OBJECTIVE: To investigate the clinical significance of systematic retroperitoneal lymphadenectomy during interval debulking surgery (IDS) in advanced epithelial ovarian cancer (EOC) patients. METHODS: We retrospectively reviewed the medical records of 124 advanced EOC patients and analyzed the details of neoadjuvant chemotherapy (NACT), IDS, postoperative treatment, and prognoses. RESULTS: Following IDS, 98 patients had no gross residual disease (NGRD), 15 had residual disease sized <1 cm (optimal), and 11 had residual disease sized > or =1 cm (suboptimal). Two-year overall survival (OS) and progression-free survival (PFS) rates were 88.8% and 39.8% in the NGRD group, 40.0% and 13.3% in the optimal group (p<0.001 vs. NGRD for both), and 36.3% and 0% in the suboptimal group, respectively. Five-year OS and 2-year PFS rates were 62% and 56.1% in the lymph node-negative (LN-) group and 26.2% and 24.5% in the lymph node-positive (LN+) group (p=0.0033 and p=0.0024 vs. LN-, respectively). Furthermore, survival in the LN+ group, despite surgical removal of positive nodes, was the same as that in the unknown LN status group, in which lymphadenectomy was not performed (p=0.616 and p=0.895, respectively). Multivariate analysis identified gross residual tumor during IDS (hazard ratio, 3.68; 95% confidence interval, 1.31 to 10.33 vs. NGRD) as the only independent predictor of poor OS. CONCLUSION: NGRD after IDS improved prognosis in advanced EOC patients treated with NACT-IDS. However, while systematic retroperitoneal lymphadenectomy during IDS may predict outcome, it does not confer therapeutic benefits.
Adult ; Aged ; Aged, 80 and over ; Cytoreduction Surgical Procedures/*methods/mortality ; Disease-Free Survival ; Female ; Humans ; Lymph Node Excision/*methods/mortality ; Lymphatic Metastasis ; Middle Aged ; Neoplasms, Glandular and Epithelial/mortality/*surgery ; Ovarian Neoplasms/mortality/*surgery ; Retroperitoneal Space ; Retrospective Studies ; Treatment Outcome

We experienced a case that right massive pleural effusion was successfully controlled with Denver shunt from the right chest cavity to right femoral vein. A 80-years-old woman had received hemodialysis due to chronic renal failure twice in a week. She was diagnosed as right breast cancer and underwent right breast conserving surgery at December, 2008. In postoperative follow-up duration, she had difficulty in breathing and visited to the emergency room in our hospital. She was diagnosed as respiratory failure due to right massive pleural effusion from the X-ray result and the blood gas analysis. There was no pleural effusion within the left chest space. No malignant cell was detected in the effusion. We thought that diuretics and shunt tube from the right chest cavity to the abdominal cavity would be ineffective because of her chronic renal failure, and for that reason, we placed the shunt tuve from the chest cavity to the right femoral vein. Respiratory failure and the quality of life were successfully improved for about 7 months by using it. Palliat Care Res 2011; 6(1): 301-307

Since November 1999 we have attempted to use a right heart bypass (RHB) system for beating heart coronary artery bypass grafting (CABG), which system produce better exposure of lateral and posterior wall of the heart and so enable us to facilitate bypass grafting to these branches. We report on our initial clinical experience with this system and the purpose of this study is to evaluate the efficacy of this system. To clarify the efficacy of the RHB system, we compared the intraoperative and postoperative clinical course, as well as outcome, between patients who underwent beating heart CABG with RHB and patients without RHB. Seventy-seven patients underwent beating heart CABG with RHB (RHB group) between November 1999 and December 2001. In the same period, 88 patients underwent beating heart CABG without RHB. Of these latter, 30 patients needed displacement of the beating heart in order to expose target coronary arteries (OPCAB group). Perioperative clinical parameters were compared between the groups. Patients in the RHB group received more grafts (2.4±0.6) than patients in the OPCAB group (2.0±0.2, p=0.002). There were no hospital deaths in either group. While displacing the beating heart, SvO₂ decreased and pulmonary artery pressure increased in both groups. Nevertheless, the value of SvO₂ was significantly higher in RHB group while displacing to expose the circumflex region (p=0.048) and the distal right coronary artery region (p<0.01). The effect of elevation of pulmonary artery pressure in the RHB group was lower than that in the OPCAB group, but it was not statistically different. Water balance during operation was 2, 898±1, 019ml in the RHB group and the 2, 237±807ml in OPCAB group (p=0.002). Body temperature following operation was 36.0±0.8°C in the RHB group and 36.5±0.8°C in the OPCAB group (p<0.01). However, no differences were found in postoperative blood loss, required transfusion, duration of mechanical ventilation, ICU stay and hospital stay. No patient had postoperative complications related to the RHB system. The introduction of the RHB enabled bypass grafting to posterior wall vessels with better exposure and under greater hemodynamic stability. Therefore we think it a very effective support system which enable multiple coronary revascularization on beating heart CABG.

We describe two patients who underwent repeat off-pump coronary revascularization by axillocoronary artery bypass grafting. A 63-year-old man (case 1), who had undergone coronary artery bypass grafting (CABG) 13 years previously, was admitted to our hospital with exertional angina. The saphenous vein grafts (SVG) to the left anterior descending artery (LAD), circumflex artery (Cx), and right coronary artery (RCA) all were occluded. The left internal thoracic artery (LITA) also was occluded because it had been injured. Because the patient declined to undergo a redo CABG, percutaneous transluminal coronary angioplasty (PTCA) to the LAD was attempted. However, coronary dissection occurred, and an emergency operation was performed. A 66-year-old man (case 2), who had undergone CABG 12 years previously, was admitted with unstable angina. The LITA to the LAD and the SVG to the RCA were occluded. The SVG to the Cx had 99% stenosis in its mid-portion and was the cause of the angina. PTCA and stenting of this SVG were performed. Two weeks later, an operation was done. In both patients, the left axillary artery was selected as the site of the proximal anastomosis. Both patients underwent off-pump bypass grafting to the LAD from the left axillary artery using a SVG. Both grafts were patent postoperatively. This approach resulted in early symptomatic improvement.

A 61-year-old woman had extracardiac unruptured aneurysms of the right and noncoronary sinuses of Valsalva, detected incidentally on electrocardiogram taken for a physical checkup. Two-dimensional echocardiography revealed that the sizes of the aneurysm of the right and noncoronary sinuses were 41×40 and 38×28mm respectively, but the shape of left coronary sinus was almost normal. The aortic valve leaflet was normal and the diameter of the aortic annulus and sinotubular junction was 23 and 27mm respectively. The Doppler color-flow echocardiogram showed moderate aortic regurgitation which resulted in prolapse of the right aortic cusp due to deformity of the annulus. We performed modified aortic root remodeling using a tailored Dacron graft to preserve the native aortic valve. Right and noncoronary sinuses of Valsalva were all excised with a small button of the aortic wall around the ostia of the right coronary artery. The left coronary sinus was left as it was. Then each commissure received sub-commissural annuloplasty and was pulled up. The defect of Valsalva was reconstructed with a 26mm Dacron tube graft, the proximal end of which was tailored to a scallop shape and that correspond to left coronary sinus was excised. The right coronary artery was reimplanted utilizing the Carrel patch method. Although we needed additional CABG to the right coronary artery and IABP support due to vasospasm of the right coronary artery, the postoperative course was uneventful. Echocardiography of the aortic valve before discharge showed a normal function without regurgitation.

We investigated the effects on medical education of early exposure of undergraduate students to a summer camp for children with asthma. An objective evaluation by the editorial staff found final improvements in the following areas (in descending order of frequency): learning of basic medical behavior (91% of students); cooperative attitude of medical staff in general treatment with the patient and the patient's family (88%); understanding of childhood growth and development (80%); knowledge of childhood asthma (69%); and mastery of basic techniques for therapy and examination (41%). The differences in the ratio of improvement (%) before and after visiting the camp, were (in descending order of frequency): cooperative attitude of medical care staff in general medical treatment with the patient and the patient's family (47%); understanding of childhood growth and development (45%); knowledge of childhood asthma (38%); learning of basic medical manner (34%); and mastery of basic techniques for therapy and examination (25%). These findings suggest that a summer camp is useful for exposing undergraduate medical students to children with asthma and is effective for helping them understand patients and family-oriented pediatric medicine.

Diffuse peritonitis due to perforation of pyometra is relatively rare. We experienced three cases of this type of peritonitis between 1993 and 1999. Three women aged 77, 83 and 91 years had mild abdominal pain, slight fever and defecation for nearly one week. Following these, severe abdominal symptoms developd. These patients underwent emergency laparotomy as they were diagnosed with diffuse peritonitis. At first, intestinal perforation was suspected, but perforation of pyometra was confirmed when lapasortomy was done. On preoperative examinations, physical findings were scanty in comparison with hemological ones, and free air on abdominal X-ray films was not detected. Thus, we failed to establish the preoperative diagnosis. The prognosis was very poor in two of the three patients. One was with advanced cervical cancer and the other was in multiple organ failure on admission. Differential diagnosis of this disease is important for the management of acute abdominal diseases in elderly women.

Seven patients with congenital heart defects suffered from multiple major hemorrhages from the lung after surgery and 5 of them died at 8 to 54 postoperative days because of respiratory insufficiency. In a patient with tetralogy of Fallot associated with pulmonary atresia, bleeding occured after the second shunt operation, presumably from rupture of bronchial collateral vessels. The clinical diagnoses of the other 6 patients were coarctation of the aorta (CoA) with common atrioventricular canal (CAVC) in 1, triple shunt in 1, persistent truncus arteriosus in 2, total anomalous pulmonary venous connection in 1 and CAVC in 1. Subclavian flap aortoplasty was performed without pulmonary artery banding in the patient with CoA and CAVC, whereas complete repair was performed in the other 5 patients. As these patients were associated with severe pulmonary hypertension preoperatively and 4 of them encountered pulmonary hypertensive crisis, the hemorrhage from the lung may be related to pre and postoperative high pressure of the pulmonary artery. Dilatation and rupture of the pulmonary capillary net was demonstrated in the patient with CoA and CAVC. These findings suggest the hypothesis that bleeding occurred due to rupture of the capillary net as a result of transmission of high pressure. Major bleeding from the lung is a rare but catastrophic complication after repair of congenital heart defects. As the treatment is difficult, early surgical intervention and treatment of postoperative pulmonary hypertension are important in complex lesions with severe pulmonary hypertension.

The School of Medicine, University of Tsukuba, was founded in 1974 and had graduated 1, 561 students by 1994. From 1980 through 1987, 44% to 73% of graduates became hospital staff, 16% to 40% became university staff, and 0% to 8% became general practitioners. More than 80% of graduates did a 2-year residency (sotsugo-kenshu) at our university hospital and 40% completed a 6-year residency. Almost 10 years of postgraduate training was required to become an established medical practitioner. This length of time indicates that postgraduate training is the most important part of the medical career. About 80% of graduates earned doctor of philosophy (Ph. D.) degrees, whereas 93% became registered specialists, indicating that graduates tended to become specialists rather than to pursue Ph. D. degrees. This difference is more evident among female graduates: 85% became specialists whereas only 53% received a Ph. D. Most graduates considered the School of Medicine to have a good curriculum, but some younger graduates had complaints. The graduates chose their career specialties on the basis of their own interests and aptitudes. We should take these data into account to prepare a system of life-long education and learning.

We performed surgical treatment for 21 patients of airway obstructions associated with congenital heart disease from December 1986 to March 1993. In all patients perioperative bronchoscopy demonstrated the cause and site of airway obstructions. Seven patients with corrective cardiac surgery (7/7), 7 with palliative cardiac surgery (7/10) and 2 with surgery for airway diseases (2/4) could be weaned from respirators following surgical treatment. Five patients died postoperatively. A respirator was required in 16 patients (76%) preoperatively. The suspension of pulmonary artery with intraoperative bronchoscopy was carried out in 6 patients. Five (5/6) were successfully extubated earlier postoperative day (mean 8.4 days), whereas only five in 10 patients without that procedure could be weaned from the respirator at a mean of 2 months. Identification of potential airway obstruction and early extubation is needed to reduce the mortality and morbidity caused by airway obstruction associated with congenital heart disease. Preoperative bronchoscopy is useful for diagnosis of airway obstructions and essential for decision making concerning surgical treatment. To early extubation in patients with marked airway obstructions, we recommend appropriate choice of the surgical procedure combined the suspension of pulmonary artery.