A 64-year-old man with a history of abdominal aortic occlusion was admitted because of anterior chest pain. Angina pectoris with ischemic mitral regurgitation were diagnosed by transthoracic echocardiography and coronary artery angiography. He underwent coronary artery bypass grafting and mitral valve annuloplasty with a 26-mm Physio-ring. Because of difficulty in weaning from cardiopulmonary bypass, he required IABP support which was introduced via the ascending aorta. On the 2nd postoperative day, IABP was discontinued and the sternum was closed. His postoperative course thereafter was uneventful without any neurological complications. Postoperative echocardiogram showed good mitral valve function. He was discharged 16 days after surgery.

To facilitate safer operations, we provided a preoperative rehabilitation and educational program covering exercise and diet for obese patients with severe osteoarthritis. Participants totaled 11 patients of which 9 had metabolic syndrome. Exercises included the usual muscle strengthening ones, a range of motion exercise and 30 minutes of walking within parallel bars four times a day. This was combined with a diet program. The averaged results showed that body weight changed from 73.5kg to 64.7kg, body mass index from 31 to 27, and waist size from 106 to 94cm. Blood tests indicated that the average triglyceride level changed from 219 to 127mg/dL and fasting blood glucose from 146 to 94 mg/dL. Total steps walked per day changed from 2840 to 6953 and SF36 improved in all items. Significant improvements were noted in all items tested. Our program provided an effective rehabilitation for patients before operation by reducing patient' symptoms due to metabolic syndrome, reducing leg pain and body weight - while increasing activity, and improving quality of life, while simultaneously decreasing the risk of postoperative venous thromboembolism.

A 6-year-old boy was admitted with infective endocarditis and aortic regurgitation. Clinical signs of infection were severe. The leukocyte count was 13, 100/μl and the C-reactive protein (CRP) was elevated to 17.2mg/dl. Blood culture was positive for Staphylococcus aureus. Echocardiography showed a vegetation 3mm in diameter on the aortic valve, and a perforation of the right coronary cusp with moderate aortic regurgitation. With antibiotic therapy, clinical signs and laboratory data of infection improved at an early stage. We decided to operate after his complete recovery from infection. Laboratory data normalized completely in 6 weeks, but echocardiography demonstrated aneurysmal change of the right coronary sinus and severe aortic regurgitation. The Ross operation was performed on the 44th day. At operation, it was noted that the non-coronary cusp was destroyed completely leaving only strings of fibrous tissue. A perforation of 3mm in diameter was also found on the right coronary cusp. There was a mural aneurysm near the right coronary orifice without abscess formation in the surrounding structure. A pulmonary autograft was transplanted to the aortic root after resection of the destroyed aortic cusps, aortic root and the mural aneurysm. The right ventricular outflow tract was reconstructed using an autologous pericardium as a posterior wall and the Monocusp ventricular outflow patch (MVOP) #22 as an anterior transannular patch. The postoperative course was uneventful. Postoperative echocardiography revealed no aortic regurgitation.

Cardiac surgery associated with idiopathic thrombocytopenic purpura (ITP) is rare, and only 10 cases have been reported in the literature. In this report, we described the successful surgical management of a patient with ITP, diabetes mellitus and malfunction of mitral bioprosthetic valve. A 62-year-old male, who underwent mitral valve replacement (MVR) by means of a Carpentier-Edwards valve prosthesis and CABG ten years ago, developed malfunction of mitral prosthetic valve. The preoperative platelet count was 52, 000/mm³ and PA-IgG elevated markedly. The diagnosis of ITP was based on findings of bone marrow examinations. Thrombocytopenia was treated by steroids for 4 weeks and large dose γ-globulin (20g/day) for 5 days preoperatively, but platelet count did not increase. Platelet rich plasma (PRP) was transfused prior to cardiopulmonary bypass (CPB) and fresh blood was added to the priming material of CPB. Re-MVR was performed by means of mechanical valve prosthesis. After operation, large doses of γ-globulin and transfusion of PRP were performed for 3 days, and the postoperative course was uneventful. Other reports in addition to this study reveal that cases of cardiac surgery associated with ITP should be initially controlled preoperatively with steroids or high-dose γ-globulin, and if these treatments are harmful or ineffective, splenectomy should be considered.

Surgical mortality associated with ruptured abdominal aneurysm remains high, especially in elderly patients, despite recent progress in improved patient management. We present the successful salvage of a 90-year-old woman with ruptured abdominal aortic aneurysm. She was transferred from another hospital because of severe abdominal and back pain and pulsatile abdominal tumor. One hour after admission, shock suddenly developed. We diagnosed her illness as ruptured abdominal aneurysm on enhanced CT scan. Emergency surgery was performed. The hematoma surrounding the aneurysm occupied the retroperitoneal space below the level of the diaphragm (Fitzgerald III). Aortic cross clamp was quickly performed below the level of the diaphragm approaching from the lesser omentum. After controlling bleeding, the site of the aortic cross clamping was changed to the infrarenal aorta. The aneurysm was resected and replaced by a knitted Dacron Y-graft (albumin coated). Duration of surgery was 5 hours and 5 minutes. Blood loss was 6200ml. After surgery, artificial ventilation was required for ten days to avoid hypoxemia. On the 5th postoperative day disseminated intravascular congulation (DIC) developed but she recovered. On the 30th postoperative day, she was discharged. Advanced age may not be an absolute contraindication for surgical treatment even in cases of rupture.

An 11-year-old boy, who underwent a Rastelli operation using a 14mm artificial graft and left pulmonary artery (PA) plasty with an autologous pericardium patch 7 years previously, had severe recurrent left pulmonary stenosis. Reoperation was performed including right ventricular outflow tract reconstruction and left PA plasty. The PA at the most stenotic site was only 2mm in diameter; it was enlarged to 10mm by good exposure and an incision on the pulmonary intima. A bovine pericardium patch with a handmade ePTFE valve was sutured onto the autologous tissue not onto the pulmonary intima to avoid restenosis and in expectation of the growth of the pulmonary orifice. On postoperative 3-D CT, the left pulmonary artery was patent and 9mm in diameter. Pulmonary scintigraphy showed an improvement in the left pulmonary perfusion. This sutureless technique was useful in this case of severe pulmonary stenosis.

A 73-year-old man visited our hospital with complaints of fever, epigastric painand jaundice. Laboratory examinations showed elevation of GOT, GPT, ALP, LAP and amylase. Abdominal ultrasonography revealed gall bladder stones. Endoscopic findings showed parapapillary diverticulum, but the common bile duct stone was not revealed by endoscopic retrograde cholangiography. He was conservatively treated and then discharged. Two months after, the patient was readmitted for cholecystitis and underwent cholecystectomy. After further 2 months, he was again admitted for the same symptoms as those on first admission. We diagnosed this case as Lemmel's syndrome and performed emergency endoscopy. Endoscopic findings revealed the meal rest inside the parapapillary diverticulum. After we removed the meal rest obstructing the orifice of the papilla of Vater using grasping forceps, we performed EST. Purulent bile gushed out from the orifice. Two years have elapsed since them. Cholangitis has not recurred during this period. Therefore, we concluded that EST is effective in treating Lemmel's syndrome.

We evaluated bedside learning in the department of pediatric surgery by conducting a questionnaire survey of senior medical students at Chiba University School of Medicine. We obtained responses from 70 of 95 students (74%). Although 84% of students responded by making lists of patients' problems. Many students indicated insufficient knowledge about diseases and insufficient technical skills for medical treatment as the reasons they could not solve these problems. This finding indicates that students do not have sufficient basic knowledge and clinical skills for bedside learning. These skills must be acquired and evaluated before bedside learning can be started.

A survey was carried out on how the To-no District is coping with the need of first aid for patients requiring life-supporting treatment before hospitalization. Although there were cities in this district where statistics on first aid were not available, the survey found that, during the 4-year period from 1994 through 1997, bystander CPR (cardiopulmonary resuscitation) saved 11.2% of the lives of patients with CPA (cardiopulmonary arrest). Incidentally, 11.3% of the population attended CPR courses offered by public institutions. Gifu Prefecture has helicopters for use in rescue work, but the survey found that some cities had not ever sponsored drills using helicopters in life-saving operations. Our findings revealed the indifference of the general public as well as administrators in this district toward emergency care. Public recognition of the importance of the care of suddenly ill or injured patients must be gained. Furthermore, acquisition of skills required for first aid by lay people and technical improvement of these skills in professional rescuers are necessary. The authors think that these are the community educational responsibility of hospitals and other medical institutions.

  Our palliative care team intervened in a patient with sciatica resulting from metastasis to sacral bone after surgery for rectal cancer. Rapid pain control and a change in the route of rescue drug administration from the stoma were needed. Partial opioid rotation was performed. The dose of 25.2 mg in 72 hours in a transdermal fentanyl patch decreased to 16.8 mg in 72 hours, and the dose of 3.6mg in an hour by continuous intravenous injection of morphine was added. The change in the rescue root to intravenous administration by a patient-controlled analgesia pump gave the patient relief from his pain. He was able to attend his daughter's wedding. His family were all pleased with the relief provided. The advantages of this partial opioid rotation are summed up in the following three points: (1) The required time is relatively short; (2) It can be expedient for analgesia due to the addition of different opioids; and (3) The partial opioid rotation produces fewer adverse effects than a full opioid rotation. Adjustment of the amount of drugs for pain relief in cancer patients is important with the situations of the patient and the family taken into consideration fully.