Akio Otaki

Concomitant major hepatectomy and inferior vena cava reconstruction

The development of techniques for liver transplantation and preservation has led to several surgical innovations for the resection of hepatic malignancies that invade the inferior vena cava (IVC) and the hepatic venous confluence. The resection of hepatic malignancies invading the IVC has become technically feasible and relatively safe since the introduction of total hepatic vascular exclusion (HVE), with or without bypass. The more aggressive approach, involving concomitant hepatic and IVC resection and subsequent replacement of the IVC using autologous or synthetic materials, has also been adopted. If a subtotal hepatectomy could not be performed, total hepatectomy with liver transplantation was a valuable option. But there is no agreement on the management of these tumors in a cirrhotic liver, so the choice of operative procedures used for these patients remains debatable. We reviewed the records of eight hepatic malignancies, including histologically proven five hepatocellular carcinomas (HCC) in cirrhotic livers, and the records of patients with metastatic carcinoma in noncirrhotic livers who underwent concomitant hepatic resection and IVC reconstruction.

Oozing from the Pericardium as an Etiology of Cardiac Tamponade Associated with Screw-In Atrial Leads

AIZAWA, K., et al.: Oozing from the Pericardium as an Etiology of Cardiac Temponade Associated with Screw‐In Atrial Leads. Screw‐in atrial pacing leads are widely used. Cardiac tamponade is a complication. An 81‐year‐old woman with advanced atrioventricular block underwent permanent pacemaker implantation and subsequently developed cardiac tamponade. At surgery, the lead‐tip screw was found penetrated through the right atrium but not through the pericardium. The source of bleeding was confirmed to scratching the inner pericardial membrane by the screw tip. Although cardiac tamponade due to perforation and leakage is known, tamponade caused by the trauma of an atrial screw on the pericardium with resultant ooze is less well described.

Induction of acute-phase reactive substances during open-heart surgery and efficacy of ulinastatin. Inhibiting cytokines and postoperative organ injury.

OBJECTIVE A systemic inflammatory response after open-heart surgery using cardiopulmonary bypass may be responsible for postoperative organ dysfunction. Ulinastatin, a protease inhibitor, plays an important role in host defense under periods of stress. METHODS We studied the efficacy of ulinastatin on changes in acute-phase reactive substances during and after open-heart surgery. Patients undergoing open-heart surgery were divided into an ulinastatin group (Group U) and a control group (Group C). In Group U, we introduced 600,000 units of ulinastatin into a priming solution for cardiopulmonary bypass, 300,000 units into a cardiopulmonary bypass circuit at the removal of aortic cross-clamping, and 300,000 units a day for 5 days following surgery. RESULTS Immediately after cardiopulmonary bypass, alpha 1-antitrypsin levels decreased significantly in both groups, and increased significantly on the second day after surgery. Ulinastatin levels decreased after cardiopulmonary bypass in Group C. Significantly high levels of ulinastatin were obtained in Group U. Interleukin-6, interleukin-8, and polymorphonuclear elastase were markedly induced, and high levels of plasma concentration continued for several days after surgery. At all sample points, these concentrations in Group U tended to be lower than those in Group C. A significantly positive correlation was seen between the maximum levels of interleukin-8 and polymorphonuclear elastase, but these cytokine and polymorphonuclear elastase levels did not correlate with parameters such as the duration of anesthesia, surgery, cardiopulmonary bypass, or aortic cross-clamping. CONCLUSIONS Our study suggests that high-dose ulinastatin administration to maintain a sufficient concentration of circulating protease inhibitors may suppress overinduction of cytokines and polymorphonuclear elastase in open-heart surgery.

Screening for abdominal aortic aneurysm and occlusive peripheral vascular disease in Japanese residents

To evaluate the prevalence of abdominal aortic aneurysm (AAA) and occlusive peripheral vascular disease (PVD) in Japanese residents, and to examine the correlations between these diseases and the risk factors of atherosclerosis, 348 residents of a village in central Japan aged between 60 and 79 years were screened. The screening for AAA was performed using ultrasonography (US) and that for PVD was performed by palpation and Doppler US. No AAA was found, and a right common iliac arterial aneurysm was detected in a 79-year-old man (0.3%). The mean diameter of the infrarenal abdominal aorta was 18.7 mm and an abdominal aorta of 25 mm or greater in diameter was seen in 16 participants (4.6%), all of whom need to be followed up. PVD was suspected in two patients (0.6%) with a low ankle brachial pressure index. Of a total of five patients diagnosed or suspected of having a common iliac arterial aneurysm or PVD, four (80%) had at least one risk factor for atherosclerosis. Thus, we conclude that Japanese residents with risk factors predisposing them to atherosclerosis such as hypertension, obesity, abnormal serum lipid levels, and a history of smoking should be selectively screened for AAA and PVD due to the low prevalence of these diseases and from the viewpoint of cost-effectiveness.

A Malignant Triton Tumor in the Anterior Mediastinum Requiring Emergency Surgery : Report of a Case

We report herein the case of a 17-year-old woman with von Recklinghausens disease who was diagnosed as having a giant malignant Triton tumor located in the anterior mediastinum, which had adhered to the heart and the great vessels. An emergency operation was performed to relieve the tracheobronchial stenosis and congestive heart failure caused by the pressure of the tumor. Extracorporeal circulation was not required and the tumor could be excised only piece by piece. To our knowledge, this is the first report of a malignant Triton tumor being located in the anterior mediastinum.

Postoperative brain complications following retrograde cerebral perfusion

This study was undertaken to investigate the neurological risk factors associated with the retrograde cerebral perfusion (RCP) technique, by examining the relationship between intraoperative parameters and postoperative brain complications. A total of 12 patients who underwent surgery for thoracic aortic aneurysms using the RCP technique were included in this study. Profound hypothermia was induced through cardiopulmonary bypass which was established with a femoral arterial cannula and bicaval return. During RCP, a venous drainage cannula from the superior vena cava (SVC) was switched over to the arterial return circuit, and oxygenated blood was retrogradely infused through the SVC. The perfusion flow rate was maintained at 273 ± 113 ml/min and the SVC pressure was maintained at 15 ± 6mmHg. The RCP time was 68 ± 27 min with a range of 27–130 min, and the lowest rectal temperature was 16 ± 1°C. The total elapsed time until emergence from anesthesia after the operation was 12 ± 6h. The operation time correlated with the awakening time (r=0.729,P=0.0088). Longer RCP times of up to 101 and 130min tended to result in postoperative brain damage. The lowest rectal temperature also correlated with the awakening time (r=0.697,P=0.0149), and an inverse correlation between the SVC pressure and the awakening time was observed (r=−0.727,P=0.0091). These findings demonstrate the importance of reducing both the RCP and operation times to decrease the incidence of brain damage. If carried out under optimal conditions, including perfusion pressure and brain temperature, RCP could be marginally prolonged safely without causing major neurological complications.

Postoperative infections related to pacing wires, pulmonary Arterial catheters, and drainage tubes temporarily Inserted during open-heart surgery

Bacterial examinations of temporary pacing wires (P-wires), pulmonary arterial (P-A) catheters, and drainage tubes temporarily inserted during open-heart surgery were performed in 213 patients. Bacteria were detected in 19 (2.8%) of 672 specimens gathered from the subject patients, with coagulase-negative Staphylococcus (CNS) being most frequently observed. P-wires accounted for 17 out of 19 of the culture-positive specimens, and 7 of the P-wires remained in place for more than two weeks. The frequency of infection with the P-wires was significantly higher than with the P-A catheters or drainage tubes. The period of time that the P-wire was left in place significantly longer than for P-A catheter or drainage tube. There was, however, no statistically significant difference between the culture-positive and negative groups in respect to age, detention periods, operation times, CPB times, or length of ICU stay. As a result of these findings, we have concluded that P-wires should be removed as soon as possible following surgery, and in any case, a meticulous care should be taken to prevent transcutaneous infection.

University of Wisconsin solution versus modified collins solution for canine heart preservation: An experimental study

We investigated the efficacy of University of Wisconsin (UW) solution for its ability to preserve hearts for 12 hours as compared with the results with modified Collins (MC) solution. After orthotopic transplantation, hearts stored in the UW solution (68%) showed significantly (p<0.05) better recovery of maximum rate of increase of left ventricular pressure than those stored in the MC solution (41%) (MC group: n=6, UW group: n=7). The serum CPK values 2 hours after reperfusion were significantly (p<0.01) higher in the MC group (6528 IU/L) than in the UW group (2021 IU/L). Myocardial adenosine triphosphate (ATP) levels were measured using phosphorus 31 nuclear magnetic resonance spectroscopy during 12 hours of cold storage (MC group: n=5, UW group: n=4). ATP levels continued to decrease throughout the storage, and fell to 39% (MC group) and 23% (UW group) of the control after 12 hours with no significant difference. Significant differences between the two groups were present in water content before (MC group: 77.6%, UW group: 75.8%;p<0.05) and after (MC group: 77.6%, UW group: 75.8%;p<0.025) 12 hours of storage (MC group:n=6, UW group:n=5). These results demonstrated that the UW solution was superior to the MC solution when used to preserve hearts for 12 hours.

Extracorporeal membrane oxygenation for respiratory failure

We report herein our experience with extracorporeal membrane oxygenation (ECMO) for respiratory failure over a 3-year period. ECMO was employed in seven patients: in five for respiratory failure caused by adult respiratory distress syndrome (ARDS), Goodpastures syndrome, hypoxia after ventricular septal defect closure, interstitial pneumonia, or lung metastasis from choriocarcinoma; and in two for tracheal obstruction. Nafamostat mesilate was used as the main anticoagulant with a small amount of heparin. The period of ECMO support for the five patients with respiratory failure ranged from 54 to 251 h, with an average time of 125 h. Five of the seven patients were able to be weaned from ECMO, and the two who had tracheal obstruction survived. The other three patients who were weaned from ECMO died of underlying diseases or complications 1–25 days after weaning. The complications which occurred during ECMO support were an abnormal electroencephalogram, multiple organ failure, and mediastinitis. Thus, we conclude that ECMO needs to be induced early to obtain a better outcome in patients with respiratory failure, and that it is particularly effective for transient airway obstruction.

Successful treatment of Wolff-Parkinson-White syndrome with concomitant mitral stenosis by simultaneous surgery

We report the case of a 61-year-old man with type B Wolff-Parkinson-White (WPW) syndrome associated with a right atrioventricular (AV) accessory pathway and concomitant mitral stenosis, who underwent successful operative treatment by simultaneous surgery. His preoperative course had been characterized by cardiac failure and repeated episodes of atrial tachyarrhythmia, in the form of fibrillation and flutter, which were difficult to control by conventional medication. Preoperative electrocardiograms (ECGs) had suggested that the accessory pathway was located in the right posterior to posteroseptal wall; however, at the time of surgery, epicardial electrophysiological mapping with sock electrodes revealed a preexcitation area in the AV groove at the lateral right margin of the heart. This discrepancy was thought to have been due to the presence of mitral stenosis or multiple accessory pathways. Thus, division and cryoablation of the accessory pathway by an endocardial approach, in addition to mitral valve replacement, were performed under cardiopulmonary bypass. His postoperative course was uneventful, and subsequent ECGs revealed that the delta waves had disappeared. The successful outcome of this patient demonstrates the effectiveness of simultaneous surgery for WPW syndrome associated with valvular disease.