Hirofumi Takemura

The importance of intraoperative fluid balance for the prevention of postoperative acute exacerbation of idiopathic pulmonary fibrosis after pulmonary resection for primary lung cancer.

OBJECTIVES Postoperative acute exacerbation (PAE) of idiopathic pulmonary fibrosis (IPF) is a serious complication that is hard to treat. Therefore, it is important to manage IPF patients in such a way as to avoid PAE. Conversely, the relationship between postoperative acute lung injury and perioperative fluid administration has been reported. Herein, we analyse the perioperative risk factors of PAE of IPF, including fluid management. METHODS Fifty-two patients diagnosed as having clinical IPF who underwent pulmonary resection (segmentectomy, lobectomy or bilobectomy) for primary lung cancer were analysed retrospectively. Preoperative predictive factors and perioperative management items, especially fluid management, were evaluated. RESULTS The incidence of PAE of IPF was 13.5% (7 of 52 patients). Six patients (85.7%) died of respiratory failure induced by uncontrollable PAE of IPF. Upon univariate analysis, the amount of the intraoperative fluid infused (ml/kg/h), the intraoperative fluid balance (ml/kg/h) and the preoperative C-reactive protein (CRP) level were found to be significantly higher in IPF patients who developed PAE than in those who did not. A multivariate logistic regression analysis showed that the intraoperative fluid balance and the preoperative CRP were prognostic factors for PAE of IPF [P = 0.026, odds ratio (OR) = 1.312 and P = 0.048, OR = 1.280, respectively]. CONCLUSIONS To prevent PAE of IPF, intraoperative management that minimizes intravenous fluid administration is essential. Moreover, caution is particularly important in patients with preoperative evidence of inflammation.

Skeletal muscle targeting in vivo electroporation-mediated HGF gene therapy of bleomycin-induced pulmonary fibrosis in mice

Lung fibrosis is a common feature of interstitial lung diseases, and apoptosis and fibrinogenesis play critical roles in its formation and progression. Hepatocyte growth factor (HGF) is one of the ideal therapeutic agents for prevention of lung fibrosis because of its antiapoptotic and fibrinolytic effects. The aim of this study is to establish nonviral HGF gene therapy of bleomycin-induced lung fibrosis avoiding the viral vector-related side effects. C57BL/6 mice were injected with 3.0 mg/kg body weight of bleomycin intratracheally. Following bleomycin injection, 50 μl of pUC-HGF (1 mg/ml) was injected into each of the quadriceps muscle. Immediately after plasmid injection, in vivo electroporation was performed with pulse generator. Skeletal muscle-targeting electroporation induced transgene expression on day 1 and persisted for 4 weeks, and human HGF was also detected in the lung. In mice transferred with HGF, pathological score (1.0±0.3 vs 3.2±0.6), TUNEL-positive cell index (4.5±1.1 vs 14.2±3.1), and hydroxyproline content (9.0±1.3 vs 14.4±5.1 μmol/g) were significantly reduced compared with the control. Furthermore, survival rate of HGF mice was significantly improved compared with the control. Our data indicate that HGF gene therapy with a single skeletal muscle-targeting electroporation has a therapeutic potential for bleomycin-induced lung fibrosis and this strategy can be applied as a practical gene therapy protocol for various organs.

Improvement of the survival rate after rat massive hepatectomy due to the reduction of apoptosis by caspase inhibitor

Background and Aim:  Acute liver failure after massive hepatectomy is caused by both necrosis and apoptosis in the remnant liver. We investigate the protective effect of the caspase inhibitor on apoptosis after massive hepatectomy in rats.

Normothermic total arch replacement without hypothermic circulatory arrest to treat aortic distal arch aneurysm in a patient with cold agglutinin disease

Cold agglutinin disease although rare, can lead to serious complications for patients undergoing cardio-thoracic surgery, especially when cardiopulmonary bypass is applied under hypothermic circulatory arrest. We describe normothermic total arch replacement without hypothermic circulatory arrest in a patient with cold agglutinin disease. The patient tolerated all procedures well and did not develop cerebral ischemia due to surgical maneuvers or thrombotic or haemolytic complications due to cold agglutinin disease. Although endovascular aortic repair is the first choice under such complex conditions, this method could also serve as an alternative strategy when endovascular aortic repair is precluded.

Two-stage portal vein ligation facilitates liver regeneration in rats.

Background/Aims: Recent reports have demonstrated that some patients are unable to undergo scheduled liver resection after preoperative portal vein embolization due to insufficient hypertrophy of the future remnant liver. The present study examined whether two-stage portal vein ligation (PVL) increases hypertrophy of the future remnant liver compared to conventional PVL in rats. Methods: Rats were divided into 3 groups: group A, ligation of left primary branch; group B, ligation of right and left primary branches; group C, ligation of the left primary branch, followed by 2-stage PVL 7 days postoperatively. To evaluate liver regeneration, the proliferating cell nuclear antigen labeling index (LI), mitotic index (MI) in the caudate lobe and weight ratio of caudate lobe to body weight were measured. Results: The weight ratio of caudate lobe to body weight was significantly higher in group C than in groups A or B 14 days postoperatively. In groups A and B, LI and MI in the caudate lobe peaked 2 days postoperatively, then decreased to preoperative levels by 7–8 days postoperatively, but remained significantly elevated until 10–14 days postoperatively in group C. Conclusion: Two-stage PVL increases hypertrophy of the future remnant liver compared to conventional PVL in rats.

Pulmonary epithelioid hemangioendothelioma

We report two cases of pulmonary epithelioid hemangioendothelioma (PEH). Both patients presented with multiple bilateral pulmonary nodules, <10 mm diameter, on computed tomography (CT). Multiple pulmonary metastases were considered, but no primary malignant lesion was detected by other imaging modalities including 18F-fl uorodeoxyglucose positron emission tomography (18F-FDG-PET)/CT. Moreover, the nodules did not show increased uptake of 18F-FDG. We performed pulmonary wedge resections by video-assisted thoracoscopic surgery (VATS). Histological and immunohistochemical analysis revealed PEH in both. Positivity for the monoclonal antibody MIB-1 in the tumor cells was 5% in the fi rst case and 5%–10% in the second case. Slow tumor progression was detected with CT in the second case. Although 18F-FDG PET/CT is effective for screening other malignant lesions, it does not appear to be of direct use in the diagnosis and surgical planning of PEH. Pathological diagnosis by VATS is the most effective method. MIB-1 positivity should be analyzed as to whether it is a prognostic factor of PEH.

Reduction of fibrosis in a rat model of non-alcoholic steatohepatitis cirrhosis by human HGF gene transfection using electroporation.

Background and Aim:  To study the histological changes caused by transfection of the hepatocyte growth factor (HGF) gene using electroporation (EP) in a non‐alcoholic steatohepatitis (NASH) cirrhotic liver model.

Surgical technique of lung segmental resection with two intersegmental planes

Lung segmental resection is of two types: a simple type with resection of only one intersegmental plane, such as lingual or superior segmentectomy; and a complicated type with resection of two or more intersegmental planes, such as anterior segmentectomy. We present a method of identifying the intersegmental plane by physiological function. First, we cut the segmental pulmonary artery and vein. The entire lobe is then inflated with pure oxygen for 5 min. Immediately after oxygen inflation, the segmental bronchus is deflated and stapled. After a couple of minutes, the intersegmental plane is easily detected. In 117 patients who underwent segmentectomy, mean blood loss was 122 ± 193 ml and mean duration of drainage was 3.5 ± 4.8 days. Postoperative complications related to operative procedures occurred in 14 cases (12.0%). Our method of detecting intersegmental planes is convenient and useful for subsegmental resection, particularly for complicated-type cases.

An unusual case of the right subclavian artery aneurysm resulting from long-term repetitive blunt chest trauma

This case report describes a right subclavian artery aneurysm secondary to long-term repetitive blunt trauma. A 62-year-old man with a right subclavian artery aneurysm had had a history of bird hunting using a shotgun that impacted substantially against his right clavicula and shoulder weekly for >20 years. The patient underwent open repair with partial sternotomy and distal balloon control. The aneurysmal sac was resected, and the right subclavian artery was reconstructed with a primary end-to-end anastomosis. Histopathologic examination of the resected aneurysmal wall revealed that all three layers of the arterial wall were comparatively intact, with fibrosis and lipid deposition in the intima and in various degrees of degeneration in the media, suggesting a true aneurysm.

Complete resection of asymptomatic solitary right atrial metastasis from renal cell carcinoma without inferior vena cava involvement

pump speed to approach the lower operating limit of 1800 rpm. Implications include (1) lower accuracy of estimated flow at lower speeds, (2) less ability to correct suction conditions by lowering pump speed, and (3) increased potential for pump thrombosis or rotor instability. Second, the HeartWare HVAD inflow cannula length was designed for placement through the left ventricular apex and is not optimized for the right ventricle. Shortening the length of the inflow cannula to accommodate the shallower right ventricular cavity in the right ventricular outflow tract is achieved by placing additional felt rings under the fixation ring (Figure 2, B). Other locations that may potentially allow normalchestclosure includeplacementintotherightatrium or the diaphragmatic surface of the right ventricle. For this patient, the goals for pump flows were 3 to 4 L/min through the RVAD and 5 to 6 L/min through the LVAD. Anticoagulation strategy consisted of aspirin and warfarin sodium, with an international normalized ratio goal of 2 to 3. We were successful in this case; however, this is the first report of HeartWare HVAD use in the role of RAVD after HeartMate II implantation. Firm recommendations regarding the potential widespread applicability of this therapy are therefore limited.