During past 15 years 78 patients were operated for thoracic aortic aneurysm. Patients operated in emergency or dead within 24 hours after operation or with preoperative renal failure were excluded and remaining 65 patients were studied for factors affecting postoperative renal dysfunction. Postoperative renal dysfunction was based on the serum creatinine value which was within normal limit before operation and exceeded 1.5mg/dl after operation, or which increased by 1mg/dl and more from preoperative value. 23 patiens developed postoperative renal dysfunction and the incidence was 35.4%. As preoperative factors, old age, male and high value of preoperative serum creatinine were significantly (p<0.01) related with postoperative renal dysfunction. As intraoperative factor, decreased urine output per operative hour was significantly (0.01<p<0.05) related. Other preoperative factors; hypertension, diabetes, location of aneurysm, dissecting and nondissecting, intraoperative factors; operation time, volume of operative bleeding, minimum systolic blood pressure during operation, clamping time of aorta, minimum temperature of rectum, difference of adjuncts (temporary shunt or extracorporeal circulation), postoperative factors; systolic blood pressure at arriving ICU, urine output of first postoperative day were not significantly related. Between the operative procedures of graft replacement and extraanatomic bypass, no significant difference was recognized in occurrence of postoperative renal dysfunction, but patients with patch angioplasty etc. developed no renal dysfunction. In the complications within one week after operation, central nervous system dysfunction, infection and hemorrhage had a tendency to occur together with renal dysfunction. For prevention of postoperative renal dysfunction it is important to minimize the renal ischemia, to protect the kidney and to maintain urine output during operation, particularly in patients of preoperative decreased function of kidney and of old male with advanced arteriosclerosis. Also it is necessary to choose the less invasive procedure of operation for patients of severely decreased function of kidney and to consider about organ system relations in patients of postoperative renal dysfunction.

Transluminal angioplasty during vascular reconstructive procedures was performed to 18 lesions in 13 patients. Ages ranged from 57 to 81 years with a mean of 72.7 years, and all patients were men. Transluminal angioplasty during the thromboendarterectomy or bypass grafting was performed to 3 patients for inflow dilatation, 3 patients for outflow dilatation and 1 patient for renal artery dilatation. Transluminal angioplasty with thrombectomy for the anastomotic stenoses of EPTFE grafts was performed 11 times for 7 patients. The results of this method for arteriosclerotic lesions were as follows; patency was 100% at 1 year and 80% at 3 year. Four patients died during the follow-up periods and the dilated lesions were all patent at the time of death. The results of this method for anastomotic stenoses were as follows; patency was 34.6% at 6 month and 0% at 10 months. Graft infection occurred in 1 of 4 patients to whom transluminal angioplasty was performed 2 times. The patency of transluminal angioplasty during vascular reconstructive procedures for arteriosclerotic lesions was good. Transluminal angioplasty for anastomotic stenoses was noninvasive and easily performed with the thrombectomy, but the patency was not so good and there was the risk of graft infection by repeated operations.

Thromboexclusion method for thoracic aortic aneurysm was studied in 10 patients who had dissecting aneurysm in 7 and atherosclerotic aneurysm in 3. The aortic aneurysms extended from the left subclavian artery to the diaphragma or more widely. The operations were extraanatomic bypass and permanent aortic clamp proximal to the aneurysm in 9, and proximal and distal to the aneuysm in one. The follow up periods were 14 days to 80 months. Eight patients survived more than 3 months and 5 of them had thromboexclusion of aneurysm to the diaphragma. One with the aneurysms of incomplete thromboexclusion resulted in aneurysmal rupture 28 months after operation, and recovered by additional clamp distal to the aneurysm. Another had aneurysmal rupture, and died 63 months after operation. A patient had the penetration of the clamp to the pulmonary artery, and died 12 months after operation. Temporary paraplegia occurred in a patient 15 months after operation. Two patients developed constipation without ileus. Any difference of blood pressure between upper and lower extremities was not recognized, and no patient had deterioration of renal function. Indication of this method should be strictly selected, and careful follow up study is mandatory.

A recent study evaluated the effect of pleurotomy for harvesting internal thoracic arteries (ITAs) on pulmonary complications after coronary artery bypass grafting (CABG). Fifty consecutive patients with pleurotomy (group I) were studied retrospectively and compared with a control group of fifty patients undergoing CABG without pleurotomy during ITA harvest (group II). Group I was divided into two groups; forty patients using left ITAs with left open pleurotomy (group Ia), and ten patients using bilateral ITAs with bilateral open pleurotomy (group Ib). On the other hand, group II includes 22 patients without pleurotomy (group IIa) and 28 patients with closed pleurotomy (group IIb). In group I, ITAs were dissected from the chest wall with mediastinal pleura and then isolated from the pleura by pleurotomy. Before sternal closure, an L-shaped pleural tube was inserted into the deep costophrenic sinus and the pleurotomy remained open. In group II, ITAs were simultaneously dissected from the chest wall and mediastinal pleura, and if the pleura was damaged, the pleurotomy was approximated before sternal closure. There was no significance in the number of bypass grafts, aortic crossclamp time, cardiopulmonary bypass time and temperature. ITA harvest time with open pleurotomy was shorter than that of closed pleura (15min versus 25min). Postoperatively, the ventilation time and duration of chest drainage also showed no significance, however group Ia and Ib showed significantly more fluid accumulation removed by chest drainage (Ia, 288±193ml; Ib, 285±198ml, versus IIb, 169±98ml). On postoperative day 30 no pleural effusion was observed in group I but it was seen in one case in group IIb which had diaphragm paralysis. In conclusion, open pleurotomy results in minimal pulmonary complications with optimal chest drainage and offers significant advantages for harvesting ITAs.

Ischemic heart disease (IHD) poses a major complicating factor for abdominal aortic aneurysm (AAA) repair. To identify patients with IHD, we evaluated patients scheduled to undergo AAA repair with dipyridamole-thallium scintigraphy (DTS) and coronary angiography (CAG). If indicated, coronary revascularization was performed. Finally, an assessment of the effectiveness of these preventive measures was made. One hundred and ten patients scheduled to undergo AAA repair were identified and treated accordingly over a 20-year period. As the pre-operative evaluation and prophylactic surgical revascularization strategies were instituted in 1983, the patients were divided into 2 groups: 25 patients between 1973-1982 (group A) and 85 patients between 1983-1992 (group B). The mean age of patients in group A was 65.3 years. The male/female ratio within this group was 21:4. One patient in the group had a history of IHD and 9 had hypertention. The mean age of patients in group B was 67.7 years. The male/female ratio within this group was 77:8. Fourteen patients in this group had a history of IHD and 27 had hypertension. Screening and treatment of IHD in group B was as follows. All patients with a history of IHD underwent CAG. Of the 32 patients with cardiac risk factors, including hypertension and hyperlipidemia, or ECG abnormalities who underwent DTS, 8 were referred for CAG. Thirty-nine patients with no risk factors and a normal ECG proceeded to AAA repair without further workup. Perioperative myocardial infarction occurred in 2 patients in grouzp A, leading to death in 1 patient. Coronary revascularization was performed in 5 patients in group B. No perioperative myocardial infarction occurred in this group. Pre-operative identification of high-risk cases with DTS, CAG, and coronary revascularization in patients with IHD may prevent cardiovascular complications in patients undergoing AAA repair.

OBJECTIVE: To examine the surgical-pathological predictors of para-aortic lymph node (PAN) metastasis at radical hysterectomy, and for PAN recurrence among women who did not undergo PAN dissection at radical hysterectomy. METHODS: This is a retrospective analysis of a nation-wide cohort study of surgically-treated stage IB–IIB cervical cancer (n=5,620). Multivariate models were used to identify independent surgical-pathological predictors for PAN metastasis/recurrence. RESULTS: There were 120 (2.1%) cases of PAN metastasis at surgery with parametrial involvement (adjusted odds ratio [aOR]=1.65), deep stromal invasion (aOR=2.61), ovarian metastasis (aOR=3.10), and pelvic nodal metastasis (single-node aOR=5.39 and multiple-node aOR=33.5, respectively) being independent risk factors (all, p<0.05). Without any risk factors, the incidence of PAN metastasis was 0.9%, while women exhibiting certain risk factor patterns (>20% of the study population) had PAN metastasis incidences of ≥4%. Among 4,663 clinically PAN-negative cases at surgery, PAN recurrence was seen in 195 (4.2%) cases that was significantly higher than histologically PAN-negative cases (2.5%, p=0.046). In clinically PAN-negative cases, parametrial involvement (adjusted hazard ratio [aHR]=1.67), lympho-vascular space invasion (aHR=1.95), ovarian metastasis (aHR=2.60), and pelvic lymph node metastasis (single-node aHR=2.49 and multiple-node aHR=8.11, respectively) were independently associated with increased risk of PAN recurrence (all, p<0.05). Without any risk factors, 5-year PAN recurrence risk was 0.8%; however, women demonstrating certain risk factor patterns (>15% of the clinically PAN-negative population) had 5-year PAN recurrence risks being ≥8%. CONCLUSION: Surgical-pathological risk factors proposed in this study will be useful to identify women with increased risk of PAN metastasis/recurrence.
Cohort Studies ; Female ; Humans ; Hysterectomy ; Incidence ; Lymph Nodes ; Neoplasm Metastasis ; Odds Ratio ; Recurrence ; Retrospective Studies ; Risk Factors ; Uterine Cervical Neoplasms

Objective: The practices pertaining to hereditary breast and ovarian cancer (HBOC) in Japan have been rapidly changing owing to the clinical development of poly(ADP-ribose) polymerase inhibitors, the increasing availability of companion diagnostics, and the broadened insurance coverage of HBOC management from April 2020. A questionnaire of gynecologic oncologists was conducted to understand the current status and to promote the widespread standardization of future HBOC management. Methods: A Google Form questionnaire was administered to the members of the Japan Society of Gynecologic Oncology. The survey consisted of 25 questions in 4 categories: respondent demographics, HBOC management experience, insurance coverage of HBOC management, and educational opportunities related to HBOC. Results: A total of 666 valid responses were received. Regarding the prevalence of HBOC practice, the majority of physicians responded in the negative and required human resources, information sharing and educational opportunities, and expanded insurance coverage to adopt and improve HBOC practice. Most physicians were not satisfied with the educational opportunities provided so far, and further expansion was desired. They remarked on the psychological burdens of many HBOC managements. Physicians reported these burdens could be alleviated by securing sufficient time to engage in HBOC management, creating easy-to-understand explanatory material for patients, collaboration with specialists in genetic medicine, and educational opportunities. Conclusion Gynecologic oncologists in Japan are struggling to deal with psychological burdens in HBOC practice. To promote the clinical practice of HBOC management, there is an urgent need to strengthen human resources and improve educational opportunities, and expand insurance coverage for HBOC management.

Inflammatory bowel disease (IBD), including Crohn's disease (CD) and ulcerative colitis (UC), is a chronic inflammatory disease of the gastrointestinal tract, with increasing prevalence worldwide. IBD Ahead is an international educational program that aims to explore questions commonly raised by clinicians about various areas of IBD care and to consolidate available published evidence and expert opinion into a consensus for the optimization of IBD management. Given differences in the epidemiology, clinical and genetic characteristics, management, and prognosis of IBD between patients in Japan and the rest of the world, this statement was formulated as the result of literature reviews and discussions among Japanese experts as part of the IBD Ahead program to consolidate statements of factors for disease prognosis in IBD. Evidence levels were assigned to summary statements in the following categories: disease progression in CD and UC; surgery, hospitalization, intestinal failure, and permanent stoma in CD; acute severe UC; colectomy in UC; and colorectal carcinoma and dysplasia in IBD. The goal is that this statement can aid in the optimization of the treatment strategy for Japanese patients with IBD and help identify high-risk patients that require early intervention, to provide a better long-term prognosis in these patients.
Asian Continental Ancestry Group ; Colectomy ; Colitis, Ulcerative ; Colorectal Neoplasms ; Consensus ; Crohn Disease ; Disease Management* ; Disease Progression ; Early Intervention (Education) ; Epidemiology ; Expert Testimony ; Gastrointestinal Tract ; Hospitalization ; Humans ; Inflammatory Bowel Diseases* ; Japan* ; Prevalence ; Prognosis

Background/Aims: PF-00547659 is a monoclonal antibody against human mucosal addressin cell adhesion molecule-1 (MAdCAM-1) that prevents the binding of α4β7+ lymphocytes to MAdCAM-expressing sites in the gastrointestinal tract with high affinity and selectivity, and is being developed for the treatment of Crohn’s disease (CD). Methods: OPERA is a randomized, multicenter, double-blind, placebo-controlled study to investigate the efficacy, safety, and pharmacokinetics of PF-00547659 following subcutaneous administration in subjects with active CD, a history of failure or intolerance to anti-tumor necrosis factor and/or immunosuppressants, high-sensitivity C-reactive protein > 3.0 mg/L, and ulcers on colonoscopy. The primary endpoint was Crohn’s Disease Activity Index-70 response at week 8 or 12. Subpopulation analyses for Asian subjects were performed as some differences are observed in genetics and clinical phenotypes in Asian CD patients compared with Western patients. Results: In this study, 265 CD subjects were randomized, with a subpopulation of 21 subjects (8 Japanese and 13 Korean) defined as the Asian population. In the overall and Asian populations; PF-00547659 was pharmacologically active as evidenced by soluble MAdCAM and circulating β7+ central memory CD4+ T-lymphocytes, although no clear evidence of efficacy was observed in any clinical endpoints; pharmacokinetics of PF-00547659 in the Asian subpopulation was generally comparable to the overall population; and the safety profile of PF-00547659 appeared acceptable up to 12 weeks of treatment. Conclusions In the overall and Asian populations, efficacy of PF-00547659 could not be demonstrated using any clinical endpoints compared with placebo. Pharmacokinetics and safety of PF-00547659 were generally comparable. Further studies with larger numbers of patients are required to confirm our results. (Trial Registration Number: NCT01276509)