We report a patient who was successfully treated with a herbal formulation of goreisan (Wu-ling-san) for recurrent vomiting associated with pyloric stenosis, with significant simultaneous improvement of congestive heart failure.
A 78-year-old woman was in a bedridden state after cerebral infarction and was being fed through a nasal tube. She often experience repeated vomiting and aspiration pneumonia. Cicatricial stenosis was found in the pyloric region and we performed an expansion operation with balloon endoscopy. However, symptoms did not improve and her heart failure worsened. Therefore, we administered goreisan. Urinary output volume increased, edematous changes gradually disappeared, and pleural effusion decreased. The stenosis-related lesion did not change, but the vomiting ceased, even after nasal tube feeding was resumed.
Goreisan is an herbal formula used to promote diuresis that is considered to correct water absorption in digestive organs. In this case, goreisan was effective for the improvement of many symptoms.

We report a case of chronic heart failure with hypotension, successfully treated with goreisan (Wu lin san).In this case, goreisan improved both the heart failure symptoms and water regulation. This 91-old woman had been receiving treatment for congestive heart failure, mitral regurgitation, aortic regurgitation and atrial fibril lation, and had undergone pacemaker implantation due to sick sinus syndrome. She underwent repeated hospi talization due to aggravation of her chronic heart failure. She was re-admitted because of systemic edema as well as exacerbation of heart failure symptoms which included pleural effusions. Blood pressure remained constant at about 80/50 mmHg. She was prescribed furosemide 40 mg. Thereafter, cerebral infarction compli cations arose. Therefore, it became difficult to increase the quantity of diuretics. We administered goreisan without change to the other oral medications. Many of her symptoms improved and the pleural effusion resolved without affecting blood pressure.
Goreisan is one representative herbal formula for promoting diuresis. In this case, it is thought that goreisan showed actions that influenced water regulation.

We report a patient with Multiple system atrophy that was successfully treated with the herbal formulation Hachimijiougan.A 79-year-old man was hospitalized with Multiple system atrophy. He showed slow movement, frozen gait, finger tremor, dizziness on standing up with slowly progressive characteristics. Various medications had been administered for orthostatic hypotension, but the effect was insufficient.So we administered Hachimijiougan without changing the other oral medications. After administration, orthostatic hypotension was improved, and he became able to perform various activities of daily living.In this case, we thought that Hachimijiougan improved autonomic nervous system disorders such as the orthostatic hypotension in a patient with Multiple system atrophy.

A 75-year-old man received a diagnosis of an abdominal aneurysm and underwent abdominal aortic replacement. His left internal iliac artery was sacrificed because of the difficulty of reconstruction. Rhabdomyolysis of the left gluteus muscle resulted in acute renal failure (ARF) postoperatively. Continuous hemodiafiltration (CHDF) was performed from postoperative day (POD) 1 through POD 10 for the management of his ARF. During CHDF, the maximum value of serum creatinine was 5.10 mg/dl and it returned to the normal range of 1.10 mg/dl on POD 20. We conclude that the early deployment of CHDF was effective in rhabdomyolysis-induced ARF.

An emergency percutaneous cardiopulmonary support system (PCPS) was employed 11 arrest victims (5 males, 6 females; mean age 59.3 years) refractory to conventional resuscitation measures. Cardiac operation was subsequently performed in two patients and coronary angioplasty in two. The 7 other patients continued on cardiopulmonary support by PCPS after successful resuscitation. Duration of support was 10.5±9.1 (mean±S. D.) hours, the flow rate was 2.5±0.7l/min, and PCPS was applied 5-70min (mean, 24.9min) following the onset of cardiac arrest. The entire intraluminal surface of PCPS device had been heparin coated, activated coagulation time was maintained about 150 seconds, with or without minimal systemically administered heparin. Seven of 11 patients (63.6%) were successfully weaned from the PCPS. The early survival (<30 days) was 6 patients (54.5%), and late survival was 4 patients (36.4%). We conclude that PCPS can improve survival in patient unresponsive to conventional resuscitation when instituted soon after cardiac arrest.

Between December of 1989 and May of 1993, 7 of 338 patients (2.1%) who underwent median sternotomy for cardiac operations developed mediastinitis. All of these infections caused by Staphylococcus species. Six of seven patients with mediastinitis were successfully treated with debridement, irrigation and omental transposition into the mediastinum. Between December of 1989 and May of 1992, sterile bone wax was used as a hemostatic agent in 233 of these patients. Between June of 1992 and May of 1993 an argon beam coagulator was used in place of bone wax in 105 patients. The incidence of mediastinitis significantly differed in relation to whether patients received bone wax or not (7 of 233 patients who did (3.0%) versus none in 105 patients who did not (0%) p<0.01). We conclude from this study that bone wax may be a promoting agent in postoperative mediastinitis, so the routine use of bone wax should be reconsidered.

Bypass grafting from the ascending thoracic aorta to the common iliac artery was performed to manage proximal hypertension in a patient with atypical coarctation of the thoracic aorta. The patient's history was significant for an acute aortic thrombosis at the level of the diaphragm for which she underwent an axillo-bifemoral bypass grafting as an emergency operation. Although she was doing well following the initial bypass grafting, the second bypass grafting was required to treat proximal hypertension refractory to medical management. The axillo-femoral bypass graft had a smaller diameter and a longer subcutaneous distance, and the blood supply to the abdominal viscera may have been insufficient. The proximal hypertension was well controlled following ascending thoracic aorta to common iliac bypass, because the diameter (16mm) of the graft is larger than that of the axillo-bifemoral bypass graft (8mm).

Dacron prostheses are the most widely used grafts in replacement procedures for abdominal aortic aneurysms, but they are not perfect grafts. We encountered a rare case of late graft complication. A 66-year-old man was admitted to our hospital with a pulsatile mass in an abdominal operation scar. He had received placement of a Y-shaped Cooley double velour knitted Dacron graft 18 years previously. Computed tomography and angiography demonstrated graft dilatation and an aneurysm. After resection of the graft aneurysms, the operative findings showed a non-anastomotic aneurysm formation due to longitudinal division near the graft guideline. In this case, this graft failure may have been due to the deterioration of the filter of the Dacron prosthesis itself. Therefore it is important to perform careful long-term follow-up in patients with implanted Dacron arterial prostheses.

Abdominal aortic aneurysms (AAA) are frequently associated with clinically significant coexistent ischemic heart disease (IHD). Cardiac events are the most common cause of death after AAA repair. Preoperative coronary evaluation and revascularization have been recommended to reduce postoperative cardiac complications following AAA repair. In this study, we retrospectively reviewed all patients who underwent AAA repair and compared operative results in patients with and without IHD. Of 388 patients who underwent elective AAA repair, 382 (98.5%) had aortography and coronary angiography for preoperative evaluation. Significant coronary artery disease was seen in 124 patients (32.5%). As a result of the evaluation, 46 patients (12.0%) were considered candidates for medical therapy, 18 for percutaneous coronary intervention (PCI), and 60 for coronary artery bypass grafting (CABG). In 24 patients (6.3%) who needed CABG and had large sized AAAs (>60mm), simultaneous CABG and AAA repair were performed. In the remaining 36 patients (9.4%) who needed CABG and had medium sized AAAs (40mm<, <60mm), staged operation was performed. We performed retrospective review comparing postoperative cardiac events and operative mortality among these treatment groups. There were 5 operative deaths (5/388, 1.3%) in patients following AAA repair. There were 2 operative deaths (2/124, 1.6%) in patients with significant IHD and 3 deaths (3/258, 1.2%) without IHD. In patients with IHD, 1 patient who received medical therapy died of acute renal failure and another one who received PCI died of acute myocardial infarction. There were no operative deaths or cardiac-related events in patients who received CABG before or concomitant AAA repair. There was only 1 cardiac-related event in all patient groups following AAA repair. Coronary arteries were preoperatively evaluated in almost all patients with AAA. If IHD was significant, the treatment for the IHD preceded AAA repair. Our strategy succeeded in reducing operative mortality and cardiac-related events in patients with both AAA and IHD. If a patient with a large sized AAA (>60mm) needs CABG, one-stage operation is recommended.

A chronic traumatic thoracic aortic aneurysm, 19 years after a traffic accident was successfully treated. A 34-year-old man was admitted because of chest discomfort. An upper GI examination was performed and an esophageal submembranous tumor was suspected. However, a chest CT examination showed a thoracic descending aortic aneurysm, the maximum size of which was 7.5cm×5.5cm. The final diagnosis was chronic traumatic thoracic aortic aneurysm. Generally most cases of chronic traumatic thoracic aortic aneurysm have no symptoms for a long time after an accident. However, some have reported that the development of an aneurysm is due to not receiving treatment. We performed graft replacement using the temporary bypass method because it was an easy technique and required less heparinization. Chronic thoracic aortic aneurysms have lower risk of bleeding during the operation than acute cases. For chronic cases which have stable hemodynamics, adjunctive methods (e. g., partial extracorporeal bypass, left ventricular bypass and temporary bypass) may facilitate a safe operation.