in the lesion. The findings for the rest of the liver were suggestive of mild liver cirrhosis. While PNT is similar to nodular regenerative hyperplasia (NRH), in NRH there is diffuse nodular transformation of the whole liver, whereas in PNT only the area adjacent to the porta hepatis is affected. The portal flow defect in PNT may be the result of attenuation of the portal tracts in the lesion. This case is of interest because there was only one PNT lesion, rather than multiple lesions, and because it occurred in a cirrhotic liver, thus giving rise to the suspicion of hepatocellular carcinoma. PNT is a benign disorder, thus it is essential to establish a definitive diagnosis by imaging and ultrasound-guided histological biopsy to prevent unnecessary hepatic resection.

1 We evaluated in vitro inhibitory effects of six types of antibiotic, aztreonam (AZT), cefamandole (CMD), cefmetazole (CMZ), cefotiam (CTM), flomoxef (FMOX) and latamoxef (LMOX), on platelet aggregation, using healthy volunteers' blood. Four types-FMOX, LMOX, CTM and CMD-inhibited, in concentration of 2500 ?g/ml, the secondary aggregation induced by 3.0 ?M adenosine diphosphate (ADP), and also inhibited the aggregation induced by 0.5 ?g/ml collagen. AZT in the same concentration, did not inhibit the aggregation induced by collagen, and it inhibited only ADP induced aggregation. CMZ, in the same concentration, inhibited neither of the two aggregations. 2 The inhibitory effects of the antibiotics on collagen- induced aggregation were dependent on the concen tration of respective antibiotics. When classified by the strength of inhibitory action, LMOX and FMOX were strong, followed by CTM and CMD. The action of AZT and CMZ was weak. In particular, LMOX showed a 32% inhibitory effect at concentration of 50 ?g/ml, a level near the blood concentration obtained with clinical usual dose. 3 No relationship was observed between inhibitory effects of antibiotics on ADP- or collagen-induced aggregation and the presence or absence of carboxyl group and/or N-methyltetrazolethiol group in the chemical structure.

We report herein a case of spontaneous subcapsular hepatic hemorrhage which occurred in a 33-year-old woman 1 day after she had been delivered of her second child by cesarean section following an uneventful pregnancy. She complained of right upper quadrant pain on the 1st postoperative day, and computed tomography (CT) showed subcapsular low-density masses in both liver lobes, while extravasation was demonstrated by CO2 intraarterial digital subtraction angiography (IADSA). The hemorrhage was successfully controlled by transcatheter arterial embolization (TAE). However, on the 3rd day after TAE, an exploratory laparotomy was performed to establish an exact diagnosis to explain the persistent abdominal pain and abnormal liver function tests. Subcapsular hematomas in both lobes were confirmed and no visible laceration was present. The patient recovered gradually by spontaneous absorption of the hematomas and was discharged on the 22nd postoperative day. Spontaneous hepatic hemorrhage associated with pregnancy is a very rare complication, and establishing a correct diagnosis and initiating appropriate therapy are essential for this life-threatening disease.

61歳の男性で二尖弁による大動脈弁閉鎖不全に急性A型大動脈解離をきたしSJM25A弁による大動脈弁置換と上行大動脈置換術を施行した. エントリーは上行大動脈中央部前壁に認めた. 弁輪より約3cm高位側と腕頭動脈直下で上行大動脈を離断切除し偽腔をGRF糊で補強閉鎖し人工血管との直接吻合を行った. 術後2か月目に大動脈基部の再解離から吻合部破綻をきたし, 再度緊急手術を行った. 人工弁機能は正常で, 同弁を温存した Cabrol 法による冠状動脈再建術を施行し, 同時に剥離操作中に損傷した遺残解離腔を伴い拡大した弓部大動脈を全置換し救命した. 本症例での手術を中心に検討した.

再発時に血中AFP値の再上昇を欠いた縦隔原発胚細胞性腫瘍を経験した.症例は16歳男性で, 前縦隔腫瘍の診断で1995年5月腫瘍摘出術を行い, 血中AFP値は5,490ng/ml から373ng/ml に低下した.併合奇形腫の病理組織診断を得, 術後のmodified PVB therapy で血中AFP値は7.2ng/mlと正常域まで低下し, 画像上腫瘍遺残もなく外来で経過を観察していた.7ヵ月後に再発を認めたが, 血中AFP値は5.2ng/mlであった.翌年1月胸膜・肺全摘術を施行したが, 第9病日に死亡した.術後の病理組織学的検査で化学療法による腫瘍構成成分の変化とAFP産生を伴わない成分の増殖を認めた.腫瘍マーカーの上昇する縦隔原発胚細胞性腫瘍では, 腫瘍マーカーが治療効果や臨床経過の指標になり, 一般に再発時には再上昇する.自験例は, 再発時に血中AFP値の再上昇を認めず, 急速に腫瘍が増大した稀な症例と思われ報告する.

Reports of double cancer of esophageal cancer and a cancer of other organ are relatively common, and sometimes we see case reports of gastric cancer arising in the reconstructed gastric tube following an operation for primary esophageal cancer in the literature. In this paper a case of carcinoma developed in the reconstructed gastric tube four years after operation for esophageal and gastric cancers in a 69-year-old man is presented. When the patient was 65 years old, he was admitted to the hospital because of dysphagic. Radiographic and endoscopic studies revealed an ulcerative and localized type tumor (type II of Borrmann's classification) in the mid esophagus and a superficial type of early gastric cancer (IIc type) in the upper porition of the stomach. Subtotal esophagectomy and partial gastrectomy with lymph node dissection were performed, followed by reconstruction with a gastric tube through ante-thoracic routes. Pathological findings on the excised specimen showed well differentiated squamous cell carcinoma invaded the adventitia of the esophagus with lymph node metastasis in the mid portion of the esophagus and well differentiated tubular adenocarcinoma confined to the submucosal layer without lymph node metastasis in the lesser curvature of the stomach. Four years after the operation, two superficial type lesions (IIc and IIa+IIc type) were observed in the reconstructed gastric tube on his periodic endoscopic examination. The lesions were diagnosed as adenocarcinoma on biopsy specimens. Lower one third of the gastric tube was safely resected for two lesions, followed by reconstruction of the remnant gastric tube with jejunum in Rouxen Y type anastomosis. On excised specimen of the gastric tube two superficial type lesions were present and diagnosed as early gastric cancer. All three lesions in the stomach were consisted of early gastric cancer (one mucosal and two submucosal tumors), histologically same, negative lymph node and being separated distinctly by normal gastric wall each other, whereas one lesion mild vessel invasion was presented. Finally they were diagnosed as multiple gastric cancers. The patient is still alive and well as of 5 years after the initial operation. Periodic endoscopic examination disclosed carcinoma on the reconstructed gastric tube with an advisable reoperative prognosis.

A 53-year-old woman was seen at the hospital because of epigastralgia and was pointed out have multiple ulcer like lesions of the stomach on upper gastrointestinal series. Mucosa-associated lymphoid tissue (MALT) lymphoma was diagnosed by endoscopically obtained biopsy specimen. High serum antiboty titer for Helicobacter pylori (H. pylori) was noted. H. pylori was identified on the biopsy specimen using by polymerase chain reaction. Although H. pylori was completely eradicated by amoxicillin-metronidazole-bismuth subnitrate triple therapy and lansoprazole, MALT lymphoma did not disappeared. Thus, a total gastrectomy with lymph node dissection was indicated. The histological sections showed multifocal small lesions of lymphoma cells and medium-sized follicle centrocyte-like cell infiltration in the mucosa and submucosa. The intramucosal lesions showed lymphoepithelial lesions. These findings were indicative of MALT lymphoma. She had been doing without any signs of recurrence as of 13 months after the operation. Recently the relation between MALT lymphoma of the stomach and H. pylori has been indicated, and the disappearance of gastric MALT lymphoma due to eradication of H. pylori has been increasingly reported. We propose the guidelines for the treatment of MALT lymphoma that H. pylori is eradicated first and thereafter an operation is performed if it is ineffective. On the other hand, we should continue to conduct gastric endoscopy even after H. pylori disappear, and perform an operation if sign of recurrence is noted.

This study was conducted to clarify the pathogenesis of portal vein obstruction (PVO) associated with intrahepatic stones. Five cases with PVO and intrahepatic stones were studied retrospectively. The coincidence rate of PVO in intrahepatic stones was 5.8% (5 of 86 cases), and that of intrahepatic stones in PVO, 45.5% (5 of 11 cases). All cases had one or more symptoms of cholangitis, such as high-grade fever, abdominal pain, and jaundice prior to diagnosis of PVO. The portal vein was occluded at the main trunk in 4 and in the left branch in 1. Intrahepatic stones were found in bilateral hepatic lobes in 3 and in the left lobe in 2. Numerous calcium bilirubinate stones were packed in dilatated intrahepatic bile ducts of an excised specimen of the liver. Microscopically, arterial structures could be seen, but the portal vein ceased to be evident about the involved bile duct. Based on the results of this study, persistent cholangitis and packed gallstones were concluded essential to the development of PVO accompanied by intrahepatic stones.

A case of kidney metastasis from primary gallbladder cancer is presented. Five years after operation for gallbladder cancer, a 73-year-old woman exhibited hematuria. Imaging disclosed a 5×4cm solid mass in the right kidney and enlarged lymph nodes behind the inferior vena cava adjacent to the right renal vein. The right kidney and adjacent tissues, including retroperitoneum and regional lymph nodes, were resected en bloc. The renal tumor was diagnosed as a metastasis from the primary adenocarcinoma of the gallbladder, based on histological similarities, absence of other primary adenocarcinoma, and fluctuations in CA19-9 levels during the progress and after the resection of the metastatic tumor. The initial operation had been an extended cholecystectomy with wedge resection of the liver bed, plus regional lymphadenectomy. The excised gallbladder had a 2.3 ×1.2cm nodular tumor in the fundus. Histological examination indicated the gallbladder tumor to be a moderately differentiated tubular adenocarcinoma invading the subserosal layer. Mild lymphatic invasion was recognized in the gallbladder wall, although lymph node metastasis was negative. We believe this patient represents the first case of kidney metastasis from gallbladder cancer. The mode of spread of the gallbladder cancer to the kidney appeared to be lymphogenous.

The authors report a successful application of hypothermia, along with intra-aortic balloon pump (IABP) support, to postcardiotomy ventricular failure. Surface-cooling hypothermia was applied in 8 patients after open heart surgery. The original cardiac procedure consisted of 3 aortocoronary bypass graftings (ACBGs), 2 aortic valve replace ments (AVRs), 1 repair for left ventricular (LV) rupture after mitral valve replacement (MVR), 1 MVR+ACBG, and 1 MVR+AVR+tricuspid valve annuloplasty (TAP). Their ages ranged from fifty-two to sixty-eight years with a mean of sixty-one years. Hemodynamic criteria for induction of hypothermia included cardiac index (CI) less than 2.0 L/min/m2 with left atrial pressure greater than 18 mmHg despite the use of IABP and maximum pharmacologic support. Blood temperature was maintained at around 33°C. By six hours after induction of hypothermia the tissue oxygen consumption decreased significantly with no hemodynamic deterioration as compared with that before cooling. The duration of hypothermia ranged from thirty-six to one hundred fifty-nine hours with a mean of seventy-eight hours. All 8 patients finally discontinued IABP support with a mean driving time of one hundred thirty-two hours. Five of them were ultimately discharged from the hospital and returned to their previous life-style. The authors believe that, from the perspective of monetary and personal resources, the use of hypothermia with IABP support could be a therapeutic option for patients with postcardiotomy ventricular failure.

We report a case of 11-year survival with carcinoma arising from a congenital choledochal cyst. A 34-year-old Japanese woman was admitted due to epigastric discomfort. Ultrasonography revealed a choledochal cyst involving a polypoid tumor. Endoscopic retrograde cholangiopancreatography revealed pancreaticobiliary maljunction in which the main pancreatic duct joined the dilated common bile duct 2 cm above the papilla of Vater. A choledochal cyst containing a polypoid tumor was resected with the regional lymph nodes. Grossly, a 2×2-cm papillary tumor was noted in the posterior wall of the choledochal cyst. Microscopically, the tumor was well-differentiated tubular adenocarcinoma invading the mucosa and fibromuscular layer. Neither anticancer chemotherapy nor radiotherapy was performed. The patient recovered uneventfully after the operation and has been well for 11 years without evidence of recurrent cancer. The good results in this patient may have been due to the early stage of the cancer.

This study was conducted to assess the efficacy of portal vein reconstruction with an expanded polytetrafluoroethylene (e-PTFE) graft. Five patients underwent interposition of the portal vein with e-PTFE graft following en bloc resection of the entire pancreas and the portal vein for advanced pancreatic cancer. The length of the excised vein ranged from 5 to 7 cm and that of the implanted graft (8 or 10 mm in diameter), 3 to 7.5 cm. In 4 of the 5 cases, the graft was patent at five to eighteen months following implantation. One patient died of respiratory failure two months after operation, and partial occlusion of the graft was noted at autopsy. Four patients died of recurrence of the original disease five to eighteen months after operation. The implanted graft taken at autopsy eighteen months after operation was covered uniformly with thin neointima on the internal surface. Microscopic examination showed endothelial cells covering the surface of the neointima, and capillary vessels had developed in the neointimal layer. Experimentally, five grafts, 0.8 cm in diameter and 2.5 cm in length with external ring support, were interposed in the portal vein in pigs. All grafts were patent during a four-month follow-up period. The authors conclude that the e-PTFE graft is a suitable prosthesis for replacement of the portal vein following its resection.

今回我々は, 胸壁デスモイド腫瘍の1例を経験した.本症は稀で発生には外傷の関与が指摘されている.症例は43歳男性で1993年2月に左鎖骨および左第4肋骨を骨折した.1994年3月に左胸痛が出現し, 胸部X線で腫瘤陰影を認めた.同年5月胸膜腫瘍の疑いで腫瘍摘出術を行った.腫瘍は骨折部位に一致して2個あり, fibromatosisの病理組織診断を得た.術後は良好に経過したが, 同年12月に腫瘍の再発を認め再入院した.腫瘍は肺尖部から左鎖骨, 左側胸壁にみられ外科的切除は左上肢の機能障害を生じると判断され, 総線量60Gyの放射線照射を行った.現在照射後6ヵ月を経過したが, 腫瘍の増大傾向はない.

Primary cancer of the appendix is a rare entity which is hardly diagnosed preoperatively. It is often diagnosed histologically after resection of the lesion as appendicitis or ileocecal tumor. A 68-year-old woman was admitted to the hospital because of a fist-sized tumor in the right lower abdomen and tenderness. On Barium enema performed 3 months before admission, the appendix was clearly visualized and no abnormalities were seen in the ileocecum. Laparotomy was carried out under a diagnosis of acute appendicitis. It revealed tumor formation due to periappendiceal abscess, and so drainage was done. About one month later when inflammation was alleviated, appendectomy was performed. The pathological diagnosis was made after the surgery with positive cancer cells on the stump of the resected appendix. Right hemicolectomy was subsequently performed on the 8th postoperative day. We must carefully examine the pathological findings of the resected specimen of the appendix entertaining a possible malignant lesion of the organ, especially for tumor-forming lesions.

In 7 patients with type-A acute aortic dissection, the sternum was not closed because of excessive hemorrhage after grafting. Only the skin was closed, the sternal edges being left apart and the anastomotic sites being packed with dry gauze in the mediastinum to control the life-threatening sequela. All patients except for 1 who died of uncontrollable bleeding had successful delayed sternal closure within three days after the first operation. One patient who had late chest wound infection died, but the remaining 5 patients had neither mediastinitis nor chest wound infection and are now in good or fair clinical condition. The authors conclude that delayed sternal closure is an effective method of dealing with excessive postbypass bleeding following operation of type-A acute aortic dissection.

弁膜症581例の周術期にIABPを使用した42例を検討した. 適応は術後LOS, 体外循環離脱困難, 不整脈, 心不全の各19, 11, 11, 1例で使用時期は術前, 術中, 術後が各4, 18, 20例であった. 42例中26例 (62%) がIABPより離脱, 16例 (38%) が生存し, 16例が離脱不能であった. IABP離脱可能群と不能群間には体外循環時間, 大動脈遮断時間, IABP使用24時間後の心係数に有意差がみられた. IABP離脱後生存群, 死亡群間では術後腎不全, 感染の発生頻度に差がみられた. 46%は多臓器不全で死亡した. 弁膜症に対するIABPの治療効果は不良で, 成績には術中, 術後因子が深く関与した. 治療成績の向上には術後腎不全, 感染の防止, さらに多臓器不全への進展防止に努めることが肝要である.

肺移植あるいは心肺移植の適応と考えられたEisenmenge r症候群の一例について述べた.症例は51歳, 男性1労作時に呼吸困難が出現し近医を受診した.心室中隔欠損症を疑われ心臓カテーテル検査を行った.肺動脈圧は120/42 (70) mmHgと肺高血圧を示し肺対体血圧比 (Pp/Ps) 0.91, 肺対体血流量比 (Qp/Qs) 1.26, 肺対体血管抵抗比 (Rp/Rs) 0.34であった。肺血管抵抗 (PVR) が14.2unit・m2と高く, また, トラゾリン注入試験の反応が悪く12.5unit・m2と高値を示した.確定診断を得るために更に開胸肺生検を行った.病理組織学的にHeath・Edwards分類Grade IVと診断され, 不可逆性の肺血管病変と判断された.本例はEisenmellger 症候群を呈した心室中隔欠損症で, 肺移植あるいは心肺移植を考慮すべきものと考え, 文献的に考察し検討した.

症例は71歳, 女性.高度の貧血と胸部異常陰影を指摘され紹介入院となった.眼瞼下垂・四肢の筋力低下は無く, 胸部X線写真で縦隔陰影が拡大, 胸部CTでは前縦隔に平滑な腫瘤を認めた.抗アセチルコリン受容体抗体 (a-Ach R Ab) 価が上昇し, 骨髄穿刺所見で赤芽球系細胞はほとんど見られなかった.赤芽球癆合併胸腺腫の診断で拡大胸腺摘出術を行った.胸腺腫は, 充実性で浸潤はなく正岡分類のStage Iであった.術直後に非脱分極性筋弛緩剤による遷延性無呼吸を生じ, Waning現象も確認された.赤芽球癆は術後一過性に改善したが, 再び進行した.ステロイド・蛋白同化ホルモン等を併用しパルス療法も施行し, 徐々に症状は安定した.現在術後3年を経過したが, 貧血の進行はなく社会復帰している.

Elective surgery for abdominal aortic aneurysm (AAA) has become a safe operation, although the mortality related to ruptured AAA remains considerably high. Factors affecting survival of 32 consecutive patients with ruptured AAAs were evaluated. The postoperative mortality was 50% (16/32) compared with 1.9% for 103 elective AAA patients. Factors associated with poor prognosis were systolic blood pressure of less than 90 mmHg and severe metabolic acidosis on arrival to the hospital, size of the aneurysm, and massive blood transfusion. The high mortality and morbidity rates of the ruptured AAA patients emphasize the need for early and aggressive treatment of AAA in the elective setting in the patient at high risk. In follow-up study, however, the actuarial survival following ruptured AAA surgery, excluding hospital mortality, was 77% at five years. It did not differ statistically from that of patients who had elective AAA surgery. The quality of life survey following surgery showed no discernible differences between ruptured and elective AAA surgery.

From 1982 through 1992, 103 patients (mean age: 69 years) underwent an elective repair of an abdominal aortic aneurysm (AAA) at our institution. One or more postoperative complications occurred in 30 patients (29%), with a mortality rate of 1.9%. Factors which were found to be significantly associated with postoperative complications based on an univariate analysis included male sex (P = 0.0082), operation time (P = 0.0006), the size of the aneurysm (P = 0.0045), the amount of blood loss during operation (P = 0.0037), poor lung function (P = 0.0155), and the platelet count (P = 0.0468),. A simple linear regression analysis showed that there were significant correlations among the AAA size, the duration of operation and the amount of blood loss. The age at operation, however, did not influence morbidity or mortality. Complete survival information was obtained in 96 (95%) patients, while the influence of preoperative risk factors on late survival was also examined by the Kaplan-Meier method. The factors influencing long-term survival were determined to be renal dysfunction and age at the time of operation.

We report here a long-term survivor of ruptured hepatocellular carcinoma (HCC). A 37-year-old Japanese man complained of sudden abdominal pain after taking an alcoholic drink. Ultrasonographic examination showed a large amount of fluid in the abdominal cavity. Emergency laparotomy was performed. A solid mass showing extrahepatic growth was present in the right lobe of the liver. No active bleeding site was detected, but the tumor was covered with old blood coagula. The tumor was covered with the greater omentum to prevent further hemorrhage. Following assessment of the extent of the tumor and of liver function, delayed hepatectomy was performed. Histological examination indicated the tumor to be HCC. Twenty-six months after initial hepatic resection, partial resection of the liver was performed again for recurrent tumor. The patient has survived without recurrence for more than 5 years. The long survival was due, we believe to the liver being non-cirrhotic, the delayed hepatic resection, and the early detection of the recurrent tumor.

1982年より1992年7月までに教室で経験した腹部大動脈瘤待機手術103例の手術成績, 術後合併症と遠隔予後を検討した. 対象は男性83例, 女性20例で, 平均年齢は69歳であった. 手術死は2例 (1.9%) で, 術後合併症は男性例に多く (p