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Summary: Intimal sarcoma of arteries is a rare malignant tumor, which often mimics other vascular disorders; therefore, preoperative diagnosis is often challenging. We herein report a 71-year-old man who presented with fever and elevated inflammatory markers who had a mass in the left internal iliac artery with rapid growth. Based on clinical findings, a diagnosis of mycotic aneurysm was made. We performed surgical intervention, including resection of the affected vessels with omentopexy, although intraoperative findings were not typical of a mycotic aneurysm. Microscopic and immunohistochemical examination demonstrated undifferentiated intimal sarcoma. The patient died of multiorgan failure two months after the surgery. The vascular surgeon should consider the possibility of a diagnosis of intimal sarcoma for patients with atypical findings and the importance of histological and immunohistochemical examination for precise diagnosis in surgical vascular cases.

Although rare, superior mesenteric artery aneurysms (SMAAs) are life-threatening due to their high rupture rate. We herein report a case involving an 80-year-old man who presented with acute cholecystitis and who was incidentally found to have a 36-mm peripheral SMAA. A surgical intervention was performed, involving resection of the SMAA and reconstruction of the superior mesenteric artery (SMA) using an autologous vein graft. Intraoperative and histological findings indicated an inflammatory aneurysm, and the postoperative course was uneventful. We believe that resection of the aneurysm and reconstruction of the SMA is the preferred procedure for SMAAs to maintain adequate mesenteric circulations.

Objective The aim of this retrospective study was to investigate the early operative results and detect the factors influencing the fate of radial artery grafts (RAGs) by evaluating the mid-term patency. Methods We retrospectively reviewed 410 patients who underwent isolated coronary artery bypass grafting using RAG. RAGs were anastomosed to 526 coronary arteries. Mid-term angiography was performed in 214 patients at an average 4.9 years after the operation. Results The early patency of RAGs was 97.6%. Cumulative 5-year patency was 86.5% for RAG, 94.1% for LITA graft, and 81.0% for saphenous vein graft (SVG). RAG was significantly superior to SVG in mid-term patency. Individual grafting (not sequential grafting) (hazard ratio [HR]: 2.535; 95% confidence interval [CI]: 1.293-5.281; p = 0.006) and grafting to the target coronary artery with ≤75% proximal stenosis (HR: 1.947; 95% CI: 1.090-3.484; p = 0.025) were found to be independent risk factors influencing late RAG patency. Conclusions The patency of RAGs was superior to that of SVGs in the studied population. When using RAGs, grafting to the target vessel with severe proximal stenosis is favorable. The RAG is suitable for sequential grafting.

Immunoglobulin G4 (IgG4)-related disease, characterized by high serum IgG4 concentrations and IgG4-positive plasma cell infiltration, often presents as an inflammatory aneurysm. We herein report the case of a 78 year-old man, presenting with elevated inflammatory markers and IgG4 concentrations, who was diagnosed with IgG4-related inflammatory abdominal aortic aneurysm with dense perianeurysmal fibrosis. Before the surgical intervention, steroid therapy was administered to resolve his perianeurysmal inflammatory fibrosis. Half a year after the initiation of steroid therapy, there was an improvement in serum inflammatory markers and IgG4 concentrations, and the perianeurysmal fibrosis had regressed. Thus, we performed a surgical intervention including resection of the aneurysm and interposition with a prosthetic graft. Histopathological examination demonstrated few IgG4-positive plasma cells were distributed in the adventitia, which was suspected to be associated with the preoperative steroid therapy. This case study suggests preoperative steroid therapy is a useful therapeutic strategy for IgG4-related abdominal aortic aneurysm because it allows the use of open surgical procedures with reduced surgical risk.

Tolvaptan is an orally administered selective vasopressin 2 receptor antagonist that promotes aquaresis. This study aimed to evaluate the efficacy and safety of tolvaptan on management of systemic fluid balance after cardiovascular surgery using cardiopulmonary bypass. .Sixty-four patients who underwent cardiovascular surgery using cardiopulmonary bypass in our hospital were enrolled for this prospective, randomized study. These patients were divided into three groups: tolvaptan 15 mg+furosemide 20 mg (TH group), tolvaptan 7.5 mg+furosemide 20 mg (TI group), and furosemide 40 mg+spironolactone 50 mg (C group). The endpoint was safety management of systemic fluid balance using tolvaptan without renal dysfunction and electrolyte imbalance.The mean daily urine output in the TH and TL groups (2656±767 and 2505 ±684 mL) was significantly higher than that in the C group (1956±494 mL, TH vs C: p0.01 and TL vs C: p=0.03). The lowest serum sodium level during medication in the TH group (139.3 ±2.3 mEq/L) was significantly higher than that in the C group (137.1±2.9 mEq/L, p=0.03) The lowest serum osmolality during medication in the TH group was significantly higher than that in the C group (284.8 ±4.3 vs 279.5± 6.3 mOsm/kg, p0.01). None had critical hypernatremia, hyperosm6lality, or renal dysfunction in any. of the groups.Tolvaptan exerts, a strong diuretic effect compared with conventional diuretics (furosemide and spironolactone) during the postoperative period after an operation using cardiopulmonary bypass without adverse effects on electrolyte balance and renal function.

Profunda femoris artery aneurysm is a rare vascular disorder, which is often diagnosed incidentally on identification of synchronous aneurysms. Herein, we report the case of a 63-year-old man, presenting with a hepatic cyst, who had left profunda femoris artery and left internal iliac artery aneurysms. We performed surgical intervention, including resection of the aneurysm and reconstruction of the profunda femoris artery using a prosthetic graft. The postoperative course was uneventful, and computed tomography revealed good graft patency. We believe surgical reconstruction of the profunda femoris artery should be completed except in complicated cases, such as rupture or aneurysm in the distal segment of the profunda femoris artery.

Background To effectively detect surgical patients carrying methicillin-resistant Staphylococcus aureus (MRSA) in a pediatric ward, we investigated who should be tested through bacteriological surveillance on admission. Methods In 1124 patients, bacteriological examination of throat swabs and stool samples was performed within 48 hours after admission. The relations between carrier rate (CR) of MRSA and a history of hospitalization, neurological disorder (ND), and age group were retrospectively investigated. Results The CR of all patients was 7.8%. The CRs of the patients with no history of hospitalization, a history of hospitalization before the previous year, and a history of hospitalization within the past year (HWPY) were 2.3%, 3.4%, and 14.5%, respectively; the CR of those with HWPY was significantly higher than the CRs of the other 2 groups (p0.0001). The CR of the patients with an ND (19.2%) was significantly higher than that of the patients without an ND (6.1%) (p0.0001). The CRs of the patients3 (11.7%) and 15 (11.9%) years old were higher than that of other patients (3.8%) (p0.05). With multivariate logistic regression analysis, HWPY, an ND and age groups3 and k15 were independent risk factors. Conclusions - HWPY, an ND, and being3 or k 15 years old were found to be risk fqctors for carrying MRSA on admission. Active bacteriological surveillance on admission should be performed for patients with these risk factors.

Purpose: This study aimed to determine if preoperative time course changes in serum C-reactive protein (CRP) levels can predict clinical outcome of surgical intervention for active infective endocarditis. Methods: Surgically treated patients (n = 109) with active infective endocarditis were reviewed retrospectively. We divided the patients into 2 subgroups according to preoperative transition of increasing or decreasing serum CRP levels, and performed a comparative study. The increasing CRP group included 29 patients and the decreasing CRP group included 80 patients. Results: There were more patients with methicillin-resistant Staphylococcus aureus and New York Heart Association functional class IV in the increasing CRP group. Hospital mortality was signifi cantly higher in the increasing CRP group (34.5%) than that in the decreasing CRP group (5.0%) (p

The present study aimed to identify novel useful clinical biomarker of high grade lung neuroendocrine tumors (LNETs). Based on the results of QSTAR LC-MS/MS analysis, we selected complexin-2 (CPLX2) (upregulated 8.7-fold) as a potential biomarker in high grade human LNETs, and validated its expression immunohistochemically in comparison with non-small cell lung carcinomas (NSCLCs). CPLX2 was strongly positive in 16.3% of examined LNETs, but completely negative in all adjacent non-cancerous tissues and NSCLCs. Importantly, positive CPLX2 expression was associated with lymph vessel invasion (P=0.016), pathological stage (P=0.031), and poor disease-specific survival (P=0.004) of patients with LNETs. Preoperative serum CPLX2 level measured by ELISA was significantly elevated in high grade LNETs as compared with %NCs non-cancer controls (NCs) (P=0.002) and NSCLCs (P< 0.001). Receiver operating characteristic (ROC) curve analysis was used for separating high-grade LNET patients from NSCLC patients. The area under the ROC curve (AUC) was 0.825. The calculated optimal cut-off point for CPLX2 level in the serum was 17.8 pg/ml (Youden index=0.591), while sensitivity and specificity was 94.1% and 65.0%, respectively. CPLX2 is suggested as a novel potential clinically useful biomarker for the diagnosis, prognosis and adequate choice of therapy for patients with high grade LNETs.

OBJECTIVES: Guidelines recommend the avoidance of direct return of pericardial blood based on evidence from coronary surgery. A continuous auto-transfusion system (CATS) can be a good alternative to cardiotomy suction by reinfusing aspirated pericardial blood without the necessity of intermittent collection. To clarify the effects of direct return of pericardial blood in aortic valve replacement (AVR), we compared the effects of cardiotomy suction and an alternative CATS on perioperative coagulofibrinolysis and inflammation systems, and clinical outcomes. METHODS: In 40 AVR operations between April 2009 and April 2011, the retransfusion method of pericardial blood during cardiopulmonary bypass (CPB) was allocated to the use of cardiotomy suction (non-Cell-Saver group, n= 20) or CATS (Cell-Saver group, n= 20) under identical protocols of anticoagulation and transfusion. The blood from the left ventricular vent was returned to the venous reservoir. We obtained blood samples at nine points up to the morning after surgery. RESULTS: Perioperative values for coagulofibrinolysis markers, such as thrombin–antithrombin III complex, fibrinogen degeneration products, D-dimer and plasmin-α2 plasmin inhibitor complex, were significantly lower in the Cell-Saver group than those in the non-CellSaver group from 1 h after the initiation of cardiopulmonary bypass to 3 or 6 h after termination of cardiopulmonary bypass (P< 0.05 for all markers). A fibrinolysis inhibition marker of plasminogen activator inhibitor-1 and the inflammation markers of interleukin-6, 8 and 10 as well as tumour necrosis factor-α were not significantly different. The amount of packed red blood cells required after the termination of CPB was significantly less in the Cell-Saver group compared with that in the non-Cell-Saver group (P= 0.004). There were no significant differences in the other clinical outcomes between the two groups. CONCLUSIONS: In AVR, the avoidance of direct return of pericardial blood induced considerable suppressions of coagulofibrinolysis responses. ACATS is a favourable alternative for managing pericardial blood during cardiopulmonary bypass. Our results support the published guidelines and could help to establish ideal strategies for eliminating the use of cardiotomy suction, thus facilitating less-invasive valve surgeries with marked suppression of coagulofibrinolysis responses.

Background: The outcomes of hepatic resection in intrahepatic cholangiocarcinoma (ICC) patients with diabetes mellitus (DM), hypertension (HT), and dyslipidemia (DL) (metabolic components) remain unclear. Methods: The outcomes of 43 ICC patients without known risk factors for ICC who underwent hepatic resection were retrospectively reviewed. These patients were divided into three groups: those followed-up for metabolic components at least every 6 months (follow-up group, n=16), those not followed-up for metabolic components (no follow-up group, n=14), and those without metabolic components (control group, n=13). Results: In the follow-up group, 13 (81%) patients were further examined for ICC during follow-up because of abnormal screening results, such as elevated serum gamma-glutamyl transpeptidase and carbohydrate antigen 19-9 (CA19-9) concentrations or detection of hepatic tumor on ultrasonography and/or computed tomography, whereas most patients in the other two groups exhibited ICC-related symptoms. No patient in the follow-up group exhibited lymph node metastasis, whereas 43% of those in the no follow-up group and 46% in the control group had lymph node metastasis (p=0.005 and 0.004 vs. the follow-up group, respectively). All 16 patients in the follow-up group were diagnosed as International Union Against Cancer pathologic stage I or II (early stage). There were no significant differences in the incidence of postoperative recurrence between the three groups; however, the incidence of extrahepatic recurrence was lower in the follow-up group than in the no follow-up group and the control group (13% vs. 78% vs. 63%, p=0.0232). The 1-, 3-, and 5-year overall survivalrates in the follow-up group were better than those in the no follow-up and control groups (93/93/66% vs. 77/34/34% and 85/24/0%, p=0.034 and 0.001, respectively). Conclusions: Routine measurement of serum gamma-glutamyl transpeptidase and/or CA19-9 levels and imaging examinations every 12 months (or 6 months, if possible) are recommended during follow-up for DM, HT, and DL to detect ICC at an early stage.

Objective: This retrospective study aimed to evaluate the results of our experience with axillary artery cannulation via a side graft in aortic valve replacement in patients with ascending aortic atherosclerotic disease. Methods: From January 2002 to 2012, we operated on 76 patients for aortic valve disease with the use of the axillary artery for arterial inflow in our institute. The indications for cannulation of the axillary artery were aortic aneurysm in 37 patients, severe aortic atherosclerosis in 28 patients, and re do surgery in 11 patients. Results: Right axillary artery cannulation via a side graft provides sufficient antegrade aortic flow of 2.6 ± 0.1 L/m2 during cardiopulmonary bypass. No additional arterial cannulation was necessary to obtain sufficient perfusion during cardiopulmonary bypass. Although permanent perioperative stroke was observed in two patients, this did not occur during the operation. There were no problems with cannulation or wound and graft infections. During the follow-up period, there were no thrombotic events due to an axillary graft stump in the right upper extremities. Conclusions: Axillary artery cannulation via a side graft is a useful and safe option for cardiopulmonary bypass in patients with atherosclerotic disease of the ascending aorta undergoing aortic valve replacement.

Aberrant hypermethylation of specific genes is present in esophageal squamous cell carcinomas (ESCCs). Such hypermethylation is also present in normal-appearing esophageal mucosae of ESCC patients and is considered to contribute to the formation of a field for cancerization. On the other hand, the presence of global hypomethylation in ESCCs or in their background esophageal mucosae is unknown. We collected 184 samples of esophageal mucosae (95 normal mucosae from healthy subjects, and 89 non-cancerous background mucosae from ESCC patients) and 93 samples of ESCCs. Methylation levels of repetitive elements (Alu, LINE1) and cancer/testis antigen genes (NY-ESO-1, MAGE-C1) were measured by bisulfite pyrosequencing and quantitative methylation-specific PCR, respectively. Methylation levels of Alu, LINE1, NY-ESO-1, and MAGE-C1 were significantly lower in ESCCs than in their background and normal mucosae. Also, in the background mucosae, a significant decrease of the Alu methylation level compared with the normal mucosae was present. In ESCCs, methylation levels of the two repetitive elements and the two cancer/testis antigen genes were correlated with each other. This is the first study to show the presence of global hypomethylation in ESCCs, and even in their non-cancerous background mucosae. Alu hypomethylation might reflect the severity of an epigenetic field for cancerization.

Massive bleeding from large vessels is a serious and life-threatening complication after radical esophagectomy. Here, we present the rare case of patient survival following two episodes of massive bleeding from a tracheo-brachiocephalic artery fistula after salvage surgery for cervical esophageal cancer following definitive chemoradiation. During the first episode of bleeding, the damaged part of the brachiocephalic artery was transected with an extra-anatomical arterial bypass (right femoro-axillo artery bypass graft) to maintain the arterial blood flow to the brain and the free jejunal graft. During the second bleeding, the distal stump of the brachiocephalic artery was reclosed. During both episodes of bleeding, the musculocutaneous flap was effectively employed to seal the stumps of the brachiocephalic artery and fill the dead space. Finally, the patient was discharged 351 days after the first surgery. (132/150).

Aim: Several investigators have shown that interferon (IFN) therapy can suppress the recurrence of hepatocellular carcinoma (HCC) after curative treatment. We investigated the effect of IFN therapy on the first and second HCC recurrence following hepatic resection of hepatitis C virus (HCV)-related HCC. Methods: Subjects included 166 patients who had undergone curative resection for a single HCV-related HCC. We analyzed the outcome after initial hepatic resection and risk factors of a second HCC recurrence following treatment for the first HCC recurrence. Results: Using multivariate analysis, a non-sustained virological response (non-SVR) was significantly associated with a high incidence of first HCC recurrence. The rate of second HCC recurrence tended to be higher in the non-SVR group than in the SVR group. In the patients with recurrence of multiple tumors or who received non-curative treatment for recurrent HCC, the second HCC recurrence rates were significantly higher. Multivariate analysis demonstrated that non-curative treatment for first HCC recurrence was an independent risk factor for a second HCC recurrence. Among the patients who received curative treatment for their first HCC recurrence, the rates of second recurrence were significantly higher in the non-SVR group than in the SVR group. Multivariate analysis also revealed that SVR was independently associated with prevention of a second HCC recurrence. Conclusions: These results suggest that on first HCC recurrence, a curative treatment should be considered in order to prevent a second recurrence if possible. In addition, IFN therapy contributes to improved prognosis after curative treatment, even in patients with recurrent HCC.

Aortic stenosis (AS) and systemic atherosclerosis have been shown to be closely related. We evaluated the prevalence of aortic arch plaques and their possible association with the risk of cerebral infarction in patients with severe AS. Transesophageal echocardiography was performed in 116 patients with severe AS (55 men, mean age 71 ± 7 years, mean aortic valve area 0.68 ± 0.15 cm(2)) who were scheduled for aortic valve replacement. The presence, thickness, and morphology of the aortic arch plaques were evaluated using transesophageal echocardiography. Cerebral infarcts (chronic cerebral infarction and cerebral infarction after cardiac catheterization and aortic valve replacement) were assessed in all patients. Compared to age- and gender-matched control subjects, the patients with severe AS had a significantly greater prevalence of aortic arch plaques (74% vs 41%; p0.0001) and complex arch plaques such as large plaques (≥4 mm), ulcerated plaques, or mobile plaques (30% vs 10%; p = 0.004). Multivariate logistic analyses showed that the presence of complex arch plaques was independently associated with cerebral infarction in patients with AS after adjusting for traditional atherosclerotic risk factors and coronary artery disease (odds ratio 8.46, 95% confidence interval 2.38 to 30.12; p = 0.001). In conclusion, the results from the present study showed that there is a greater prevalence of aortic arch plaques in patients with AS and that the presence of complex plaques is independently associated with cerebral infarction in these patients. Therefore, the identification of complex arch plaques using transesophageal echocardiography is important for risk stratification of cerebrovascular events in patients with severe AS.

Reactive oxygen species stimulate lymphatic metastasis by accelerating epithelial-to-mesenchymal transition and lymphangiogenesis in the tumor microenvironment. Hence, systemic oxidative stress level may correlate with nodal involvement in patients with a malignant tumor. We examined 46 patients with clinical stage I lung adenocarcinoma who had undergone pulmonary resection with mediastinal lymph node dissection. Serum reactive oxygen metabolite (ROM) level was measured as an indicator of systemic oxidative stress. We investigated the association between nodal involvement and clinicopathological factors. Preoperative serum carcinoembryonic antigen (CEA; P = 0.045), cytokeratin 19 fragment (CYFRA21–1; P = 0.038), and ROM (P = 0.007) levels were significantly higher in patients with nodal involvement than in those without nodal involvement. A receiver operating characteristic curve was constructed to determine whether patients with and without nodal involvement could be differentiated on the basis of their serum ROM levels. The area under curve was 0.763 and the prognostic cut-off value was set at 318 Carratelli units. In univariate analysis, clinical stage IB (odds ratio [OR] = 4.55; P = 0.033), CEA-positive (OR = 5.56, P = 0.018), and ROM-positive (OR = 10.46, P = 0.006) were significant predictive factors for nodal involvement. In multivariate analysis, ROM-positive was an independent predictive factor for nodal involvement (OR = 6.22, P = 0.045). Preoperative serum ROM level was an independent significant predictive factor for nodal involvement in patients with clinical stage I lung adenocarcinoma. Hence, serum ROM level may be a useful biomarker for staging of lung adenocarcinoma.

A 58-year-old man underwent surgery for the treatment of lung adenocarcinoma at our hospital. He had a history of spinal caries at the age of 3 and frequent recurrent asthma-like symptoms thereafter. Chest plain radiography revealed an irregularly shaped mass in the left hilum and a thoracic cage severely deformed by kyphosis. A pulmonary function test demonstrated a severe restrictive ventilation pattern. He underwent a left upper lobectomy without mediastinal dissection. His asthma-like symptoms were exacerbated by difficulty in expectoration of sputum for several days after surgery, but the symptoms disappeared without any medical care. Dyspnea, hemoptysis, and intrathoracic hemorrhage were observed on the 8th postoperative day. Computed tomography revealed torsion of the residual left lower lobe, but the symptoms spontaneously disappeared in a week. The patient had complained of frequent coughing and mild dyspnea on exertion for years, but his quality of life was unchanged after the lobectomy. Bone metastasis was detected 3 years after the surgery, and the patient then underwent chemotherapy. However, he died of the disease 4 years 2 months after the surgery.

Poststernotomy mediastinitis (PSM) following cardiovascular surgery remains an intractable complication associated with considerable mortality. It is therefore necessary to assess the risk factors associated with hospital mortality and evaluate the surgical treatment options for PSM.We identified 59 (2.2%) patients who developed PSM after cardiovascular surgery between January 1991 and January 2010. PSM was defined as deep sternal wound infection requiring surgical treatment. In all, 31 patients were infected with methicillin-resistant Staphylococcus aureus (MRSA); and 14 patients died in hospital from PSM. A total of 51 patients were treated by simple closure or tissue flap reconstruction after débridement (traditional treatment), and 8 underwent closure or reconstruction after negative-pressure wound therapy (NPWT). The risk factors for in-hospital mortality due to PSM were analyzed by comparing the characteristics of survivors and nonsurvivors. The available surgical treatments for mediastinitis were also assessed.Univariate analysis identified age, sex, pulmonary disease, MRSA infection, prolonged mechanical ventilation and prolonged intensive care unit stay as risk factors for in-hospital mortality (P0.05). Multiple logistic regression analysis identified MRSA infection (odds ratio 20.263, 95% confidence interval 1.580-259.814; P = 0.0208) as an independent risk factor for hospital mortality. NPWT was associated with significantly less surgical failure than traditional treatment (P = 0.0204). There were no deaths as a result of PSM in patients who underwent NPWT irrespective of the presence of MRSA infection.MRSA infection was an independent risk factor for PSM-related in-hospital mortality. NPWT may improve the prognosis for patients with MRSA mediastinitis.

A 38-year-old man had Stanford type B chronic aortic dissection. Blood pressure was diffi cult to control, and further examination revealed primary aldosteronism. Magnetic resonance images showed a 1-cm nodule in the left adrenal gland. Graft replacement for aortic dissection under extracorporeal circulation and resection of the left adrenal gland were undertaken simultaneously. The postoperative course was uneventful, and blood pressure was controlled without antihypertensive drugs.

Thrombin generation is considered unavoidable during cardiac surgery using cardiopulmonary bypass (CPB). We compared the effects of open and closed circuits on coagulation and fibrinolysis under identical conditions of priming volume, heparin-coating, and anticoagulation and transfusion protocols. Thirty coronary surgery patients were randomized to surgery using open circuits with open reservoirs and cardiotomy suction (open group, n=15) or closed circuits without either (closed group, n=15). In the closed group, a cell-saving device was used instead of cardiotomy suction. Blood samples were collected at eight time points from before the operation to the first postoperative morning. Thrombin-antithrombin III (TAT), fibrinogen degradation products, and D-dimer were not elevated during CPB in the closed group, but were significantly increased in the open group (P

Popliteal artery entrapment syndrome (PAES) is a rare cause of acute limb ischemia in adult patients but commonly demonstrates as claudication in young patients. The most significant, although rare, complication associated with PAES is aneurysm formation. We present the case of an elderly patient with a unilateral popliteal artery aneurysm owing to symptomatic anatomic entrapment. This report presents the oldest patient ever reported with this syndrome and highlights the advantage of multimodal treatment. As multidetector computed tomography highly contributed to the rapid diagnostic confirmation and choice of treatment in the popliteal fossa, limb salvage was achieved in this patient.

2004年1月から2008年12月に縦隔リンパ節郭清を伴う肺葉切除を施行したc-1A期非小細胞肺癌症例131症例を対象とし，術後病理学的リンパ節転移陰性群と陽性群間の臨床病理学的因子を検討した．男性72例，女性59例，平均年齢67歳．腺癌107例，非腺癌24例であった．pN0症例113例，pN1症例6例，pN2症例12例であった．リンパ節転移陰性例（n＝113）および陽性例（n＝18）を比較検討すると術前血中SLX値の中央値はそれぞれ21.6U/mlおよび28.5U/mlであり，リンパ節転移陽性例で有意に高値であった（p＝0.001）．ROCカーブから血中SLX値についてカットオフ値（26U/ml）を決定し，臨床病理学的因子について多変量解析を行うと血中SLX値のみが独立予測因子であった（リスク比：3.527，p＝0.021）．c-1A期非小細胞肺癌症例において術前血中SLX値陽性例は術前精査，術式選択について慎重な検討が必要と考えられた．

Di-(2-ethylhexyl)phthalate (DEHP), an excellent plasticizer for poly(vinyl chloride) (PVC), is a known endocrine-disrupting chemical. This study was designed to investigate whether a new non-DEHP bilayer tube reduced the release of DEHP, suppressed inflammatory cytokines, and altered coagulation-fibrinolysis systems. Sixteen patients undergoing coronary artery bypass grafting (CABG) were randomly assigned to the non-DEHP bilayer group (group B, n = 8), or the noncoated PVC group (group N, n = 8). The level of DEHP in the blood was measured before and after cardiopulmonary bypass (CPB). The levels of interleukin-6 (IL-6), D-dimer, and thrombin-antithrombin complex (TAT) were also measured at six points during and after CPB. DEHP was significantly lower in group B (472 +/- 141 ng/ml) after CPB compared with group N (2094 +/- 1046 ng/ml). The IL-6 level was significantly lower in group B (151 +/- 131 pg/ml) than group N (206 +/- 224 pg/ml) 180 min after protamine administration. The D-dimer level was significantly lower in group B 60 min after protamine administration (6.2 +/- 2.4 microg/ml in group B vs 10.4 +/- 4.5 microg/ml in group N) and 180 min after protamine administration (4.4 +/- 0.7 microg/ml in group B vs 7.3 +/- 2.7 microg/ml in group N). Group B had a tendency toward reduced postoperative bleeding compared with group N at any time. The bilayer tube was superior to the noncoated tube in terms of the inhibition of DEHP release, inflammatory cytokines, and the fibrinolysis system.

Objective— Unrestricted somatic stem cells (USSCs) were successfully identified from human cord blood. However, the efficacy of USSC transplantation for improving left ventricular (LV) function post myocardial infarction (MI) is still controversial. Methods and Results— PBS, 1×10 6 human fibroblasts (Fbr), 1×10 5 USSCs (LD), or 1×10 6 USSCs (HD) were transplanted intramyocardially 20 minutes after ligating the LAD of nude rats. Echocardiography and a microtip conductance catheter at day 28 revealed a dose-dependent improvement of LV function after USSC transplantation. Necropsy examination revealed dose-dependent augmentation of capillary density and inhibition of LV fibrosis. Dual-label immunohistochemistry for cardiac troponin-I and human nuclear antigen (HNA) demonstrated that human cardiomyocytes (CMCs) were dose-dependently generated in ischemic myocardium 28 days after USSC transplantation. Similarly, dual-label immunostaining for smooth muscle actin and class I human leukocyte antigen or that for von Willebrand factor and HNA also revealed a dose-dependent vasculogenesis after USSC transplantation. RT-PCR indicated that expression of human-specific genes of CMCs, smooth muscle cells, and endothelial cell markers in infarcted myocardium were significantly augmented in USSC-treated animals compared with control groups. Conclusions— USSC transplantation leads to functional improvement and recovery from MI and exhibits a significant and dose-dependent potential for concurrent cardiomyogenesis and vasculogenesis.

Purpose The cause of pectus excavatum has been hypothesized to be overgrowth of the costal cartilage. According to this theory, the length of costal cartilages must be longer in the side of deep depression in asymmetric patients. To challenge this hypothesis, we measured the lengths of ribs and costal cartilages and investigated lateral differences. Subjects and methods Twenty-four adolescent and adult patients with asymmetric pectus excavatum (14-30 years of age) with no history of surgery were investigated in this study. The fifth and sixth ribs and costal cartilages were individually traced to measure their full lengths on 3-dimensional computed tomographic (CT) images. As an index of asymmetry, sternal rotation angle was measured in the chest CT images. Patients with a 21° or greater angle of sternal twist were designated as an asymmetric group and those with an angle of smaller than 20° as a symmetric group. Lateral differences in the fifth and sixth costal and costal cartilage lengths were compared between the groups. Results On comparison of the costal and costal cartilage lengths in the asymmetric group, the right fifth ribs and costal cartilages were significantly shorter than the left ( P = .02 and .03, respectively), and right sixth ribs were also significantly shorter than the left ( P = .004), but right sixth costal cartilages were not ( P = .31). In the symmetric group, the lengths of the left and right fifth ribs and costal cartilages were showing no significant difference ( P = .20 and P = .80, respectively), and those of the sixth ribs and costal cartilage were also showing no significant difference ( P = .97 and P = .64, respectively). Discussion The ribs and costal cartilages on the right side with severer depression were significantly shorter or not different than those on the contralateral side. Based on these findings, the theory of costal cartilage overgrowth is contradictory. The etiology of asymmetric chest deformity should be reevaluated.

Background The modified Bentall technique, which was reported by Svensson in 1992, is an aortic root composite valve graft replacement involving reimplantation of the left coronary ostium with a long interposed graft wrapping behind the composite graft. The technique is technically advantageous, particularly for complicated or redo aortic roots. To justify the technique, the midterm outcome needs to be evaluated. Methods Since 1992, 40 patients (4 with Marfan syndrome) underwent the modified Bentall technique (Svensson's modification). The mean age was 54.7 ± 13.6 years, and 32 patients (80.0%) were male. All hospital survivors have been consecutively followed with annual echocardiographic evaluations. Furthermore, in 2007, multislice computed tomography was performed at 4.7 ± 3.5 years (maximum, 14.9 years) postoperatively in 30 patients who had preserved renal function. Results No patients have experienced any complications regarding the technique at the follow-up of 5.7 ± 4.0 years (maximum, 14.9 years), although there were 2 hospital deaths of emergency cases and 5 late deaths owing to noncardiac causes. In 35 patients (92.1% of hospital survivors), no structural complications were detected by multislice computed tomographies of the 30 patients or coronary angiograms of the remaining 5 patients. The consecutive echocardiographic follow-ups showed well-preserved left ventricular function with the most recent ejection fraction being 0.581 ± 0.078. Conclusions This Svensson's modification technique was associated with favorable midterm outcomes by multislice computed tomography and consecutive echocardiographic evaluations, indicating long-lasting advantages as well as technical benefits. Thus, the technique can be considered as a helpful and justifiable alternative method.

This study was designed to determine the clinical characteristics and verify the results of surgical treatment for non-small cell lung cancer (NSCLC) in patients with hepatocellular carcinoma (HCC), from the results of retrospective analysis of the cases. We retrospectively reviewed our database of 751 patients who underwent curative surgical intervention for NSCLC from January 1993 to December 2006 and found 11 patients with NSCLC with coexisting or previously treated HCC at a perioperative period of lung cancer surgery. Postoperative complications and long-term outcome were analyzed. All cases had coexisting liver cirrhosis. The overall morbidity was 27.2% (n = 3). All complications were considered to be the result of liver cirrhosis-related conditions, such as liver failure (n = 2), postoperative bleeding from the thoracic tube (n = 2), and gastrointestinal bleeding (n = 1). There was no operative mortality. The 1-, 3-, and 5-year survival rates of patients with lung cancer were 88.9%, 74.1%, and 74.1%, respectively. The 1-, 3-, and 5-year survival rates for death from hepatic causes were 79.5%, 79.5%, and 39.8%, respectively. Overall survival rates were 70.7%, 58.9%, and 29.5%, respectively. Preoperative indicators of liver function, such as serum values of total bilirubin (P

Nonbacterial pleuritis caused by rupture of a metastatic adenocarcinoma is extremely rare and has not yet been reported. A 59-year-old man with a history of rectal cancer surgery 6 years earlier presented with a solitary lung mass in the periphery of the right lower lobe on computed tomography. Transbronchial biopsy disclosed a suspected metastatic adenocarcinoma, and he was admitted for pulmonary metastasectomy. He had been asymptomatic, but 4 weeks after the diagnostic bronchoscopy, the patient suddenly complained of a right back pain and dyspnea at rest; shortly after that, he developed a fever of 39 degrees C. A chest X-ray showed right pleural effusion, collapse of the right lower lobe, and elevation of the right diaphragmatic dome, but without pneumothorax. Emergent video-assisted thoracoscopy revealed a perforated tumor in the collapsed lower lobe, and a right lower lobectomy was carried out. The postoperative course was uneventful, and he was well without recurrent disease 2 years after pulmonary resection.

われわれは稀な右房原発悪性リンパ腫の1手術例を経験した．症例は呼吸困難，全身浮腫を主訴とする85歳，女性で，心臓超音波検査にて右房内に腫瘤病変を指摘され当院紹介となった．腫瘤による血流障害のため重症心不全を呈していたため緊急手術を施行した．手術は体外循環使用心停止下に施行した．右房内腫瘤は最大径50mmで，術中迅速病理検査にて血管肉腫あるいは悪性リンパ腫と診断された．腫瘍が心房中隔から三尖弁輪およびIVCにかけて右房壁へ浸潤していたため完全摘除は困難と判断し，腫瘍を可及的に切除するにとどめた．病理検査によりB cell malignant lymphomaと診断されたので化学療法を開始した．右房内の腫瘍はほぼ消失し，右心不全症状も改善したが，化学療法による副作用のため全身状態の悪化を来たしMRSA肺炎を併発し術後第52日目に死亡した．心臓原発腫瘍の中で悪性リンパ腫は約1%と非常に稀であり，その診断，治療方法につき若干の文献的考察を加えて報告した．

This study aimed to establish the clinical significance of preoperative serum cytokeratin 19 fragment (CYFRA21-1) and Sialyl Lewis(x) (SLX) in patients with stage I non-small cell lung cancer (NSCLC). The study involved 137 patients (87 male, 50 female; median age 69 years) with completely resected stage I NSCLC. SLX, carcinoembryonic antigen (CEA), squamous cell carcinoma antigen (SCC), and CYFRA21-1 were examined. Receiver operator characteristic (ROC) curves were constructed to determine prognostic cut-off values. Among the 137 patients, we identified 30 with recurrence within 3 years. The 5-year survival rates in patients with (n=30) and without (n=107) recurrence were 14% and 81%, respectively. The serum concentrations of SLX, CEA, and CYFRA21-1 in the recurrence group were significantly higher than those in the non-recurrence group. The areas under the ROC curve (AUC) were 0.72, 0.65, 0.53, and 0.64 for SLX, CEA, SCC, and CYFRA21-1, respectively. The prognostic cut-off values were 36U/ml, 7.8ng/ml, 1.5ng/ml, and 3.2ng/ml for SLX, CEA, SCC, and CYFRA21-1, respectively. A log-rank test revealed that age, performance status, T factor, lymphatic invasion, vascular invasion, SLX, CEA, SCC, and CYFRA21-1 were all significantly associated with survival. By multivariate analysis, age, performance status, lymphatic invasion, SLX (risk ratio, 4.11) and CYFRA21-1 (risk ratio, 3.47) were independent prognostic factors. For patients positive for both CYFRA21-1 and SLX, the relative risk was 5.32 compared with patients who were negative for both markers. The 5-year survival rates were 80% in the group negative for both markers (n=86); 52% in the group positive for one of the markers (n=43); and 13% for the group positive for both markers (n=8) (p0.001). We concluded that serum SLX and CYFRA21-1 were prognostic markers for stage I NSCLC. Their combination should contribute to the classification of stage I NSCLC patients. There is a need to consider adjuvant and neoadjuvant therapies to improve prognosis in patients positive for both tumor markers.

Long-term outcome of surgery for non-small cell lung cancer with comorbid liver cirrhosis is not well known. We aimed to establish the factors influencing survival in such cases.We retrospectively reviewed 33 patients who had undergone surgery for non-small cell lung cancer with comorbid liver cirrhosis. Clinical features, early outcome, survival time, and cause of death were investigated. Factors influencing survival were estimated by univariate and multivariate analyses.There were 2 in-hospital deaths (6.5%). Five-year survival rate for lung cancer death (n = 9) was 59.7%, whereas for hepatic death (n = 6), it was 62.9%. Factors influencing lung cancer death were nodal stage and limited resection (p0.05 for each). Factors influencing hepatic death were serum total bilirubin (p0.0001) and cholinesterase (p0.05), platelet count (p0.05), and alpha-fetoprotein (p0.05). Lung disease factors such as local extensiveness of the tumor and pathologic stage, and surgical factors such as performance of mediastinal dissection and limited surgery, also influenced survival from hepatic death (p0.05 for each).Although pulmonary resection invasiveness may have some impact on long-term liver function, the life expectancy of patients with cirrhosis does not seem to be severely affected by pulmonary resection itself. Curative surgery should be performed if possible, even in patients with cirrhosis.

Endobronchial inflammatory pseudotumor (EIP) is an uncommon, benign entity in the central airways, frequently causing acute respiratory insufficiency by occluding the trachea or main-stem bronchi. Surgical resection of the tumor is a treatment option; however, it is associated with high morbidity. W

We report a rare case of inverted Schneiderian papilloma causing exceedingly high serum levels of carcinoembryonic antigen (CEA) and squamous cell carcinoma-associated antigen (SCC). A 74-year-old man presented with a 6-month history of a productive cough, bloody sputa, and dyspnea. Chest computed tomography showed massive infiltration in the lower lobe with multiple focal soft tissue densities. Blood biochemical analysis revealed a serum CEA level of 107.0 ng/ml (normal

Background— Therapeutic effect of stem cell transplantation (SCTx) for myocardial neovascularization has been evaluated by histological capillary density in small animals. However, it has been technically difficult to obtain imaging evidence of collateral formation by conventional angiography. Methods and Results— Peripheral blood CD34+ and CD34− cells were isolated from patients with critical limb ischemia. PBS, CD34− cells, or CD34+ cells were intramyocardially transplanted after ligating LAD of nude rats. Coronary angiography of ex vivo beating hearts 5 and 28 days after the treatment was performed using the third generation synchrotron radiation microangiography (SRM), which has potential to visualize vessels as small as 20 μm in diameter. The SRM was performed pre and post sodium nitroprusside (SNP) to examine vascular physiology at each time point. Diameter of most collateral vessels was 20 to 120 μm, apparently invisible size in conventional angiography. Rentrop scores at day 28 pre and post SNP were significantly greater in CD34+ cell group than other groups ( P P R =0.82, P Conclusions— The SRM, capable of visualizing microvessels, may be useful for morphometric and physiological evaluation of coronary collateral formation by SCTx. The novel imaging system may be an essential tool in future preclinical/translational research of stem cell biology.

Sorin Bicarbon (SB) and Edwards Mira (EM) valves have an identical mechanical design but different sewing cuffs. The purpose of this retrospective study was to analyze the long-term clinical and echocardiographic outcomes after mitral valve replacement with these two valves in a combined population of patients.We retrospectively reviewed records of 73 patients who underwent mitral valve replacement using SB (n = 19) or EM (n = 54) valves. Preoperatively, 49 patients (68.1%) were in New York Heart Association (NYHA) functional class III or IV. Concomitant procedures were performed in 52 patients (71.2%). Early and late postoperative echocardiography was performed in 69 and 57 patients, respectively.Operative mortality was 4.1%, and early morbidity was 9.6%. Overall patient survival at 9 years was 85.1% +/- 4.8%. Actuarial freedom from valve-related death was 95.4% +/- 2.6% at 9 years. As shown by Doppler echocardiography, the early and late mean transprosthetic pressure gradients were 3.4 +/- 1.4 mmHg and 3.8 +/- 2.1 mmHg, respectively. At the end of follow-up, 98.4% of survivors were in NYHA class I or II.The Sorin Bicarbon and, Edwards Mira mechanical valves in the mitral position provide satisfactory long-term clinical and echocardiographic performance.

Active infective endocarditis (IE) is classified into two groups; hospital acquired IE (HIE) and IE other than HIE, which was defined as community-acquired IE (CIE). Eighty-two patients underwent surgical treatment for active IE. Seventy-one cases were CIE group and eleven were HIE. There were six patients with native valve endocarditis and five cases of prosthetic valve endocarditis in the HIE group. We compared the surgical outcome of both types of active IE retrospectively. The preoperative status of the patients in the HIE group was more critical than that in the CIE group. Streptococcus spp. were the major micro-organisms in the CIE group (39%), while 82% of the HIE cases were caused by Staphylococcus spp. All Staphylococcus organisms in the HIE group were methicillin resistant. There were 10 hospital deaths, three in the CIE group and seven in the HIE group. Operative mortality in the HIE group was significantly higher than in the CIE group (63.6% vs. 4.2%, P

This study aimed to establish the clinical significance of preoperative serum cytokeratin 19 fragment (CYFRA21-1) and sialyl-Lewis x (SLex) as prognostic markers.The study involved 272 patients (181 male, 91 female; median age 69 years; range, 32 to 92) with non-small cell lung cancer (NSCLC) who underwent pulmonary resection with mediastinal lymph node dissection. Tumor markers carcinoembryonic antigen (CEA), squamous cell carcinoma antigen (SCC), CYFRA21-1, and SLex were examined.A log-rank test revealed that age, gender, performance status, CEA, SCC, CYFRA21-1, and SLex were associated with the survival rate. By multivariate analysis, age, gender, performance status, CYFRA21-1 (risk ratio, 2.42) and SLex (risk ratio, 6.18) were independent prognostic factors. For patients positive for both markers, the relative risk was 6.10 compared with patients negative for both markers. The patients were divided into three groups: negative for both CYFRA21-1 and SLex (n = 97); positive for either marker (n = 136); and positive for both markers (n = 39). The 1-, 3-, and 5-year survival rates were the following: 98%, 82%, and 75% in the first group; 90%, 63%, and 49% in the second group; and 62%, 31%, and 25% in the third group (p0.001). Sixty-four percent of patients positive for both markers were histologic stage III/IV, and 68% of patients negative for both markers were stage I.Serum CYFRA21-1 and SLex were prognostic markers for NSCLC. Their combination should contribute to the classification of NSCLC patients. Preoperative staging should be carefully performed in patients positive for both tumor markers.

Landiolol, a highly cardioselective beta1-blocker, has cardioprotective effects against ischemia-reperfusion injury, although the precise mechanism is still unclear. The aim of this study was to clarify the cardioprotective mechanism of landiolol. Experiments were performed on Langendorff-perfused rat hearts undergoing 20 min stabilization, and 45 min of ischemia followed by 60 min of reperfusion. Various drugs with or without landiolol (100 microM) were administered before ischemia for 20 min. Preischemic administration of landiolol reduced cardiac cellular damage and improved the recovery of cardiac function by about 40%. The alpha1 blocker prazosin, the protein kinase C (PKC) inhibitor chelerythrine or the K(ATP) channel blocker glibenclamide, but not the selective mitochondrial K(ATP) channel blocker 5-hydroxydecanoate abrogated the cardioprotective effect induced by landiolol. Following landiolol pretreatment the activation of PKCepsilon and heat shock protein 27 were significantly higher than that in control. These data indicate that preischemic application of landiolol induces cardioprotective effects through PKCepsilon-mediated pathway, similar to that afforded by ischemic preconditioning.

Reactive oxygen species (ROS) play an important role in the pathogenesis of diabetic complications. Antioxidant Biofactor (AOB) is a mixture of commercially available fermented grain foods and has strong antioxidant activity. This study investigated the effect of AOB supplementation of standard rat food on markers of oxidative stress and inflammation in Otsuka Long-Evans Tokushima Fatty (OLETF) rats with type 2 diabetes. Blood glucose, hemoglobin A1c, plasma free fatty acid, triacylglycerol and plasminogen activator inhibitor-1 (PAI-1) were significantly higher in OLETF rats than in non-diabetic control Long-Evans Tokushima Otsuka (LETO) rats at 29 weeks. AOB (6.5% of diet) was given to rats during 29–33 weeks of diabetic phase in OLETF rats. OLETF rats with AOB supplementation showed decreased blood glucose, hemoglobin A1c, triacylgycerol, low density lipoprotein, cholesterol and PAI-1. Mitochondrial ROS production was significantly increased in heart, aorta, liver and renal artery of OLETF rats. Uncoupling protein 2 (UCP2) is known to regulate ROS production. We found aortic UCP2 protein expression increased in OLETF rats, and AOB returned UCP2 expression to normal. Aortic endothelial NO synthase (eNOS) was also increased in OLETF rats more than in LETO rats at 33 weeks. In contrast, phosphorylated vasodilator-stimulated phosphoprotein, an index of the NO-cGMP pathway, was significantly diminished. AOB increased eNOS proteins in LETO and OLETF rats. In conclusion, AOB significantly improved the NO-cGMP pathway via normalizing ROS generation in OLETF rats. The data suggest that dietary supplementation with AOB contributes to nutritional strategies for the prevention and treatment of type 2 diabetes mellitus.