Ten patients with distal aortic arch aneurysm underwent prosthetic graft replacement using moderately hypothermic cardiopulmonary bypass and selective cerebral perfusion via antero-axillary thoracotomy. Central cannulation was performed in the ascending aorta and venous drainage from the right femoral vein. The mean patient age was 74 years and the mean surgical duration was 5h and 12min. One patient died of multiple cerebral embolisms. Nine patients survived without major complications. Anastomosis between the vascular graft and the distal aorta can be easily achieved via left thoracotomy. Moderate hypothermia provides less coagulopathy and is less invasive. The rate of cerebral complications was acceptable. This technique is preferable for surgical treatment of the distal aortic arch.

Elective resection of abdominal aortic aneurysms is now a safe operation, but mortality related to ruptured abdominal aortic aneurysm (rAAA) remains high. In many reports, there has been much discussion about the factors that affect the mortality rate of patients who had rAAA repair. Preoperative shock is the most frequently cited prognostic factor related to survival. At the induction of anesthesia in these patients it is not rare for hypotension to cause deep shock. To prevent these deep shock states, we make a mid-abdominal skin incision simultaneously at the induction of general anesthesia just after preparation. Forty-four cases of rAAA underwent emergency surgery with this technique between April 1993 and December 1999. We also reviewed medical records of these 44 consecutive patients to evaluate clinical factors in mortality after rAAA resection. The overall hospital mortality rate was 18.2% (8/44) in our series. Factors associated with poor prognosis were the duration of preoperative shock state (p=0.031), an episode of cardiac arrest (p=0.015), an episode of loss of consciousness (p=0.018), systolic blood pressure of less than 60mmHg at the induction of anesthesia (p=0.019), intraperitoneal rupture (p=0.010) and intraoperative massive blood transfusion (p=0.043). These findings suggest that these factors may be reflections of preoperative shock and intraoperative technical errors. The surgical results of rAAA have improved significantly due to the prevention of hypotension which may cause a state of deep shock at induction of anesthesia. Although the patient's outcome after rupture of AAA is partly determined before intervention by the surgeon, efforts for rapid diagnosis and prompt flawless surgery can increase survival.

Chylorrhea is a rare complication after cardiothoracic surgery, occurring in 0.5-2% of patients. It is extremely rare after coronary artery bypass grafting. The initial management of chylorrhea is conservative, but if it is unsuccessful, surgical intervention is indicated. Recently, some cases treated with octreotide have been reported. We report two cases of chylorrhea after internal thoracic artery harvest treated with octreotide.

A 61-year-old man underwent an emergency operation for a ruptured infrarenal abdominal aortic aneurysm. Operations included bifurcated graft replacement of the abdominal aorta, oversewing of five lumbar arteries between L3 and L5, and ligation of the occluded inferior mesenteric artery. Because of the severe adhesions and arteriosclerotic changes over the bifurcation of the abdominal aorta and both common iliac arteries, prolonged aortic cross-clamp time was needed. In spite of stable his postoperative general condition, he suffered paresthesia and complete sensory loss on the left lower leg and the right sole. Moreover he was found to have paresis on the left leg and the right thigh. Knee and ankle deep-tendon reflexes were absent on the left. Lasègue's sign was positive bilaterally, which was more brisk on the left. There was no incontinence of urine and feces. EMG showed neurogenic polyphasic potentials on the lower extremities. MRI of the thoracolumbar spine and sacrum showed no evidence responsible for this neurological deficit, but IV-DSA revealed complete occlusion of the left common and internal iliac arteries. Following the active rehabilitation, he was able to walk unaided, but remained to have residual paresthesia on the left lower leg at his discharge. It was concluded that ischemic injuries to the cauda equina resulted in this rare complication, which seemed to be secondary to oversewing of critical lumbar arteries, prolonged aortic cross-clamp time, and the acute occlusion of the left common and internal iliac arteries.

A 76-year-old man underwent the aorto-femoral bypass with prosthetic graft at other hospital. Prosthetic graft infection with abcess at inguinal wound occurred 4 months later. A obturator foramen bypass was performed and the infected graft and the inguinal vessels were removed. The obturator foramen bypass is useful extra-antomical bypass.

The subjects consisted of cases of unruptured abdominal aortic aneurysm operated upon between 1989 and 1992 with or without blood transfusion. The blood transfusion group contained 13 patients and the non-transfusion group consisted 17 patients. Non-transfusion cases accounted for 57% and there was no operative death in this group. In 6 patients a Cell saver was used, and it was effective in 3 patients (20%) for non-transfusion. There were significant differences in preoperative hemoglobin, preoperative hematocrit, maximum diameter of aneurysm and bleeding volume in the blood transfusion group and non-transfusion group (p<0.05). In non-transfusion operations the Cell saver appears advantageous.

A man in his seventies sustained continuous bleeding from local recurrence at the residual rectal stump after Hartmann's surgery for rectal cancer. This patient declined chemotherapy and radiation therapy and conventional local anti-hemorrhagic treatments had not been effective. To assess the risk of Mohs' paste application to the rectal recurrence area, we checked the anatomical structures surrounding the application site by a CT study. In addition, two reasons we evaluated this Mohs' paste treatment to the rectal recurrence would be very safe were as follows: 1. A small amount of Mohs' paste was needed for the small rectal bleeding site. 2. Mohs' paste would not be applied to the rectum used for stoma. To avoid applying Mohs' paste to the neighbouring normal structures, a gauze coated with Mohs' paste was inserted into the rectum and placed only on the local recurrence site. Petroleum jelly was applied to the surface of normal rectal mucosa to prevent fixation. Bleeding and malodorous effusion decreased significantly without side effects such as pain, bleeding, or ulceration. Thereafter, additional fixation was not necessary. When all the other antihemorrhagic modalities are not available, Mohs' paste could be used for bleeding or an effusion from non-superficial tumors after a thorough risk assessment on this treatment.

Purpose: Refractory ascites is one of common symptoms in patients with breast cancer. Case report: A woman in her fifties was admitted with massive ascites and was diagnosed with advanced breast cancer with multiple liver metastases. Diuretics, hormonal therapy, and chemotherapy could not control the ascites. Therefore, we implanted a peritoneovenous shunt to continue the cancer treatment with good quality of life. Despite the liver metastases had progressed during subsequent chemotherapies, no ascites had been detected for 8 months. Conclusion: We believe that peritoneovenous shunt can be an effective treatment that support anticancer therapy and palliative care in patients with cancer accompanied by intractable ascites.