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Background Tracheal immunogenicity has been controversial. Although replacement of allotracheal epithelia by the host epithelia has been reported in rat orthotopic tracheal grafting, the immunological effect of epithelial replacement is still uncertain. Methods We performed orthotopic tracheal grafting of nine cartilage rings in the following groups: 1, Lewis → Lewis ( n = 30); 2, ACI → DA ( n = 25); 3, Lewis → F344 ( n = 23); 4-A, DA → Lewis ( n = 41); 4-B, DA → Lewis with tacrolimus therapy (1 mg/kg/d for 10 days) starting from the day of the operation ( n = 31); 4-C, retransplantation of DA allografts to secondary naive Lewis rats 10 or 15 days after primary grafting ( n = 11); 4-D, DA → Lewis with tacrolimus therapy starting from postoperative day 10 ( n = 6). Survival times and histopathology were assessed. Epithelial replacement was evaluated by immunohistochemistry. Results All rats survived in groups 1, 2, and 3. Even in the fully histoincompatible group 4-A, survival ratio on day 120 was 15%. Epithelial replacement was in progress on day 10 in this group. However, all tacrolimus-treated rats died by day 54 and epithelial replacement did not occur on days 30 and 50 in group 4-B. In group 4-C, retransplantation after complete epithelial replacement increased the long-surviving rats. In group 4-D, all rats receiving tacrolimus therapy after complete epithelial replacement survived over 120 days. Conclusions These results suggest that complete replacement of tracheal epithelia by the host promotes spontaneous acceptance of orthotopic tracheal allografts in rats.

An automatic power-generating system (AGS) which converts kinetic energy into electric energy for quartz watches was tested as a power source for implantable cardiac pacemakers. An automatic power-generating mechanism and a capacitor (0.33 F) were removed from a quartz watch (SEIKO) and encapsulated in a polyvinyl case. Characteristics of the AGS were investigated by acceleration equipment. The capacitor in the AGS was charged to 2.0 V (0.66 J) by placing it on the equipment for about 30 minutes. The equipment has a 2 Hz cycle and generates +/- 1.7 G at the end of each half cycle. The AGS (fully charged to 2.0 V) was used as the power source for a pulse generator circuit built using commercially available CMOS IC. The circuit generated pulses of 0.5 ms width at 1 Hz (60 pulses min-1). The voltage of the AGS was maintained at 1.6 V while it was being charged by the accelerations. The generator supplied pulses of 0.75 V, 1.47 mA through a 510 omega load. With fully charged AGS, the generator was also used to pace a mongrel dog's heart at 140 beats min-1 for 60 minutes. During pacing, the AGS supplied 420 mJ to the circuit and the cardiac muscle. The AGS was placed on the right ventricular wall of the mongrel dog under anaesthesia. Energy of 80 mJ is stored in a capacitor by the heart beating at about 200 beats/min for 30 minutes. Thus the AGS generated 13 microJ per heart beat. This result suggests that the AGS may supply enough energy for use in a cardiac pacemaker.

This paper describes a self-tuning method of membership functions in a fuzzy-logic-based cardiac pacing system and validates its feasibility in a double sensor system which has minute ventilation and oxygen saturation level as its guides for the rate regulation. Though the agreement between the pacing rates (fuzzy rates) calculated with three linguistic variables for each parameter and the target rates were not satisfactory, it was improved significantly by tuning the membership functions. Almost the same evaluated values with those obtained by using six linguistic variables for each parameter were obtained. Time required for the self-tuning process was about 40 s (386CPU, 20 MHz) which was fast enough for the system. The smaller number of linguistic labels results in a smaller number of rules, which is beneficial in implantable cardiac pacemakers with limited memory capacity. A fuzzy-logic-based cardiac pacing system is promising for the realization of custom-made cardiac pacemakers.

Surgery for infective endocarditis (IE) is technically demanding, especially the one for active IE.Operations were performed in 21 patients with a mean age of 52.2 +/- 18.8 years. Fifteen patients were male, and 6 were female. There were 15 patients with active IE and 6 patients with healed IE. Isolated pathogens were Streptococcus in 8 cases, Staphylococcus in 3, and Enterococcus in 2. Two patients had prosthetic valve endocarditis. When the lesions affected the aortic valve, aortic valve replacement (AVR) was performed. When the lesions affected the mitral or tricuspid valves, valve repair was the treatment of choice.Six patients underwent AVR and 15 patients underwent a mitral valve operation (mitral valve repair in 13, replacement in 2). In 2 patients, mitral valve repair was changed to replacement, judged by intraoperative transesophageal echocardiogram. One patient underwent isolated tricuspid valve repair. Total survival and survival free of reoperation at 45 months was 95.2%. The grade of mitral regurgitation (MR) decreased from 3.7 +/- 0.1 to 0.2 +/- 0.1, and that of tricuspid valve regurgitation (TR) recovered from 3.5 +/- 0.5 to 1.0 +/- 1.0 at 21 +/- 15 months after the operation.Valve repair operations were useful in the mitral and tricuspid valve positions, even in the presence of active IE. Both mechanical valve and bioprosthesis showed good results after AVR for IE.

Empyema caused by methicillin-resistant Staphylococcus aureus (MRSA) remains an intractable infection producing high mortality. The authers report a case of MRSA empyema following video-assisted thoracic surgery (VATS) for lung cancer. The case was 73-year-old male with some risks such as pulmonary emphysema, decreased renal function, and previous history of brain infarction. He received wedge resection and the staple lines were wrapped with polyglycolic acid (PGA) felt. Ten days after the operation, he was complicated MRSA pyothorax. By thoracoscopic procedures under local anesthesia, fibrinopurulent tissues were cleaned and 3 of chest tubes were replaced. Intrathoracic infected space was cleaned with physiological saline solution. The patient made favorable progress and recovered. Further empyema has not been developed for 24 months. VATS under local anesthesia and irrigation technique was safe and so useful. Nowadays, PGA felt is often used to reinforce the staple lines of lung. PGA felt is an absorbable but artificial material. We have to care about infectious problems. However, we could control the MRSA pyothrax without removing the PGA felt.

The case was 54-year-old male with some risks such as chronic heart failure, atrial fibrillation, and liver chirrhosis. He was admitted because of severe back pain and diagnosed as empyema by preoperative thoracentesis. By thoracoscopic procedures under local anesthesia, fibrinopurulent tissues were cleaned as much as possible and 3 of chest tubes were replaced. The final diagnosis was Bacillus cereus pyothorax by bacterial cultures of pleural effusion. Intrathoracic cavity was cleaned with physiological saline solution. The patient made favorable progress and recovered. Thoracoscopic surgery under local anesthesia with thoracic irrigation was so effective and safe methods to control the infection.

A 55-year-old man was admitted to our hospital with a growing cystic lesion in the left middle field of the lung. After we diagnosed it as non-small cell lung cancer, we performed left upper lobectomy. A series of chest X-ray revealed that the cyst was formed by the check-valve mechanism due to the lung cancer, retrospectively. We should keep in mind the existence of lung cancer and other malignant tumors adjacent to cystic lesions.

We report a case of a previously healthy 76-year-old male with cavitating pleomorphic carcinoma of the lung. He was admitted because of an abnormal lung shadow on chest X-ray. Computed tomography (CT) showed a well-demarcated nodular shadow within thin-walled cavity in the right upper lobe. Because the lesion was revealed as adenocarcinoma by transbronchial lung biopsy, right upper lobectomy was performed. By histopathologic examination of the resected specimen, the nodule contained a component of spindle cell features and the cavity wall was composed of adenocarcinoma. The final diagnosis was pleomorphic carcinoma. Postoperative course has been uneventful for 12 months after surgery.

We examined the usefulness of soft X-ray radiography of the specimen which was obtained by the lung wedge biopsy.From September 2002 to September 2005, we entered the 10 cases (5 men and 5 women) which were consisted of 15 lesions. We performed lung wedge biopsy after computed tomography (CT)-guided lung marking, and then confirmed the lesion in the specimen by means of soft X-ray radiography.We could confirm impalpable small lung lesions in all cases.The confirmation method of impalpable small lung lesion that combined CT-guided lung marking with soft X-ray radiography was very useful.

We report a case of acute empyema with intraoperative intractable air leaks in a child. A 4-year-old girl was admitted with parapneumonic empyema by Staphylococcus aureus. Conventional conservative therapies such as antibiotics, chest tube drainage were failed. Then we performed dissection and debridement with video-assisted thoracoscopic surgery in fibrinopurulent phase of acute empyema. Intraoperative findings showed that the parietal pleura was very weak by Staphylococcus aureus pneumonia. Air leaks occurred,but pleural defects could not be closed by sutures and ligations. We could seal intractable air leaks to use fibrin glue soaked bioabsorbable polyglycolic acid felt sheet. Lung expansion promptly recovered and the patient was discharged on the 34th postoperative day without complications.

The prognosis of the lung cancer patients with aortic invasion is thought to be very poor in general. Thoracic aorta resection and reconstruction was performed in 6 patients, aortic arch in 2, descending aorta in 4. An intraoperative and a postoperative major complication occurred in each 1 patient. Five patients survived more than 1 year after operation, and 1 of them has been living without relapse for more than 5 years. Pulmonary resection with the involved aorta can be done safely using cardiopulmonary bypass, with encouraging long-term survivals in patients without N2 or N3 nodal metastasis.

We performed left upper lobectomy in 64-year-old man with non-small cell lung cancer (NSCLC) simultaneously metastatic to the brain. He was treated by stereotactic irradiation (STI) 2 months later after lobectomy. He has been doing well now without recurrence for 5 years after the operation. We think that STI and radical lobectomy are good alternatives for patients with NSCLC metastatic to the brain.

We performed 12 operations for aortic dissection in octogenarians from 1997 to 2004. Male : female = 1 : 11. Mean duration of follow-up is 33 +/- 19 months. As regards the etiology, acute type A aortic dissection was 8, chronic type A aortic dissection was 3 and chronic type B aortic dissection with distal arch aneurysm was 1. Total arch replacement was performed in 2 patients and hemiarch replacement in 10. In all patients with acute type A aortic dissection, hemiarch replacement was performed with the aid of selective cerebral perfusion or deep hypothermic circulatory arrest with retrograde cerebral perfusion. Postoperative respiratory failure was found in 1 patient, re-exploration for bleeding in 1, mediastinitis in 1 and temporary neurological dysfunction in 1. There was no hospital mortality. Two patients were died of respiratory failure 4 and 27 months after surgery. The results were acceptable. We recommend that age should not be the only determinant in deciding whether emergency operation should be performed in octogenarians.

A 61-year-old female was admitted because of an abnormal lung shadow on chest X-ray. She had suffered from idiopathic thrombocytopenic purpura (ITP) for more than 7 years. Computed tomography (CT) revealed that an irregular shadow, about 2 cm in diameter, was located in the upper lobe of the right lung. After intravenous immunogrobulin injections for 5 days, a hematology test indicated increased platelet counts and we performed thoracoscopic surgery successfully without blood transfusions. However, 4 months after surgery, a hematology test indicated decreased platelet counts again. Thirteen months after the operation, gastrointestinal fiberscopic examination showed Helicobacter pylori infection. After the urea breath test, eradication therapy let to a recovery in platelet counts.

The prognosis of the lung cancer patients with malignant pleural effusion is extremely poor. Intrapleural perfusion hyperthermo-chemotherapy for the treatment of malignant pleural effusion was performed in 120 lung cancer patients and showed better prognosis than conventional treatment. After successful local control by hyperthermo-chemotherapy, extrapleural pneumonectomy was performed in 8 patients with clinical N 0 or N 1 and M 0 lung cancer. All patients survived for more than 1 year. The only 1 patient survived for more than 3 years and 3 months without recurrence. Almost all patients who died within 2 years had pathological n 2, carcinomatous pericarditis, cancer invasion beyond extrapleural space and so on. Extrapleural pneumonectomy after hyperthermo-chemotherapy can be a choice of surgical treatment if the n 2 disease, pericarditis, and extrapleural invasion of disseminated cancer cells should be excluded precisely.

A 73-year-old man, who underwent coronary artery bypass grafting (CABG) 2 years previously, had suffered from acute type A aortic dissection with concomitant mild to moderate aortic regurgitation. A median resternotomy was performed. Arterial and venous cannulae were inserted into the femoral artery and vein to institute a cardiopulmonary bypass. The intimal tear was existed just above the sino-tubular junction. As the non-coronary sinus was involved in the dissection severely, it was resected in a scallop-shaped configuration. The aortic graft was tailored accordingly and anastomosis was performed in a curviliner fashion following the edge of scallop and the horizontally between the right and left coronary sinuses. Next, total arch replacement was performed using an aortic arch branched graft. Postoperative course was uneventful. Aortography revealed no aortic regurgitation and good patency of bypass graft.

A 57-year-old female was admitted because of chest and back pain. Computed tomography (CT) revealed that many well-marginated lymph nodes were located in mediastinum and abdominal para-aortic area, especially in the right lower mediastinum. These lymph nodes were enhanced at contrast material-enhanced CT. We performed thoracoscopic surgery. The histopathologic diagnosis was multicentric Castleman disease (MCD). MCD should be considered in the differential diagnosis of multiple lymph nodes swelling with hyper globulinemia. Thoracoscopic surgery is the useful method to resect the lymph nodes and diagnose MCD.

We report air embolism following computed tomography (CT)-guided lung needle marking. A 55-year-old man was admitted to our hospital with left pulmonary tumor, characterized as ground glass opacity (GGO). To localize the tumor, lung needle marking under CT guidance was performed. Almost immediately, the patient experienced symptoms of cerebral arterial air embolism. CT revealed air in the left ventricle. About 2.5 hours later the symptoms and the air disappeared. Three days later a video-assisted thoracoscopic wedge resection was performed. The patient's postoperative course was uneventful, and he was discharged in good condition.

A 44-year-old male was admitted to our hospital owing to severe dyspnea of sudden onset. Chest X-ray disclosed bilateral giant bullae. His pulmonary function was severely depressed. VC (%) was 2.61 l (66.3%) and FEV1% (%) was 1.47 l (64.5%). Indication of surgical repair of giant bullae are; space occupying lesion more than 25-50% in 1 thorax, progressive dyspnea, enlargement over time irrespective of symptoms, and expectation that re-expand the normal lung. He was conducted two-staged bullectomy using video-assisted thoracoscopic surgery (VATS) with small incisions. First operation was performed to left lung. Pulmonary function improved. VC (%) increased 3.02 l (76.8%) and FEV1% (%) 2.36 l (76.6%). After second operation, which was performed to right lung, VC (%) was 2.40 l (60.5%) and FEV1% (%) was 2.21 l (92.1%). Hugh-Jones grade improved class IV to class I. Postoperative course was uneventful and he was discharged 15 days after second operation. Two-staged bullectomy was appropriate in this case, because he might have suffered from re-expansion pulmonary edema after first surgery. The extent of recovery of pulmonary function was unpredictable. And performing right lung bullectomy just after the left bullectomy may be dangerous, because the patient have to receive anesthesia with his resected left lung. There is some possibility that patient who has bilateral giant bullae shows severe dyspnea during the progress, care should be taken to conduct operation as soon as possible.

A case of a patient with a intrathoracic chronic expanding hematoma presenting as a neoplasm is reported. A chronic encapsulated intrathoracic hematoma is rare condition and is clinically included in a category of chronic hemorrhagic empyemas as a type of chronic empyemas in Japan. The clinical picture of our case suggested a slowly growing tumor. Though needle biopsy was performed, only blood was aspirated. Intraoperative findings revealed a intrathoracic hematoma with a tough capsule. It adhered to the chest wall hardly. Histopathological investigations revealed that the capsule consisted of a collagenous outer layer and a newly vascularized inner layer with fibrosis. Hemosiderin deposits suggested recurrent bleeding from fragile vessels. The mechanisms of hematoma formation and its expanding nature are discussed. The hematoma appeared to have been enlarged by repeated exudation or bleeding from capillaries inside the capsule.

A 58-year-old man, who had undergone emergency graft replacement of ascending and total aortic arch using gelatin-resorcin-formalin (GRF) glue 1 year before, complained of progressive shortness of breath. Ultrasound cardiography revealed severe aortic regurgitation and dissecting aneurysm of aortic root. He underwent composite graft replacement with the aid of the right axillary artery perfusion and deep hypothermic circulatory arrest. The redissected brownish intima was identified in the area of noncoronary cusp. There was no special finding in the subsequent histopathological examination. The use of GRF glue for reconstructing the dissected aortic root is associated with a certain amount of risk of aortic wall redissection. Therefore, care should be taken to ensure proper use of GRF glue.

Recently many cardiovascular operations have been performed with minimally invasive cardiac surgery (MICS). It is reported that MICS is superior to standard full sternotomy in regard to cosmetic and post-operative recovery. In our institution, aortic valve repair operations have been performed to aortic valve insufficiency. This time, we performed aortic valve repair by minimal access "J" sternotomy. A 63-year-old male with degenerative aortic regurgitation underwent aortic valve repair by MICS. He had experienced dyspnea on exertion 7 days before admission. Preoperative transthoracic echocardiogram showed the grade of aortic regurgitation (AR) was severe. Surgery was successful and the grade of AR became trivial. This combined procedure have merits for patients because of freedom from anticoagulation and small incision. Such combined surgery may be indicated in the treatment in a subset of patients with degenerative AR.

An automatic power generating system developed for quartz watches was tested as a power source for implantable cardiac pacemakers. An automatic power generating mechanism and a capacitor (0.33 F) were taken out of a quartz watch and encapsulated in a polyvinyl case (AGS). Characteristics of the AGS were investigated by reciprocating equipment (2 Hz). The capacitor in the AGS was charged to 2.0 V (0.66 J) by placing it on the equipment for about 30 minutes. The AGS. which was charged, to 2.0 V was used as a power source for a pulse generator circuit that was made by the commercially available CMOS IC. The pulse generator supplied pulses of 0.5 msec width through a 510 /spl Omega/ load at 1 Hz (60 bpm). The voltage of the AGS was maintained at 1.6 V while it was being charged by the reciprocations. The pulse generator supplies a pulse of 0.75 V, 1.47 mA through a 510 /spl Omega/ load. The AGS, which was placed on the wall of the right ventricle in a mongrel dog under anesthesia, stored 80 mJ in a capacitor at about 200 bpm during 30 minutes.

A method was proposed for discrimination of ventricular arrhythmias using fuzzy logic. The classifier uses four features of ECG waveforms; amplitude variation ratio, interval variation ratio, peak sharpness, QRS complex width, and assigns each waveform a number of 0-100. The performance of the algorithm was evaluated on the surface and intracardiac electrocardiograms of ventricular tachycardia (VT), ventricular fibrillation (VF) and normal sinus rhythm (NSR) in mongrel dogs. NSRs were evaluated 90-100 while VFs less than 10. VTs were assigned the numbers of 30-75. An automatic detection and defibrillation experiment was performed with this algorithm.

In redo coronary artery bypass grafting (CABG), graft selection and revascularization methods are major problems. We experienced a redo-CABG with occluded previous vein grafts. These grafts were to the circumflex artery and right coronary artery. We conducted operation using cardiopulmonary bypass. We at this operation, chose right internal thoracic artery (RITA) as a conduit and anastomosed it to the side of functioning left internal thoracic artery (LITA) graft, and then diogonal branch, posterolateral branch, and atrioventricular branch were revascularized with the RITA. Post operative course was uneventful. Internal thoracic artery (ITA) is superior to vein graft and other arterial graft as to long term patency. We believe composite Y graft with the use of bilateral ITA can be one of the revascularization strategy in redo CABG.

The natural history of patients with Marfan syndrome is depressing, however, cardiovascular surgery can improve the prognosis. We reviewed the results of this surgical procedure for 10 years. Fourteen Marfan patients underwent cardiovascular surgery for a total of 21 times. Hospital mortality was 4.8% (1 case died on the 105th day after entire thoraco-abdominal aortic replacement because of pyothorax and sepsis), and the 5- and 10-year Kaplan-Meier survival was 92.9% and 77.4% respectively. Reoperation free rate was 51.4% and 38.6% respectively. Cardiovascular surgery in Marfan syndrome can be performed with good result. Aggressive surgical management and close follow-up of patients who undergo surgery is important.

The question whether the tumor is primary or metastatic sometimes arises in patients with intrathoracic tumor. Especially, adenocarcinoma presents more difficulties in distinguishing primary tumors from secondary or deciding its origin. We reported a case of mediastinal signet-ring cell carcinoma. A 51-year-old female was admitted because of an abnormal shadow during mass screening. Chest X-ray showed a semicircular, well-demarcated shadow on right cardiophrenic angle. Chest computed tomography (CT) revealed a homogeneous mass, approximately 4 cm in diameter. The investigations of whole body failed to reveal any other tumor. At operation, the tumor was adherent to the esophagus but easily resected. Histologically, the tumor was mainly composed of signet-ring cells. Immunohistochemically, surfactant apoprotein (SPA) was strongly demonstrated in tumor cells. SPA is specific to the lung and the tumor was diagnosed as the metastasis in mediastinal lymph nodes. The primary site was considered to exist in lung. But the primary site was not found over 46 months in spite of repeated further examinations.

Aortic reconstruction procedures and brain protection methods are very important among operative factors that have direct influence on surgical results. We nowadays use hypothermic circulatory arrest (HCA) with or without retrograde cerebral perfusion (RCP) as brain protection methods during hemiarch replacement (HAR) and selective cerebral perfusion (SCP) during total arch replacement (TAR) using 4-branched arch graft. The purpose of this study was to verify the appropriateness of this strategy. From April 1997 to August 2001, we performed 120 TAR assisted by SCP and 30 HAR assisted by HCA with or without RCP. Incidences of in-hospital death and postoperative neurological dysfunction were compared between the 2 groups. In-hospital deaths were 4 (3.3%) and 1 (3.3%), permanent neurological dysfunction were 3 (2.5%) and 1 (3.3%), temporary neurological dysfunction were 4 (3.3%) and 1 (3.3%), 3-year survival were 92 +/- 3% and 97 +/- 3% and cerebral infarctions after discharge were 2 and 0 in TAR and HAR, respectively. Appropriate selections of aortic reconstruction procedures and brain protection methods lead to good operative results in aortic arch repairs.

EBAG9, an estrogen-responsive gene located at 8q23 was identified in an effort to clone CpG-binding sites. Its product was later found to be identical to RCAS1, a cancer cell-surface antigen implicated in immune escape. We determined the sequence of the complete cDNA and the genomic structure for EBAG9. EBAG9 gene copy number in 21% (27 of 129) primary breast cancers we examined; EBAG9 mRNA was consistently expressed in cancer cell lines. Detailed physical mapping of the 8q arm, including polymorphic markers for EBAG9 and the CMYC loci, revealed allelic gain of either EBAG9, CMYC, or both, in 45% (58 of 129) of the breast cancers we examined. The EBAG9 gene was increased exclusively in 16 of the 27 tumors showing gain at that locus; the other 11 showed gain of a larger chromosomal region containing both EBAG9 and CMYC. Analysis of subsequent series of 144 primary breast cancers for allelic gain at EBAG9 and CMYC locus showed a similar degree of gain at EBAG9, CMYC, or both. When a total of 273 breast cancers from two series were combined and analyzed for clinicopathological correlation, almost all of the tumors with EBAG9 increased but not those with CMYC. Twenty-eight of 29 were T1/T2 stage carcinomas (5 cm in diameter), whereas one third (21 of 61) of the tumors in which CMYC was increased but EBAG9 was not, were advanced T3-stage tumors (P = 0.0012). These data suggest that EBAG9 and CMYC gene are independent targets of gain and that overrepresentation of EBAG9 may play a specific role in early stages of breast carcinogenesis.

Antegrade Selective Cerebral Perfusion (SCP) has proved to be a safe and reliable method of brain protection during operations of aortic arch aneurysms. Arch vessel cannulation is a crucial step in the institution of SCP that determines its success to a significant extent. A simple and safe cannulation technique along with a newly developed flexible perfusion cannula is described.

The determination of purse-string suture line is one of the most important point in endoventricular circular patch plasty (Dor operation) for postinfarction left ventricular aneurysm (LVAN), especially for ischemic cardiomyopathy (ICM). We suggest following three points to decide appropriate suture line. First, the purse-string suture on the basal side should be placed on the 1-2 cm level under diagonal branch. Secondly, lateral wall should not be over excluded to maintain left ventricular function. And the third, akinetic or dyskinetic lesion of apex and septal wall should be excluded as much as possible. Nine cases of five LVAN and four ICM were underwent Dor operation in our institute from Dec. 1999 to Jan. 2000. All patients were weaned from cardiopulmonary bypass easily except one patient, who was operated under IABP support, because of his preoperative severe heart failure. All patients recovered well without any serious complications and postoperative left ventricular graphies were satisfactory. Left ventricular ejection fraction and stroke volume index were increased from 34 +/- 17 to 55 +/- 16% and from 38 +/- 7 to 47 +/- 6 ml/m2, end-diastric and systric volume index decreased from 141 +/- 37 to 88 +/- 19 ml/m2 and from 96 +/- 41 to 41 +/- 23 ml/m2 respectively. The Dor procedure adopted our idea led to satisfactory result in hemodynamic and also in morphologic study.

A 63-year-old man was admitted to our institution with a hard tumor on the left side of the neck. He was diagnosed as having advanced esophageal cancer (Stage IV) with a massive supraclavicular lymph node metastasis, and the lesion was thought to be unresectable. He was treated with chemotherapy (CDDP-VDS-5-FU) and radiation therapy, and all the tumors completely disappeared on endoscopic and CT examination. A stricture with scarring was detected in the esophagus at 6 months after treatment. No neoplastic tissue was detected in the lesion, and his dysphagia was relieved by dilation of the stricture. Recurrence on the left side of the neck was detected by CT at 2.5 years after chemoradiation therapy. However, the tumor has not grown over the 2-year interval since then, so it seems to be dormant. He has now survived with a good QOL for 5 years since the first hospital admission. We conclude that advanced esophageal cancer can be treated with chemoradiation therapy if the patient is in sufficiently good overall condition.

CTLA4Ig, a soluble recombinant fusion protein that contains the extracellular domain of the CTLA4 and Fc portion of IgG1, strongly adheres to the B7 molecule to block CD28-mediated costimulatory signals and inhibits in vitro and in vivo immune responses. In vivo gene transfer using adenovirus vector achieves a high transfection rate into organ cells that usually contain adenoviral receptors. In this study, we investigated expression levels of the transfected gene and the survival times of the allografts in cardiac recipients systemically administered adenoviral vectors containing CTLA4Ig.Hearts from DA rats (RT-1a) were transplanted into a cervical location in LEW recipients (RT1(1)). The adenoviral vectors containing CTLA4Ig was injected via a recipient vein immediately after grafting.The serum level of CTLA4Ig reached to maximum at 51-93 microg/ml 3 to 7 days after gene-transfection and declined after 14 days, although detectable levels were observed up to 49 days. The median survival time of the allografts in the gene-transfected group were significantly prolonged (27 days) in compared to the control group (6 days). In addition, down-regulation of IL-2 and IFN-gamma mRNAs and persistence of IL-4 and IL-10 transcripts were observed in the graft infiltrating cells.The adenovirous-mediated CTLA4Ig gene transfer into a recipient liver by systemic administration resulted in remarkable prolongation of cardiac allograft survival. Its action mechanisms may be mediated by inhibition of CD28-associated signal transduction, reduction of Th1-type cytokine production, and continuous expression of Th2-type cytokines in the activating lymphocytes.

We report a rare case of a 50-year-old woman with intermittent gastrointestinal (GI) bleeding and diagnosed as having primary aortoenteric fistula (PAEF) with inflammatory abdominal aortic aneurysm (IAAA). She was transferred to our institution with suspected PAEF as assessed by duodenoscopy and CT scan. As the patient was in shock due to massive GI-bleeding two days after admission, we performed an emergency laparotomy. The fistula was closed and the aneurysm replaced by a Woven Dacron Graft with an inter-positioning omental flap. A high index of suspicion is the most important diagnostic aid to prevent overlooking this often fatal disease.

In a series of one hundred and one cases of surgical treatment for acute aortic dissection between January 1986 and September 1997, we evaluated 29 cases presenting with organ ischemia. These consisted of 23 cases of acute type A dissection (type A) and 6 cases of type B dissection (type B). Organ ischemia was diagnosed by (1) aortography, (2) a retrospective review of the history and (3) physical examination or laboratory data. The 23 surgical cases of acute type A dissection consisted of, coronary ischemia 8 cases, cerebral and spinal cord ischemia 9 cases, intestinal ischemia 3 cases, lower extremities ischemia 10 cases, and plural organs ischemia 8 cases. In the 6 cases of acute type B, we noted 4 intestinal ischemias and 2 lower extremities ischemias. The operative mortality rates when subdivided according to ischemic organ were: coronary ischemia 50%, cerebral and spinal cord ischemia 11%, intestinal ischemia type A 33%, type B 50%, and lower extremities ischemia type A 33%, type B 0%. The operative mortality rates, especially for patients presenting with acute myocardial infarction or intestinal ischemia, were relatively high. In cases of acute aortic dissection when organ ischemia occurred, we believed that it was necessary to perform early thoracic aortic repair and reconstruction of the ischemic organ.

Between 1983 and 1997, we operated upon 91 patients with type A acute aortic dissection. The dissection was localized in 22 patients and extensive in 69 patients. All patients underwent graft replacement and 61 (67%) patients underwent simultaneous replacement of ascending aorta and total aortic arch. The hospital mortality rate were 9% for the localized dissection and 21% for the extensive dissection. The actuarial survival rates in patients with localized dissection at 5 and at 10 years was 91% and 76%, whereas those in patients with extensive dissection at 5 and at 10 years was 68% and 62%. The freedom from dissection related death or reoperation in operative survivors with localized dissection at 5 and at 10 years was 100% and 83%, whereas those in patients with extensive dissection at 5 and at 10 years was 78% and 56%. The simultaneous replacement of ascending aorta and total aortic arch in patients with extensive dissection was effective to obliteration of the distal false channel, although this extended procedure has to be carefully adopted in high risk patients with associated complications such as acute dissection organ ischemia.

Laparoscopic inguinal hernia repair (LH) requires similar scar size to traditional open repair. To perform LH with minimal access, finer instruments were used. A 5-mm laparoscope was inserted from the umbilicus, and surgical instruments were inserted through 5- and 3-mm trocars to perform LH by the transabdominal preperitoneal approach. Polyester mesh was placed over the hernia orifice and the peritoneum was closed with 3-0 silk sutures. Sixteen patients underwent smaller access LH and 24 had standard LH. Although smaller access LH took longer (105.7 versus 83.9 min), significantly fewer patients required analgesia after smaller access LH than after standard LH (12.5 versus 70.8%), and the postoperative hospital stay was shorter (4.6 versus 5.6 days). In addition, a better cosmetic outcome was obtained with smaller access LH. In conclusion, access was minimized by using fine-caliber instruments and polyester mesh, making LH less invasive and improving the cosmetic outcome.

The patient of 21-year-old female, who had undergone VSD closures at the age 5 and had been pointed out to have aortic valve stenosis at that time, was admitted to our hospital with complaints of palpitation and easy fatigability. Pressure gradient of 140 mmHg between left ventricle and ascending aorta, and poststenotic dilatation of max 55 mm in diameter from ascending aorta to hemi aortic arch was recognized by cardiac catheterization and aortogram. For fear of aortic dissection in late phase caused by dilatation of ascending aorta left over, graft replacement from ascending aorta to hemi aortic arch was carried out simultaneously adding to aortic valve replacement (AVR). We are of the opinion that not only AVR but also simultaneous graft replacement should be performed actively on the case with dilatation of ascending aorta of over 55 mm in diameter in order to prevent aortic dissection.

We report a successful case of total aortic arch replacement using selective cerebral perfusion for ruptured pseudoaneurysm into the left lung after graft replacement of the descending thoracic aorta. A 74-year-old female who had graft replacement of the descending thoracic aorta for ruptured acute type B dissecting aneurysm into the left pleural cavity was admitted with a complaint of severe hemoptysis. Preoperative enhanced computed tomography revealed a large pseudoaneurysm of the aortic arch and massive hematoma around it. She was diagnosed as having a ruptured pseudoaneurysm into the left lung. A graft replacement of the total aortic arch with the aid of selective cerebral perfusion was performed. At the time of operation, a pseudoaneurysm which was from an intimal defect in the aortic wall 2 cm proximal to the suture line was found. It was suspected that the cause of the pseudoaneurysm was due to clamp injury during the initial operation. Postoperatively, she had no cerebral complications, and digital subtraction angiography showed excellent reconstruction of the aortic arch. One month after the operation, she had recovered sufficiently to be discharged from our hospital.

A 74-year-old male was admitted to our hospital because of left pneumothorax with persistent air leakage. He had undergone negative pressure drainage, chemical pleurodesis and transbronchial embolization in another hospital. Chest X-ray and CT scan showed collapse of the left lung and a defect of the pleura in the left lung S9. Patch closure was performed for the round pleurobronchial fistula (35 x 35 mm in size) using polyglycol acid felt and fibrin glue. But as severe air leakage was observed again about 24 hours after surgery, omentopexy was performed. The postoperative course was uneventful, and he was discharged 17 days after the second surgery.

Patient was a 70-year-old female diagnosed as Behçet's disease 1973. She underwent descending thoracic aortic aneurysm operation 1980. She had graft replacement for a residual thoracoabdominal aortic aneurysm on April 28, 1994. She didn't accept steroid therapy although she had a slight inflammatory reaction on admission. The graft replacement of thoracoabdominal aortic aneurysm was done with an aid of Carmeda closed chest support system bypass and segmental aortic cross clamping. Reattachment of the intercostal and lumbar arteries to the graft was used with button technique or interposition technique. Visceral branches including celiac axis, superior mesenteric and right renal arteries were reconstructed to an opening made in the graft with button technique and reattachment of left renal artery was used with graft interposition during selective perfusion of visceral arteries. She started steroid therapy with 5 mg of predonine to prevent inflammatory reaction postoperatively. The thoracoabdominal aortic aneurysm accompanied with Behçet's disease was relatively rare and this is a long survival case.

From January 1986 to September 1995, total aortic arch replacement (TAR) for aortic dissection was performed using selective cerebral perfusion in 151 patients. In 18 patients, the surgical procedures of extended aortic arch replacement (EAR) involving the proximal descending aorta through a median sternotomy were applied. To evaluate the outcome of EAR, the early and late results were compared with those of non-extended aortic arch replacements (NAR) through a median sternotomy (n = 66). The early mortality rates for EAR and NAR were 5.6% and 16.7%, respectively (NS); the lower rate for EAR may be due to the fact that EAR were performed more recently than NAR. The differences between EAR and NAR with respect to the amount of blood transfused intraoperatively and the respiratory index at 12 hours after surgery were not statistically significant. In addition, the extracorporeal bypass time in EAR was no longer than that in NAR. Thus, as compared with the NAR procedure, the EAR procedure did not have a negative effect on early outcome. Regarding late results, the actuarial survival rates after EAR and NAR, respectively were 87% and 72% at 1 year, 87% and 69% at 3 years (NS). The early thrombo-occlusion rates of the remaining false lumens after TAR in broad aortic dissections were 56% after EAR and 33% after NAR (p = 0.21). These results suggest that EAR may be a more useful procedure in some patients requiring TAR.

A 52-year-old man with dissecting thoracoabdominal aortic aneurysm (impending rupture) involving the celiac, superior mesenteric and renal arteries underwent graft replacement of the thoracoabdominal aorta with reconstruction of all visceral branches and intercostal arteries (Th11,12) with the aid of femoro-femoral bypass. The bypass was performed using a heparin coated percutaneous cardiopulmonary support system with low doses of heparin, maintaining activated coagulation time at about 300 seconds. During the reconstruction of the major visceral branches, the branches were separately cannulated from inside the aorta, and perfused selectively via partial extracorporeal circulation. The intercostal arteries were reconstructed segmentally to minimize the duration of ischemia. During the repair of the intercostal arteries, Fogarty balloon catheters were inserted into the intercostal arteries to prevent back bleeding and ischemia. The patient had a satisfactory postoperative course.

Between January 1979 and May 1996, 23 Marfan patients underwent surgeries for type A aortic dissection; 8 patients with localized type dissection and 15 with extensive type. All of the 23 patients suffered from annuloaortic ectasia (AAE) which was treated by composite graft replacement, 10 of these patients had a concomitant replacement of the aortic arch. The operative mortality rate was 8.7%, and the causes were associated with the methods of coronary artery reattachment to the graft. Of the 15 patients with the extensive type dissection, there were 11 patients who had a non-thrombotic communicating false lumen in the untreated segments of the distal dissected aorta after the first operation and from this group there were seven patients who had anastomotic leakage around the distal suture line of the graft replacement that was demonstrated by aortography. Extensive graft replacement ranging from the entire thoracic aorta to the total aorta were performed in 10 (43.5%). Late deaths occurred in three patients (13.0%) and these causes were LOS and graft infection after the second operation and prosthetic valve endcarditis 6 months after the first operation. The present data indicate that Stanford type A aortic dissection with Marfan syndrome should be undertaken on the basis of a prior achievable plan to perform an entire aortic replacement. The dissection should also be performed using a procedure which doesn't leave distal anastomotic leakage.