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A 46-year-old woman with acromegaly and hyperthyroidism due to a pituitary adenoma. She had high serum thyroid-stimulating hormone (TSH) levels and very high serum growth hormone (GH) levels. Transsphenoidal removal of the tumor, post-operative irradiation, frontal craniotomy for removal of residual tumor and large-dose bromocriptine therapy were carried out consecutively. After therapy, serum GH levels gradually decreased, but not to the normal range, and serum TSH levels remained at inappropriately normal levels. Using immunoperoxidase techniques, GH-, TSH- and follicle-stimulating hormone (FSH)-containing cells were demonstrated in the adenoma. A long-acting somatostatin analogue (SMS 201-995, 600 micrograms/day) suppressed the serum GH level to the normal range with a concomitant suppression of TSH. Furthermore, the paradoxical serum GH responses to TRH and LH-RH were slightly improved. No important subjective side-effects were noted. Therefore, SMS 201-995 appeared to be a very effective drug in this patient with a GH- and TSH-producing pituitary tumor.</P>

Over the last three years, we have used ventricular assist devices (VAD) in 7 patients. Of these 7, four patients with combined aortic and mitral valvular disease underwent double valve replacement; one patient with annuloaortic ectasia underwent a Cabrol's operation; another had aortic valve replacement; the last patient had triple coronary artery bypass grafts. The only patient who could be weaned from CPB developed cardiogenic shock after the operation. LVADs supported 6 patients for 4 to 8 days and a BVAD supported one patient for 9 days. All patients survived the weaning procedure. Three were discharged from the hospital and survived 7 to 21 months. The 4 other patients died of multiple organ failure. Three of these four suffered from both renal failure and infection, while one patient had arrhythmia and died of ileus. These data suggest that renal failure and major infection can be serious detrimental complications to VAD support.

A biventricular bypass type total artificial heart (BVB-TAH) utilizing two pusher-plate pumps was developed and implanted in a sheep for 48 days with excellent results. A Hall effect sensor was utilized to operate each pump independently with a full stroke at variable rates (VR). With this system, the animal's hemodynamics was kept physiologically, and all metabolic parameters except hemoglobin and hematocrit returned to normal three weeks after implantation. However, signs of infection appeared on the forty-second day, and consequently the animal fell into a state of shock. Even at that time the BVB-TAH maintained circulation by increasing pumping rate automatically. On the forty-eighth day, the animal could not stand and suffered from anuria; the experiment was then terminated after 1,140 h pumping. At autopsy, there was an enlarged heart with an atrophic change, 1,900 ml of pleural effusion, and 3,100ml of ascites fluid. Blood culture taken on the forty-seventh day yielded Acinetobacter calcoaceticus. The BVB-TAH operated in an independent VR mode maintained entire circulation, and has a capability of substituting the native heart function in any situation.

We report a case requiring biliary reconstruction with right hepatic lobectomy due to biliary strictures caused by continuous cholangitis after laparoscopic bile duct injury. The patient, a 55-year-old woman, underwent laparoscopic cholecystectomy for cholelithiasis at another hospital. Although a bile leakage from the intraabdominal drain was observed several days after the operation, the patient was not given adequate treatment to stop the leakage. Two months after the initial laparoscopic cholecystectomy, she was referred to our hospital. Endoscopic retrograde cholangiopancreatography (ERCP) showed complete obstruction of the common hepatic duct, which was caused by clipping during laparoscopic cholecystectomy. Cholangiography from percutaneous transhepatic biliary drainage (PTBD) catheters revealed that sections of the secondary branches of the right intrahepatic bile duct had become constricted due to persistent cholangitis. Fortunately, the left hepatic duct was judged to be normal by imaging. Therefore, we elected to perform a right hepatic lobectomy and left hepaticojejunostomy, because we felt that performing a hepaticojejunostomy without hepatic resection would put the patient at risk of continuing to suffer from cholangitis. The patient was discharged on the 55 th postoperative day, and, 5 years after reconstructive surgery, is healthy and has remained free from biliary strictures in the remnant liver. Appropriate decision-making is essential in the treatment of biliary injury after laparoscopic cholecystectomy. Surgeons should not hesitate to perform biliary reconstruction with hepatic resection to reduce the risk of cholangitis or biliary strictures of the remnant liver. More importantly, preoperative clear imaging of the biliary tree and suitable management of any biliary injury which might occur are necessary to avoid having to perform reconstructive surgery.

Angiography is gold standard technique as preoperative examination for unruptured aneurysmal surgery. Neurosurgeons have observed the unexpected irregular shape and size of the aneurysmal dome and neck in many cases of unruptured cerebral aneurysms during aneurysmal microsurgery, and known the discrepancy between the findings of angiography and operative view. We could not find out the report described the preoperative evaluation of outer-wall (contour) of aneurysm. In the present study, we attempted to evaluate the outer-wall of an unruptured cerebral aneurysm using three-dimensional CT cisternogram (3D-CTC) to provide useful preoperative information. The study was performed on three cases of unruptured cerebral aneurysm that were identified incidentally by MR angiography. We performed three-dimensional CT aniography (3D-CTA) and 3D-CTC for each patient. In the present study, we visualized the contours of vessels and aneurysms using a 3D-CTC in three cases of unruptured cerebral aneurysm. We found the discrepancy between the 3D-CTC contour image and the intra-luminal image 3D-CTA image. This method may be useful for the decision of the surgical approach and have the potential to evaluate the anatomical structure of aneurysmal dome and neck preoperatively.

We studied the differentiation of thyroid nodules using fine-needle aspiration biopsy (FNA) and Tl-201 scintigraphy quantitative analysis. One-hundred and thirty-one thyroid nodules were examined: 83 follicular lesions (58 benign and 25 malignant lesions) and 48 non-follicular lesions (8 benign and 40 malignant lesions). During Tl-201 scintigraphy examinations, an early and a delayed image were acquired 10 and 120 min after an intravenous injection, respectively. The T/N ratio (counts of nodular lesion/counts of contralateral normal thyroid tissue) of each image was calculated quantitatively. We assessed the ability of the Tl-201 scintigraphy and of the FNA analysis to differentiate benign and malignant lesions and determined the cut-off levels for the assays. For the follicular lesions, the area under the ROC (Receiver Operating Characteristic) curve (Az) for the Tl-201 scintigraphy data was greater than that for the FNA data. For the non-follicular lesions, the Az for the FNA data was greater than that for the Tl-201 scintigraphy data. We set cut-off levels at 1.370 for follicular lesions, and 1.070 for non-follicular lesions. The sensitivity and specificity were 76% and 82.7% for follicular lesions, and 90% and 87.5% for non-follicular lesions, respectively. The overall accuracy of the analysis was 84.0%.

A 34-year-old woman was admitted to our emergency room with a high fever, abdominal pain, dyspnea and confusion. High fever and abdominal pain had first occured after a cystocele operation 5 months earlier. Later, congestive heart failure with mural thrombus formation, peripheral polyneuropathy and ischemic cerebrovascular accident were identified in clinical follow-ups, and multiple arterial and venous thromboses were seen on cranial and abdominal magnetic resonance imaging angiography. The patient's symptoms improved with anticoagulant treatment. Antiphospholipid syndrome with elevated serum anticardiolipin IgG levels was diagnosed, and ischemic peripheral polyneuropathy with axonal degeneration was determined by sural nerve biopsy. In antiphospholipid syndrome, elevated anticardiolipin antibodies appear to be the most common acquired blood protein defect causing thrombosis. Disseminated vascular thrombosis in catastrophic antiphospholipid syndrome can result in multiorgan failure with increased morbidity and mortality. It rarely occurs secondary to various infections as in the case of our patient, who suffered postoperative intraabdominal infection. It is important to note that peripheral nervous system involvement is rare in antiphospholipid syndrome.

We present a case of a primary advanced gastric tumor that was composed of 2 different pathological components: small cell carcinoma and moderately-differentiated adenocarcinoma. The patient was still alive four years after the surgery was performed, without recurrence. A large part of the tumor consisted of a diffuse sheet of small cell carcinoma, which transitioned into another small portion consisting of moderately-differentiated tubular adenocarcinoma components. Therefore, this case raised the possibility that small cell gastric carcinoma may originate from totipotential stem cells of the stomach. Although small cell carcinoma progresses aggressively, and patients with it have an extremely poor prognosis, this patient recovered uneventfully after the surgical resection, and has remained in good health, without any recurrences.

Levamisole was administered to 177 patients with gastrointestinal cancer (88 curative resection, 58 noncurative resection and 31 without resection). It was administered at a daily dose of 150 mg for three consecutive days every other week. The administration was started, as a rule, 3 days before operation. This medication was repeated as frequently as possible at least for one month. The cellular immunity and 18-month survival rate of treated and control groups were compared. Levamisole effectively improved peripheral lymphocyte blastformation against phytohemagglutinin and increased the numbers of peripheral blood lymphocytes. Levamisole caused extremely high blastformation rates, in general, enhanced PPD reactions in non-curative resection cases 7 months after operation and showed no influence upon the number of peripheral blood lymphocyte. The effect of levamisole on the 6-month survival rate was most marked in patients without resection. Increased 12-month survival rate was marked in non-curative resection cases and, to a lesser extent, curative resection cases. Patients without resection had a slightly improved 12-month survival rate. Levamisole improved the 18-month survival rate in resectable cases; however, there were no significant differences in 18-month survival between levamisole and control groups of patients not undergoing resection. The results suggest that levamisole is effective in the patients whose tumor cells have been decreased by any method.

The effect of subdiaphragmatic vagotomy on food intake and defecation was studied in guinea pigs. Weights of food and feces were measured for at least three weeks after vagotomy. The weight of daily food intake and feces evacuated increased about 15 and 30% after vagotomy compared with controls whereas it did not change in sham operated animals. The weight of scybalum decreased after vagotomy although the number increased markedly. It was considered that an increase in food intake after vagotomy may result from blocking of satiety signals mediated by the vagus; moreover, that the increase in feces may depend on the enhancement of scybalum formation in the proximal colon resulting from increasing food intake and transportation of the larger amount of the contents after vagotomy.

A 60-year-old man was admitted to our hospital with a right inguinal swelling that had been growing in size without any pain for 7 months. We diagnosed the growth as a right inguinal hernia and operated on him. The growth, however, was found to be a tumor it situated along the spermatic cord and testicular vessels. We diagnosed it as a lipoma. The tumor was resected near part of the internal inguinal ring. Histopathological diagnosis showed well-differentiated liposarcoma of the sclerosing type. Postoperative computed tomography (CT) revealed a large residual tumor in the retroperitoneum. We believed that the tumor was a retroperitoneal liposarcoma and that it developed in the inguinal region. The residue of the liposarcoma was resected onto the right inguinal tract. A periodic follow up has been performed and no evidence of recurrence or metastasis has been seen in the 4 years and 9 months since the second surgery. No adjuvant therapy was performed. Inguinal liposarcomas are relatively rare and in most cases these tumors are thought to originate in the spermatic cord. The origin of the tumor is believed to be the retroperitoneum

A prospective study was performed to determine the accuracy of magnetic resonance imaging (MRI) compared with operative findings in the evaluation of patients associated with rotator cuff tears. Fifty-four of 60 shoulders (58 patients) examined by MRI were confirmed as full-thickness tears and 6 as partial-thickness tears at the time of surgery. The oblique coronal, oblique sagittal, and axial planes of T2-weighted images with the 0.5 tesla MRI system were obtained preoperatively and compared with operative findings. MRI correctly identified 46 of 54 full-thickness rotator cuff tears and 5 of 6 partial-thickness tears. A comparison of MRI and operative findings in full-thickness cuff tears showed a sensitivity of 85%, a specificity of 83%, and a positive prospective value (PPV) of 99%. A comparison of partial-thickness tears showed a sensitivity of 83%, a specificity of 85%, and PPV of 39%. Linear regression analysis showed an excellent correlation between the MRI assessment and measurement at the time of surgery (r = 0.90, P < 0.01). MRI was useful in evaluating large and medium-sized rotator cuff tears, but less useful in distinguishing small full-thickness tears from partial-thickness tears.

Continuous caudal anesthesia has been commonly used for intra- and post-operative analgesia in infants and children. However, it has a potential risk of bacterial infection, especially in infants in whom the catheter site is easily contaminated with loose stool. To avoid infection, the authors applied a new procedure using subcutaneous tunneling for continuous caudal anesthesia. In the 18 cases studied with subcutaneous tunneling, clinical signs of infection were absent and bacterial colonization was not found on the catheter tip after 3.9 +/- 1.4 days of catheterization. The incidence of catheter colonization after continuous caudal anesthesia without tunneling had been reported. In their reports, the incidence of catheter colonization ranged from 20% to 37%. Therefore, caudal catheterization with subcutaneous tunneling is a simple and safe method, and has proved very effective to reduce the risk of epidural infection.

It is recognized that sustained ischemia-induced hyperactivity is related to abnormalities in dopamine function. However, it is unclear that dopaminergic neurotransmission triggers such ischemia-induced hyperactivity. Therefore, the relationship between dopaminergic neurotransmission and ischemia-induced hyperactivity was investigated in an animal model using Mongolian gerbils. When haloperidol 2 mg/kg was administered i.p. 30 min after ischemia, the ischemia-induced hyperactivity at 24 h after ischemia was blocked. General behavior was similar to that of sham-operated animals. Haloperidol at doses of 0.1 and 0.2 mg/kg had no effect on locomotor activity in sham-operated animals and decreased ischemia-induced hyperactivity when the drug was administered 24 h after ischemia; these doses did not have any effect on ischemia-induced hyperactivity when the drug was administered 30 min after ischemia. On the other hand, when the animal was confined to a small, restrictive cage for the 24 h period immediately following ischemic injury, locomotor activity at 24 h after ischemia increased. Such behavior also increased in animals when they were returned to their original more permissive cages immediately after ischemia. It is conceivable that the decrease in the level of activity was not related to ischemia-induced hyperactivity. These data suggested that the inhibition of ischemia-induced hyperactivity can be induced by complete blockage of dopaminergic receptors immediately after ischemia.

We report a case of retroperitoneal hematoma presenting as femoral nerve pulsy on antiplatelet therapy. The patient, a 78-year-old man who had undergone antiplatelet treatment using ticlopidine, was admitted to our hospital with complaints of sudden-onset low abdominal and back pain. Computed tomography showed an iso-density mass in the right retroperitoneum within the psoas muscle. We made a diagnosis of retroperitoneal hematoma compressing the femoral nerve and performed an operation to remove the hematoma in order to decompress the femoral neuropathy. Postoperatively, the patient rapidly recovered from the femoral neuropathy. In the particular case in which no antagonist against the ticlopidine is available, surgical decompression could produce a good outcome.

To elucidate the effect of adrenomedullin (AM) on fluid homeostasis under cardiopulmonary bypass (CPB), we investigated the serial changes in plasma AM and other parameters related to fluid homeostasis in 13 children (average age, 28.2 months) with congenital heart disease during cardiac surgery under CPB. Arterial blood and urine samples were collected just after initiation of anesthesia, just before commencement of CPB, 10 min before the end of CPB, 60 min after CPB, and 24 h after operation. Plasma AM levels increased significantly 10 min before the end of CPB and decreased 24 h after operation. Urine volume increased transiently during CPB, which paralleled changes in AM. Simple regression analysis showed that plasma AM level correlated significantly with urinary vasopressin, urine volume, urinary sodium excretion, and plasma osmolarity. Stepwise regression analysis indicated that urine volume was the most significant determinant of plasma AM levels. Percent rise in AM during CPB relative to control period correlated with that of plasma brain natriuretic peptide (r = 0.57, P < 0.01). Our results suggest that AM plays an important role in fluid homeostasis under CPB in cooperation with other hormones involved in fluid homeostasis.

A 69-year-old woman was admitted to our hospital because of anal bleeding and fatigue. The patient was previously diagnosed as having Evans' syndrome on the basis of hematological examination and had been treated with predonisolone for 8 years. On admission, severe anemia and thrombocytopenia were noted. Colonoscopy and Barium enema studies demonstrated an irregular tumor with hemorrhagic ulceration in the rectum, which was histopathologically confirmed as an adenocarcinoma. After red blood cells and platelets were transfused, and the patient was treated with high-dose gammaglobulin, predonisolone, and camostat mesylate, the platelet count gradually increased and hemolysis was well controlled. The patient then underwent Hartmann's operation and splenectomy without any postoperative complications. Predonisolone and high-dose immunoglobulin therapy in a rectal cancer burdened patient with Evans' syndrome is considered useful in combination with surgical treatment. This is the first case report of rectal carcinoma resection in a patient with Evans' syndrome.

We investigated the usefulness of helical computed tomography(CT)in the morphological diagnosis of pulmonary vein stenosis, particularly that in infants and small children. In total, 20 helical CT examinations were performed in 10 post-operative cases of Total Anomalous Pulmonary Venous Drainage(TAPVD), 3 cases of single right ventricle, and 1 case of single left ventricle. In all cases, distinct morphological imaging was possible. Pulmonary vein stenosis could be categorized into three types: (1)stenosis from the anastomosis of the common pulmonary vein (CPV)-the left atrium (LA) to the peripheral pulmonary vein; (2) stenosis only at the anastomosis of CPV-LA; and (3) stenosis due to compression by nearby organs. Coronal views by multiplanar reconstruction (MPR) provided morphological information along the up-down direction of the body axis. Morphological diagnosis of pulmonary vein stenosis is important in deciding prognosis and therapeutic regimens, and helical CT was considered useful for such diagnosis in our 14 young patients.

We examined whether ambulatory ability before surgery might influence the post-operative D-dimer level after total hip arthroplasty (THA). One hundred two patients with hip osteoarthritis receiving THA were included in the current study. The patients were all female, and their ages ranged from 45 to 81 (average 65.0 +- 9.3 years). Age, operated side, body mass index (BMI), disease duration before surgery, pre-operative pain evaluated by visual analogue scale (VAS), total cholesterol value, maximal circumference of the lower leg of the operated side, and timed "Up & Go"test (TUG) before surgery, were retrospectively investigated to examine their relationship with D-dimer levels on post-operative day 7. Patients were divided into 2 groups according to the D-dimer value: over 10 microg/ml (Group D), and under (Group N). Patients in group D (N= 52)were older, had a higher BMI, and had less ambulatory ability than patients in group N (N= 50). As age showed a relationship with the D-dimer value on the 7th day and TUG results, patients in the 2 groups were further subdivided into 50's, 60's, and 70's age brackets. In the 50's bracket, patients in group D had higher BMI than patients in group N, but time for TUG was not significantly different. In the 60's and 70's bracket, patients in group D had less ambulatory ability than patients in group N, but the time for TUG was not directly correlated with the D-dimer value. The results suggest that pre-operative low ambulatory ability in patients with osteoarthritis over 60 years might influence the postoperative D-dimer after THA, indicating the potential risk for post-operative deep venous thrombosis.

A 67-year-old male visited his physician because of a 2-month history of cough and sputum. An abnormal shadow at the left upper mediastinum on chest x-ray film was detected, and the patient was referred to our department for further examination. Chest x-ray film revealed a round shadow at the left upper posterior mediastinum. Computed tomography(CT)revealed a uniform iso density mass about 4 cm in diameter, with a well-defined border. After the intravenous contrast administration, a slight peripheral enhancement was seen around the mass. On magnetic resonance imaging, the mass was hypointense in T1-weighting and hyperintense in T2-weighting. The contrast pattern was the same as that observed in the CT scan. On sagittal and coronal sections, the mass was adjacent to the aortic arch. Although a benign tumor was mostly suspected based on imaging findings, a malignant tumor was also possible. Accordingly, we resected this mass with video-assisted thoracoscopy. Findings at operation were a cystic mass. The pathological findings were compatible with benign parathyroid cyst, which was suspected to be the cystic degeneration of a parathyroid adenoma.