A 67-year-old man was admitted to our emergency room with strong chest and stomach pain. Electrocardiography and echocardiography revealed myocardial infarction of the anterolateral wall and cardiac tamponade. To investigate the cause of cardiac tamponade, we recommended 16-slice-non-gated MDCT. However, this revealed no aortic dissection, but did show loss of contrast in the anterior apex myocardial wall, diffuse stenosis of the LAD (left anterior descending artery ; Seg.7) and occlusion of D2 (second diagonal branch). A definitive diagnosis of blow-out type free wall rupture of the left ventricle was obtained. In the operating room, pulseless electrical activity (PEA) developed, so median sternotomy was immediately performed and bleeding from the anterolateral wall was found. After establishing extracorporeal circulation, surgical repair with a direct mattress suturing technique using felt-strips and CABG (SVG to #8) were performed. Complete hemostasis was achieved. The postoperative course was eventful : respiratory dysfunction due to deteriorating interstitial pneumonia developed. However, MDCT is a useful and non-invasive tool for the immediate detection of ventricular rupture and acute dissection of the ascending aorta, both of which may be the cause of cardiac tamponade.

The excellent long term-patency rates achieved using the internal thoracic arteries (ITAs) have expanded the variety of graft arrangements of these conduits for multivessel coronary revascularization. We encountered 2 patients who underwent multivessel coronary artery bypass, by using these terminal branches of the left ITA effectively. In both patients, LITAs were taken down using the skeletonization technique with a harmonic scalpel. One patient had 2 grafts using the off-pump technique with the Y-composite grafts constructed by the main LITA trunk and LITA terminal branch, which were anastomosed with the left anterior descending branch (LAD) and diagonal branch (D₁), respectively. The other patient had 6 grafts under on-pump cardiac arrest, including the natural LITA terminal branches which were anastomosed with the LAD and D₁. Postoperative multidetector computed tomography (MDCT) revealed excellent long-term patent grafts in both patients. In conclusion, the terminal branches of the ITA, if of suitable size and length, could be used effectively to construct a Y-anastomosis for the coronary arteries, when consideration for the size of the target coronaries and native-coronary blood flow competition.

This report describes the surgical technique for partial left ventriculectomy (PLV) and perioperative management. We have performed PLV to treat end-stage non-ischemic cardiomyopathy in 6 patients (4 men and 2 women, mean age: 59 years) since February 1998. Preoperative New York Heart Association (NYHA) functional class was III or more in all patients. On echocardiography, the mean left ventricular diastolic dimension was 75mm, and the mean ejection fraction was 29%. One patient was operated on with cardiogenic shock, and 5 were elective cases. A wedge of the left ventricular muscle was removed from the apex to the base of the two papillary muscles. Associated surgical procedures were as follows; mitral valve reconstruction in 5 patients (4 replacements and 1 annuloplasty), tricuspid annuloplasty in three, and aortic valve replacement in one. Five elective patients were successfully weaned from cardiopulmonary bypass, but one emergency surgery case required intraaortic balloon pumping. Two patients died in the hospital: one elective case was due to multiple organ failure, and one emergency case due to low output syndrome. Three of 4 survivors returned to NYHA functional class I-II, and 1 remained in class III. We are very cautious to ensure that extended PLV does not to lead to serious diastolic dysfunction. The complete reconstruction of the mitral valve and the preservation of annular-chordal-papillary muscle continuity result in the maintenance of left ventricular function and geometry. The practical principles in the post-PLV period are to maintain adequate preload and to avoid excessive afterload. Further studies are required to further enhance outcome.

It is a common notion that the right gastroepiploic artery (RGEA) tends to exhibit more hardening than the internal thoracic artery (ITA) and that it shows varied development among patients, since RGEAs are structurally rich in musculature. Therefore, a preoperative examination should be conducted to determine whether or not they are appropriate for grafting. In general, catheter-angiography is widely employed for such examinations. Our recent research on the availability of CT-angiography as an alternative has revealed that CT-angiography is a minimally-invasive, simple way of testing, and provides very clear and detailed angiographical pictures. We therefore concluded that it was a highly effective method in deciding the appropriateness of RGEA for graft.

We report a case of total aortic arch replacement for ruptured aortic arch aneurysm in an oldest-old person. The patient was a 92-year-old woman with hypertension, who had normal daily activity. She consulted another hospital because of hemoptysis. A chest roentgen exam showed an outpouching of the first left arch. In our hospital, chest computed tomography revealed a saccular thoracic aortic aneurysm, 43mm in maximum diameter, which seemed to be the cause of hemoptysis. The patient and her family wanted to have operation. While waiting for the operation, she coughed up a large amount of blood and suffered respiratory failure, requiring a mechanical respirator. Two days later, in the operation room, she coughed up a large amount of blood again and suffered long term hypoxygenation. Though she underwent total aortic arch replacement, she developed septic shock with MRSA pneumonia. However, she was weaned from ventilatory support on the 24th postoperative day. On the 86th postoperative day, ambulatory was possible. She had no ischemic cerebral damage. In extensively elderly patients, careful attention must be paid to decide an the indications for highly invasive surgery such as total aortic arch replacement.

We performed redo off-pump coronary artery bypass (OPCAB) through a left thoracotomy using a PAS·Port system for proximal vein graft anastomoses for a patient with symptomatic ischemia in the left circumflex system. A 60-year-old man underwent OPCAB (LITA-LAD, RA-4PD) 7 years previously. Coronary angiography revealed a remarkable lesion in the left circumflex system, but the left internal thoracic artery graft (ITAG) and the radial artery graft (RAG) were patent. OPCAB was performed through a left thoracotomy to avoid injury to the patent grafts. With the heart beating, a saphenous vein graft (SVG) was anastomosed sequentially from the descending aorta to the first and second obtuse marginary arteries. Avoiding descending aortic clamping, a proximal anastomosis was made using the PAS·Port system and the SVG was routed anterior to the pulmonary hilum. The postoperative course was uneventful and he was discharged on the 22nd postoperative day. Cardiac CT showed patent SVG and adequate proximal anastomosis. In this case OPCAB through left thoracotomy was effective. The selection of the graft inflow source and bypass routes according to the individual patient is essential for the success of the procedure.

Malignant pericardial mesothelioma was successfully resected in a 70-year-old man, who had been admitted complaining of palpitation. Chest X-ray films showed slight cardiac enlargement. A moderate amount of pericardial effusion was noted by echocardiography. Chest X-ray commputed tomography and MRI revealed a localized pericardial tumor. Total excision of the tumor was accomplished through a left thoracotomy approach because the tumor showed neither invasion to the myocardium nor dissemination to the pericardium. The patient was discharged following an uneventful postoperative course. No sign of recurrence has been encountered for nine months after surgery. However careful observation is needed.

A total of 478 resected gastric cancer cases were studied. The male-female ratio was 1.6, -294 males and 184 females. The patients were divided into two groups, namely, the elderly group (patients aged 70 and over) and the non-elderly group (patients aged 69 and below). In the elderly group males were predominant over females. The number of elderly patients accounted for 34.1% of the total number of stomach cancer cases. This percentage is higher than the national average. In the elderly group, cases detected by stomach health screening or health diagnosis tests were a few, but many cases were in stage IV. The number of inoperable cases was somewhat high, radical gastrectomy was performed on a few of the patients, and the resection rate was somewhat low. A tendency was observed for multiple cancer focuses ; in regard to the regions of occupation or spreading and tissue type, the upper region was less likely and the lower region was more likely to be affected, the anterior wall and the circle were likely to be affected. A tendency was observed for the localization of highly differentiated tissue in the patients. Although no difference was observed in the direct surgical mortality rate, the 5 year survival rate was unfavorable, suggesting the patients might have died due to other diseases. In the elderly group, those who suffered from diseases and preoperative complications comprised 92% of the total, and abnormalities during preoperative examinations were detected in 96% of these patients. Postoperative complications developed in 42%. Postoperatively, psychological problems must be taken into consideration. In elderly patients who are operable, although it is desirable to actively perform surgery aiming at radical operations, it is thought necessary to cope carefully with resection of the stomach. If a radical operation is performed after carefully evaluating preoperative risks and with adequate preparations, it is thought possible for elderly patients to achieve favorable therapeutic results and improvement in their QOL differing little from non-elderly patients.

Study was made on total of 304 cases of cancer of the large intestine resected during the period of 12 years from 1978 to 1989.
Colon cancer accounted for 56.8% of the total and rectal cancer 43.2%. There were no sexual differences. Those people aged 50 and older represented 86.0% of the total number of the cases. By age group, those in their 60s topped the list with 27.3%, followed by those in 70s with 24.4%. Almost all the cases (95.1%) were of the patients who had visited the hospital, having noticed symptoms themselves. A very few cases were detected among the people without subjective symptoms when they received group medical Checkups.
By region, 39.4% of the colon cancer cases were found in S, followed by A. In the cases of rectum cancer, Rb accounted for 50.7%. Of the total caces, 74.5% had cancer on the left side of the large intestine.
Resection rate was 91.5%. The rate of resection leading to cure was 71.8%. Broken down by histological staging, stage I came to 11.7%; stage II, 30.9%; stage III, 21.8%; stage IV, 11.7%; stage V, 23.8%.
The 5-year-survival rete averaged 57.1%. In pre-surgery tests, the positive rate of CEA was as low as 46.6%. The positive rate for early cancer was extremely low. Measurement of CEA levels as an auxiliary diagnosis, therefore, did not prove itself to be useful in searching for cancer.