Naomichi Nishikimi

Hepatectomy with simultaneous resection of the portal vein and hepatic artery for advanced perihilar cholangiocarcinoma: an audit of 50 consecutive cases.

Objective:To outline our experience with hepatectomy with simultaneous resection of the portal vein and hepatic artery for advanced perihilar cholangiocarcinoma, and to discuss the clinical significance of this challenging hepatectomy. Summary Background Data:Only a few authors reported negative results for this surgery in a very limited number of patients. Methods:We retrospectively reviewed medical records of 50 patients with advanced cholangiocarcinoma who underwent hepatectomy (left trisectionectomy in 26, left hepatectomy in 23, and right hepatectomy in 1) with simultaneous resection and reconstruction of the portal vein and hepatic artery, focusing on surgical outcome and survival. Results:The operative time was 776 ± 191 minutes, and blood loss was 2593 ± 1890 mL. Time of vessel resection and reconstruction was 25 ± 19 minutes for the portal vein and 119 ± 56 minutes for the hepatic artery. A total of 27 (54.0%) patients developed several kinds of complications, including intra-abdominal abscess (n = 13), wound infection (n = 9), bile leakage from liver stump (n = 9), and liver failure (n = 7). Relaparotomy was necessary in 5 (10.0%) patients. One (2.0%) patient died of a postoperative complication. Microscopic cancer invasion of the resected portal vein was found in 44 (88.0%) patients, while that of the resected hepatic artery was found in 27 (54.0%). The distal bile duct margin, proximal bile duct margin, and radial margin were positive for cancer in 2 (4.0%), 4 (8.0%), and 17 (34.0%) patients, respectively. Consequently, R0 resection was achieved in 33 (66.0%) patients. The 1-, 3-, and 5-year survival rates were 78.9%, 36.3%, and 30.3%, respectively. Survival for 30 patients with pM0 disease who underwent R0 resection was better, being 40.7% at the 3- and 5-year time points. Conclusion:Major hepatectomy with simultaneous resection and reconstruction of the portal vein and hepatic artery is technically demanding. However, this surgery can be performed with acceptable mortality by an experienced surgeon and offers a better chance of long-term survival in selected patients.

Immunohistochemical analysis of arterial wall cellular infiltration in Buerger's disease (endarteritis obliterans)☆☆☆

PURPOSE The diagnosis of Buergers disease has depended on clinical symptoms and angiographic findings, whereas pathologic findings are considered to be of secondary importance. Arteries from patients with Buergers tissue were analyzed histologically, including immunophenotyping of the infiltrating cells, to elucidate the nature of Buergers disease as a vasculitis. METHODS Thirty-three specimens from nine patients, in whom Buergers disease was diagnosed on the basis of our clinical and angiographic criteria between 1980 and 1995 at Nagoya University Hospital, were studied. Immunohistochemical studies were performed on paraffin-embedded tissue with a labeled streptoavidin-biotin method. RESULTS The general architecture of vessel walls was well preserved regardless of the stage of disease, and cell infiltration was observed mainly in the thrombus and the intima. Among infiltrating cells, CD3(+) T cells greatly outnumbered CD20(+) B cells. CD68(+) macrophages or S-100(+) dendritic cells were detected, especially in the intima during acute and subacute stages. All cases except one showed infiltration by the human leukocyte antigen-D region (HLA-DR) antigen-bearing macrophages and dendritic cells in the intima. Immunoglobulins G, A, and M (IgG, IgA, IgM) and complement factors 3d and 4c (C3d, C4c) were deposited along the internal elastic lamina. CONCLUSION Buergers disease is strictly an endarteritis that is introduced by T-cell mediated cellular immunity and by B-cell mediated humoral immunity associated with activation of macrophages or dendritic cells in the intima.

Decrease in prevalence of Buerger's disease in Japan

BACKGROUND Buergers disease is a peripheral arterial occlusive disease that is becoming rare in Western countries but is more common in Asia. Whether it is a specific disease entity remains controversial. This study was undertaken to investigate changes in the prevalence and characteristics of Buergers disease at a major institution in Japan. METHODS Patients with Buergers disease admitted to Nagoya University Hospital between January 1985 and December 1996 were studied retrospectively. Buergers disease was diagnosed on admission according to Shionoyas clinical criteria. RESULTS A total of 105 patients with Buergers disease were evaluated on 126 admissions; 58 were new patients who were admitted for initial treatment, and 47 patients were experiencing a worsening of Buergers disease and had a history of prior treatment. Forty-six new patients were admitted between 1985 and 1989, but only 12 new patients were admitted between 1990 and 1996 (9 +/ 3/ yr vs 2+/ 2/ yr, p = 0.0003). Between 1985 and 1989, 44 patients were admitted because of disease exacerbation, whereas only 24 such admissions occurred between 1990 and 1996 (9+/ 3/ yr vs 3 +/ yr, p = 0.0137). The number of admissions for atherosclerotic peripheral vascular disease did not change significantly in that period. Of the 105 patients, the majority (96%) were men; mean age at the time of disease onset was 36 +/ 8 years. The chief complaint on admission was gangrene/ulcer in 64%, rest pain in 13%, foot claudication in 6%, calf claudication in 6%, and other in 10%. CONCLUSION The prevalence of Buergers disease appears to be decreasing at our institution in Japan. Its clinical characteristics have not changed. A similar decrease in prevalence appears to have occurred in Western countries.

Clinical results of implantation of an endovascular covered stent-graft via midsternotomy for distal aortic arch aneurysm

UNLABELLED We have been implanting endovascular stent grafts (EVG) via midsternotomy for distal aortic arch surgery since February 1997. The early clinical results are evaluated. METHODS There were 11 true aneurysms (8 fusiform, 3 saccular) and one chronic type B dissection. The average age was 68 yr (63-81). EVGs were PTFE-covered two-8 bend Z stents in the first eight cases and made with the same stents and ultrathin woven Dacron grafts in the last four cases. RESULTS Total arch replacement and aortocoronary bypass grafting were combined in one and two patients, respectively. The average retrograde cerebral perfusion time was 42+/-8 min. The cardiopulmonary bypass time averaged 211+/-26 min. All patients awoke early after operation (4.5+/-1.2 h). All but one case was extubated within 24h. There was no operative mortality, but paraplegia and cerebral infarction were complicated in one case each. Their maximum diameter (73.9+/-21.2mm) decreased significantly after operation (68.7+/-20.1mm) and one year thereafter (63.1+/-16.0 mm). True aneurysms were thrombosed completely. A chronic type B dissection revealed impending rupture due to false lumen infection one year after operation. The whole descending aorta replacement was performed but the patient died 6 months thereafter due to cerebro-vascular complication. CONCLUSION Implantation of EVGs reduces operative invasion for distal arch surgery. This procedure should improve mortality, while long-term results have not been clarified.

Subcutaneous tissue distribution of vancomycin from a fibrin glue/Dacron graft carrier

We investigated the tissue distribution of vancomycin (VCM) incorporated in fibrin glue (FG) in a rat model. One VCM-loaded FG Dacron graft (VCM-FG, VCM 0.6 mg/ graft) was implanted in the subcutaneous tissue of the anterior abdominal wall of each rat. VCM was injected intravenously at an equal dose (0.6 mg/rat) after implantation of one control graft (without VCM-FG). After the implantation and the iv injection of an equal dose of VCM (0.6 mg/rat), the tissue distribution of VCM for up to 24 h was determined through analysis of the implanted VCM-FG grafts, which released VCM over a 24 h period. The area under the VCM concentration-time curve (AUC) of the tissue was 89.58 micrograms.h/g after the implantation of the VCM-FG graft, and 7.40 micrograms.h/g after the iv injection of VCM, respectively. The targeting index of the tissue, defined as the ratio of AUC after the implantation of the VCM-FG graft to that after VCM iv injection, was 12.11. None of the six VCM-FG Dacron grafts after implantation became infected following inoculation with S. aureus ATCC 25923 (0.1 mL 10(8) CFU/mL). These results suggest that this VCM-FG Dacron graft delivery may be useful in preventing local infection by enhancing the delivery of VCM to the local areas of the implanted site in rats.

Implantation of an endovascular covered stent-graft for distal aortic arch aneurysm via midsternotomy under pigtail catheter guidance.

We implanted an endovascular covered stent-graft for distal aortic arch aneurysm involving the left subclavian artery in 12 cases. A stent-graft was delivered just below the aneurysm via aortotomy with direct vision using a 12 F delivery sheath under guidance of a pigtail catheter placed via the groin artery. The proximal anastomosis of the stent-graft was performed with inclusion technique, and the aortotomy was then closed with it. This technique reduces operative damage by eliminating distal anastomosis and should reduce operative mortality and morbidity.

Near-Infrared Spectroscopy with Treadmill Exercise to Assess Lower Limb Ischemia in Patients with Atherosclerotic Occlusive Disease

PurposeWe used near-infrared spectroscopy (NIRS) to measure exercise-induced ischemia in patients with intermittent claudication, and compared these results with those obtained by ankle-brachial pressure index (ABPI) analysis.MethodsSixty-two patients with intermittent claudication caused by atherosclerotic occlusive disease exercised on a treadmill until reaching the maximal tolerated walking distance. We measured the ABPI at rest and after exercise until it returned to the baseline value. A NIRS probe was positioned on the patient’s calf, which allowed the continuous monitoring of oxygen saturation (StO2), oxygenated hemoglobin (Oxy Hb), and deoxygenated hemoglobin (Deoxy Hb) in the calf muscles before, during, and after exercise. During exercise, the StO2 and Oxy Hb decreased, and the Deoxy Hb increased. The time taken for each measurement to return to the baseline value was defined as the recovery time. The recovery times obtained by NIRS and ABPI were compared.ResultsThe recovery time for ABPI correlated well with that for StO2 (ρs = 0.73), Oxy Hb (ρs = 0.63), and Deoxy Hb (ρs = 0.65); however, the recovery times measured by NIRS were shorter than the recovery time for the ABPI.ConclusionsNear-infrared spectroscopy is a reliable method for monitoring peripheral circulation during and after exercise, although the data generated provided slightly different information than the results obtained by ABPI.

Hemodynamic assessment of femoropopliteal venous reflux in patients with primary varicose veins

PURPOSE The aim of this study was to assess the anatomic distribution and extent of deep venous reflux in patients with primary varicose veins (PVVs) and to investigate its influence on venous hemodynamics. METHODS Femoropopliteal venous reflux was examined using duplex color Doppler ultrasonography in 356 limbs with PVVs in 240 patients. Photoplethysmography (PPG) was performed using above-knee and below-knee tourniquets to determine the contributions of deep and superficial venous insufficiency. RESULTS Of 356 limbs with PVVs, 61 (17.1%) had femoropopliteal venous reflux, 42 (11.8%) had superficial femoral venous reflux alone, and 57 (16.0%) had popliteal venous reflux alone. Femoropopliteal venous reflux was associated significantly with clinical symptoms and shortened the half venous refilling time measured by PPG, especially in the presence of incompetent perforating veins. These findings were obtained regardless of the presence of long saphenous vein reflux. CONCLUSIONS Femoropopliteal venous reflux associated with PVVs plays an important role in the pathophysiologic mechanism of venous stasis and influences venous hemodynamics in the presence of incompetent perforating veins and short saphenous vein.

Fate of limbs with failed vascular reconstruction in Buerger’s disease patients

We surveyed the recent condition of lower limbs with failed vascular reconstruction in patients with Buergers disease. Forty-three patients (mean age: 41.2+/-8.7 years) received infrapopliteal vascular reconstruction at Nagoya University Hospital. Symptoms at the time of surgery were intermittent claudication in 11 patients, rest pain in 13 and ulcer/gangrene in 19. Inquiry about the condition of the lower limbs was made during March 1998. Eight patients were lost to follow-up and three patients had died. In the remaining 32 patients, mean follow-up period was 140.5+/-42.0 months. Graft was occluded within a week after surgery in six patients with ischemic ulcer/gangrene, three of whom underwent a major amputation while the trophic lesion healed in the remaining three patients. Two grafts were occluded among the 11 patients with intermittent claudication. One of these patients had mild rest pain and the other reported intermittent claudication. Two of the patients with intermittent claudication were lost to follow-up. Among the 13 patients with rest pain, one had died and six were lost-to-follow-up. Although the remaining six patients complained of intermittent claudication, half had an occluded graft. Of the 19 patients with ulcer/gangrene, two had died and all nine of those with occluded graft complained of intermittent claudication. Fate of limbs with failed vascular reconstruction was satisfactory.

Comparison of doppler and oscillometric ankle blood pressure measurement in patients with angiographically documented lower extremity arterial occlusive disease

To assess the reliability of the oscillometric method in patients with peripheral vascular disease, ankle blood pressure measurement by Doppler and oscillometry was compared. This study represents a prospective, non-blinded examination of pressure measurements in 168 patients. Twenty-two patients were included who had abdominal aortic aneurysms (AAA) and 146 had peripheral arterial occlusive disease (PAOD). Patients with PAOD were divided into 2 groups according to angiography results: a crural artery occlusion group (CAO, n = 32), and a no crural artery occlusion group (NCAO, n = 114). All subjects underwent pressure measurement by both Doppler and oscillometry. The correlation coefficient was 0.928 in AAA patients and 0.922 in PAOD patients. In CAO patients, there were significantly fewer patients whose oscillometric pressure was equivalent to the Doppler pressure (DP), as compared to NCAO patients, because the oscillometric pressure (OP) was 10% higher than DP in 44% of CAO patients. A high correlation exists between Doppler and oscillometric ankle pressure measurements irrespective of the type of vascular disease. However, the oscillometric method could not be substituted for the Doppler method completely, because there were several patients whose OP was greater than DP especially in those with crural artery occlusive disease.