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BACKGROUND: The subcategory “solid component of tumor” is a new criterion of tumor categories in the updated eighth edition of the TNM classification. Nevertheless, the predictors of lymph node metastasis among patients with clinical T1 adenocarcinoma, based on the TNM classification 8(th) edition, remain unclear. This study aimed to identify the preoperative predictors of lymph node metastasis in clinical T1 adenocarcinoma by comparing clinicopathological characteristics between the groups with and without lymph node metastasis. METHODS: We performed a retrospective observational single-center study at the Sendai Kousei Hospital. From January 2012 to September 2019, we included 515 patients who underwent curative lobectomy or segmentectomy and mediastinal lymph node dissection among those with clinical T1 adenocarcinoma according to the UICC-TNM staging 8(th) edition. They were divided into two groups: those with lymph node metastasis (positive group) and those without (negative group). The clinicopathological factors were retrospectively analyzed and compared between the groups. RESULTS: In univariate analysis, carcinoembryonic antigen (>5.0 ng/mL) (P=0.0007), maximum standardized uptake (>3.5) (P0.85) (P3.5) (odds ratio =10.4, P5.0) (P=0.048) was the only predictor of lymph node metastasis among patients of cT1b, while no parameters were identified as significant predictors among patients of cT1c. CONCLUSIONS: SUVmax and CEA are useful preoperative predictors of lymph node metastases in patients with clinical T1 adenocarcinoma, stratified to T1b and T1c, based on the 8(th) TNM classification.

Primary mediastinal liposarcomas are rare malignancies, comprising fewer than 1% of all mediastinal tumors. We herein report a radical resection of a massive liposarcoma arising from the anterior mediastinum. A 63-year-old male patient presented with a 4-week history of dyspnea that had worsened over the previous several days. The patient had also experienced hoarseness for 2 weeks. Chest X-ray and computed tomography revealed a huge tumor occupying the entire left thoracic cavity. Anesthesia was induced when the patient was in the left semilateral position. The patient was moved into the right lateral position after initially stabilizing anesthesia with separate lung ventilation. The fourth rib was initially resected for thoracotomy, but there was no clearance between the tumor and the adjacent mediastinal structures, and two more ribs were therefore removed. The tumor had not invaded the other structures such as the chest wall, lung, or mediastinum. To reduce the tumor blood flow, the left internal mammary artery was ligated before the tumor was resected en bloc. The tumor was diagnosed as a liposarcoma arising from the thymus. The patient remains alive with no evidence of disease recurrence at 22 months after the operation.

Background. Transfer of viable tissue flaps and thoracoplasty are effective against pleural space complications after pneumonectomy but highly disfiguring. The aim of this study was to explore the possibility of engineered tissue to treat space complications after pneumonectomy. Methods. A left pneumonectomy was performed in mice, and the cavity immediately filled with the cellularized collagen matrices. First, bone marrow derived-mesenchymal stroma cells with luciferase expression were used as donor cells to evaluate cell viability and angiogenesis using bioluminescence imaging. Second, using bone marrow cells from GFP mice, histologic evaluation, immunohistochemistry for von Willebrand Factor, and flow cytometric analysis was performed compared with acellular matrix implants. The effect on bacterial clearance was examined using an empyema model with Staphylococcus aureus expressing luciferase. Results. Embedded cells proliferated within the denatured collagen matrices ex vivo. In vivo, bioluminescent imaging activity could be detected till day 8, and the slope (suggesting rate of perfusion with luciferin) increased with time up to day 6 but decreased after day 7. Although GFP-positive donor cells decreased with time, total cellularity increased. Furthermore, vessels stained by von Willebrand factor were significantly increased. Both cellularized and acellularized matrices showed bacterial clearance in vivo. Conclusions. Cells within collagen matrices survive in the thoracic cavity at early time points. Cellularized matrices quickly lead to neovascularization and recipient cell infiltration. Both cellularized and acellularized matrices show bacterial clearance in vivo. This study indicates the potential feasibility of a novel tissue engineering approach to problems of the postpneumonectomy space.

卵巣嵌頓を伴う小児大腿ヘルニアの稀な1例を経験した. 症例は4カ月, 女児. 右鼠径部腫瘤を主訴に当院へ紹介された. 右鼠径部に3cm大の発赤した腫瘤を認め鼠径ヘルニア嵌頓と術前診断し緊急手術を施行したところ大腿ヘルニア卵巣嵌頓と判明し右付属器切除術と腹腔側よりのヘルニア門閉鎖を行った. 経過は良好で術後1年6カ月の現在再発を認めていない. 小児大腿ヘルニア嵌頓は非常に稀な疾患であり, 現在まで本症例を含めて6例しか報告されていない. さらに卵巣切除を必要とした症例は本症例が初めてであった. 小児大腿ヘルニアの術前診断は困難であるが鼠径部腫瘤の原因の一つとして考慮すべきであり, 卵巣嵌頓が疑われた場合, 用手還納にこだわらず早期手術を選択すべきであると思われた.

症例 : 37歳, 女性. SLE経過観察中に胸部レントゲン, CTにて肺動静脈瘻を指摘された. 増大傾向のため当科に紹介された. 全身にチアノーゼを認め, CTおよび血管造影では, 右S6に存在し一部葉間に突出する最大径50mmの瘻で, A6・V6が拡張し, 独立した流入・流出血管と考えられた. 患者が若年者であったため核出術の方針とした. 手術所見では瘻は葉間に突出しており, 血流の乱流が観察された. まず太いA6およびV6を露出し根部で結紮したが, 瘻は縮小せず静脈血の噴出を認め流入血管が他にもあると考えられた. 核出術を続けるが出血を認めるため, 核出術のみは困難と判断し, S6の区域切除術を行った. 切除標本ではS6に対しA7からの分岐血管を認めるなど区域間の枝が瘻に入り込んでいた. 術後は合併症もなく, チアノーゼは消失し血液ガスも正常化した. まとめ : 流入血管が太く大きな瘻の症例を経験した. 流入血管の術前評価が難しく数本存在しており, 区域切除術で安全で確実に手術を行えた.

A 65-year-old man experiencing chest oppression was admitted to our hospital. Contrast-enhanced chest computed tomography (CT) showed a 71×52-mm cystic mass with an enhanced wall in the thymus. The CT-guided needle biopsy of the tumor only revealed the presence of necrotic tissue. However, the tumor spontaneously decreased in size significantly to 33×21 mm in 2 months. The patient underwent right hemi-lobectomy of the thymus, which showed necrotic tissue in the center of the mass;the fibrotic cystic wall included several masses of type B3 thymoma cells( so called" well-differentiated thymic carcinoma", Masaoka stage II). Because of avoiding local recurrence, extended thymectomy including lymph node resection was additionally performed. The patient received radiation therapy postoperatively and has shown no sign of recurrence in 3 years of follow-up care.

Circulating blood volume is important in managing fluid balance and cardiac function after surgery under cardiopulmonary bypass. Appropriate management differs among the valve disorders, but perioperative blood volume has not yet been considered. From February 2001 to March 2003, perioperative blood volume, fluid balance, cardiac index, and left ventricular stroke work index were measured in 31 patients: 10 with aortic stenosis, 9 with aortic regurgitation, 3 with mitral stenosis, and 9 with mitral regurgitation. All immediate postoperative blood volume measurements were less than preoperative values, and gradually returned to baseline. At all time points, blood volume in patients with aortic or mitral regurgitation was high, whereas it was low in those with stenosis, especially mitral stenosis. Fluid balance was positive in all patients. Postoperatively, there was a positive correlation between cardiac index and blood volume in all groups. The left ventricular stroke work index in the mitral regurgitation group was significantly higher than other groups, the aortic stenosis group was slightly lower, the mitral stenosis and mitral regurgitation groups were higher than the baseline, and the aortic regurgitation group was essentially unchanged. Thus, it is necessary to consider blood volume perioperatively in different valvular diseases to manage water balance.

Background: Cardiopulmonary bypass decreases intestinal mucosal blood flow because of nonpulsatile and low-pressure blood flow resulting in bacterial translocation (BT) and atherosclerosis also has peripheral blood flow deficiency. The risk of nonpulsatile and low-pressure blood flow for atherosclerotic animals and the effect of statin administration, which has pleiotropic effects, were studied. Methods: Wistar rats were divided into four groups: group N (normal diet), group C (high-cholesterol diet), group S (group C plus pitavastatin therapy), and group I [group C plus inducible nitric oxide (iNOS) inhibitor therapy]. First of all, vascular responses were measured. Then the rats underwent nonpulsatile/low-pressure blood flow in the intestine, and the serum peptidoglycan concentration as a parameter of BT, the small intestinal PO2 ratio (intestinal PO2/PaO2) as a parameter of mucosal blood flow, and NO concentrations were measured before surgery (T0), at the end of 90 min of stenosis (T1), and 90 min after the release of stenosis (T2). Immunostaining for nitrotyrosine was also performed at T2. Results: Group C had vascular endothelial dysfunction without histological changes, which indicated early atherosclerosis. The serum peptidoglycan concentration increased significantly at T2 only in group C. The intestinal PO2 ratio was decreased at T1 in all the groups, and retuned to baseline at T2 in group N and group S, but not in group C or group I. Jejunal NO only in group C was significantly higher at all time points and ileal NO production at T1 and T2. There tended to be a positive stain for nitrotyrosine along the mucosal epithelium in group C. Conclusion: In the setting of early atherosclerosis, intestinal blood flow does not only improve after nonpulsatile/low-pressure blood flow but causes BT because of a large amount of NO from high enzymatic intestinal iNOS activity, and pitavastatin treatment can prevent BT by improving both issues.

Cardiopulmonary bypass causes a systemic inflammatory response, which can lead to capillary leak syndrome. In 15 adults undergoing elective cardiac surgery with cardiopulmonary bypass, we determined the volume and peak time of capillary leakage from the measurements of extracellular fluid volume and circulating blood volume taken preoperatively, at various intervals up to 24 hours after surgery, and on the 7th postoperative day. Extracellular fluid volume rose from 15.5 ± 2.7 Lpreoperatively to a peak 4 hours after surgery of 18.3 ± 3.2 L and remained elevated at 24 hours. Circulating blood volume fell from 4.10 ± 0.68 L preoperatively to 3.20 ± 0.58 L at the end of surgery. Fluid administered intraoperatively did not raise the circulating blood volume. Intraoperative fluid balance was positive at 2.62 ± 0.72 L but negative at all time points postoperatively. There was significant postoperative capillary leakage, increasing from 4.7% ± 2.3% of body weight at the end of surgery to a peak 4 hours later of 5.4% ± 2.0% and falling to 2.8% ± 3.3% at 24 hours. This knowledge of the pattern of change in capillary leakage after cardiac surgery with cardiopulmonary bypass might serve as a valuable guide for postoperative management.

症例は61歳,男性.平成11年8月8日大量吐血し当院内科受診.食道静脈瘤破裂,肝硬変の診断にて内視鏡的静脈瘤結紮術を施行された.その後入院中であったが,平成11年8月27日朝より腹痛出現し,次第に増強しショックとなり,腹部CTにて盲腸から上行結腸にかけて高度の腸管浮腫を疑う著明な腸管の壁肥厚像を認めたため外科紹介となり緊急手術を施行した.上行結腸に虚血性変化を認めるも術中確定診断するには至らず,右結腸切除術を施行した.病理所見にて粘膜下層に著明な好中球のびまん性浸潤を認めることから蜂窩織炎性大腸炎と診断された.術後敗血症性ショック,肝,腎不全,播種性血管内凝固症候群となり集中的治療にもかかわらず術後16日目に死亡した. 本疾患は非常に稀な疾患であるが,発症時すでに重篤で,予後不良である場合が多い.早期診断のためには,肝硬変患者における急性腹症に対して本疾患も念頭に置く必要があると思われる.

Using a new method based on pulse dye densitometry, circulating blood volume (BV) was measured without direct sampling in patients undergoing open-heart surgery, and the effects of phosphodiesterase (PDE) III inhibitor administration during cardiopulmonary bypass (CPB) were evaluated. Sixteen patients scheduled for elective coronary artery bypass grafting were randomly assigned to the PDE III inhibitor group or control group. BV was determined before CPB, and immediately, and 4 and 12h after operation. After declamping of the aorta, the PDE III inhibitor amrinone (1 mg/kg) was infused as a single bolus into the venous reservoir in the PDE III inhibitor group. BV decreased significantly soon after the operation in the control group. It did not decrease in the PDE III inhibitor group (48.6 +/- 44 and 60.6 +/- 8.0 ml/kg for the control and PDE III inhibitor groups. respectively). Four hours after surgery and beyond no significant changes in BV were observed in either group. The body fluid balance was negative in both groups. In conclusion, a single administration of PDE III inhibitor during CPB was found to sustain BV soon after operation and, therefore, is useful for postoperative management of open-heart surgery.

Bacterial translocation is believed to occur during cardiopulmonary bypass (CPB) because serum endotoxin concentrations rise. Intestinal ischemia during CPB, however, has never been proven directly. The condition of the intestinal mucosa during CPB was studied by measuring serum diamine oxidase (DAO) activity, an index of intestinal ischemia. Serum DAO activity, blood lactate concentration, and the arterial ketone body ratio (AKBR) were measured intraoperatively in four successive patients who underwent aortic arch replacement by the open distal anastomosis method. DAO activity rose after restoration of blood flow to the lower half of the body, and continued to rise throughout CPB. The lactate concentration also rose, mirroring the change in DAO activity, and returned to nearly normal 12 h after the operation. The AKBR decreased during CPB, with a mean minimum vale of 0.16 ± 0.07 immediately after the restoration of blood flow to the lower half of the body. The parallel rise in DAO activity and serum lactate concentration once blood flow to the lower half of the body was restored implies that ischemic injury to the mucosa of the small intestine occurs during CPB. The continued rise in these parameters throughout CPB is consistent with ongoing injury due to splanchnic hypoperfusion, as reflected in the decrease in the AKBR during the same period.

We report the successful treatment of a 79-year-old man with an extremely rare mycotic aneurysm of the aortic arch due to Salmonella. The patient presented with persistent fever, hoarseness, and hemosputum. Computed tomography showed a large saccular aneurysm with a hazy aortic wall in the aortic arch. We conducted emergency total arch replacement, debriding surrounding infectious tissue. Cultures from the aneurysm grew Salmonella enteritidis. Infection recurred 1 week postoperatively, requiring open irrigation and omentum transposition. These surgical procedures, along with appropriate antibiotics, brought infection under control.

Background Atherosclerosis with hypoadiponectinemia can be further aggravated by intestinal ischemia/reperfusion (II/R)–induced injuries, such as bacterial translocation and lung injury. We investigated the effect of statin administration on the risk of II/R-induced injury in atherosclerotic rats with hypoadiponectinemia. Methods Wistar rats were divided into 4 groups: (1) the Normal group (normal diet), (2) the Chol group (2% high cholesterol diet), (3) the St-1w group, and (4) the St-2w group (Chol group plus pitavastatin administration for 1 or 2 weeks, respectively). The serum concentrations of lipids and adiponectin were measured preoperatively. After midline laparotomy (time, T0), the superior mesenteric artery was occluded with a microvascular clamp for 30 min, followed by 360 min of reperfusion (T1). Intestinal and lung nitric oxide (NO) concentrations were measured. Intestinal injury was assessed by microcirculatory flow, histology, and permeability. Bacterial translocation was assessed by analysis of serum peptidoglycan concentration. Lung injury was assessed by histologic examination, pulmonary permeability index, and wet/dry lung weight ratio. Results The 2-week administration of statins with high-cholesterol feeding (St-2w group) improved hypoadiponectinemia to levels similar to those of the Normal group. Intestinal and lung NO concentrations were significantly lower at T1 in the Normal and St-2w groups than in the Chol group. Statin administration improved poor recovery of intestinal microcirculatory flow in the Chol group. At T1, intestinal and lung injuries were significantly aggravated and serum peptidoglycan concentration was significantly elevated in the Chol group compared with the Normal and St-2w groups. The 1-week administration of statins had no significant influence on serum adiponectin levels, tissue NO concentration, or tissue injury. Conclusion Administration of pitavastatin reduces the risk of II/R-induced injury in atherosclerotic rats with hypoadiponectinemia by improving hypoadiponectinemia and inhibiting inducible NO synthase–produced NO. Furthermore, preoperative improvement of hypoadiponectinemia may be important as an index of the protective effect of pitavastatin for II/R-induced injury in atherosclerotic rats with hypoadiponectinemia.

BACKGROUND Magnetic metal particles such as magnesium ferrite (MgFe2O4) induce heat energy under an alternating magnetic field that was produced by electric current. We have developed a new heating device using a sintered MgFe2O4 needle under an alternating magnetic field. This device can repeatedly heat target tissue at lower temperatures than that for radiofrequency ablation therapy. This study aims to assess whether the new heating device has the ability to heat rat liver tissue. METHOD A small needle made from MgFe2O4 particles was prepared by sintering at 1100 degrees C and inserted into rat liver tissue. The rat liver was then heated under an alternating magnetic field, 4 kA/m, for 30 min. We measured the temperature of rat tissue during the heat treatment, and sequentially evaluated histological changes and hepatocyte cellular activity after heat stimulus by using nicotinamide adenine dinucleotide diaphorase staining and terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling staining. RESULTS The mean temperature of the liver tissue during heating was 60.7 +/- 1.1 degrees C. Immediately after heating, nuclei of the hepatocytes were hyper-chromatin, with hepatocytes negative for nicotinamide adenine dinucleotide diaphorase activity in the heat-injury area. The injury area spread progressively until 3 d after heating, when the area was surrounded by fibroblasts, with hepatocytes positive for terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling staining. CONCLUSIONS This is the first time that a ferromagnetic metal heating device under an alternating magnetic field has achieved a temperature beyond 60 degrees C and led hepatocytes to complete cell death. This device would be of future use as a local heat-treatment for human liver cancer.

Background We previously observed increased serum diamine oxidase activity during clinical cardiopulmonary bypass, indicating small intestinal mucosal ischemia followed by bacterial translocation. Materials and methods In seven female rabbits undergoing cardiopulmonary bypass for 1 h, we analyzed the localization of diamine oxidase immunohistochemically, and measured its activity in serum and abdominal organs before and after cardiopulmonary bypass (CPB). Results Preoperatively, diamine oxidase activity and immunoreactivity were high in the small intestine, localized to villus tips. Serum activity increased significantly after CPB, whereas small intestinal diamine oxidase decreased with mucosal injury. Conclusions In this model serum diamine oxidase activity appeared to reflect CPB induced intestinal mucosal injury.

To compare in a prospective randomized study Mersilene tape and standard metal wire for complications and pain upon sternal wound closure.Sixty-four patients scheduled for cardiac surgery were prospectively randomized to undergo sternal closure using either Mersilene tape (n=30) or standard metal wire (n=34). The intensity of postoperative pain from the chest wound was assessed using a visual analogue scale (VAS) on the second and seventh postoperative days and one month after surgery. The examinations with chest X-ray and computed tomography (CT) one month after surgery were performed to evaluate the chest wound and sternum. Follow-up data on sternal and wound healing was assessed for up to one year.No deaths, sternal dehiscence or infection occurred in either group. No wound complications were observed in either group during the year following surgery. A review of data revealed that there was no difference in the intensity of postoperative pain according to the VAS between the two groups. Chest CT demonstrated that no patients in either group had cuts in the sternum.This prospective randomized study showed Mersilene tape sternal closure not to be more closely associated with increased complications or patient discomfort due to sternal wound than the standard wire closure.

The degree of preoperative cerebrovascular disease in patients undergoing cardiovascular surgery has not been well studied. Thus, the purpose of this study was to evaluate the prevalence and severity of cerebrovascular disease in such patients.The subjects were 91 patients who underwent cardiovascular surgery. We investigated the prevalence and severity of cerebral infarction (CI), intracranial artery stenosis (ICAS) ofor =50%, cervical carotid artery stenosis (CCAS) ofor =50%, and periventricular hyperintensity (PVH) using magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA).The prevalence of cerebrovascular diseases was: CI, 79 patients (86.8%) [33 had some small infarctions, 38 had multiple small infarctions, eight had broad infarctions greater than 15 mm); ICAS, 17 patients (18.7%)]; CCAS, 30 patients (33.0%) [21 had stenosis of70%, and nine had stenosis ofor =70% or occlusion]; and PVH, 79 patients (86.8%).Patients undergoing cardiovascular surgery have a high prevalence of cerebrovascular disease in varying degrees.

Objective: To demonstrate that small intestinal mucosal ischemia occurs during cardiopulmonary bypass by measuring serum diamine oxidase activity, an index of small intestinal mucosal ischemia, in perioerative patients undergoing cardiovascular surgery with and without cardiopulmonary bypass. Methods: Twelve successive patients who underwent coronary artery bypass grafting with cardiopulmonary bypass (Group I) were compared to 10 patients who underwent off-pump coronary artery bypass grafting (Group II). Serum diamine oxidase activity, blood lactate concentration, and serum peptidoglycan concentration were measured perioperatively. Results: Serum diamine oxidase activity rose after the start of cardiopulmonary bypass and continued to rise throughout cardiopulmonary bypass in Group I, while activity was unchanged in Group II. The serum lactate concentration mirrored the change in the diamine oxidase activity in both groups. The peptidoglycan concentration in Group I rose after the start of cardiopulmonary bypass and returned to near normal concentrations after surgery. Conclusions: The parallel rise in diamine oxidase activity and the serum lactate concentration in Group I implies that ischemic injury to the mucosa of the small intestine occurs during cardiopulmonary bypass, and the rise in the serum peptidoglycan concentration indicates that bacteremia did occur. Thus, cardiopulmonary bypass causes hypoperfusion of small intestinal mucosa and consequently bacterial translocation. q 2003 Elsevier B.V. All rights reserved.

Carotid artery disease is one of the important factors of neurological complications after cardiac surgery. In this study we present our surgical experience and discuss its implication for patients with carotid and cardiac disease.Five patients underwent combined carotid endarterectomy (CEA)/cardiac surgery including thoracic aortic repair. There were three male and two female patients, with a mean age of 67+/-10 years (range, 54-75 years). All patients had an 80% or greater stenosis in the unilateral internal carotid artery. Three patients had coronary artery disease and underwent combined CEA/off-pump coronary artery bypass grafting (OPCAB). One patient had an aortic valve stenosis (AS) with repeated syncope and chest pain, and underwent combined CEA/aortic valve replacement. The remaining patient had an extremely large aortic arch aneurysm (90 mm) and underwent combined CEA/total arch replacement.There were no surgical or hospital deaths. No perioperative complications including myocardial infarction and stroke occurred. During the follow-up period, lasting from 2 months to 27 months (mean, 13 months), there were no late deaths, neurological complications nor cardiac events.Combined CEA/cardiac surgery offered an acceptable morbidity in these complex patients. Due to the preliminary nature of our study, further follow-up and experience with our management strategy are necessary.

Cardiac surgery with cardiopulmonary bypass is associated with a systemic inflammatory response. We examined combined use of heparin coating of the cardiopulmonary bypass circuit and a leukocyte-depleting arterial line filter to reduce this response. Thirty patients were allocated randomly to equal groups with a conventional circuit and arterial line filter (C group), a heparin-coated circuit with a conventional filter (H group), or a heparin-coated circuit with a leukocyte-depleting arterial line filter (HF group). Cytokines and respiratory function were repeatedly measured perioperatively. Plasma interleukin (IL)-6 concentrations in the HF group were lower than in the C group immediately following bypass and operation, at 4 h, and 12 h (p < 0.05). Plasma IL-8 was lower in the HF group than in the C group at 4 h (p < 0.05). The respiratory index was lower immediately after bypass in the HF group than the C group (0.61 +/- 0.2 versus 1.05 +/- 0.4, p < 0.05). Heparin-coated circuits with leukocyte-depleting filters decrease inflammatory responses and improve pulmonary function during operation.

Objectives: The number of patients with end-stage renal disease undergoing open heart surgery continues to grow. We evaluated continuous ambulatory peritoneal dialysis and the extracorporeal ultrafiltration method during cardiopulmonary bypass in the management of these difficult patients.Methods: These 2 methods were used in 4 patients with renal failure who underwent open heart surgery between July 1997 and March 1999. Preoperative continuous ambulatory peritoneal dialysis was conducted using standard protocols. Extracorporeal ultrafiltration method was used only during cardiopulmonary bypass. Continuous ambulatory peritoneal dialysis was initiated upon arrival at the intensive care unit. Mean follow-up was 12 months.Results: Postoperative blood urea nitrogen and creatinine concentrations were lower than preoperative concentrations. No patients required hemodialysis. All 4 patients were discharged to their homes. No deaths occurred.Conclusions: Continuous ambulatory peritoneal dialysis and extracorporeal ultrafiltration method are combined to treat patients with end-stage renal disease who require open heart surgery. This combination is simple, and does not require specialized personnel, and obviates the hemodynamic instability associated with hemodialysis.