An 84-year-old man with a thoracic aortic aneurysm underwent total arch replacement with selective antegrade cerebral perfusion. Immediately after the operation, respiratory distress and hypotension developed and Chest X-ray films and computed tomography showed bilateral lung edema. Echocardiography showed a small, underfilled left ventricle, but with preserved systolic function. We suspected transfusion-related acute lung injury (TRALI), and started sivelestat and steroid pulse therapy. His respiratory condition gradually improved, and he was discharged on postoperative day 78. The diagnosis of TRALI was confirmed by positive test results of an HLA class I antibody in the transfused fresh frozen plasma and T- and B-cells of the patient. TRALI should be considered as a cause of acute lung injury after surgery with blood transfusion.

To evaluate the efficacy of the retroperitoneal approach (RP) when compared with the transperitoneal approach (TP) in elective aortoiliac reconstruction, 41 cases were reviewed. From February 1987 through October 1991, 16 patients underwent aortoiliac reconstruction through the TP approach and 25 patients underwent operation through the RP approach for abdominal aortic aneurysms (AAA). The TP approach was associated with larger intraoperative blood loss (648.6±416.5ml) when compared with the RP approach (357.7±208.9ml) (p<0.01). The TP approach was associated with greater intraoperative blood transfusion (2093.8±1179.0ml) when compared with the RP approach (1010.4±905.3ml) (p<0.01). Both groups had similar operative times. Postoperative initiation of oral water intake was prolonged in the TP group (50.2±27.4hr) when compared with the RP group (22.3±8.9hr) (p<0.01). Postoperative initiation of walking training was prolonged in the TP group (88.7±37.1hr) when compared with the RP group (60.1±23.2) (p<0.01). This experience demonstrates that the RP approach is a preferable alternative to the TP approach in elective aortoiliac reconstruction.

We developed a new double-lumen balloon catheter for retrograde cerebral perfusion (RCP) via jugular vein cannulation. Between November 1996 and September 2000, 34 of 73 patients treated with surgical procedures for thoracic aortic aneurysms underwent RCP using the new catheter during circulatory arrest under deep hypothermia. Nine patients underwent a median sternotomy, and 25 underwent a left thoracotomy. In all cases, the new catheter installation under fluoroscopy was easy, and it took about 15min. The mean RCP time, pressure, and flow rate were 26.8min, 20.0mmHg, and 202.6ml/min, respectively. Our procedure using the new catheter was safe and easy in RCP during circulatory arrest in aortic arch replacement regardless of surgical approaches such as a left thoracotomy or median sternotomy.

Our strategy for treatment of thoracic aortic aneurysms with severely stenotic or occluded cerebral vessels is as follows. 1) The status of cerebral vessels and brain is assessed in detail by a team of neurologists and neurosurgeons, 2) cerebral surgical treatment is performed prior to aortic arch surgery, and 3) reconstruction of the total arch is performed using the arch-first technique through a median sternotomy. We successfully performed artificial graft replacement of the total aortic arch in two patients with old cerebral infarcts and severely stenotic cerebral vessels. In both cases, the operation was performed through median sternotomy under circulatory arrest by feeding the blood to the ascending aorta and draining it from the right atrium. Cerebral protection during reconstruction of the aortic arch was provided by profound hypothermia and retrograde cerebral perfusion (RCP). Prior to the incision of the aneurysm, cerebral branches were dissected to avoid escape of debris into cerebral vessels. The graft replacement was completed in 4 steps: 1) anastomosis of each of the 3 arch vessels, 2) distal anastomosis of another graft for the elephant trunk procedure, 3) anastomosis of the arch graft and the graft for the elephant trunk, and 4) proximal anastomosis. Just after cerebral branches were anastomosed to the 3 branches of the graft, the blood was supplied to the brain through the side branch of the graft instead of RCP. No signs of neurological deficit occurred postoperatively. The above protocol provided protection of high-risk patients with old cerebral infarcts from possible postoperative brain damage.

From May 1975 to August 1991, 90 patients (56 males and 34 females) underwent Bentall's operations or its modified technique. In our modified technique the coronary ostium is cut out like a button and anastomosed to the aortic graft and aortic grafts are not wrapped by the aortic wall. Preoperative diagnoses were AAE (25 patients, 28%), Stanford type A dissection (19, 21%), Marfan's syndrome (16, 18%), aortitis syndrome (12, 13%), AR+ascending aortic aneurysm (6, 7%), syphilitic aortitis (5, 6%), AS+ascending aortic aneurysm (3, 3%), Valsalva's sinus aneurysm (2, 2%) and other diseases (2, 2%). The hospital mortality rate was 17% (15/90) for all cases. The hospital mortality for aortic dissection (37% (7/19)) and reoperation cases (75% (3/4)) were very high. There were 10 cases of late death and the 10 year actuarial survival rate was 66.3%. Among 11 cardiovascular events which occured in the late phase, 5 were dissection at other aortic sites in the type A dissection and Marfan syndrome cases, and 3 were pseudoaneurysm formation at the site of coronary or the aortic anastomosis in the aortitis syndrome cases, and a detachment of the composite graft in the Marfan's syndrome cases. The 10-year event-free rate was 92.0% for non-specific AAE, 68.8% for aortitis syndrome, 61.9% for Marfan's syndrome and 47.3% for Stanford type A dissection. Non-specific AAE had excellent long-term results, but Marfan's syndrome and dissection had poor results. The button technique for coronary reconstruction is effective for all cases and its long term results are good, but, even with this technique, coronary pseudo-aneurysm occured in cases of aortitis syndrome.

The new St. Jude Medical aortic valve graft prosthesis was evaluated for composite graft replacement of the aortic root in 32 patients at three institutions. This study was performed in conformity with the Japanese Drugs, Cosmetics and Medical Instruments Act. The grafts were preclotted with blood of serum albumin: coronary artery reconstruction was performed employing the classical Bentall procedure (4 cases), Cabrol's procedure (14 cases), the interposition graft technique (8 cases) or the button technique (6 cases); concomitantly the aortic arch was replaced in one patient, and the mitral valve was replaced in two patients. One early death (3%) occurred as the result of shock sustained prior to establishing cardiopulmonary bypass. Postoperative complications included perivalvular leakage (one case), perioperative myocardial infarction (two cases), hepatitis (one case). There were no late deaths and no complications related to the SJM valve graft prosthesis. The SJM valve graft prosthesis is a safe and reliable prosthesis for use as a composite graft replacement of the aortic root.

We have used two methods for education of pathology at the Yokohama City University School of Medicine: 1) clinicopathological conferences on autopsy cases and 2) journal club using “Case Records of the Massachusetts General Hospital” published in the New England Journal of Medicine. Both methods are extremely effective for stimulating students' enthusiasm for learning, improving presentation skills, and consolidating the minds of students as future medical staff members. Furthermore, journal club enhances the affinity for reading medical English.

OBJECTIVE: The aim of this study was to evaluate the clinical behavior and management outcome of recurrent endometrial stromal sarcoma (ESS). METHODS: A retrospective review of charts of 10 patients with recurrent ESS was performed and relapse-free interval, relapse site, treatment, response to treatment, duration of follow-up and clinical outcome extracted. Survival outcome measures used were post-relapse survival which was defined as the time from first evidence of relapse to death from any cause. Living patients were censored at the date of last follow-up. RESULTS: The median age and median relapse-free interval at the time of initial relapse were 51.5 years and 66.5 months, respectively. The number of relapses ranged from one to five. Sixteen surgical procedures for recurrent disease included nine (56.0%) complete resections. There was no statistically significant difference between initial recurrent tumors and second/subsequent recurrent tumors in the rate of complete surgery (44.4% vs. 71.4%, respectively, p=0.36). Of the eleven evaluable occasions when hormonal therapy was used for recurrent disease, disease control was achieved in eight (72.7%). There was no difference between initial recurrent tumors and second/subsequent recurrent tumors in disease control rate by hormonal therapy (85.7% vs. 50.0%, respectively, p=0.49). The 10-year post-relapse survival rate was 90.0% and the overall median post-relapse survival 119 months (range, 7 to 216 months). CONCLUSION: Post-relapse survival of patients with ESS can be expected to be >10 years when treated by repeated surgical resection and hormonal therapy or both.
Adult ; Aged ; Antineoplastic Agents, Hormonal/therapeutic use ; Chemotherapy, Adjuvant/mortality ; Disease-Free Survival ; Endometrial Neoplasms/drug therapy/*mortality/surgery ; Female ; Humans ; Middle Aged ; Neoplasm Recurrence, Local/*mortality ; Retrospective Studies ; Sarcoma, Endometrial Stromal/drug therapy/*mortality/surgery ; Treatment Outcome

In conventional pharmacological research in the field of mental disorders, pharmacological effect and dose have been estimated by ethological approach and in vitro data of affinity to the site of action. In addition, the frequency of administration has been estimated from drug kinetics in blood. However, there is a problem regarding an objective index of drug effects in the living body. Furthermore, the possibility that the concentration of drug in blood does not necessarily reflect the drug kinetics in target organs has been pointed out. Positron emission tomography (PET) techniques have made progress for more than 20 years, and made it possible to measure the distribution and kinetics of small molecule components in living brain. In this article, we focused on rational drug dosing using receptor occupancy and proof-of-concept of drugs in the drug development process using PET.
Brain ; Central Nervous System ; Drug Evaluation ; Electrons ; Kinetics ; Mental Disorders ; Norepinephrine Plasma Membrane Transport Proteins ; Positron-Emission Tomography ; Receptors, Dopamine D2 ; Serotonin Plasma Membrane Transport Proteins

PURPOSE: Small bowel obstruction (SBO) remains a common complication after pelvic or abdominal surgery. However, the risk factors for SBO in ulcerative colitis (UC) surgery are not well known. The aim of the present study was to clarify the risk factors associated with SBO after ileal pouch-anal anastomosis (IPAA) with a loop ileostomy for patients with UC. METHODS: The medical records of 96 patients who underwent IPAA for UC between 1999 and 2011 were reviewed. SBO was confirmed based on the presence of clinical symptoms and radiographic findings. The patients were divided into 2 groups: the SBO group and the non-SBO group. We also analyzed the relationship between SBO and computed tomography (CT) scan image parameters. RESULTS: The study included 49 male and 47 female patients. The median age was 35.5 years (range, 14–72 years). We performed a 2- or 3-stage procedure as a total proctocolectomy and IPAA for patients with UC. SBO in the pretakedown of the loop ileostomy after IPAA occurred in 22 patients (22.9%). Moreover, surgical intervention for SBO was required for 11 patients. In brief, closure of the loop ileostomy was performed earlier than expected. A multivariate logistic regression analysis revealed that the 2-stage procedure (odds ratio, 2.850; 95% confidence interval, 1.009–8.044; P = 0.048) was a significant independent risk factor associated with SBO. CT scan image parameters were not significant risk factors of SBO. CONCLUSION: The present study suggests that a 2-stage procedure is a significant risk factor associated with SBO after IPAA in patients with UC.
Colitis, Ulcerative* ; Female ; Humans ; Ileostomy* ; Logistic Models ; Male ; Medical Records ; Risk Factors ; Tomography, X-Ray Computed ; Ulcer*