[The calcified ascending aorta--preoperative evaluation and intraoperative management].

Aortic calcification was evaluated preoperatively by computed tomography (CT) in 136 of 275 candidates for coronary artery bypass surgery (age range, 30-80) years (mean 60.2 years), including 110 men and 26 women), from April 1989 to March 1991. Calcification in the mid-ascending aortic wall was detected in 20 (14.7%) cases, calcification in all regions of the aorta was more common in patients older than 60 years (22.5%, n = 71), than younger (6.2%, n = 65) (p less than 0.01). Atherosclerosis of the ascending aorta was identified intraoperatively in 25 (18.3%) cases. Practically, the specificity of CT findings was excellent (98.3%), but the sensitivity was less satisfactory (72.0%) due to the presence of atherosclerosis without calcification. In cases of arteriosclerosis of the ascending aorta, great care was taken to prevent embolism secondary to a dislodged atheromatous plaque. The "aortic no-touch technique", with in situ internal thoracic artery and right gastroepiploic artery anastomosis under ventricular fibrillation, was performed in 6 cases, a single aortic cross-clamp was applied in 19 cases, and conventional methods were employed when the ascending aorta was normal or the "no-touch" or "single-clamp" procedure could not be used (control, 111 cases). No neurologic complications occurred in the "no-touch" group, while 2 cerebral infarctions occurred in the single-clamp group (10.5%) and the control group (1.8%) respectively. These differences between groups was not significant. Patients with a calcified ascending aorta are at higher risk for neurologic complications of coronary bypass. The risk can be decreased by minimizing surgical trauma to the ascending aorta by the use of "no-touch" techniques.


[The local hyperthermochemotherapy for pleural carcinomatosis].

Local hyperthermochemotherapy was performed in 17 cases to control malignant effusion and intrathoracic disseminated lesions. Of these 15 patients, 11 cases primary lung cancer, 4 cases metastatic lung cancer had pleural carcinomatosis and 2 cases were malignant diffuse mesotheliomas. The procedure was radiofrequency hyperthermia (13.56 MHz) maintaining the peripleural temperature at 42-43 degrees C for 45-60 minutes, combined simultaneously with the intrathoracic administration of cisplatin (1-2 mg/m2, bolus) through a thoracic double lumen trocar tube. The treatment was repeated from 2 to 4 times at 7-day intervals. In 14 cases (87.5%) complete or partial response according to the criteria of the Japan Lung Cancer Society were obtained. There were 2 cases of no change and one case that was impossible to evaluate. In one lung cancer case, the disappearance of pleural disseminated lesions was confirmed by flexible thoracoscopy after the procedure. In 12 cases, there were abdominal complaints due to side effects of the hyperthermochemotherapy, such as vomiting and nausea, but these symptoms were milder than those caused by intravenous injection of anti-cancer agents, for example cisplatin, in conventional chemotherapy treatment. The median survival time and 2 years survival of the patients with the present procedure were 15 months and 41.7% respectively. Although distant metastases appeared in most cases, none had local recurrence and particularly noteworthy pleural effusion was well controlled. The above experience suggested that the local hyperthermochemotherapy is useful to control pleural effusion and can improve the quality of life of patients with pleural carcinomatosis.


[Reinfusion of autologous platelet-rich plasma improves hemostasis after cardiopulmonary bypass].

Although it is reported that postoperative bleeding is reduced by reinfusing autologous platelet-rich plasma (PRP) after cardiopulmonary bypass (CPB), the effect of PRP on hemostasis is not reported in detail. We prepared PRP and fresh whole blood (WB) from the blood of seven patients each prior to their undergoing CPB, and reinfused them autologously to the patients intravenously after the CPB was terminated. In this article, the effect on hemostasis of autologous PRP and WB was described. Platelet aggregation rates and blood coagulation factors were examined before, during and after bypass. Platelet counts, ADP-induced platelet aggregation and the activities of coagulation factors II, V and VII-X were significantly greater in prepared PRP than in WB (p less than 0.01 or p less than 0.05). A mean volume of 724 +/- 109 ml of PRP or 401 +/- 63 ml of WB was reinfused within about 30 minutes after heparin was neutralized by protamine sulfate. The platelet counts increased from 4.3 +/- 1.4 x 10(4)/mm3 to 14.1 +/- 1.6 x 10(4)/mm3 after PRP reinfusion and the platelet aggregation rates increased significantly (p less than 0.01) after PRP reinfusion compared to WB transfusion. The activities of coagulation factors VII-X also increased significantly (p less than 0.05) after reinfusion of PRP when compared to transfusion of WB. The activated partial thromboplastin time decreased to 1.2 times the baseline in the PRP group but remained 1.5 times the baseline in the WB group (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)


[Assessment of long-term systemic ventricular function after the surgical repair in patients with atrioventricular discordance].

Long-term systemic ventricular function at rest and during supine bicycle exercise was studied in 12 patients with atrioventricular discordance (AVD group) using multigated radionuclide blood pool imaging. For comparison, similar measurements were made in eight children (control group). The mean age at the exercise test was 12.3 years in AVD group and was 14.8 years in the control group. In AVD group, ages at the operation ranged from three to 21 years (mean 12.3 years), and the exercise test was performed from one to 9.8 years after the operation (mean 5.3 years). The operative procedures in AVD group consisted of closure of the ventricular septal defect in 11 patients, extracardiac conduit between the left ventricle and the pulmonary artery in nine patients, postero-lateral left ventricular outflow reconstruction in two patients, tricuspid annuloplasty in one patient, and tricuspid valve replacement in one patient. Exercise tolerance of AVD group was less than that of the control group. Heart rate and blood pressure were significantly increased during exercise in both groups. In the control group, end-diastolic count index (EDCI) (= end-diastolic volume) remained unchanged and end-systolic count index (ESCI) (= end-systolic volume) decreased during exercise. In contrast, both EDCI and ESCI were decreased in AVD group. As a consequence, systemic right ventricular ejection fraction (RVEF) increased during exercise in the control group, but remained unchanged in AVD group. Although stroke count index (SCI) (= stroke volume index) did not increased during exercise in AVD group, output count index (OCI) (= cardiac index) increased with the increase of heart rate.(ABSTRACT TRUNCATED AT 250 WORDS)


[A study of arrhythmia following pulmonary operation in patients with bronchogenic carcinoma].

A total of 238 patients undergoing resection of lung cancer were studied for the occurrence of postoperative arrhythmia. Transient arrhythmia was observed in 43 of them (18.1%). Ninety-one percent of 43 patients developed atrial fibrillation (Af), even though no arrhythmia was noted on ECG in any patient preoperatively. Cardiac dysrhythmia occurred 5.2 +/- 3.8 days after operation and lasted for 1.3 +/- 0.9 days (mean +/- SD). There was a significant difference (p less than 0.05) in the incidence of postoperative arrhythmia between the male group (39/188 = 21%) and the female group (4/50 = 8%), however the cause of a difference is unknown. The incidence was higher in patients undergoing pneumonectomy than in those undergoing lobectomy. Patients, who suffered from postoperative arrhythmia, has significantly low values on pulmonary function test (FEV1.0% = 68.7%) preoperatively. The increased cardiac load after the reduction of the pulmonary vascular bed was regarded as the most important factor of arrhythmia. Prophylactic administration of digoxin was performed in another 61 male patients after resection of lung cancer. And it was found to be effective in decreasing the incidence of postoperative atrial fibrillation (5/61 = 8%).


[Efficacy of nicorandil on myocardial protection during coronary artery bypass grafting--a comparison with diltiazem].

Diltiazem (DTZ), a calcium slow channel blocker, is estimated to be highly effective for myocardial protection and the prevention of perioperative coronary spasms (PCS). However, the use of high doses of DTZ sometimes results in difficulty in coming off cardiopulmonary bypass due to negative chronotropic activity. Nicorandil (NCD) has remarkable coronary vasodilating effect but possesses little negative chronotropic activity. The purpose of this study was to compare NCD with DTZ with respect to effect on myocardial protection during coronary artery bypass grafting (CABG). As parameters, excess lactate (delta XL), redox potential (delta Eh), left and right ventricular stroke work indices (LVSWI, RVSWI), cardiac index (C.I.), systemic vascular resistance index (SVRI.), myocardial isoenzymes (CK-MB, LDH1), number of PCS and recovery time of chronotropic action were used. delta XL, delta Eh, LVSWI, RVSWI, C.I., SVRI, CK-MB, LDH1 were measured at 0, 1, 3, 6, 9, 18 and 24 hours after the removal of aortic cross clamping. The degree of chronotropic action was evaluated by the length of the recovery time to self beat or normal sinus rhythm after the removal of aortic cross clamping. Forty patients who underwent CABG with retrograde cold blood cardioplegia between Dec. 1989 and May 1991 were divided into the NCD group (n = 20), in which 1.1 micrograms/kg/min NCD was continuously administered from the beginning of the operation and the DTZ group (n = 20), in which the initial St. Thomas cardioplegia containing 5 mg/L and subsequent cold blood cardioplegia solution contained DTZ 3.5 mg/L, for a total DTZ dose of less than 10 mg.(ABSTRACT TRUNCATED AT 250 WORDS)


[A case report of radiation osteomyelitis 9 years after irradiation for thymoma].

Radiation osteomyelitis of the sternum is rare and usually difficult to cure. A 75-year-old man, who had undergone an exploratory sternotomy for a mediastinal tumor, not resected after all, 9 years earlier and received radiation therapy successively for the histological diagnosis of malignant thymoma, was admitted to our hospital with the chief complaint of fever and pus discharge of the anterior chest wall. He also suffered from diabetes mellitus. The skin around the fistula was dark-red and atrophic due to irradiation dermatitis and the manubrium was fissured in the midline. Open drainage and two-stage operation of direct closure was tried in vain. This case was treated successfully by resection of necrosed portion of sternum and pectoral muscle flap closure.


[Ischemic cardiomyopathy associated with ischemic mitral regurgitation--a case report of successful repair].

We experienced a case of 62-year-old man with ischemic cardiomyopathy and mitral regurgitation. He had a heart failure of New York Heart Association class IV together with unstable angina. His further examination showed an enlarged left ventricle with markedly reduced ejection fraction (12.9%) and ischemic mitral regurgitation of grade III associated with 3-vessel disease. He underwent three coronary artery bypass graftings and mitral annuloplasty by a modification of Kay's method. He showed a remarkable improvement of heart failure and cardiac function together with a disappearance of mitral regurgitation. He discharged from hospital in NYHA class II on the 50th postoperative day and lives an almost normal life now. Operative indication and management of ischemic cardiomyopathy and mitral regurgitation were discussed.


[Double valve replacement for secondary atrioventricular regurgitation due to dilated cardiomyopathy--a case report].

A successful surgical case of double valve replacement for a patient with dilated cardiomyopathy was performed. A 45-year-old man was admitted to our hospital with paroxysmal atrial fibrillation and congestive heart failure. Echo cardiogram and cineangiography showed dilatation and decreased contraction of the left ventricle. A diagnosis of dilated cardiomyopathy was established since neither coronary artery disease nor valvular disease were observed. He was treated with medication of diuretics and pacemaker implantation. However, mitral and tricuspid regurgitation occurred and progressed 7 years later. Since then, he repeated admission and discharge against the strong medication. He became medically uncontrollable at the age of 58. Because of this, surgical treatment had to be considered. Double valve replacement for mitral and tricuspid valve was performed on September, 1989. Avoidance of cardiopulmonary bypass was only possible with the aid of catecholamine. Poor left ventricular function and pleural effusion frequently shown on chest X-ray film complicated the postoperative course. And with hospital treatment, he discharged three months after the operation. He has been doing well without any significant complaint during the past two years and cardiomegaly has been decreasing as well.


[A successfully treated case of thoracic meningocele with von Recklinghausen's disease].

Intrathoracic meningocele is an uncommon disease. Only 95 cases in the foreign literature and 13 cases in Japanese literature have been reported since Phol Meningocele occurs most frequently in the sacral and lumbar spinal regions. In this present paper, an 18-year-old female with intrathoracic meningocele associated with neurofibromatosis is described. The patient was admitted to our Surgical Clinic with a complaint of constrictive pain in the upper chest. The meningocele was diagnosed preoperatively and resected surgically by left thoracotomy. The patient has been followed up to for six years without any evidences of local recurrence. However, she recently complains of headache and weakened eyesight because of pituitary tumor, the operative indication of which is now discussed.


[A successfully treated case of empyema with a large tracheal fistula after a radical operation of esophageal cancer by fixation and plombage with major pectoral muscle flap].

We reported a successfully treated case of empyema with a large tracheal fistula which had developed after a radical operation of esophageal cancer (reconstructed with stomach). This 59-year-old male was treated by the method of fixation and plombage with major pectoral muscle flap and thoracoplasty, because we could not use the omentum that were frequently used nowadays for closure of the fistula. The size of the tracheal fistula was a large as the main bronchus bronchoscopically. Postoperative care were the following, the endotracheal tube was inserted from the tracheal stoma to the left main bronchus and 9 days left hemi-ventilation was performed. Continuous suction was performed at the same time from the right main bronchus in order to prevent secretion and blood pour into the left lung. Bronchoscopical examination done 28 postoperative day, the small fistula remained the tip of the muscle flap. But 72 postoperative day, the surface of the fixed muscle flap was replaced by normal bronchial mucomembrane and tracheal fistula was obliterated. Major pectoral muscle could be used as local flap to obliterate empyema cavity associated with tracheal fistula. We believe that utilizing an muscle flap for those who had undergone abdominal operation like our case is a valuable method.


[Atrial septal defect associated with von Willebrand's disease--a case report].

Von Willebrand's disease is common hemorrhagic disorder that deserves particular attention in the patient undergoing open-heart surgery, because of perioperative unexpected bleeding. The present case is atrial septal defect associated with Willebrand's disease, affecting a 19-year-old female who has the past history of bleeding tendency with frequent subcutaneous bleeding. It is mandatory to maintain adequate levels of both factor VIII coagulation and ristocetin cofactor activities during the perioperative period. An infusion study of heat-treated evaluate the response and half-life of both factor VIII coagulation and ristocetin cofactor activities; and to calculate the effective dose and duration of the drug action as well as to formulate a protocol for patient's management in the perioperative periods in order for the surgical intervention to be performed uneventfully. Our case demonstrated that it is possible to perform an open heart surgery in patients with von Willebrand's disease without major bleeding as far as the levels of both factor VIII coagulation and ristocetin cofactor activities are maintained above 50% in the postoperative critical period.


[Cystic tumors of mediastinum].

Nine of twenty-four mediastinal tumors showed cystic lesions were operated at Kinki University Hospital. These nine mediastinal cysts included 5 of thymic cysts, 3 teratomas and one pericardial cyst. By the preoperative imagings, thymic cysts showed a smooth wall and homogenous content with water density. Teratoma consisted of cystic and solid parts, and the irregular thickness of the wall was found. One of these teratomas was ruptured into the pleural cavity, it has been proposed that digestive enzyme derived from pancreatic tissue with Langerhans island caused autolysis and necrosis with result in rupture. Pericardial cyst located at cardiophrenic angle mostly and which is useful on diagnosis.


[The giant cavernous hemangioma of the neck].

A 67-year-old female who had complains of dyspnea and giant mass in the right neck. The plain CT scan and selective angiography showed an giant mass in the neck and extended into antero-superior mediastinum which pressed intrathoracic trachea. The tumor was resected completely by oblique neck incision and partial median sternotomy. It was 15 x 9 x 5 cm in size. The histological diagnosis was cavernous hemangioma. The giant cavernous hemangioma in neck extended into mediastinum is rare.


[A case of idiopathic ventricular tachycardia with ventricular fibrillation successfully treated with cryoablations and implantable cardioverter defibrillator].

A 16-year-old girl with medically refractory idiopathic ventricular tachycardia (VT) with ventricular fibrillation (VF) underwent cryoablations of the VT origin and received implantable cardioverter defibrillator (ICD). Intraoperative epicardial and endocardial mapping demonstrated the earliest activation site of VT in the infundibular septum of right ventricle. Cryoablations were applied through a pulmonary arteriotomy under mild hypothermic cardiopulmonary bypass with the heart beating. Because of the episodes of VF. ICD implantation was followed. Her postoperative course was uneventful and she remains free from VT and VF.


[Resection of tracheal carcinoma using partial cardiopulmonary bypass--report of a case].

A 43-year-old male was admitted to our hospital with chief complaints of stridor and dyspnea. Bronchoscopy revealed a tumor obstructing almost the whole lumen of the trachea. As it was impossible to insert an endotracheal tube into the distal site of the stenosis in the mediastinum, we used partial cardiopulmonary bypass to maintain gas exchange. The axillary artery and the femoral artery and vein were cannulated for the bypass using local anesthesia. During 105 minutes of bypass, the PaO2 value was good but the PaCO2 value increased up to 70 mmHg. After the trachea was opened, the anesthetic gas was administered across the operative field through the endotracheal tube and the cardiopulmonary bypass was discontinued. Tracheolaryngectomy and permanent tracheostomy with relocation to the right and caudal side of the brachiocephalic artery was performed successfully. The post operative course was very smooth. The patient has been well for 6 months since the surgery. Partial cardiopulmonary bypass proved to be useful for maintaining gas exchange during reconstructive surgery of the trachea. We treated a case of tracheal carcinoma by resection while using partial cardiopulmonary bypass. We believe this is the ninth such case reported Japanese literature.


[An operated case of malignant localized mesothelioma of the pleura].

An operable case of pedunculated localized mesothelioma of the pleura, a 62-year-old male, came to our clinic with chief complaint of chest X-ray abnormal shadow. On suspicion of pleural tumor, resection was performed. The operative findings revealed that the tumor was arising from visceral pleura of S1 + 2 a segment of left upper lobe, and didn't invade into peripheral tissue. The microscopic findings revealed that the tumor was consist of spindle tumor cells and capillary-like lesions, and had high cellularity and many mitosis. The tumor was diagnosed as localized malignant mesothelioma. Immunohistochemical stainings were performed using six monoclonal antibodies, vimentin, CEA, EMA, keratin (AE1, AE3), Leu-M1. Only vimentin reacted with tumor cells.


[Primary hemangiopericytoma of the chest wall--a case report].

An extremely rare case of a primary hemangiopericytoma of the chest wall was reported. A 40-year-old female without any complaints was detected to have an abnormal shadow in the right chest wall on a chest X-ray film. The tumor was 2.6 x 2.2 x 2.0 cm in size and was resected together with the 8th rib which adhered to the tumor. Postoperative pathohistological examination led to the diagnosis of hemangiopericytoma. Postoperative course was uneventful, and the patient is now doing well and has had no recurrence for 11 months since the operation. A brief review was made on 9 cases collected from the literature.


[Coarctation of aorta with right aortic arch and anomalous left subclavian artery].

The occurrence of coarctation in patients with right aortic arch is extremely rare. We have encountered a 21-year-old man with anomalous left subclavian artery. He was diagnosed when he was 13. On angiography he exhibited a right aortic arch. The left common carotid artery, right common carotid artery and the right subclavian artery diverged from the proximal side of the coarctation. The left subclavian artery diverged from the distal side. The right brachial arterial pressures measured 158-72 mmHg, while the left brachial arterial pressures measured 98-80 mmHg. Clinical studies revealed no vascular ring and no other anomalies were found in this patient. An attempt at treatment was made with extra anatomical bypass grafting from the ascending aorta to the descending aorta. No pressure difference due to coarctation remained after operation.


[Pulmonary arteriovenous malformation with systemic blood supply].

A forty-eight year-old woman who had suffered from exertional dyspnea and cyanosis since her youth was found to have abnormal shadow in her right lower lung at the roentgenographic examination. Pulmonary angiography showed cavernous network between pulmonary artery and vein of the 8th, 9th, and 10th segments. Bronchial artery was dilated, supplying the cavernous lesion. From these findings this lesion was diagnosed as pulmonary arteriovenous malformation feeded by bronchial artery. Right lower lobectomy was performed. The effect of resection was confirmed by intraoperative arterial gas analysis before and after the excision. She has been doing well without any signs of recurrence for 3 years after the surgery.


[Adjunctive methods during surgery for thoracoabdominal aneurysms--effect of selective visceral arteries perfusion incorporated with partial femoro-femoral bypass].

In this study, we report the effect of selective perfusion to the visceral arteries during aortic cross-clamping at surgery for thoracoabdominal aortic aneurysms with an adjunct of femoro-femoral (F-F) extracorporeal bypass. The total series comprising 28 patients were divided into 3 groups according to the perfusion mode to the celiac and the renal arteries, i.e., group I; the arteries were continuously perfused by the extracorporeal bypass, group II; aortic cross-clamp excluded the branches from the bypass flow but selective perfusion was employed, and group III; the liver or the kidneys were subjected to ischemia. As a result, group III developed hepatic failure at the incidence of 50% which was characterized by hepatocellular damage followed by cholestatic dysfunction. As for postoperative renal function, this group revealed persistently high level of serum creatinine, and 60% of this series resulted in renal failure. On the contrary, group II showed a comparable effect to group I on the preservation of hepato-renal function, and there were no differences in the incidence of hepatic or renal failure between the two groups. Multiple organ failure was a predominant cause of hospital death, and it developed only in the cases with aortic cross-clamp time more than 90 minutes. However, avoiding ischemia achieved in group I or II significantly reduced the incidence of MOF and its related deaths. It is concluded that selective perfusion system incorporated with an aid of F-F partial bypass was a useful measure to protect vulnerable organs from ischemia and to reduce postoperative mortality and morbidities.


[Two-stage Jatene procedure after Mustard or Senning operation].

We have successfully performed a two-stage Jatene procedure in four patients who showed severe anatomical right ventricular dysfunction after atrial switch (Mustard or Senning) operation for transposition of the great arteries. All four patients developed an adequate left ventricular pressure for the arterial switch operation by one or two-stage pulmonary artery banding. Left ventricular posterior wall thickness increased sufficiently enough after the banding although left ventricular ejection fraction showed significant decrease. After Jatene procedure left ventricular ejection fraction recovered, and RV end-diastolic volume which had been prominently enlarged preoperatively was dramatically normalized. Cardiac index increased from 3.6 +/- 1.6 l/min/m2 preoperatively to 5.3 +/- 6.1 l/min/m2 postoperatively with the decrease in left atrial pressure. Postoperative electrophysiological study revealed the recovery of sinus node function and atrial conduction by means of the take-down of atrial switch operation previously performed. We conclude that the Jatene procedure should be an ideal alternative in patients with right ventricular dysfunction after atrial switch operation. The left ventricle could be prepared by an effective pulmonary artery banding in most instances.


[Long-term results of the Blalock-Taussig shunts].

One-hundred and thirty-six patients received the classical Blalock-Taussig shunts between 1980 and 1990. Their age range at operation was 4 days to 12.8 years and their median age was 13 months. The operative mortality rate was 0.7% (1/136). The survivors were followed up from 1 month to 11.5 years, 5.4 years in average. Twenty-five patients required another shunt and the mean interval to that procedure was 2.4 years (modified Blalock-Taussig 23, classical Blalock-Taussig 2, Glenn 1, internal mammary artery-pulmonary artery shunt 1). Forty-five patients received corrective operations, there were four operative deaths (Fontan 2, Rastelli 2). There were 15 late deaths of which three deaths were not cardiogenic. One year after operation, 91.0% of patients remained in well-palliated condition. At three years after operation, 76.4% of patients continued to be in well-palliated condition. There were twelve neonates in this series. Their age range was 4 to 26 days and their median age was 13 days. There was no operative death. Five patients required second shunt. There were two late deaths. At present, six patients continue to be in well-palliated condition 8 months to 9 years after first operation. Angiographic findings showed the stenotic change of the vascular anastomoses in 49.3% (35/71) of patients. This study suggests that polydioxanone suture (PDS) will be useful for the growth of the anastomoses in Blalock-Taussig operation.


[Management of type A acute aortic dissection--results of the cases with thrombosed false lumen].

By reviewing the outcome, we studied the propriety of our principles for the treatment of type A acute aortic dissection in 45 patients, encountered during the 10-year period between 1981 and 1990. We conducted a comparative study of patients with a thrombosed false lumen (type T) and a patent false lumen (type P) to examine the effect of an acutely thrombosed false lumen on the prognosis of this disease. For the 25 patients treated in the first 6 years (1981-1986), operation was performed as soon as exact diagnosis was made, regardless of the presence of complications and the type or severity of the disease. Early death occurred in 9/20 operated cases and in 4/5 unoperated cases, so 13/25 patients died for a 52.0% mortality rate. For the 20 patients who received treatment in the latter period (1987-1990), we gave priority to conservative treatment for type T cases that were free from complications, and adopted a treatment method attaching greater importance to the resection of intimal tears. As a results, early deaths were observed in only 4 type P patients (20.0%) who underwent operation, a significant better result (p < 0.05). For patients in whom we were able to excise the intimal tear (30.0%, early mortality rate), the results were better than in those in whom the intimal tear were left alone (53.8%). The results were particularly good in type T patients (25.0% of them underwent intimal tear resection and 71.4% underwent no operation for the intimal tear).(ABSTRACT TRUNCATED AT 250 WORDS)


[Glucose tolerance and insulin secretion in infants with the left to right shunt congenital heart disease].

Between 1980 and 1988, 32 infants under three years of age with left to right shunt congenital heart disease underwent cardiac catheterizations, and their glucose tolerance and insulin secretion were investigated. These patients were divided into three groups by weight and compared. Group I consisted of 11 patients whose weights were 80% or more of the ideal body weight (IBW) for their age. Group II consisted of 10 patients whose weights were between 70% and 80% of the IBW. Group III consisted of 11 patients whose weights were less than 70% of the IBW. The CTR and biochemical blood studies showed no difference. By cardiac catheterization, Group III showed higher pulmonary/systemic vascular pressure ratio (Pp/Ps) than Group I. The mixed venous O2 saturation (SvO2) were 69.5 +/- 6.41% in Group I, 64.8 +/- 5.78% in Group II, 57.2 +/- 3.59% in Group III. Group III showed the lowest SvO2 of the three. Group III also showed the lowest arterial O2 saturation (SaO2). This indicates that the patients of Group III had the most serious congestive heart failure. In the 0.5 g/kg intravenous glucose tolerance tests, the K values (glucose disappearance rates) were as follows: Group I: 3.30 +/- 0.597, Group II: 2.91 +/- 0.624, Group III: 2.48 +/- 0.417. Group III showed the lowest values of the three. This indicates the deterioration of glucose tolerance in Group III. In the examination of serum insulin secretion, Group III showed the lowest serum insulin levels: 26.6 +/- 18.3 mmu/ml at 3-minute intervals, 22.8 +/- 14.3 mmu/ml at 5-minute intervals. After cardiac catheterization, corrective operations were performed on 17 patients out of 32. Fifteen patients survived, though 2 patients of Group III died early postoperatively. The results of glucose tolerance test and serum insulin levels before and after operation in 12 survivors were compared. Although the K values had been 2.8 +/- 0.41 before operation, it rose up to 3.81 +/- 0.81 three to four weeks after operation. The serum insulin levels at 3, 5, 10 and 15-minute intervals also rose after operation. This indicates the improvement of glucose tolerance and insulin secretion due to the improved circulation. It is suggested that the adequate nutritional management before and after operation on infants with serious congestive heart failure, because they tend to have malnutrition before operation. Aggressive and careful nutritional management is advisable.


[Changes in left ventricular function during exercise after lung resection--study with a nuclear stethoscope].

In 29 cases undergoing lung resection, effects of the surgery on left ventricular function were investigated indirectly with a Nuclear Stethoscope. Various parameters were measured following an exercise load before and after surgery. There were significant decreases in post-operative resting levels of stroke volume (SV) (p < 0.001), end-diastolic volume (EDV) (p < 0.001), ejection fraction (EF) (p < 0.05) and ejection rate (ER) (p < 0.001) and significant increase in heart rate (HR) (p < 0.001) when compared to pre-operative resting levels. Neither filling rate (FR) nor cardiac output (CO) showed significant difference. At maximum exercise load, there were significant decreases in post-operative EDV (p < 0.005), SV (p < 0.005), ER (p < 0.001) and FR (p < 0.005), but no significant differences were detected in HR and EF; consequently, there was a significant decrease in CO (p < 0.005). Ratio of the levels at maximum load to those at resting of each parameter did not show significant difference between before and after operation with regard to any parameters except CO and FR which showed significant decrease (p < 0.005 and p < 0.001, respectively). Effects of the surgery on left ventricular function were studied according to amount of lung resection. In 13 cases where more than two lobes were resected, similar significant differences to those mentioned above were found in all parameters except EF. In cases where a single lobe was resected, only ER and FR showed similar tendency to that described above. Effects of the surgery on left ventricular function were also studied according to age of patients.(ABSTRACT TRUNCATED AT 250 WORDS)


[Analysis of the determinant factors for open heart surgery without blood transfusion by the quantification theory--possibility of application of maximum surgical blood order schedule for open heart surgery].

In order to complete operations without blood transfusion we have chosen means of preoperative autologous blood saving and intraoperative autotransfusion, but we have not always achieved our purpose. We examined 29 patients (13 patients without blood transfusion and 16 with blood transfusion) to analyze the determinant factors as to whether open heart surgery without blood transfusion may be indicated or not, according to the quantification theory (type II) and to examine the possibility to apply the maximum surgical blood order schedule (MSBOS) for the open heart surgery by the quantification theory (type I). The analysis of determinant factors revealed hematocrit (Ht) value before saving of blood (more than 40%) as the best contributor of possibility of non-blood transfusion surgery, followed by the amount of blood loss during operation (less than 600 ml), the amount of saving blood (more than 800 ml), body weight (less than 70 kg), calculated Ht value on the beginning of cardiopulmonary bypass (CPB) (more than 24%), CPB time (less than 120 minutes) and the amount of postoperative blood loss (less than 600 ml). The prospective using blood volume at the operation was precisely calculated by the values of 4 preoperative factors, that is, the amount of saving blood, calculated Ht value on the beginning of CPB, CPB time and body weight. Therefore it is important to increase the amount of preoperative saving blood and decrease the amount of surgical bleeding in order to perform operations without blood transfusion, and is possible to apply the MSBOS for the open heart surgery.


[An assessment of the separation of mediastinal lymph nodes by preoperative mediastinoscopic examination as a dissecting measure in the surgical treatment of lung cancer].

The availability of the separation of mediastinal lymph nodes by preoperative mediastinoscopic examination as a dissecting measure was analyzed according to prognosis retrospectively because mediastinal lymph nodes dissection is made with ease and certainty after the examination. The separation by mediastinoscopic examination did not have an impact on the mediastinal lymph nodes dissection for carcinoma of the left lung and superior mediastinal lymph nodes metastases (# 1-4), but an influence on the dissection for carcinoma of the right lung and middle and lower mediastinal lymph nodes metastases (# 5-9). This result showed the existence of occult metastases and the good effects caused by the separation of mediastinal lymph nodes. In the histological type, the effects were present in squamous cell carcinoma and p-N0 adenocarcinoma, but it was concluded that the prognosis in adenocarcinoma was associated with other factors rather than lymph node metastasis. Therefore, it can be seen that the separation of mediastinal lymph nodes by preoperative mediastinoscopic examination is available as a dissecting measure.


[Coronary revascularization with arterial graft alone].

In the period from December 1989 until July 1991, coronary revascularization were performed on 56 patients using arterial grafts and no venous grafts. The ages of the patients ranged from 43 to 85 years (average; 66.8 years), and there were 33 males and 23 females. Twenty-four patients had angina pectoris, 23 had old myocardial infarction and 9 had acute infarction. There were 3 patients with single-vessel coronary disease, 19 with double-vessel, 31 with triple-vessel and 9 with left main coronary disease. The bypass grafts used were 58 left internal thoracic artery (LITA) grafts, 29 right internal thoracic artery (RITA) grafts, and 56 right gastroepiploic artery (RGEA) grafts. Thus, 143 grafts were used and an average of 2.6 bypasses were created per patient. There were two operative deaths. One of these patients had acute myocardial infarct. Investigation of postoperative graft patency was performed in the 122 grafts that could be examined angiographically after surgery. Only 7 were obstructed, yielding a patency rate of 94.3%. By using both the ITA and RGEA, in situ anastomoses with all the coronary arteries could be performed. Also in emergency surgery arterial grafting was possible. This operative form is considered to be a useful technique and may be expected to produce favorable long-term results.


[A case of leiomyoma of the chest wall].

A case report of a leiomyoma of the chest wall is presented. So far as we examined, this is the first case of the leiomyoma of the chest wall in Japan. A 40-year-old woman was admitted to our hospital because of an abnormal shadow in the right upper lung area in a chest X-ray film. The thoracic CT and MRI demonstrated a tumor of the chest wall projecting into the thoracic cavity. The tumor was excised. Histological examination indicated that the tumor was a benign leiomyoma. This tumor seems to originate from the wall of the small vessels histologically. The patient's postoperative course is uneventful.


[A case of acute A type aortic dissection with lower extremity ischemia--percutaneous fenestration of the aortic septum followed by ascending aortic graft replacement by open distal anastomosis and retrograde cerebral perfusion].

A 56-year-old woman with severe back pain and a cold, pulseless right extremity was admitted to our hospital. Angiogram revealed a type A aortic dissection extending from ascending aorta to the aortic bifurcation with no definite re-entry point. The false lumen gave origin to the right renal artery and the right external iliac artery was occluded. Therefore, a catheter was manipulated into the true lumen through a percutaneous right femoral artery approach, and was advanced into the false lumen through the right posterolateral wall of the dissecting aortic septum. Fenestration was then performed with fully dilated angioplasty balloon across the septum. Immediately after the procedure, the patient's symptoms improved. The day after the fenestration, replacement of the ascending aorta with 24 mm woven Dacron graft was followed under the deep hypothermia and the retrograde cerebral perfusion. The patient followed a satisfactory postoperative course and postoperative angiogram showed a complete closure of the entry at the ascending aorta and adequate revascularization of the right renal and external iliac arteries.


[A successful transatrial repair of post-infarction ventricular septal defect].

A 63-year-male underwent successful operation for the ventricular septal perforation (VSP) caused by the inferior myocardial infarction. As the condition was stable, an operation was performed at the 43rd day after onset of myocardial infarction. Exposure was obtained by the opening the right atrium and retracting the tricuspid valve. The defect was in the posterior portion of the ventricular septum and closed using a Dacron patch. His postoperative course was uneventful. Postoperative examinations show no residual shunt. We believe that this approach may offer reduced mortality and morbidity in a selected group of patients with acquired posterior VSP, by avoiding such complications as further trauma to the ventricle, hemorrhage, and arrhythmias.


[Successful surgical treatment of coronary aneurysm following PTCA].

A case of 50-year-old man who developed coronary aneurysm at the initial PTCA site following dilatation was reported. The patient was suffered severe effort angina pectoris and admitted to our hospital. Coronary angiography revealed 99% stenosis in the right coronary artery (RCA), and the underwent balloon dilatation of the RCA lesion with 3.0 mm balloon catheter at 3 atm of pressure. PTCA provided sufficient coronary dilatation, however a small dissection remained. He was discharged from the hospital without any symptom. Two months after PTCA he was suffered from recurrent angina, and electrocardiographic exercise stress test was positive for ST segment depression in inferior wall. The repeat coronary angiography showed severe stenosis of the original lesion and aneurysm formation at the area of dissection which occurred during initial angioplasty. Coronary artery bypass surgery with a saphenous vein graft performed successfully.


[A case of superficial esophageal carcinoma with remarkable changes in appearance on endoscopy].

Iodine staining and biopsy has been utilized in the endoscopic examination of superficial esophageal carcinoma. 59-year-old male was occasionally revealed to have esophageal carcinoma. There existed 0-IIb type superficial esophageal carcinoma in 1/3 circulation on the first endoscopic study. After 3 weeks, only erosive change of 5 mm in diameter could be observed. In the microscopic study of the resected specimen, there were phagocyte infiltration, epithelial cell ballooning, and remnant carcinoma cells in only basal layer. It was suggested that epithelium had desquamated and regenerated with extrinsic stimulation, therefore its appearance changes remarkably.


[An adult case of dyspnea and overinflation of the residual lung with disappearance of the postpneumonectomy space after left pneumonectomy].

Mediastinal shift and overinflation of the residual lung after pneumonectomy are well known, and sometimes cause pulmonary insufficiency. However, most of such cases occur after surgery in childhood or adolescence. We present a 49-year-old woman who had dyspnea and severe overinflation of the residual lung after left pneumonectomy. She had undergone pneumonectomy at the age of 33 years. Dyspnea on exertion occurred 4 years later, and became much more severe 9 years later (H-J IV degrees). Computed tomography showed that the postpneumonectomy space and completely disappeared and the right lung was overinflated to the left posterior axillary line. Low vital capacity with high residual volume and low maximal ventilatory volume were detected by pulmonary function test. Pulmonary function after pneumonectomy is difficult to predict because mediastinal shift and overinflation of the residual lung may occur. To avoid this, prosthesis plombage for the postpneumonectomy space is necessary.


[A case report--combined Jatene procedure and extended aortic arch reconstruction for the original Taussig-Bing malformation associated with hypoplastic aortic arch, subaortic stenosis and coarctation of the aorta].

A successful repair with combined Jatene procedure (Lecompte modification) and extended aortic arch reconstruction in a two-month-old boy with the original Taussig-Bing malformation, associated with hypoplastic aortic arch, subaortic stenosis and coarctation of the aorta was described. The ascending aorta was measuring 8 mm and the distal aortic arch was 4 mm in outer diameter. The interventricular rerouting was not feasible, because the infundibular septum was almost aligned to the interventricular septum. So that arterial switch operation was preferred. The primary interventricular foramen was enlarged by wedge resection and the secondary interventricular foramen was closed with a patch of preserved equire pericardium. An extensive patch angioplasty of entire aortic arch down to descending aorta was performed with a composite patch of Xenomedica (preserved equire pericardium) and Dacron velour. Hypertrophied muscle bundles were resected for relief of subaortic stenosis. Jatene procedure was then performed. During neo-pulmonary reconstruction, distal pulmonary orifice was shifted towards right to avoid kinking and compression on the coronary arteries. One stage correction consisting of Jatene procedure and extended aortic arch reconstruction was considered to be a procedure of choice in this type of complex anomalies.


[A case of infective endocarditis with multiple embolic complications].

A 13-year-old girl was admitted to a hospital because of fever and sore throat. Staphylococcus aureus was obtained on blood culture, and she was treated with antibiotics under the diagnosis of sepsis and DIC. Echocardiography showed huge vegetation attached to the posterior leaflet of mitral valve and severe mitral regurgitation. CT scan revealed multiple heterogeneous high density areas in her brain. She was transferred to our hospital for further examination and treatment. Large verrucae on the mitral valve, severe regurgitation and repeated embolism urged us to the emergency mitral valve replacement. Debridement of abscess on the posterior wall of the left atrium and ventricle necessitated patch plasty of those structures and mitral ring as well. Operative and postoperative examination showed mycotic aneurysm of right coronary artery, multiple brain hemorrhage, arterial obstructions of extremities and splenic infarction. Sooner she recovered except for slight macular degeneration caused by retinal embolism.


[A case report of spinal epidural hematoma complicated after open heart surgery].

The authors reported the first case of acute spinal epidural hematoma (SEH) developed after open heart surgery. The patient was noticed that her legs felt weak and numb on the first postoperative day evening. On the next day morning, neurological examination revealed that flaccid paralysis of both legs and also loss of all sensory perception below the level of Th-6 spine bilaterally. The prolonged effect of anesthesia and painless onset made delayed recognition of the lesion. SEH (Th5-7) was diagnosed with MRI and decompressive surgery was immediately done, sixty hours after the beginning of cardiac operation. But in this case neurological deficits were not changed. We concluded that a routine diagnostic approach was very important procedure to find out this serious complication for all patients underwent open heart surgery in early period of its onset.


[A case of acute right ventricular infarction and life-saving right ventricular assistance following emergency coronary revascularization and resection of a left ventricular aneurysm--discussion of indication and proper assist flow volume].

Right ventricular assistance (RVA) using centrifugal pump in combination with IABP was used to treat a patient who was difficult to wean from a cardiopulmonary bypass following emergency coronary revascularization and resection of a ventricular aneurysm performed to treat acute right ventricular infarction due to a PTCA complication. After 131 hours of RVA at 3.2 to 4.8 l/min, it was possible to remove the pump. No heparin was administered during this time, changing the pump head twice, was used for 64 and 50 hour period, no thrombi were detected either time. After being weaned from RVA, the patient developed severe respiratory dysfunction, but on the 10th postoperative day (POD) IABP was weaned, and on the 13th POD the artificial respirator was withdrawn. The results of the postoperative cardiac catheterization were favorable, the patient was discharged on the 57th POD, and has returned to society at the present time. The indications for RVA include a central venous pressure > 20 mmHg and a cardiac index < 1.8 l/min/m2, and tissue perfusion pressure and general preoperative condition should severe as guides. The higher the assisted flow volume the more efficacious in relieving ventricular load, but, since there is a limit to how much the left ventricle and lungs can withstand, it should not exceed levels which ensure the maintainance of cardiac output and tissue perfusion pressure.


[A case report of translocation method for active infective aortic valve endocarditis with aortic root abscesses].

We experienced a case of 51-year-old woman who underwent emergency aortic valve replacement by translocation method for active infective aortic valve endocarditis with aortic root abscesses. Postoperative course was complicated as the following. Three days later, the perforation of noncoronary sinus of Valsalva into the right atrium was noted and she developed progressive heart failure due to the massive left-to-right shunt. The second operation was performed immediately for the patch closure of the perforation through the right atriotomy. Two months later, unstable angina appeared because of the stenosis of the vein graft to the left coronary artery, leading to the emergency third operation in which LITA was placed to the left anterior descending artery. In spite of these complications she recovered gradually and she was discharged 6 months after the first operation. She is now doing well in NYHA class 2. Translocation method is quite useful for such a case of the aortic valve endocarditis with periannular abscesses in whom conventional valve replacement is supposed to be impossible, but the long durability of this type of the repair is unknown. Careful follow-up of the patient is mandatory.


[Two cases of post-thymectomy myasthenia gravis].

The first patient was a 37-year-old man with an invasive and lymphoid cell dominant thymoma (stage III). He underwent extended total thymectomy and partial resection of the upper lobe of the left lung. Four years after the operation, he had ptosis and diplopia and was diagnosed as having myasthenia gravis (positive Tensilon test and raised antiacetylcholine receptor antibody titer). His symptoms improved with the steroid therapy. The second patient was a 37-year-old woman with an invasive and mixed type thymoma (stage III). Extended total thymectomy with combined resection of the mediastinal pleura and right phrenic nerve was performed, but the tumor recurred in the right thorax 2 years postoperatively. Subtotal resection of the parietal pleura and recurrent tumors was performed by right thoracotomy, and steroid therapy was given. She developed malaise, ptosis and diplopia three months later, and was diagnosed as having myasthenia gravis. Her symptoms disappeared after the steroid therapy was stopped. A review of the Japanese literature is presented and problems regarding the pathogenesis of this disease are discussed.


[Aortic arch and descending aortic replacement under deep hypothermia and circulatory arrest through left thoracotomy--case report].

Graft replacement of the transverse aortic arch and the descending thoracic aorta was done for two cases with Stanford type B aortic dissection involving the aortic arch. Cardiopulmonary bypass was established with left atrium and femoral vein for venous line and femoral artery for arterial line. Patients were cooled until their EEG activity had disappeared, then the bypass was discontinued. Lesser curvature of the transverse aortic arch was resected and graft was sutured by beveled fashion. After reinstitution of the bypass, intercostal arteries (Th8-10) were reattached to the graft and distal anastomosis was made above the diaphragma. Postoperative recovery was uneventful in both cases.


[A case of squamous cell carcinoma of the lung treated by right sleeve upper lobectomy after photodynamic therapy].

This patient, a 62-year-old female, with squamous cell carcinoma of the lung was inoperable because of poor pulmonary function due to severe bronchial stenosis by a tumor at the orifice of the right main bronchus. As the tumor decreased in size after photodynamic therapy (PDT), the bronchial stenosis decreased and her pulmonary function improved sufficiency to permit surgery. When right upper sleeve lobectomy was performed, only limited peribronchial inflammation related to PDT procedure was detected indicating only slight extrabronchial influence of PDT. This suggests that PDT is a viable adjunct modality in case in which surgery might possible be performed. The patient has a good postoperative course and is alive 18 months after surgery without any evidence of recurrence.


[A case report of well differentiated fetal adenocarcinoma].

A 32-year-old female, who was admitted with complaints of cough and an abnormal shadow in the left lower lobe, was diagnosed as adenocarcinoma of the lung by TBLB. She underwent left lower lobectomy and lymph node dissection. Histopathological findings showed well differentiated fetal adenocarcinoma (WDFA). Well differentiated fetal adenocarcinomas are considered to have a histogenesis similar to that of pulmonary blastoma and may be a tumor with one-sided development of pulmonary blastoma showing only an epithelial component.


[A case of primary acinic cell tumor of the trachea].

A 62-year-old woman complained cough and hemosputum. Chest X-ray film and thoracic computed tomography revealed tumor shadow, localizing in the upper trachea, measuring 2 x 1 cm. Through a median sternotomy, resection of the trachea of 4 cartilagous rings was made, followed by end-to-end anastomosis. Fixing of tracheal anastomosis was performed for 2 weeks using SOMI brace. The size of tumor was 1.3 cm in diameter. Histologically, nodular tumor foci were seen close to the normal trachea gland, localing in tracheal mucosa. Tumor cells with basophilic cytoplasma developed acinical structure. Postoperative course was uneventful. This patient is alive 42 months after resection. This disease is extremely rare, we have found only 4 reported cases including our case in the world literature and only 2 cases in the Japanese literature.


[Left ventricular approach for muscular ventricular septal defects in infant].

Two infants less than 4 months of age underwent repair of apical muscular VSD with left ventriculotomy. First case was 3 months old boy who had already undergone enlargement of the hypoplastic aortic arch with subclavian flap aortoplasty and pulmonary artery banding because of the associated aortic coarctation. Second case was 4 months old Down syndrome girl who associated with ASD and PDA. Both infants were diagnosed the apical muscular VSD with echocardiography and left ventriculography. We performed short longitudinal left ventriculotomy which was parallel to the left anterior descending coronary artery between the diagonal branch and left circumflex artery. VSD was closed with Gore-Tex patch using 6-0 prolene buttress stitches. Post operative echocardiography showed good LV contractile function (Ejection Fraction = 71%, 80%), and no residual interventricular shunt. Left ventriculotomy for the apical VSD closure allowed good exposure and did not reduce the LV function even in infants. Therefore, we concluded that left ventriculotomy was an useful procedure for the apical muscular VSD in infants.


Interaction between vascular prostheses and rifampicin in the prevention of the grafts infection. An experimental study.

Infections caused by synthetic prostheses are relatively rare (1.5-6%) but serious complication in vascular surgery. There is no doubt that during and immediately after surgery bacterial contamination may occur. An in vitro study was carried out in the Vascutek laboratories, which revealed a high affinity between prostheses in Dacron gel and Rifampicin. This affinity, the result of an ionic bond, was demonstrated by the fact that after 5 days Rifampicin was still present on the prostheses. Encouraged by this result, an experimental study was carried out in sheep. Five sheep were operated on making a prosthetic graft in both of the common carotid arteries: on one side a Gelseal Dacron prosthesis was implanted after being soaked for 15 minutes in a solution containing 1 mg/ml Rifampicin. A Knitted Dacron prosthesis was implanted in the contralateral carotid artery, again after pretreatment with Rifampicin. Explants were made after 2, 24, 48, 72 and 96 hours, and the concentration of Rifampicin on the prostheses was assessed on the basis of the diameter of the inhibition area on Staphylococcus aureus cultures. The results showed that the Gelseal Dacron prostheses maintained Rifampicin concentrations with an antibacterial activity up to 72 hours; this property disappears with the Knitted Dacron prostheses after only 24 hours. These results confirm the high affinity of Gelseal Dacron and Rifampicin also in in vivo experimental models.


Indobufen vs acetylsalicylic acid plus dipyridamole in long-term patency after femoropopliteal bypass.

To compare the effects of indobufen (INB) with those of ASA+dipyridamole (DP) on graft patency, 113 patients undergoing femoropopliteal bypass surgery were randomly and blindly assigned to treatment with INB 400 mg daily or with ASA 900 mg daily plus DP 225 mg daily. Treatment started 2 days before surgery and lasted for 12 months. All patients underwent two angiographic examinations: the first early after surgery (mean 6 days) and the second at the end of the study (mean 368 days). The 1 year cumulative patency rate for INB was 60% higher but not statistically different from the ASA-DP group (53.2%). The relative risk (INB/ASA+DP) calculated by the Mantel-Haenszel test was 0.86 (confidence limits 0.54-1.35). Only the site of operation (above-knee or below-knee) has a significant prognostic value on the fate of the graft.


[Individualization of operative procedures for uterine prolapse based on categorization using X-ray urethrocystohysterography and postoperative outcomes evaluated with a scoring system].

A urethrocystohysterography (UCHG) and a prolapse scoring system (PSS) have been used to assess the types of uterine prolapse and postoperative outcomes since 1979. UCHG was useful in identifying the type of uterine prolapse and in selecting operative procedure. UCHG was done by injecting contrast medium into the bladder and uterine cavity and inserting a metallic bead chain into the urethra. A lateral pelvic X-ray was then taken at rest and during straining. The length of the uterus (UL), distance from the pelvic outlet (PO) to the bladder base (BB), distance from PO to the uterine fundus (UF), and distance from the ischial spine (IS) to UF were measured on the UCHG. We found that there were three types of uterine prolapse on the UCHG findings, type 1: cervical elongation without descent of uterine fundus and cystocele, type 2: uterine prolapse with moderate descent of uterine fundus and cystocele, and type 3: giant vaginal eversion including completely prolapsed uterus, marked cystocele, enterocele and rectocele. The operative time of vaginal hysterectomy with anterior and posterior colporthaphy (VH with AP repair) correlated well with UL and PO-UF distance on UCHG, and blood loss. Operating time was significantly shorter and amount of blood loss was significantly smaller in cases of Machester operation (cervical amputation, fixation of cardinal ligament stumps to the anterior wall of the remaining cervix and AP repair) than in those of VH with AP repair.(ABSTRACT TRUNCATED AT 250 WORDS)


Plethysmographic findings in normal subjects using a capacitance mode.

A new strain-gauge plethysmographic system, Phlebotest, was evaluated in 19 normal subjects, yielding 38 lower limbs for study. A capacitance mode was used which allowed both the left and right calves to reach their maximal volume expansion before releasing the cuff pressure (60 mmHg in this study). Parameters such as the maximum volume change (V sec), the outflow rate during the first second after deflation (F 1.0), the expelled volume in four seconds (EV 4.0) and the surface area over the curve during the first four seconds after deflation (IND) were automatically calculated and their side differences between the left and right legs were determined respectively. There was a good linear correlation between EV 4.0 and V sec (r = 0.9274, p less than 0.0005) and the EV 4.0/V sec ratio was calculated. In contrast to the previous reports, between three consecutive determinations there were no significant differences in the measurements of these parameters, and V sec consistently kept an identical mean value. These results suggest that using this new system only one determination of calf expansion is required. The reason might be that, in addition to some technical improvements, the computer-controlled capacitance function can secure the optimal venous filling in every determination.


[Evolution and ecological changes of animal viruses].

Although the origin of viruses has not yet been clarified, definite differences in evolutionary patterns have been found among RNA. Retro and DNA viruses. These differences are reflected in infectious diseases. RNA viruses, which have RNA in their genome, replicate many times over in cells within a short period of time, destroying the host cells and causing an acute infection. As the error frequency of RNA replicase enzymes is high, the rate of evolution of RNA viruses is very rapid. Retroviruses also contain RNA as their genome, but the genome RNA is reversely transcribed to the DNA in nuclei and then incorporated into the host chromosome to replicate. The error frequency of reverse transcriptase is also high, and therefore mutations easily occur as well. The transcribed DNA is integrated into host DNA in the nucleus, and it remains in the integrated state for human entire life time, causing chronic disease or developing malignant tumors. As DNA viruses except poxviruses replicate inside the cell nucleus and the error frequency of DNA polymerase is low, the speed of mutation and the degree of resulting diversity are lower than those in the case of the RNA virus. DNA viruses tend to stay inside the body for long periods of time and easily become latent. In this paper, I shall discuss 1) the nature of viruses, 2) the origin of viruses, 3) mutation and recombination, 4) diversity of RNA viruses, 5) quickly changing viral diseases, 6) eradicated viral diseases, 7) chronic and malignant diseases, and 8) control of viral diseases.


[Trophoblast: its functional regulation and pathophysiological profiles].

The trophoblast of the human placenta is composed of two layers: syncytiotrophoblast and cytotrophoblast. Cytotrophoblast displays highly proliferative and invasive properties, while syncytiotrophoblast displays little potential for proliferation. Regulatory factors involved in processes of proliferation and differentiation of the trophoblast still remain to be elucidated. Immunohistologically, myc product was predominantly localized to cytotrophoblastic cells. A close similarity between cytologic localization of myc product and tritiated thymidine labeling of placental explant suggests that myc protein expression is linked to trophoblast proliferation. A similar pattern of cytological localization was observed with the use of anti-PDGF antibody, supporting a possibility that PDGF also plays a role in the trophoblast proliferation. Human trophoblast produces two major proteins, hCG and hPL. hCG stimulates progesterone production by corpus luteum. hPL exerts lipolytic action which assures glucose supply to the fetus. In situ hybridization with cDNA probes for hCG(alpha, beta) and hPL revealed that mRNA expression of hCG alpha and probably hCG beta are initiated before syncytial formation, whereas hPL mRNA is expressed only in fully differentiated syncytiotrophoblast. hCG levels in maternal serum are the highest in early pregnancy and thereafter decline, while hCG alpha and hPL levels increase throughout pregnancy. In patients with choriocarcinoma, serum hPL levels are extremely low despite high levels of hCG. In this context, hCG beta mRNA levels remarkably declined in term placenta compared to early placenta, and hPL mRNA was little observed in choriocarcinoma. EGF and EGF receptor (EGF-R) in 4-5 weeks placenta were almost exclusively localized to cytotrophoblasts, whereas EGF and EGF-R in 6-12 weeks placenta were predominantly localized to syncytiotrophoblasts. In the second and third trimester placentas, EGF was mainly localized to cytotrophoblasts, while EGF-R was predominantly localized to syncytiotrophoblasts. It is of great interest that the cytologic localization of EGF and EGF-R in human placenta varies according to the age of gestation. The fact that mitotically active cytotrophoblasts in 4-5 weeks placenta were positive for both EGF and EGF-R expression suggests that EGF and EGF-R may be involved in the control of multiplication of cytotrophoblasts very early in the first trimester. On the other hand, the fact that mitotically inactive syncytiotrophoblasts in 6-12 weeks placenta were positive for both EGF and EGF-R expression suggests that EGF and EGF-R may play a role in the induction of differentiated function of trophoblast in 6-12 weeks gestation. In fact, EGF stimulated hCG and hPL production and secretion by cultured early placental tissues.(ABSTRACT TRUNCATED AT 400 WORDS)


[Comprehensive study on the expression mechanism of the early pregnancy associated substances and the implication for embryo development--structural determination of early pregnancy factor molecule and analysis of its homologous peptides].

The human early pregnancy factor (EPF) has been solidly isolated under the conditions without loosing its rosette inhibition activity. The activity fraction has been purified as a glycoprotein with 24-30KD molecular weight. The peptide structure was determined in 16 amino acid sequences from N-terminal which was demonstrated to have a strong homology with a part of human epidermal growth factor precursor. This molecule has been identified from the thioredoxin homologous peptide originated from human placenta which has been recently reported as a EPF molecule by Clarke et al. The rabbit in vitro-perfusion experiments have been performed to elucidate the expression mechanisms of EPF activity. EPF has been first detected within 3 hours after fertilization in the local circulation of ovary and oviduct contained embryos. Although the embryo-derived platelet activating factor (PAF) has been known as another preimplantation factor, the exposure of synthetic PAF induced EPF activity. Many other factors should implicate to express the activity and biofunction of EPF. The datas of EPF activity on the human in vitro fertilization and artificial insemination cases suggested that it demonstrated the conceptive circumstances and that EPF might be implicated in some regurations for the pregnancy establishment.


Cerebral SPECT with 99mTc-HMPAO in extracranial carotid pathology: evaluation of changes in the ischemic area after carotid endarterectomy.

The authors report their experience in studying patients undergoing carotid endarterectomy with simple photon emission computed tomography (SPECT). This technique made it possible to identify areas of preoperative cerebral hypoperfusion in 54.8% of the patients which had a good correlation with neurological symptoms. To distinguish gradual changes in the ischemic lesions, a method of assessing the surface of the hypoperfused areas was adopted. In addition, SPECT made it possible to detect a greater number of hypoperfused areas even in sites other than those revealed by CT. Moreover, there was good correlations between the SPECT data and the grade and site of the carotid lesion and the data provided by some intraoperative monitoring procedures. The Authors therefore propose the use of SPECT in the evaluation of patients with cerebrovascular insufficiency following a carotid disease.


[Role of growth factors in the regulation of embryo development and implantation].

Although it has been reported that growth factor and extracellular matrix (ECM) play an important role in the control of cell proliferation and differentiation in general, their involvement in the regulation of early embryogenesis and implantation is poorly understood. In order to clarify the mechanism underlying establishment and maintenance of pregnancy, the effect of EGF, TGF-alpha, TGF-beta, TN (tenascin) on the development of preimplantation embryo and endometrial function were investigated. 1. Growth factors in early embryogenesis. EGF did not exert any significant effect on the development of mouse 2-cell embryo in vitro. RT-PCR revealed the presence of EGFmRNA in blastocyst and 2-cell embryo, in which it may be derived from maternal genome. PA-1 cells, human teratocarcinoma-derived cell line, share biochemical characteristics with embryo developed at and beyond blastocyst stage. Anti-EGF antibody but not EGF exerted inhibitory effect on DNA synthesis in PA-1 cell, which produced and secreted immunoreactive and bioactive EGF and contained high-affinity EGF receptor. These results indicate that autocrine/paracrine mechanism of EGF action may be a key regulation of embryo development at and beyond blastocyst stage. 2. Growth factors and ECM in implantation. The luminal fluid in DES-stimulated mouse uterus contained high concentrations of EGF and TGF-alpha. In vivo administration of EGF, like estrogen, stimulated uterine epithelial proliferation as well as progesterone receptor levels. In vivo administration of anti-EGF antibody or anti-TGF-alpha antibody significantly reduced estrogen-induced labelling index in castrated mouse uterus. The concomitant administration of TGF-beta 1 and TGF-beta 2 with estrogen further stimulated DNA synthesis in the mouse uterus than estrogen alone. These results suggest that growth factors partly may be a mediator of estrogen actions on the uterine cell proliferation and the induction of progesterone receptor, which are important preparative steps for implantation. Northern blotting and in situ hybridization using cDNA probe for mouse prepro EGF revealed the presence of prepro EGFmRNA in the early pregnant mouse uterus, especially in stroma/decidua in Day 6 of pregnancy. EGF and TGF-alpha significantly stimulated trophoblast outgrowth of the mouse blastocyst in vitro in supplementation with 0.1% of fetal bovine serum. The specific binding of EGF was detected in the outgrown trophoblastic cells and inner cell mass of cultured blastocysts by autoradiography. From these findings, it may be possible that EGF produced in stromal/decidual cells exerts stimulatory effect on trophoblast outgrowth, playing an important role in the interaction between embryo and endometrium.(ABSTRACT TRUNCATED AT 400 WORDS)


[Implantation model in vitro].

Implantation is thought to be interactive and synchronized process between mother and embryo, however, the mechanisms of the early implantation process remain unelucidated. Therefore, the effectiveness of in vitro fertilization and embryo transfer is still poor. As a result; immunohistochemically, type IV collagen and other extracellular matrix components were detected mainly below the epithelial layer. Type I and III collagens were detected diffusely in the stromal layer. In the lower stromal layer and superficial myometrial layer, type V collagen was detected. Human endometrial epithelial cells performed the re-epithelialization following glandular formation. Rabbit endometrial cells performed also re-epithelialization following the fold formation. The stromal cells were invaded into the inner layer of the folding. Estrogen added to the culture media stimulated the glandular formation. Progesterone administration after estrogen priming did not affect the glandular formation, however, the proliferation of the superficial epithelium and the re-epithelialized area were increased. Rabbit blastocysts successfully attached and implanted into the reconstructed endometrium. The development of the implanted embryos was morphologically normal. Human cultured trophoblast cells attached, invaded and penetrated into the extracellular matrix components. On the other hand, using type V collagen coated dishes, trophoblast cells could invade the stromal layer, however, type V collagen layer did not permit the trophoblast cells to invade into the collagen layer. In vivo, type V collagen, expressed in the lower stromal layer and the surface of the myometrium, may play a role to maintain the early embryo in the decidual compartment. EGTA inhibited the attachment of the blastocysts. Anti-laminin antibody and RGDS peptide, attachment domain of laminin, also inhibited the implantation. These findings suggested that the Ca2+ dependent process was necessary for the attachment between the trophoblasts and the endometrial cells, and then the implantation process was triggered after the attachment to the laminin in basement membrane. The endometrial tissue, obtained from the infertile patient, was cultured on the basement membrane extract with serially obtained maternal serum. Addition of the maternal serum after proper administration of pFSH, high estrogen conditions were made in the culture dishes. These conditions increased the height of the glandular structure and relatively decreased the area of the surface epithelium. Decreased the area of surface epithelium affected the rate of the attachment. Endometrial cell culture system associated with functional and morphological characteristics was established. Serial observation of the endometrial cells in this system revealed the rabbit and the human implantation process, and the embryo-endometrial interaction.(ABSTRACT TRUNCATED AT 400 WORDS)


Hypertensive ischemic leg ulcer (Martorell's ulcer): a specific disease entity?

Histology of seven clinically diagnosed cases of Martorell's ulcer was compared with that of twenty-seven crural ulcers of venous origin. Although the majority of Martorell's ulcers are accompanied by a longstanding hypertension with markedly elevated diastolic pressure values, the conception of a specific disease entity with a common etiology should be abandoned. Some of the cases may be due to hypertension alone, but others may be caused or at least enhanced by other microvascular disorders.


[Experimental perinatology--development of extrauterine fetal incubation system].

It goes without saying that the ideal situation for the immature fetus is growth within the normal environment of the maternal organism. Thus, in order to perform incubation that more closely resembles that of the fetus in utero, both in the extracorporeal and intracorporeal environment, an extrauterine fetal incubator, consisting of an artificial womb containing artificial amniotic fluid and a complete artificial placental system with a membrane oxygenator, was developed. Although similar experiments were performed in fetal lambs by Callaghan et al., Alexander et al., and Zapol et al., the fetuses only survived incubation for short periods of time, no longer than 55 hours. Previously, we reported the relatively long-term extrauterine incubation of goat fetuses, where by the longest period of incubation was 236 hours. However, several major problems, remained to be resolved. Here we present the case in which we succeeded in incubating a goat fetus for 3 weeks, followed by a trial birth from an artificial womb.


Results of femoropopliteal and femorotibial greater saphenous vein in situ bypass. Life table analysis.

Five-hundred-ninety-four nonselected "in situ" reconstructions were analysed retrospectively using the life table method. Especially after immediate occlusion cumulative patency is very unsatisfactory. After 5 years cumulative patency rate in these cases is 39.5% vs. 64.9% in all cases. Patency rates are influenced by the anastomotic site and the run-off quality. While statistically not significant, popliteal anastomoses perform a little better after 5 years than peripheral anastomoses (67% vs. 51% cumulative patency rate). The number of patent tibial arteries seems to be the most important determinant. In non-occluded run-off cases (three patent tibial vessels) the cumulative patency rate after 5 years is 82.2% vs. 56% in cases with only one patent tibial artery. The difference is statistically significant.


[Roles of calcium ion in reproductive physiology].

Physiological role and importance of calcium ion has been investigated based on the study of the mechanism of muscle contraction. Furthermore, calcium ion has been proved to have a wide variety of biological roles in hormonal secretion, cell proliferation and reproduction as well as in muscle contraction. In this lecture, I would like to show a method to measure intracellular calcium ion concentrations ([Ca2+]i) and to give a general information about the roles of calcium ion to induce various cell activities. Then I would like to talk about the changes in intracellular calcium concentration ([Ca2+]i) and their meaning in the field of reproductive physiology including uterine muscle contraction, pituitary LH secretion, and fertilization. 1) Uterine muscle contraction and calcium ion The function of calcium ion is most intensively investigated in muscle contraction. We show [Ca2+]i increase in cultured myometrial cells. This increase is inhibited by omission of extracellular calcium or addition of calcium channel blockers. These results support usefulness of Ca2+ channel blockers in treating threatened premature delivery. We also report the action of MgSO4 as an inhibitory agent of [Ca2+]i increase stimulated by oxytocin. 2) Pituitary gonadotropin secretion and calcium ion Pituitary LH secretion is regulated by gonadotropin releasing hormone (GnRH). GnRH induces rapid increases and then sustained releases of LH secretion. By the omission of extracellular calcium, or by addition of Ca2+ channel blockers, the sustained phase of LH secretion is abolished. GnRH also increase [Ca2+]i in a very similar manner to that of LH secretion. The [Ca2+]i increase is essential in LH secretion.(ABSTRACT TRUNCATED AT 250 WORDS)


[The present and the future of treatment of male infertility].

About 90% of male infertile patients are complaint of semen with poor quality, and of which majority are caused by idiopathic disturbance of spermatogenesis. To date, various trials have been made to stimulate spermatogenesis by means of pharmaceutical administrations, their efficacies were, however, poor as expected. The treatment of the patients with poor quality semen is, therefore, mainly focused on artificial insemination, such as intrauterine insemination (IUI) and in vitro fertilization-embryo transfer (IVF-ET), etc. (1) To inseminate the sperm artificially, it is necessary to separate progressively motile sperm with normal morphology from seminal plasma, immotile and abnormal sperm, leucocytes and bacteria. There are two methods for separating progressively motile sperm, one is the density gradient centrifugation and another is the diffusion by their own motility. We have developed various types of density gradients using Percoll, a modified silica gel; the mono-layer Percoll method and the cushion method are employed for sperm concentration, and the discontinuous Percoll density gradient with 4 steps and the continuous-step density gradient are capable of separating progressively motile sperm. The continuous-step density gradient have been employed for 271 cases of IUI, and successful 84 pregnancies were obtained with the pregnancy rate of 30.9%. (2) Cryopreservation of sperm produce various advantages in the treatment of male infertility. Cryoaccumulation of oligozoospermic semen is effective for obtaining a sufficient number of sperm, and frequent insemination with cryopreserved sperm increase the chance of fertilization. To improve the quality of cryopreserved sperm, ejaculated semen was concentrated prior freezing by means of the continuous-step density gradient.(ABSTRACT TRUNCATED AT 250 WORDS)


Partial regression of vascular structural alterations in hypertensive patients treated with alpha-beta-blocker, labetalol.

We studied the structural and functional characteristics of the vascular bed at calf level in 46 middle aged hypertensive patients (20 males and 26 females) treated with different beta-blockers. After one week of placebo, the patients were divided into three groups: group 1 was treated with labetalol, an alpha-beta-blocker (200 mg t.t.d.); group 2 was treated with acebutolol, a cardioselective beta-blocker with intrinsic sympathomimetic activity (ISA) (200 mg t.t.d.); group 2 was treated with acebutolol, a cardioselective beta-blocker with intrinsic sympathomimetic activity (ISA) (200 mg t.t.d.); group 3 was treated with metoprolol, a cardioselective beta-blocker without ISA (100 mg t.t.d.). Before and after placebo, and after three months of active drug treatment, we measured blood pressure, and rest and peak flow at the calf level by strain gauge plethysmography. Basal and minimal vascular resistances were calculated as the ratio between mean blood pressure and rest or peak flow, respectively. A significant decrease in blood pressure was observed in each group. However, basal and minimal vascular resistances decreased only in the labetalol-treated group. These observations indicate that antihypertensive agents that have similar effects on blood pressure, may have different effects on minimal vascular resistance. Therefore, maximum vasodilation of arterioles improves, suggesting that long term treatment with labetalol, but not with other beta-blockers is able to induce a partial regression of vascular structural alterations in hypertensive patients.


[Uterine leiomyoma: pathogenesis and treatment].

The pathogenesis of uterine leiomyoma is controversial. Studies on the development of smooth muscle cells in the endoderm-derive ducts (digestive and urinary tracts) and in the mesoderm-derived ducts (mullerian duct) during the fetal period revealed that the development of smooth muscle in the mesoderm-derived ducts (until at least 30 weeks of gestation) is slower than that of smooth muscle in the endoderm-derived ducts (until 12 weeks of gestation). The undifferentiated cells which proliferate and differentiate into smooth muscle in the uterus during the fetal period thus have a longer duration of unstable period being affected by many maternal environmental factors such as sex steroids and/or growth factors. The undifferentiated cells affected by some unknown maternal factors during the fetal period probably become the progenitor cells of leiomyomas. The progenitor cells of leiomyomas probably reside in the myometrium and begin to grow after menarche, and thrive during the years of greatest ovarian activity under the hormonal influence of both estrogen and progesterone, and following the menopause, with regression of ovarian steroids, growth of leiomyomas usually ceases. The growth pattern of leiomyomas indicates that LH-RH analogue, which induces temporal regression of ovarian steroids, becomes one of candidates for the conservative treatment of uterine leiomyomas. However, if we may treat leiomyomas with drugs, the definite diagnosis of uterine leiomyoma is essential. Magnetic resonance imaging (MRI) is a powerful diagnostic method for uterine leiomyomas. MRI gives us an information of the location and numbers of leiomyoma in the uterus. Moreover, it also informs us the characteristics of leiomyomas.(ABSTRACT TRUNCATED AT 250 WORDS)


Acute rupture of an aortic aneurysm mimicking the discus hernia syndrome. A case report.

Aneurysms of the abdominal aorta have been recognised as a cause of back pain and vertebral erosion. However back pain and paraplegia are uncommon, presenting complaints in patients with aortic aneurysms. A case of acute rupture of an abdominal aortic aneurysm is presented mimicking the symptoms of a discus hernia syndrome and paraplegia.


Surgery for cerebral palsy: Part 1. Classification and operative procedures for pronation deformity.

32 patients with cerebral palsy underwent operations for pronation deformity. The deformity is classified into four groups. Patients in group 1 are capable of supination beyond neutral. No surgery is necessary. Those in group 2 are able to supinate to the neutral position. A pronator quadratus release is advised and may be combined with a flexor aponeurotic release. In group 3, patients have no active supination. However a full range of passive supination is readily achieved. A pronator teres transfer is advised. Patients in group 4 have no active supination. Full passive supination may be present, but is tight. A flexor aponeurotic release and a pronator quadratus release may unmask active supinator activity. An active transfer for supination is possible as a secondary procedure.


Surgery for cerebral palsy: Part 2. Flexion deformity of the wrist and fingers.

34 children with cerebral palsy had operations to correct flexion deformities of the wrist and fingers. 30 out of 34 patients were improved functionally and cosmetically. Zancolli's classification provides sound guidelines on which to base surgical decisions.


Madelung deformity: surgical prophylaxis (physiolysis) during the late growth period by resection of the dyschondrosteosis lesion.

The majority of cases of Madelung deformity are caused by hereditary dyschondrosteosis at the wrist. The principal lesion in the ulnar zone of the distal radial physis retards growth asymmetrically, especially in late childhood. Resection of this zone and its replacement with autologous fat (Langenskiöld procedure, or physiolysis) restores growth and minimizes deformity. The resection of an abnormal ligament tethering the lunate proximally may assist carpal advancement. A series of 17 patients (24 wrists) treated over a 12-year period is presented, with sufficient follow-up for evaluation of 11 patients (15 wrists). The results of this prophylactic procedure are encouraging, and, if it is performed early, the authors believe that Madelung deformity may be preventable, or at least controllable.


A review of distal ulnar hemi-resection arthroplasty.

15 patients with pain and disability on the ulnar side of the wrist were treated by distal ulnar hemiresection arthroplasty. The patients' diagnoses fell into three groups, namely ulnocarpal impingement, primary osteoarthritis of the distal radio-ulnar joint and traumatic disruption of the distal radioulnar joint. Patients were assessed pre- and post-operatively on the basis of pain and forearm rotation. Grip strength was assessed and compared with the unaffected side. Their subjective view of the operation was also sought. The best results were seen in those patients with osteoarthritis or traumatic disruption, although all patients were improved and none made worse. No patient complained of weakness although three were assessed to have a weak grip. Subjectively, 14 of the 15 were pleased or very pleased. The procedure was well tolerated and had low morbidity.


The Sauvé-Kapandji operation. Technique and results.

For distal radio-ulnar joint disorders, the Sauvé-Kapandji procedure, previously attributed to Lauenstein, of arthrodesis of the joint and distal ulnar pseudarthrosis is a very useful procedure, yet is not often practised. This paper describes the technique and presents the results of 81 procedures in 71 patients. There was excellent patient satisfaction. The procedure is a reliable and effective method of dealing with distal radio-ulnar joint disorders, especially in rheumatoid arthritis and following distal radial fractures. Some changes to previous techniques are emphasized.


The Herbert bone screw: a ten year perspective.

It is now over ten years since the Herbert bone screw was first released in Australia. In 1984, Herbert and Fisher first published their experience with the use of this new bone screw in the management of scaphoid fractures. Since that time, there has been a growing interest in the technique and over 60 articles have appeared in the English literature. The purpose of this paper is to review and comment on the relevant publications as they relate to the biomechanical properties of the screw, to its use in the management of scaphoid fractures and to other applications in surgery of the hand.


Fracture of the proximal phalanx. An unusual complication of pulley reconstruction in a child.

We report a case of a fracture occurring in the proximal phalanx of a child following pulley reconstruction. The operative technique and the difficulties of pulley reconstruction in the immature skeleton are discussed.


Volar plate arthroplasty for closed proximal interphalangeal joint injuries.

The anatomy and histology of the volar plate at the proximal interphalangeal joint and the mechanism of fracture/subluxation of the base of the middle phalanx in closed proximal interphalangeal joint injuries is reviewed. Our current technique of repair for these injuries and its evolution from Eaton's original procedure is described. The results of 71 cases of volar plate arthroplasty performed over a five-year period for fracture/subluxations of the proximal interphalangeal joints are presented with follow-up ranging from six months to four years. 62 (87%) patients achieved a stable pain-free joint with a range of motion from 5 degrees to 95 degrees within two months. Complications were uncommon and correctable with an overall eventual patient satisfaction rate of 94%.


Intraosseous ganglion cyst of the lunate: diagnosis and management.

Intraosseous ganglion cyst of the lunate is an uncommon lesion and cause of wrist pain. Histopathologically it is identical to the common dorsal wrist ganglion and treatment by arthrotomy, curettage of the ganglion and bone graft resulted in clinical improvement in nine patients, six of whom became symptom-free.


Non-subungual melanomas of the hand.

The non-subungual area of the hand is a rare anatomical site for malignant melanoma, lesions in this site comprising only 0.37% of 8,584 cutaneous melanomas in the Sydney Melanoma Unit database. This is approximately the same frequency of melanoma as is found on the subungual region of the hand, which represents a much smaller surface area. Not only is the sub-site distribution on the hand unusual but in addition the histogenetic types of melanoma found on the dorsum of the hand are not those commonly encountered on sun exposed skin. In this study, comparison is made between melanomas occurring on the non-subungual areas of the hand and those on the foot, an anatomically similar surface area. Comparison is also made between melanomas arising on the dorsal non-subungual surface of the hand and those on the face, a region with an equivalent surface area and similar sun exposure. The results of surgical treatment of 31 melanomas of the non-subungual region of the hand are reviewed.


Complex physical therapy for the lymphoedematous arm.

Complex physical therapy was used in 78 patients with post-mastectomy lymphoedema (17 with grade 1 and 61 with grade 2). This involves: skin hygiene, a special lymphatic massage, compression bandaging and garments, and special exercises which supplement the massage. Two courses of treatment were given, lasting four weeks each, with a year between them. There was a highly significant decrease in the oedema in both grades, with more than 50% removed in the first course of treatment and 50% of the remainder in the second. There was even a small, but very significant decrease during the interval between the two courses.


Iatrogenic injection injuries of the hand and upper limb.

30 cases of iatrogenic injection injuries to the hand and upper limb are reported. 16 followed therapeutic injections (steroids--11 cases, infusions--five cases) and 14 occurred during anaesthetics procedures (local blocks--ten cases, general anaesthetics--four cases). Guidelines for minimizing the risk of injection injury are outlined.


Radical microarteriolysis in the treatment of vasospastic disorders of the hand, especially scleroderma.

Arterial spasm due to exaggerated sympathetic response is an important mechanism for Raynaud's phenomenon in scleroderma associated often with periadventitial scarring. The results of cervical sympathectomy have been unsatisfactory in the upper limb because of additional sympathetic pathways. Flatt therefore devised a distal sympathectomy by stripping the vessels of their adventitia over a short length of artery. The results of this operation were found by Wilgis in a large series to be poor in patients with scleroderma. A radical distal microarteriolysis including adventitia and surrounding scar is described and the results in 13 patients, 11 with scleroderma, are reported. Minimum follow-up is one year. All patients had relief from pain at rest and healing of painful ulceration. Mild recurrence of small ulcers was seen in only four patients.


Regression of Dupuytren's contracture.

The phenomenon of clinical regression of Dupuytren's contracture is described and discussed. It is already recognized and used in fasciotomy where it follows the release of longitudinal tension. The quite extraordinary resolution produced by continuous passive skeletal traction in extension is presented. Regression beneath grafted skin is described and discussed with its clinical implications. The generally accepted view of Dupuytren's contracture being "irreversible" now presents a challenge for further clinical and pharmacological studies. The possibility of non-surgical control does exist.


Silastic replacement of the trapezium.

A retrospective study has been made of the long-term results of silastic replacement of the trapezium, including functional, clinical and radiological assessment of 43 hands, one to 13 years postoperatively. The results showed good function and relief of pain in 88% of hands. Radiolucent bone lesions, presumably due to silastic particle reaction, occurred in 53% of hands, but their presence did not correlate well with symptoms. Four patients (9%) developed significant synovitis which was improved by removal of the prosthesis. In this series, clinical silastic synovitis occurred in the first four years, and its incidence did not increase with further follow-up to 13 years.


Intercarpal arthrodesis by dowel bone grafting.

Successful intercarpal arthrodesis requires a stable fusion with maintenance of correct alignment and spatial relationship of the carpus. The technique described utilizes a series of tube saws to fashion the arthrodesis bed and then insert a sized iliac crest dowel bone graft with a tight interference fit. This technique has been used in 24 patients over a two-year period in both medial and lateral column intercarpal fusions. All wrists had fused by the tenth post-operative month. The technique is precise, reproducible and technically simple with a high fusion rate and minimal donor site morbidity.


The plantaris tendon as a tendo-osseous graft. Part I. An anatomical study.

Comparative studies have shown that bone-bone union develops faster than a junction between grafted tendon and bone, and would thus allow earlier post-operative movement, limiting adhesion formation. In this context the nature of the insertion of the plantaris tendon into the calcaneus is reviewed as a possible source of composite bone-tendon grafts. It is proposed that the composite plantaris tendon with its bony block attachment is inserted through a hole in the distal phalanx of the finger creating an immediate firm distal fixation. From cadaver dissections it was found that in at least 80% of cases the insertion of the plantaris tendon was directly into the calcaneus, independent of the tendo Achilles, and was therefore suitable for use as the proposed tendon graft.


The plantaris tendon as a tendo-osseous graft. Part II. Clinical studies.

To minimize adhesions following tendon repair, early post-operative movement is recommended. This has proved difficult with tendon grafting because of weakness of the repair sites, particularly distally, and because of slow revascularization. A potential solution is the use of a composite tendon-bone graft in which a bone block is attached to the end of the tendon. The tendon is threaded through a hole in the distal phalanx from the dorsal to the palmar side and impacted like a cork to create an immediate strong fixation. The tendon itself is then tunnelled through the pulley system and the proximal repair is carried out with a multiple weave technique which can withstand immediate active movement. The ideal tendon-bone complex is the plantaris attached to a segment of calcaneus. A preliminary report with two case studies is presented.


Abductor pollicis longus: a case of mistaken identity.

Abductor pollicis longus, long regarded as a motor for the thumb, is anatomically and functionally a radial deviator of the wrist and should be so named. The abductor carpi is proposed. If the other radial deviators of the wrist are acting this tendon can be selectively utilized as a transfer without loss of function. Reflex spasm of this muscle probably plays an important role in the radial deviation deformity seen in the rheumatoid hand.


Closed rupture of both flexor tendons in the same digit.

Closed ruptures of both normal flexor tendons in the same finger are extremely rare, only nine cases having been reported in the literature. We describe the case of a patient who sustained a closed rupture of both flexor digitorum profundus and flexor digitorum superficialis of the ring finger, following a forced hyperextension injury. The patient was treated by a two stage reconstruction of the flexor digitorum profundus. He regained full flexion and extension of the finger.


Finkelstein's test: a descriptive error that can produce a false positive.

Over the last three decades an error in performing Finkelstein's test has crept into the English literature in both text books and journals. This error can produce a false-positive, and if relied upon, a wrong diagnosis can be made, leading to inappropriate surgery.