Hiroshi Yoshimatsu

An experimental study on viability of the devascularized trachea

This experiment was designed to evaluate the effect of varying extents of devascularization to the viability of the trachea, and the influence of preservation of the right bronchial artery on the ischemia of the widely devascularized trachea. In experiment 1, the canine trachea was devascularized in a stepwise manner, and the regional blood flow was measured in each situation. This experiment revealed that the regional blood flow decreased to one-third of the non-treated trachea when the bilateral bronchial arteries were transected, and to nil when the cervical and mediastinal trachea was devascularized. In experiment 2, in which dogs were divided into 2 groups depending on preservation of the right bronchial artery, the trachea was stepwisely devascularized and the regional blood flow measured. This experiment indicated that the regional blood flow in the trachea when the right bronchial artery was preserved did not so remarkably diminish, though the cervical and mediastinal trachea was devascularized. In experiment 3, dogs were divided into 3 groups according to the extent of devascularization of the trachea and to the presence or absence of the preserved right bronchial artery, and were followed for 2 months postoperatively. This experiment demonstrated that the preservation of the right bronchial artery prevented tracheal necrosis caused by devascularization of the cervical and mediastinal trachea. We concluded that the regional tracheal blood flow markedly decreased and that tracheal necrosis occurred following devascularization of the cervical and mediastinal trachea when the bilateral bronchial arteries were transected. The preservation of the right bronchial artery however, prevented a decrease in the regional blood flow and necrosis of the widely devascularized trachea.

Primary osteogenic sarcoma of the mediastinum.

Ikeda, T., Ishihara, T., Yoshimatsu, H., Kikuchi, K., Murakami, M., Kobayashi, K., Inoue, H., and Kasahara, M. (1974). Thorax, 582-588. Primary osteogenic sarcoma of the mediastinum. A 22-year-old man with primary osteogenic sarcoma of the superior mediastinum is reported. This case is the second instance of primary osteogenic sarcoma of the mediastinum and the first case of superior mediastinal origin to be reported. The patient had local recurrence one year after the first operation. After resection of the recurrent tumour with left upper lobectomy and partial pericardectomy followed by radiation, he has been well for more than five years without recurrence. Extraosseous osteogenic sarcoma of soft tissue is very rare and has been reported in 103 patients. The five-year survival of patients with extraosseous osteogenic sarcoma is 22·4%. The distribution and prognosis of this tumour are similar to those of rhabdomyosarcoma in soft tissue. Primary amputation or wide excision is the treatment of choice.

The latissimus dorsi muscle flap is useful for the repair of tracheal defects--an experimental study.

An experiment was designed to evaluate the limitations of the muscle flap method in treating various locations and sizes of tracheal defects. Five groups of dogs with several types of tracheal defects were prepared. Each defect was covered by the latissimus dorsi muscle flap. Defects of the tracheal membrane (posterior one-third of the tracheal wall) were successfully repaired by the muscle flap without stenosis, even if they extended to 10 rings in length or were situated at the carina. Defects in the posterior one-half of the trachea, up to 5 rings long, were repaired, with minimal stenosis. Defects of the posterior two-thirds, or anterior one-third of the trachea, resulted in marked stenosis following muscle flap repair. Tracheal movement as seen in the saver sheath type of tracheomalasia was observed when anterior support of the trachea was lost. On the other hand, the movement seen in the crescent type of tracheomalasia was observed when posterior support of the trachea was lost. We concluded that a defect of less than the posterior one-half of the trachea can be repaired by muscle flap, without inducing respiratory insufficiency. Therefore, muscle flap coverage for tracheal defects should be a useful technique in the combined resection of the tracheobronchial tree in cases of esophageal cancer.

Use of a new stapling instrument for permanent occlusion of the aorta in the surgical procedure for thromboexclusion

Permanent aortic occlusion is required in the surgical procedures for the flow reversal and thromboexclusion technique and also for the permanent exclusion of aneurysms of the thoracic aorta. We have designed a stapling instrument for the permanent occlusion of the aorta and have used it in 5 patients with aortic dissections and 2 patients with aneurysms of the thoracic aorta. This report describes our newly designed surgical stapler for the closure of the aorta with 2 case reports.

Comparative, immunological studies on Lymphangiectasia of the small intestine revealed in protein losing gastroenteropathy and Behçet’s disease

SummaryLymphangiectasia of the small intestine was demonstrated in 9 of 18 cases with protein losing gastroenteropathy and in 10 of 26 cases with Behçet’s disease. Protein losing gastroenteropathy was compared to Behçet’s disease in view of immunological aspects. Immunoglobulin containing cells in the jejunal mucosa of protein losing gastroenteropathy were decreased, whereas Behçet’s disease had normal or increased distribution. This suggested that immunoglobulin may be lost into the intestinal lumen or that production of those cells may be inhibited in protein losing gastroenteropathy. Decreased DNCB skin reaction and impaired blastoid transformation of peripheral lymphocytes in both of two diseases suggested that there should be immunological defect in those diseases. However, in Behçet’s disease, investigation of the thymus disclosed hyperplasia and the presence of lymphoid follicle which does not appear in normal state.In conclusion, protein losing gastroenteropathy is in immunological deficiency state due to the congenital or acquired disorders of lymphatics which implies abnormal protein loss, decreased immunoglobulin containing cells in the jejunal mucosa and decreased sensitivity. On the contrary, in Behçet’s disease hyperimmune state is present based on thymic hyperplasia.

Intrathoracic application of the latissimus dorsi muscle for esophageal cancer operation

In order to reinforce the difficult closure of the bronchial stump, or esophageal anastomosis, a pedicle flap, taken from the latissimus dorsi muscle, was applied to 7 patients with tracheal repairs, and 11 patients with extensively dissected areas, at the time of esophageal cancer surgery. Utilizing this technique, the complications associated with extended esophagectomy could be minimized. Intrathoracic application of the latissimus dorsi muscle flap is a useful method of supporting extended esophagectomy for esophageal cancer.

Left ventricular rupture following mitral valve replacement —A report of two cases—

Left ventricular rupture is a rare and usually fatal complication of mitral valve replacement, and we report herein, 2 successfully treated cases of type III left ventricular rupture. The laceration in the posterior ventricular wall was repaired by a wide buttressed mattress suture with teflon felt belts on either side, then covered with Oxycel and fibrin glue or a large patch and fibrin glue. Naturally, the operation must be performed carefully and gently, however, the most important etiologic factor of left ventricular rupture is the extremely friable myocardium due to aging and a long history of heart disease. Utilizing fibrin glue for successfully repairing the rupture proved very effective.

Surgical treatment of recurrent tracheo-esophageal fistula using a latissimus dorsi pedicled muscle flap--report of a case.

We report herein, a case of a child in whom a prepared latissimus dorsi muscle flap was successfully utilized in the treatment of recurrent tracheo-esophageal fistula (TEF). A 12-month-old girl who had undergone a primary repair of Gross’s type C esophageal atresia at 6 days of age and a secondary repair of recurrent TEF at 4 months of age experienced, postoperatively, repeated episodes of aspiration pneumonia caused by recurrence of the fistula. Thus, we performed a reoperation in which the fistula was excised, and a latissimus dorsi muscle pedicled flap was interposed between the tracheal and esophageal suture lines. Viability of the muscle flap was adequately achieved by means of a three-stage delayed operation. Although a minor anastomotic leakage of the esophagus was found postoperatively, it healed spontaneously, and the patient was commenced on a normal diet orally without any problems at 26 months of age.

Computed tomography for preoperative evaluations of lung cancer

Computed tomography was evaluated for its accuracy in diagnosing mediastinal node metastases, direct chest wall invasion, and direct mediastinal invasion by lung cancer among 61 patients who subsequently underwent surgery. Using 15-mm diameter or larger mediastinal lymph nodes as the criterion for metastasis, the sensitivity was 36% (8/22); the specificity was 92% (34/37). The accuracy for direct chest wall invasion was relatively high, with a sensitivity of 100% (7/7) and a specificity of 92% (22/24). Direct mediastinal invasion had a sensitivity of 67% (4/6) and a specificity of 91% (10/11). These results suggest that the ability of computed tomography to diagnose mediastinal lymph node metastasis when such nodal size is used as a criterion is limited.

An isolated aneurysm of the common iliac artery associated with an arterio-venous fistula: Autotransfusion technique and postoperative hemodynamic monitoring —A case report—

Isolated aneurysms of the common iliac artery occur less frequently than abdominal aortic aneurysms. Moreover, the rupture of an isolated iliac aneurysm into a systemic vein is considered to be very rare. The case reported herein is of a patient with a left common iliac aneurysm which ruptured into the iliac vein, who was successfully treated surgically, using Doty’s autotransfusion technique as a supportive measure. We describe our preoperative diagnosis, operative method, including the supportive measures, and the postoperative hemodynamic changes monitored by a Swan-Ganz catheter.