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Objective: Traumatic duodenal obstructions are rare, and most are caused by compression from intramural or retroperitoneal macroscopic hematomas. This report describes a very rare type of delayed traumatic duodenal obstruction without macroscopic intramural or extraluminal hematoma caused by traumatic fibrosis due to seromuscular and intramural injury and microscopic hemorrhage. Case presentation: A 31-year-old man was transferred to our center due to polytrauma with nausea and vomiting on day 53 after an accident. Gastrointestinal fiberscopy (GIF) on day 57 revealed an active stage small duodenal ulcer with patency of the pyloric ring. Although the patient underwent subdural drainage, the nausea and vomiting continued. A repeat GIF on day 91 revealed a duodenal ulcer with severe pyloric stenosis. GIF after nasogastric drainage on day 102 identified a severe pinhole stenosis. We performed surgery on day 106 and observed a constricted duodenal bulb due to a tumorous scar. We resected the stenotic section of the duodenal bulb including the pyloric ring. Conclusion: The histopathologic examination revealed constriction and fibrosis. Surgical options should be considered for patients with delayed duodenal obstruction without macroscopic hematoma around the duodenum after several months of hospitalization.

Intracystic papillary neoplasm (ICPN) is a preinvasive neoplasm of the gallbladder. Preoperative discrimination between ICPN and gallbladder cancer (GC) is difficult. The standard surgical strategy for ICPN has not yet been established. Herein, we report a case of ICPN with an associated invasive adenocarcinoma. A gallbladder tumor was detected by abdominal ultrasonography in an asymptomatic 69-year-old man, and he was referred to our hospital. Although computed tomography (CT), endoscopic ultrasonography, and magnetic resonance imaging findings in the present case were similar to those for GC, positron emission tomography-CT revealed that fluorodeoxyglucose (FDG) did not accumulate within the tumor. These imaging features suggested that patient was suspected to have GC with serosal invasion, and he underwent extended cholecystectomy and D2 lymph node dissection. He did not develop any postoperative complications, and he was discharged on postoperative day 7. There was no evidence of recurrence for 20 months after surgery. Histopathologic examination confirmed ICPN with an associated invasive adenocarcinoma. Because a previous study reported that almost half of ICPNs more than 1.0 cm in size often developed invasive cancer as our case, ICPNs more than 1.0 cm should be suspected of developing invasive carcinoma regardless of positive or negative accumulation of FDG.

Our unique rapid response system (RRS) includes a systematically organized structure by rapid response teams (RRT) and a nonorganized, nonsystematic structure for gathering hospital staffs in the scene. We examined the records of 54 patients described in this RRS. Our RRS is as follows; a medical/non-medical hospital staff who finds a victim, asks other staffs to activate the RRS by using inhospital whole paging system; predefined staffs bring predefined equipments; a standard educational course and e-learning system and a simple recording form. The mean interval between the event and the arrival of staff at the scene was 1.81 minutes. Hospital death rate per total discharged patients tended to decrease after RRS. Our unique RRS work well. The death rate among discharged patients decreased after this system was implemented.

Background: The aim of this study is to clarify the circumstances including the locations where critical events resulting in out-of-hospital cardiopulmonary arrest (OHCPA) occur. Materials and Methods: Subjects of this population-based observational case series study were the clinical records of patients with nontraumatic and nonneck-hanging OHCPA. Results: Of all 1546 cases, 10.3% occurred in a public place (shop, restaurant, workplace, stations, public house, sports venue, and bus), 8.3% on the street, 73.4% in a private location (victim's home, the homes of the victims' relatives or friends or cheap bedrooms, where poor homeless people live), and 4.1% in residential institutions. In OHCPA occurring in private locations, the frequency of asystole was higher and the outcome was poorer than in other locations. A total of 181 OHCPA cases (11.7%) took place in the lavatory and 166 (10.7%) in the bathroom; of these, only 7 (3.9% of OHCPA in the lavatory) and none in the bath room achieved good outcomes. The frequencies of shockable initial rhythm occurring in the lavatory and in bath room were 3.7% and 1.1% (lower than in other locations, P = 0.011 and 0.002), and cardiac etiology in OHCPA occurring in these locations were 46.7% and 78.4% (the latter higher than in other locations, P Conclusions: An unignorable population suffered from OHCPA in private locations, particularly in the lavatory and bathroom; their initial rhythm was usually asystole and their outcomes were poor, despite the high frequency of cardiac etiology in the bathroom. We should try to treat OHCPA victims and to prevent occurrence of OHCPA in these risky spaces by considering their specific conditions.

Background: Blood transfusion therapy (BTT), which represents transplantation of living cells, poses several risks. Although BTT is necessary for trauma victims with hemorrhagic shock, it may be futile for patients with blunt traumatic cardiopulmonary arrest (BT-CPA). Materials and Methods: We retrospectively examined the medical records of consecutive patients with T-CPA. The study period was divided into two periods: The first from 1995-1998, when we used packed red cells (PRC) regardless of the return of spontaneous circulation (ROSC), and the second from 1999-2004, when we did not use PRC before ROSC. The rates of ROSC, admission to the ICU, and survival-to-discharge were compared between these two periods. Results: We studied the records of 464 patients with BT-CPA (175 in the first period and 289 in the second period). Although the rates of ROSC and admission to the ICU were statistically higher in the first period, there was no statistical difference in the rate of survival-to-discharge between these two periods. In the first period, the rate of ROSC was statistically higher in the non-BTT group than the BTT group. However, for cases in which ROSC was performed and was successful, there were no statistical differences in the rate of admission and survival-to-discharge between the first and second group, and between the BTT and non-BTT group. Conclusion: Our retrospective consecutive study shows the possibility that BTT before ROSC for BT-CPA and a treatment strategy that includes this treatment improves the success rate of ROSC, but not the survival rate. BTT is thought to be futile as a treatment for BT-CPA before ROSC.

Hepcidin, a key regulator of iron homeostasis, is also a marker of acute inflammation. In the present study we investigated the changes in the serum hepcidin level and correlations between hepcidin and other markers of acute inflammation during the perioperative period in patients after abdominal surgery. Serum hepcidin, hemoglobin (Hb), hematocrit (Ht), white blood cell (WBC) count, frequency of neutrophils, and C-reactive protein (CRP) were measured preoperatively (Pre), and on postoperative days (POD) 1, 3, 7, and 14. In patients undergoing gastrectomy, the median levels of hepcidin preoperatively and on POD 1, 3, 7, and 14 were 6.5, 53.1, 31.7, 15.6, and 4.0 ng/dl, respectively (p

Background: Insufficient knowledge of the risks and complications of cardiopulmonary resuscitation (CPR) may be an obstructive factor for CPR, however, particularly for patients who are not clearly suffering out of hospital cardiopulmonary arrest (OH-CPA). The object of this study was to clarify the potential complication, the safety of bystander CPR in such cases. Materials and Methods: This study was a population-based observational case series. To be enrolled, patients had to have undergone CPR with chest compressions performed by lay persons, had to be confirmed not to have suffered OHCPA. Complications of bystander CPR were identified from the patients’ medical records and included rib fracture, lung injury, abdominal organ injury, and chest and/or abdominal pain requiring analgesics. In our emergency department, one doctor gathered information while others performed X-ray and blood examinations, electrocardiograms, and chest and abdominal ultrasonography. Results: A total of 26 cases were the subjects. The mean duration of bystander CPR was 6.5 minutes (ranging from 1 to 26). Nine patients died of a causative pathological condition and pneumonia, and the remaining 17 survived to discharge. Three patients suffered from complications (tracheal bleeding, minor gastric mucosal laceration, and chest pain), all of which were minimal and easily treated. No case required special examination or treatment for the complication itself. Conclusion: The risk and frequency of complications due to bystander CPR is thought to be very low. It is reasonable to perform immediate CPR for unconscious victims with inadequate respiration, and to help bystanders perform CPR using the T-CPR system.

ガラス片誤飲による咽頭喉頭頸部食道全層性損傷に対し，損傷部単純閉鎖，経頸部血管鞘的上縦隔ドレナージと傍正中アプローチによる気管切開により，頸部手術創と気管切開創との相互汚染を回避しえた症例を経験した．47歳，男性．統合失調症で入院中，ガラスビンの破片を誤飲し，呼吸循環動態は安定していたが，頸胸部CTで頸部食道にガラス片とこれから連続する深頸部気腫を認めた．手術時，ガラス片は胃内に落下しており，開腹下胃切開異物摘出，胃瘻造設，頸部食道損傷部縫合閉鎖，深頸部縦隔ドレナージ，傍正中気管切開を行った．胸鎖乳突筋前縁の斜切開から頸部食道に至りこれを反転し背側の損傷部を縫合閉鎖し，経頸部血管鞘的に持続吸引バッグ付きドレーンを留置した．気管切開の創は頸部手術創と反対側の傍正中とした．術後気管支鏡検査，CTでは，気管切開チューブは斜め方向から挿入されているのが観察されたが，気管切開チューブ交換は容易であった．

The duodenum is a central organ for iron absorption. This study was performed to evaluate changes in body iron concentration and other iron-related molecules sequentially, in patients undergoing pancreatoduodenectomy (PD). Twenty-one patients who had undergone PD at our department were enrolled in the study. Measurements of serum iron (sFe), total iron-binding capacity (TIBC), serum ferritin (sFer), C-reactive protein (CRP), interleukin-6 (IL-6), hemoglobin (Hb), hematocrit (Ht), and serum hepcidin (sHep) were performed before surgery (Pre), and on postoperative days 3 (D3), 7 (D7), and 14 (D14). The median values of sFe on Pre, D3, D7, and D14 were 73.0, 30.0, 33.0, and 41.0 μg/ dL, respectively (P

背景:致死的急速大量出血への未交差赤血球製剤（UCM-RCC）緊急輸血では不適合輸血が起きやすい．対象と方法:15例の消化管出血にUCM-RCC輸血（17回，80単位）を経験したので経過を検討した．UCM-RCC輸血の適応は，2,000mlの急速輸液でも循環不安定で交差適合試験（CMT）が待てない出血性ショック．結果:UCM-RCC輸血は1例に2～10単位，平均5.3単位実施，93％で6単位以下．血液型判定（BTT）未判定例へのO型UCM-RCC輸血は7例，1回のBTT後例へのO型UCM-RCC輸血は4例，1回のBTT後非O型症例への未確認同型UCM-RCC輸血は4例．輸血前の収縮期血圧，脈拍数，ショック指数（脈拍数/収縮期血圧），base excessの最低値は平均各，76.9mmHg，117.5回/分，1.69，-9.61mEq/l．意識障害は8例に認められた．死亡は2例（13％），ABO型不適合輸血，輸血関連急性期合併症はなかった．結論:消化管出血へのUCM-RCC輸血ではO型UCM-RCC輸血の迅速な決断が重要だが，初回請求量は6単位が妥当と思われた．

心肺停止蘇生後に姑息的胃切除を行い神経学的異常を残さず救命しえた胃癌穿孔を経験した．81歳の男性で，食欲低下と体重減少，右側腹部痛，嘔気から経口摂取不能，意識障害となり緊急搬送された．病院到着12分後に心肺停止となり6分後に蘇生した．造影CTなどで腹腔内遊離ガス，胃幽門付近の壁不整像を認め消化管穿孔，腹膜炎，腹部コンパートメント症候群によるショックと判断した．初期輸液などの敗血症性ショックに対する治療と平行して，開腹減圧と感染源制御を目的に緊急手術とした．胃体下部前壁に胃癌漿膜浸潤と穿孔，腹膜全域に播種性小病変を認め，姑息的に幽門側胃切除，Roux-en-Y吻合を行った．腫瘍は，LCirc，type 3，pT3（SE），sN3，sH0，sP1，fStage IV，ly3，v2，INFβ，tub2＞por2であった．術後は比較的容易に敗血症性ショックから離脱でき，神経学的異常の遺残はなかった．術後8か月の造影CTで腹腔内リンパ節，肝臓，肺転移を認め，術後14か月（第407病日）で死亡した．

症例は79歳，女性．右下腹部から鼠径部の発赤，浮腫で近医に入院し，右下腹部ガス壊疽の疑いで当センターへ転院となった．意識清明，血圧100/60mmHg，心拍数75/分，末梢冷感なし．腹部に圧痛，筋性防御はなかったが，右腋窩から右鼠径にかけての気腫と右鼠径部発赤，腫脹，熱感，圧痛を認めた．肛門周囲に異常はなく，血液検査では炎症所見，血小板数軽度低下，凝固異常を認めた．壊死性筋膜炎のドレナージを目的に病変部を局所切開したところ便汁が排出し腸管の大腿ヘルニア嵌頓絞扼壊死穿孔と診断した．開腹すると回腸がヘルニア門に癒着しRichter型嵌頓ヘルニアを形成し，ヘルニア内容と腹腔内とは隔離されていた．回腸部分切除と右下腹部皮膚切開，部分的デブリドマンを行った．術後は陰圧持続洗浄吸引ドレッシングとし，間歇的洗浄，デブリドマンを繰り返し，創面が肉芽で覆われるのを待って第19，33病日に植皮術を施行し第41病日に転院としえた．

症例は56歳, 男性. 前医の単純X線とCT検査で腹腔内遊離ガス像を認め, 発症後2日経過した消化管穿孔腹膜炎の診断で転送されてきた. BUN, クレアチニンの上昇があったが腎機能障害の合併と考えていた. 手術時に腹腔内膀胱遊離破裂と判明した. 術後情報を再確認し, 前医で単純X線撮影前に膀胱留置カテーテルから空気を注入したこと, 患者は発症当日大量飲酒後に下腹部を打撲していたことが判明し, 膀胱充満状態での下腹部強打による膀胱腹腔内遊離破裂, 偽腎不全, 医原性腹腔内遊離ガスという典型的病態であったことが判明した. 適切な手術の準備などのためにも, 病院間高次転送時には, 正確な情報伝達と情報確認に努め, 情報に対する先入観や思いこみを排除し, 前医からの情報のみに基づく緊急手術の適応だけの判断で手術を行うのではなく, 症例の緊急性に応じて自施設でも責任を持って術前診断を確実に行うことが重要と思われた.

54歳,男性の胸腹移行部刺創による腹腔内多臓器損傷(右横隔膜,小腸,肝,胆嚢,右腎)症例で,術中に腎周囲・後腹膜血腫の急速な増大を認め, lethal triadに向かいつつある状態と判断し, damage control (DC)に治療戦略を修正し,肝・胆嚢縫合止血,肝・腎周囲ガーゼ圧迫留置,引き続き腎動脈の経カテーテル的動脈塞栓術(TAE)を行い,一時止血に成功し,第2病日に予定再手術でガーゼ除去,胆嚢摘出術を施行し救命しえた症例を経験した. DCは通常の治療戦略とは概念を異にする一時回避的戦略であるが,大量出血やseptic shockで致命的代謝失調状態にある症例に対しては,救命のための有用な手段である.重症緊急症例では治療戦略に関して事前検討もできず,その場に居合わせた者だけでの即座の判断が要求されるが,本法の適応判断や実践は,緊急事態への対応能力の一つとして重要と思われた.

Background Although nifekalant is a class III antiarrhythmic agent without negative inotropic activity, its effect in patients with shock-refractory ventricular fibrillation remains unclear. Methods and Results Patients who had an out-of-hospital cardiac arrest with ventricular fibrillation that persisted after 3 shocks from an external defibrillator, intravenous epinephrine, and another shock were retrospectively studied. The patients received lidocaine from January 1997 through June 2001 and nifekalant from July 2001 through December 2004. Short-term survival rates (survival to hospital admission and 24-h survival) were compared between the groups. The study group comprised 120 patients (mean age: 62±16 years): 55 received nifekalant and 65 received lidocaine. Age, sex, history of ischemic heart disease, whether arrest was witnessed or not and time to arrival at the hospital did not differ significantly between the groups. As compared with lidocaine, nifekalant was associated with significantly higher rates of survival to hospital admission (67% vs 37%, p

大量の肝内門脈ガス像を呈した広範小腸壊死1例を報告する.82歳,女性.既往歴は,高血圧,胆石,逆流性食道炎と20年前に帝王切開。平成15年12月5:30,全身倦怠感,水様性下痢,嘔吐を主訴に他院受診.腹部造影CTで肝左葉の門脈内に樹枝状に広がる空気像,腹部大動脈周囲後腹膜に空気像を認め,当院へ転送された.意識レベルはJCS-1,収縮期血圧42mmHg,脈拍数146,呼吸数32,直腸温36.9℃,腹部は板状硬で圧痛を認めた.白血球数は9,270/mm^3,CRPは16.4mg/dlと上昇しており,血小板は4.1万/mm^3,PTは45%などDIC状態だった.アルブミン1.5g/dlと低栄養,BE-10.8mEq/lとアシドーシスを認めた.造影CTで上腸間膜動脈内の血栓は明らかではなかった.開腹すると,腐敗臭を伴う腹水を認め,E.coliが同定された.小腸は,Treitz靱帯より約1mから境界明瞭に壊死状態,肛門側は横行結腸中央部付近まで全層性壊死,下行結腸とS状結腸は虚血状態であった.穿孔は認められなかった.全身状態が劣悪であったため,小腸広範囲切除,結腸亜全摘,上位空腸痩造設,S状結腸断端の腹壁開腹創への固定しか施行しなかった.切除標本の病理では腸管の末梢動脈攣縮像が認められた.術後,サイトカイン吸着術,大量輸血,CHDFを含む集中治療を行ったが翌日多臓器不全で死亡した., This is a case report of grossly necrotic bowel with hepatic-portal venous gas. An 82-year-old woman with a history of hypertension, gallstone, reflux esophagitis and caesarian section, was brought to a hospital because of general fatigue, watery diarrhea, and vomiting. She was transferred to our center because abdominal contrast enhanced computed tomography (CE-CT) scan showed arborescent dialation of the hepatic-portal venous gas and air around the abdominal aorta. Her conscious level was JCS-1, systolic blood pressure 42mmHg, pulse rate 146, respiration rate 32, and her body temperature 39.6℃. She had abdominal tenderness and muscle guarding. CE-CT did not reveal any thrombus in the superior mesenteric artery. An emergency operation was performed and we found transmural bowel necrosis from 1 m distal to the Treitz ligament to the middle transverse colon and ischemic and cyanotic change of the descending and sigmoid colon. There was no perforation. We resected the necrotic bowel. Pathological examination showed small arterial spasms in the involved bowels. Although intensive care, including cytokine absorption therapy, blood transfusion, and continuous hemofiltration dialysis (CHDF) was given, she died the following day of multiple organ dysfunction syndrome (MODS).

鈍的気管損傷の診断において,CT上での気管損傷を示唆する所見を明らかにするため,過去の気管損傷症例のCT所見を検討した。過去4年間の頸胸部鈍的外傷症例で,1)頸部皮下気腫,2)胸部単純X線で縦隔気腫か深頸部気腫,3)頸部側面単純X線で深頸部(咽頭後)気腫のいずれかが認められ,4)頸胸部造影CTを施行し,かつ気管損傷診断法のgold standardとされている気管支鏡か解剖で気管損傷の有無を確定した症例を対象とした。気管支鏡か解剖で気管損傷を確認した症例群と,気管損傷を認めなかった症例群とでCT画像所見(気管に接した気腫像,気管輪郭の不整像と不連続像,気管周囲の異常低吸収域像の有無とこれらの所見の位置関係)を比較検討した。対象症例16例中5例が気管損傷と判定された。気管損傷例全例に気管輪郭の不整像か不連続像,同部に一致した気管周囲の異常低吸収域像とこれらの像から連続する顕著な気腫像のすべてを認めた。気管損傷なしと診断した11例では,気管に接した気腫像が8例(73%),気管輪郭の不整像と不連続像が5例(45%),気管周囲の異常低吸収域像が2例(18%)にみられたが,気管周囲の低吸収域像は,気管の不整像や不連続像と一致しなかった。気管損傷を示唆するCT所見のうち,気管輪郭の構造破綻を表す気管輪郭の不整像や不連続像(直接所見)は合成像も多く特異度に欠けた。損傷部周囲結合組織の挫滅とそこからの気漏を表す気管周囲の異常低吸収域とそこから連続する気腫像(間接所見)は,診断価値が高いと考えられた。

腹腔内遊離ガスと紛らわしい像を認めた多発外傷気胸症例を経験した.交通外傷で救急搬送,初療時気胸や気腹は認めなかった.急性硬膜下血腫,脳挫傷,外傷性くも膜下出血による意識障害を認め,緊急開頭血腫除去術を施行.術後の胸部単純X線検査で右横隔膜下に腹腔内遊離ガス像が疑われ,腹部CTでも腹腔内遊離ガスと判断され緊急開腹術を施行したが,気腹も消化管穿孔も認められなかった.ショック状態の外傷症例など緊急時のCTでは,読影時間が制限され複数人数での検討もできないため, CT自体の虚像が確定診断へ導く危険にも注意すべきと思われた.気胸と腹腔内遊離ガス像との鑑別点としては,肝円索・肝鎌状靱帯が正常位置に確認できるかなどが重要と思われた.

Heparin-coated cardiopulmonary bypass circuits allow a reduction in the use of systemic heparin administered during cardiopulmonary bypass. This study was carried out to investigate safety during deep hypothermic circulatory arrest in this low-dose heparin group during thoracic aortic operation. Heparin-coated cardiopulmonary bypass circuits were used in 30 adult patients who underwent thoracic aortic operations that required deep hypothermic circulatory arrest. The patients were divided into two groups. Six patients received 300 IU/kg of heparin, and the remaining 24 patients received 100 IU/kg. Clinical outcomes (mortality, incidence of stroke, and transfusion volumes during operation) were examined. All devices remained functional throughout the procedures, and no systemic emboli were detected. Two deaths occurred in the high-dose heparin group, but no deaths occurred in the low-dose heparin group (P = 0.03). The percentage of patients requiring transfusion was similar in the two groups (66.7% vs. 70.8%), but the median exposure to allogenic blood products was greater in the high-dose heparin group than in the low-dose heparin group (9.8 ± 9.5 units vs. 5.5 ± 5.2 units; P = 0.09). Reduced systemic heparinization, combined with hepar-in-coated cardiopulmonary bypass circuits during deep hypothermic circulatory arrest, can be performed with acceptably low early mortality in thoracic aortic operations. Patients are not at increased risk for stroke.

Flow dynamics in internal thoracic artery grafts 10 years after surgery are not known.Doppler examination was performed in native internal thoracic arteries as a control (n = 8) and in internal thoracic artery grafts to the left anterior descending coronary artery 6 months postoperatively (group A, n = 25), at 5 years (group B, n = 14), and at 10 years (group C, n = 11).Each graft group showed a diastolic to systolic peak velocity ratio of less than 1.0 at the proximal end, and more than 1.0 at the distal end, but the control group showed a ratio of less than 1.0 throughout the length of the artery. The diastolic peak velocity of the graft groups was significantly faster than that of the control group at the distal end (versus group A, p0.01; versus group B, p0.005; and versus group C, p0.05). The systolic peak velocity of the graft groups was significantly lower than that of the control at the proximal end (versus group A, p0.0001; versus group B, p0.005; and versus group C, p0.0005). There were no significant differences of flow velocities among the graft groups and graft diameter among the four groups.Although the internal thoracic artery is systolic predominant, when native artery is used as graft, it changes its hemodynamics to diastolic predominance, especially at the distal end. Even after 10 years, graft flow dynamics are unchanged. This hemodynamic character may be one of the factors related to the superior long-term patency.

Percutaneous endoscopic gastrostomy (PEG) is a common and safe procedure for enteral nutrition. There are few reports concerning its complications. We managed a 31-y-old bedridden case with punched out duodenal perforation without inflammation, from which the tip of the PEG tube protruded. Simple x-ray and computed tomography showed incarceration of the balloon in the duodenal bulb and extravasation of the tip of the tube. We performed simple closure with omental patching for duodenal perforation. Postoperative gastrointestinal fiberscopy on the 11th day revealed scar phase. Some PEG tubes have a balloon, which can prevent the removal of the tube, fix the position of the tube, and prevent the leakage of gastric contents from fistula. However, in our case, the inflated balloon was transferred into the duodenal bulb according to gastric strong peristalsis. This pathophysiologic mechanism is the same as ball bulb syndrome, which is known as gastroduodenal obstruction by incarceration of the gastric submucosal tumor. There is a risk of wedging of the inflated balloon of the PEG tube and perforation of the duodenum. We must not insert the tube too deeply, must not continue to inflate the balloon for a long time, and must check its position using a stethoscope, simple x-ray examination, or ultrasound.

To solve endoleakage problems of endovascular prostheses inserted in aortic aneurysms, a concept originating from tissue engineering was proposed. We proposed that in order to accelerate the thrombus inside the aneurysm, three major factors for successful tissue engineering, i.e., appropriate cells, extracellular matrices, and growth factors, should be introduced into a space between the endovascular grafts and the aneurysm. As a simulation model in animals, two kinds of fabric vascular prostheses were used. One was a small graft used as an endovascular graft and another was a large graft as an envelope for the small graft, used as the aneurysm wall. Adipose tissue fragments with fresh blood coagula were injected between the two grafts. The control was a preparation without tissue fragments. Two months and a half after surgery, the test group showed complete connective tissue formation in the space between the two grafts, but in the control, brownish thrombus remained. From this experiment, we speculated that tissue fragment transplantation will accelerate connective tissue formation of the thrombus, and this complete organization of the thrombus might reduce endoleakage.

Tissue engineering can improve the former limitations of artificial organs. This article reports the long-term clinical results of grafts constructed with fragmented autologous adipose tissue. We did a retrospective analysis of a series of 53 patients with lower leg ischemia that received 69 fragmented adipose tissue (FAT) grafts implantation at our institution. The mean follow-up period was 36.0 months. After 1, 2, 3, and 5 years, the primary potency rates were 85.3, 83.3, 73.8, and 67.7%, respectively. The lumen of occluded areas not only at anastomotic sites but also in areas far from the anastomotic sites was occupied by a thickened neointima, which had a great number of capillary blood vessels, elastic laminae, smooth muscle cells, fibroblasts, and collagen fibers. This type of intimal hyperplasia was a characteristic finding in the FAT grafts. From the results of this clinical trial, we conclude that the FAT grafts are acceptable as vascular prostheses for ischemic lower extremities. The intimal hyperplasia at sites far from the anastomotic lines suggested the possibility of neointima formation throughout the luminal surface of the grafts.

Neointima formed quickly on vascular prostheses implanted in young dogs but not in aged dogs. Previously, we found that impeding neointima formation on vascular prostheses occurred more frequently in aged animals. From these observations, we hypothesized that neointima formation was age-dependent in dogs. To test the hypothesis, 26 fabric Dacron vascular prostheses were analyzed. Half of them were retrieved from aged dogs (more than 13 years old) while the other half were from young ones (less than 1 year old). The grafts were harvested at 8 weeks and 3 months after implantation. The graft surfaces were photographed and analyzed by computer for the ratio of the areas with and without thrombus. Light and scanning electron microscopic observation revealed that most of the thrombus-free areas were lined with endothelial cells. Then the endothelialized areas were calculated. Using data obtained from macroscopic, light microscopic, and scanning electron microscopic observations, the arithmetic means were calculated as the degree of neointima formation. In young animals, the degrees at 8 weeks and at 3 months were 89.1 +/- 8.5% (mean +/- SD) and 95.7 +/- 3.3%, respectively. In old animals, they were 27.9 +/- 5.9% and 31.5 +/- 6. 8%, respectively. From these results, we concluded that neointima formation was age-dependent in dogs.

For successful in vivo tissue engineering, a growth factor release system will be useful. We adopted autologous bone marrow transplantation as an angiogenic growth factor release system. Bone marrow transplanted into a synthetic vascular prosthesis produced continuous synthesis of angiogenic growth factors, resulting in rapid neointima formation on the prosthesis after implantation. We expected a similar angiogenic phenomenon to occur if bone marrow was transplanted into ischemic myocardium. Bone marrow was transplanted into ischemic myocardium created in dogs. Marrow cells continued synthesis of angiogenic growth factors, which were effective in protecting the capillary network from ischemia, but not myocytes. Autologous bone marrow was injected intramuscularly into ischemic myocardium created in the left ventricular wall of dogs. Control operations were performed without bone marrow. On days 3 and 7, marrow cells survived, and their adjacent cells and the surrounding extracellular matrix were immunohistochemically bFGF reactive. At 3 weeks, no marrow cells were identified. Myocytes disappeared, but the capillary blood vessel networks remained. With some exceptions, these capillaries did not contain blood cell components. In the controls, scar tissue with a very small number of capillaries was formed. In conclusion, marrow cells survived for a short period of time after transplantation, and continued synthesis of angiogenic growth factors, which were effective in protecting endothelial cells from ischemia, but not myocytes. Therefore, the results also suggest that there are limitations in the treatment of ischemic myocardium using angiogenic growth factors alone.

体外循環におけるウリナスタチンの抗炎症性サイトカイン効果と臓器障害軽減効果を検討した. 冠状動脈バイパス術施行33例をウリナスタチン投与群 (UTI群, n=16) と非投与群 (Control 群, n=17) に分け比較した. 術中術後にインターロイキン6 (IL-6)・8(IL-8), 顆粒球エラスターゼ(PMNE) を測定した. また肝臓 (GOT, GPT, T-Bil), 腎臓 (BUN, Cr), 肺 (PaO2/FIO2) の術後機能障害を検討した. 大動脈遮断解除5分後IL-8 (25.5±12.8pg/dl vs. 47.8±38.9pg/dl), 経過中最高IL-8 (28.6±13.2pg/dl vs. 58.4±40.0pg/dl), 術後BUN, Crが Control 群に比べてUTI群で有意に低値を示した (p

Interleukin-6, interleukin-8, and polymorphonuclear leukocyte elastase levels in coronary sinus blood were measured and compared with those in arterial blood drawn from the radial artery before and immediately after cardiopulmonary bypass (CPB) during coronary artery bypass grafting in 20 patients. We introduced coronary sinus blood sampling as a useful method for evaluation of myocardial metabolism, myocardial protection, and reperfusion injury during CPB, especially by measurement of cytokines. Because interleukin-6, interleukin-8, and polymorphonuclear leukocyte elastase are inflammatory mediators, we speculated that they might show higher levels in coronary sinus blood than in systemic arterial blood. The results obtained from the 20 patients showed that levels of interleukin-6, interleukin-8, and polymorphonuclear leukocyte elastase increased immediately after CPB (p < .01), but there was no significant difference in these levels between coronary sinus and systemic arterial blood. We conclude that the myocardium is not a predominant source of their release during CPB. Our results also showed that the measurement of these cytokines in systemic arterial blood reflected their levels in the whole body, including the myocardium, even during cardiac operation with CPB.

Rapid endothelialization of the inner surface was reported in an autologous tissue-seeded vascular prosthesis. We applied a three-dimensional in vitro culture system to elucidate the precise mechanism of rapid endothelial coverage of a tissue-seeded vascular prosthesis. Human venous, omental, adipose and striated muscle tissue fragments were harvested from surgical specimens. They were embedded in collagen gel, and 2.0 times 105 bovine aortic endothelial cells (BAECs) were seeded on the gel. The number of BAECs was counted on Days 2 and 7. Growth rate of BAECs was facilitated on the collagen gel with omental and striated muscle tissue fragments (p < 0.05). Factor VIII-negative spindle cells migrated around tissue fragments, especially around the omental and striated muscle tissue fragments. Rapid endothelialization of a tissue-seeded vascular prosthesis may result from facilitation of EC proliferation by viable tissue fragments and migrated cells. These results confirm tissue fragments regulate EC growth, and are useful as bioengineering tools

A new method of sealing fabric vascular pros-theses with autologous adipose tissue was clinically applied as an alternative to preclotting with fresh blood. Thirty-six patients with peripheral arterial occlusive disease were implanted with highly porous fabric prostheses. The prostheses were prepared by sealing the fabric pores with autologous adipose tissue that had been chopped up into small pieces and enmeshed in the fabric by forceful injection of the tissue suspension through a syringe. There was no complication related to the sealed graft such as graft bleeding after implantation. In-hospital mortality occurred in 4 patients: 1 case each of pneumonia, pulmonary infarction, sepsis, and acute myocardial infarction. During the period of 274 ± 190 days, 3 pros-theses were found to be occluded. All the other grafts were patent. The overall patency rate was 91.4%. Postoperative angiography revealed neither intimai thickening at the anastomotic sites nor irregularity of the prosthetic surface. The method proved safe and useful for implantation of smaller caliber artificial grafts.

For resection of advanced hepatocellular carcinoma (HCC) in which tumor thrombus (TT) extends into inferior vena cava (IVC) or right atrium (RA) surgery is challenging and requires skillful techniques. Here, we report a case of recurrent HCC with TT extending to the RA, who underwent successful resection with tumor thrombectomy without concomitant cardiopulmonary bypass. A 71-year-old man, who had been followed- up for hepatitis C by a local hospital, was diagnosed as having HCC in segment 6 for which he had undergone segmentectomy of segment 6 in May 2009. During follow-up, he developed severe leg edema and ascites with investigations revealing recurrent HCC in segment 7 with TT extending to the right atrium via IVC. After transarterial embolization the patient underwent extended resection of the segment 7 with tumor thrombectomy of the IVC and the right atrium and partial resection of the IVC wall using total hepatic vascular exclusion, without concomitant cardiopulmonary bypass. Total ischemic time was 23 minutes, operation time was 6 hours and blood loss was 2,474mL. The postoperative course was uneventful. Histopathology was recurrent hepatocellular carcinoma with hepatic venous invasion. We report the case of resected recurrent HCC with TT extending to right atrium without concomitant cardiopulmonary bypass.

We experienced the first death case of the serotonin syndrome in Japan caused by fluvoxamine and tandospirone. A 15-year-old man was transported to our hospital for shock, muscle hypertonia and hyperthermia after cardiopulmonary arrest. His serum concentrations of fluvoxamine and tandospirone were 3,554 ng/mL and 698 ng/mL respectively after 24 hours from oral intake. He was dead in spite of intensive treatments. The progress of the serotonin syndrome is usually rapid. So, it should be monitored appropriately a patient with serotonin syndrome. If he has hyperthermia, immediate paralysis should be induced. We should aware of the serotonin syndrome a case of overdose on a serotonergic agent.

Forty eight year-old woman with untreated liver cirrhosis was transferred to our critical care and emergency center because of airway crisis due to retropharyngo-esophageal hematoma after slight chest contusion. We performed emergency tracheal intubation beyond stenotic part of the trachea. The hematoma did not diminished in a few days. Although we considered tracheostomy, we hesitated to perform conventional median tracheostomy because of the risk of complication of infection of the hematoma which might require drainage or removal resulting in contamination between tracheostomy site and cervical wound. We performed paramedian tracheostomy by antero-lateral skin incision to avoid these risks. Fortunately, the patient did not require drainage of the retropharyngo-esophageal hematoma. Paramedian tracheostomy should be taken into account for patients with presumably contaminated cervical wound.