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Cellular immunity against human bile proteins was investigated by the leukocyte migration inhibition test (LMIT) with 13 primary biliary cirrhosis (PBC) patients, 10 chronic aggressive hepatitis (CAH) patients and 21 healthy adults. Hepatic bile taken from patients operated on for lithiasis of the biliary tract was fractionated into five fractions with Sepharose 6B gel. A subtoxic dose of each fraction was determined in the healthy adults, and used as the antigen for LMIT. Out of the 5 fractions, only the third fraction led to an LMIT positive response in 8 out of 11 (73%) PBC patients and in 1 out of 10 (10%) CAH patients. The difference between PBC and CAH was significant (p less than 0.005). The remaining 3 PBC patients with LMIT negative responses were all under D-penicillamine treatment. Antibody to each fraction was prepared in rabbits. Using the antibodies after absorption with human serum, the localization of the antigens which were present in each fraction was investigated immunohistochemically using human liver sections. The antigen to the anti-first fraction antibody was detected specifically in the epithelial cells of the bile ducts and the ductules, and the antigen to the anti-third fraction antibody was detected specifically on the membrane of the bile canalicules. The third fraction was fractionated into three fractions by Sephadex G-200 gel. Only the first of the 3 fractions showed an LMIT positive response in 3 PBC patients, and its molecular weight was determined to be about 500,000. It is concluded that PBC patients develop cellular immunity against canalicular-antigen-containing fractions but not ductal-antigen-containing ones.

Tissue reactions at the cement-bone and artificial implant-bone interface were examined light and electron microscopically in thirty-six patients who underwent revisory operation of hip or knee replacement. The reactions were classified into three types: inert tissue, active tissue with giant cell proliferation, and active tissue with predominant foamy cell proliferation. The third type of reaction was found only in total hip replacement with bone cement. No evidence of allergic reaction to implanted materials was found in any replacement, though active cellular infiltrations were observed around loosened prostheses especially in cemented arthroplasty. The tissue reactions always occurred around instable or loosened prostheses. Thus, the present study shows that mechanical instability is the primary cause of such undesired tissue reactions.

The first operative procedure in sex reassignment surgery (SRS) for female-to-male transsexuals (FTMTS) is mastectomy. This procedure includes the removal of mammary tissue, removal of excess skin, and reduction and proper repositioning of the nipple and areola complex. We have performed mastectomies in over 120 patients since January 2001 and want to describe the operative procedures we have developed. We classified our patients into 3 groups according to the patient's breast volume and the degree of ptosis, and we selected the operative procedure that was suitable for each group. At present all costs for SRS are assumed by the patient in Japan. If the FTMTS patient undergoes the entire series of SRS operations, he has to pay more than 3,000,000 yen. Thus the surgeon should select the proper operative procedure so that the patient can avoid unnecessary additional operations. We describe herein the techniques and the strategy for performing mastectomy in FTMTS.

Scoliosis is a common clinical manifestation of Rett syndrome, a neurodevelopmental disorder that almost exclusively affects females. The spinal curve in patients with Rett syndrome is typically a long C curve of a neuromuscular type. As the onset of the scoliosis is very early and shows rapid progression, early surgical intervention has been recommended to prevent a life-threatening collapsing spine syndrome. However, there are high perioperative risks in Rett syndrome patients who undergo spinal surgery, such as neurological compromise and respiratory dysfunction due to rigid spinal curve. We herein report the surgical result of treating severe rapid progressive thoracic scoliosis in a 16-year-old girl with Rett syndrome. Posterior segmental pedicle screw fixation was performed from T1 to L3 using a computer-assisted technique. Post-operative radiography demonstrated a good correction of the curve in both the sagittal and coronal alignment. There were no postoperative complications such as neurological compromise. The patient had maintained satisfactory spinal balance as of the 3-year follow-up examination.

The extra-anatomical bypass formation and the exclusion of thoracic aortic aneurysms by the "paired clamp method" applied to the thoracic aorta of mongrel dogs, and the development of hind leg paralysis was studied experimentally in relation to the ratio between the mean excluded cavity pressure and the mean aortic pressure ratio (EA-ratio). The relationship between thrombus formation in the excluded cavity and the EA-ratio was also studied. Animals were divided into 4 groups: Group 1 underwent the cross-clamping of the descending thoracic aorta for 8 min; Group 2 underwent exclusion of the entire thoracic aorta under permanent bypass; Group 3 underwent ligation of 2/3 of the proximal intercostal arteries which branched from the excluded thoracic aorta; and Group 4 underwent division of the excluded thoracic aorta into 3 parts by ligation. No animals in group 1 developed paralysis. When EA-ratios were higher than 0.48, animals in groups 2 and 3 were not paralyzed, whereas all but 1 animals with EA-ratios lower than or equal to 0.48 were paralyzed. There was statistically significant difference between the EA-ratio of the non-paralyzed animals and that of the paralyzed animals in groups 2 and 3. Four out of 5 animals in group 4 were paralyzed. However, there was no statistically significant difference between the EA-ratio in these 4 paralyzed animals and that in the non-paralyzed animals in groups 2 and 3. When the EA-ratio was lower than or equal to 0.59, all but 1 excluded cavities of groups 2 and 3 animals were fully thrombosed 7 or 8 days after the operation. None of these animals showed the aggravation of the paralysis during the observation period and, conversely, the paralysis of almost all animals was ameliorated. These results suggested that the EA-ratio is useful in predicting the development of paralysis and thrombus formation in the excluded cavity after the operation of thoracic aortic aneurysms by the "paired clamp method".

Thirty-eight patients were operated on for mitral stenosis between March 1979 and September 1981. Thirty-six of them were examined as to their age, symptom duration, chest roentgenograms, electrocardiograms and echocardiograms to obtain various indices of left ventricular function. The usefulness of these indices as preoperative risk factors for predicting postoperative low cardiac output syndrome (LOS) was investigated. Cases which had values of ejection fraction, cardiac index, percent fiber shortening or mean velocity of circumferential fiber shortening less than 0.45, 2.0 l/min/m2, 25% and 0.80 circ/sec, respectively, in the preoperative echocardiographic examination were associated with a greater chance of postoperative LOS. Each of these factors was independently useful as a risk factor in cardiac surgery for mitral stenosis. Moreover, it was revealed that the combination of a preoperative percent fractional shortening (%FS) of less than 30% and a cardiac index smaller than 2.0 l/min/m2 indicated a strong predisposition toward postoperative LOS.

We performed laparoscopic prostatectomy in seven cases with organ-confined prostate cancer. In 6 cases, the surgery was completed successfully and the mean operative time was 424 min. Volume of blood loss was 200 to 3,200 ml and catheterization lasted 6 to 37 days. No major complications were observed in 6 of the cases. In one case, open surgical conversion was necessary mainly due to a bladder injury. Although these were the first cases of laparoscopic prostatectomy in our institution, the technical difficulty and complexity of the surgery were moderate. We believe that laparoscopic radical prostatectomy will become a standard option for the treatment of organ-confined prostate cancer.

In this paper we describe a patient with polycythemia vera (PV), who presented with hypercalcemia due to a parathyroid adenoma. In November 1999, the patient was admitted to our hospital with meteorism and constipation. Her physical examination revealed plethora and hepatosplenomegaly. Laboratory data revealed hyperparathyroidism in addition to PV: Rbc 8 x 10(6)/mm3, Hct 63.7%, serum calcium 13.4 mg/dl, serum phosphorus 1.2 mg/dl, albumin 4.25 mg/dl, and alkaline phophatase activity 433 U/l. Intact Parathyroid Hormone level (iPTH) was 376 pg/ml (n.v.12-72 pg/ml). Twenty-four hour urinary calcium excretion was higher than normal (900 mg). A parathyroid adenoma was detected with Tc-99m sesta-MIBI scanning under the left lobe of the thyroid gland and an ultrasonographic examination of the neck also supported the diagnosis. The patient was recommended for surgery. The histopathological examination confirmed the diagnosis. Postoperatively, iPTH dropped to 53.4 pg/ml at the 15 th minute and to 33.5 pg/ml at the first hour. The calcium level was 7.5 mg/dl one hour after the operation. Five days later, Hct was 40.8%. This case represents a rare association between PV and primary hyperparathyroidism, and may provide evidence for a causal link between PTH and polycythemia vera in our patient. In conclusion, this case indicates that the differential diagnosis of hypercalcemia and polycythemia vera should also include the possibility of a parathyroid tumor in addition to malignancy.

We studied parasite detectability in thick films by an acridine orange fluorescence technique (AO) to test its applicability and the use of a Malaria Diagnosis Microscope (MDM)-ESL in the detection of parasites, compared to the conventional Giemsa staining method. This study was conducted on 1,390 clinically suspected malaria cases of Thaton township, Myanmar. We found sensitivities of 82.8% for Plasmodium falciparum (P. falciparum) and 100% for Plasmodium vivax (P. vivax) and specificities of 97.1% for P. falciparum and 98.6% for P. vivax. AO had a higher sensitivity than Giemsa-stained films at low levels of parasitemia (< 1,000/microl). AO showed lower sensitivity and higher specificity than the Giemsa method at parasite levels of more than 1,000/microl. The results of using the AO method, achieved by both novice and experienced observers, showed no significant difference and required less practice to perform the test as well as to identify the parasite. The acridine orange fluorescence technique using a malaria diagnosis microscope MDM-ESL series is simple, rapid and cost effective. The microscope is conveniently operable using standard AC power or a 12-V DC car battery, and it is easily convertible to a conventional biological microscope. With the exception of species differentiation, which is not possible with this method, this method would be appropriate for both clinical and epidemiological studies.

The evaluations of the basal metabolism before the operation, at the completion, and at the follow-up examinations, have been conducted on the patients with cervical carcinoma, all under the age of 50 years, and operated on in the Clinics of Obstetrics and Gynecology, Okayama University Medical School and the following results are obtained: 1. The basal metabolism of the patients with cervical carcinoma of either stage I or stage II as compared with that of the normal women is more accelerated; while the basal metabolism of the cervical carcinoma of stage II. is more augmented than that of the cervical carcinoma stage I. 2. The basal metabolism at the completion of operation is markedly lower than that before the operation. 3. In those who received the autotransplantation of the ovary concomitantly with operation, the basal metabolism once increases at the 4th month after the operation and after that it maintains a low stable state. 4. The basal metabolism of those who received the operative castration continues increasing up to the 8th month after the operation and thereafter it returns to a rather balanced state. 5. From the aspects of the fluctuations of the basal metabolism, it has been recognized that the autotransplantation as compared with the castration exerts less influences on the somatic system and for a shorter period of time, and also the endocrine system of the former returns to the balanced condition earlier.

A sanitary mass-disposal of nightsoil constitutes one of the major public health problems in the majority of Japanese cities and towns. Under the present economic situations in Japan, however, a low construction and operation cost and a simple disposal plant easy to operate are most essential to meet the prevailing needs, not to speak of complete destruction of pathogenic bacterial and parasitic organisms contained in the excreta to be disposed of.

Seventy-nine shoulders suspected of rotator cuff tears were examined by ultrasonography (US) and forty-three received surgery. Long and short axis scans were performed and findings of each were separately classified according to a five-grade system, and the results were correlated with the actual extent of tear observed during surgery. Internal echogenicity and subacromial impingement were analyzed before and after surgery. A accuracy of US in detecting rotator cuff tears was analyzed. In addition, the correlation between cuff shape observed by US before surgery and actual shape observed during surgery was assessed. It was noted that cuff thinning and abnormalities in shape did not recover to normal after surgery. However, in the cases of discontinuities observed by US before surgery, US findings indicated that the torn cuff was anchored to the greater tuberosity and functional during active motion. Although post-operative US findings were not normal, clinical results were good in most cases. Sensitivity of US for detecting rotator cuff tear was 100% and specificity 94%. US is non-invasive, cost effective and allows the physician to examine the joint while it is in motion. Therefore, at this time, we use US as a screening method for detecting rotator cuff tears. Furthermore, US allows us to check for re-tears while the joint is in motion, which is essential for accurate diagnosis.

Ten radiograph signs were assessed by two experts for their usefulness in the diagnosis of small solitary peripheral pulmonary nodules less than 3 cm. The ten categories included notching, spicula formation, pleural indentation, vascular convergence, contour, paleness, homogeneity, cavitation, air bronchogram, and calcification. The cases included 134 lung cancers and 44 benign lung lesions resected between 1972 and 1988 at the Second Department of Surgery, Okayama University Medical School. Notching, spicula formation, pleural indentation, vascular convergence, contour, and air bronchogram were useful signs in differentiating lung cancer from benign lung lesions. However, since the radiograph signs exhibited great variation in both lung cancer and benign lung lesions, a diagnostic operation is sometimes inevitable.

Obliteration for gastric or duodenal variceal hemorrhage was performed via transileocoecal or transhepatic portal catheterization in 8 patients with portal hypertension. The patients were 6 men and 2 women, whose average age was 59 years. All of the patients had cirrhosis of the liver. The obliteration was performed as an emergency procedure in 6 cases, and 2 patients were electively treated. Transileocoecal obliteration (TIO) and transhepatic obliteration (PTO) were selected for 6, and 2 patients, respectively. Variceal bleeding was successfully controlled in all patients after completion of the therapy. One patient died after 3 months when duodenal variceal bleeding recurred. Elective surgical operations were performed on 2 patients after the initial therapy, because the vein feeding toward the varices remained. Six of the patients have survived to date without bleeding. Transient oliguria and jaundice after the therapy were noticed in 2 patients. Histological examination revealed cast formation of polymerized cyanoacrylate in the obliterated gastric varices of 2 patients. TIO and PTO seem to be safe, effective procedures to stop bleeding from ectopic varices, gastric or duodenal. This therapy is useful either to obtain accurate information about the varices or to obliterate the collateral veins in patients with ruptured ectopic varices.

A case illustrating the value of aggressive respiratory training in improving the prognosis of lung cancer complicated by low pulmonary function is reported. Preoperative and postoperative respiratory training enabled the patient with chronic respiratory failure to survive a lengthy operation and eventually breathe without assistance. The patient has survived more than 71 months, and experiences only exertional dyspnea at the time of publication. Aggressive preoperative and postoperative respiratory management may make more of the growing number of lung cancer patients eligible for standard surgical procedures.

We performed a long-term follow-up of 4 patients with penile cancer who underwent hyperthermotherapy from August 1985 until August 1992. Hyperthermia was applied using a frequency of 350 MHz with a waveguide applicator twice a week for 60 min each for an average of 9.5 times (varying from 6 to 13 times). The total heating time that the temperature of urethra could be kept above 42 degrees C, was 166 min on the average (ranging from 0 to 463 min). Two patients classified as stage I according to the Jackson classification and 1 patient classified as stage IV underwent combined radiotherapy and received an average radiation dose of 53 Gy (range, 40-70 Gy). Among these patients 2 underwent combined chemotherapy with bleomycin or peplomycin. Malignant cells disappeared posttherapeutically and in August 1992, after an average of 5 years and 9 months (varying from 4 years 6 months to 6 years 10 months), the patients were free of recurrences. The one patient on stage IV had extensive invasion of the abdominal wall, but still recovered completely. One patient on stage III underwent combined chemotherapy and hyperthermotherapy, but heating had obviously been insufficient. There was a residue of malignant cells after the treatment and we performed a penectomy. Regarding functional preservation of the penis a multidisciplinary therapy incorporating hyperthermotherapy can be expected to increase the curativity. This indicates that it could induce in an advanced case, where an operation would be difficult, complete remission.

<P>Measurements of the cerebrospinal fluid (CSF) flow using phase contrast cine magnetic resonance (MR) imaging were performed on a phantom, 12 normal subjects and 20 patients with normal pressure hydrocephalus (NPH). The phantom study demonstrated the applicability of phase contrast in quantitative measurement of the slow flow. The CSF flows of the normal subjects showed a consistent pattern with a to-and-fro movement of the flow in the anterior subarachnoid space at the C2/3 level, and they were dependent on the cardiac cycle in all subjects. However, the patients with NPH showed variable patterns of the CSF pulsatile flow and these patterns could be divided into four types according to velocity and amplitude. The amplitudes of each type were as follows: type 0 (n = 1), 87.6mm; type I (n = 2), 58.2mm (mean); type II (n = 6), 48.0 +/- 5.0mm (mean +/- SEM); and type III (n = 11), 19.9 +/- 1.8mm (mean +/- SEM). The decrease of the amplitudes correlated to a worsening of the clinical symptoms. After the shunting operation, the amplitude of to-and-fro movement of the CSF increased again in the patients with NPH who improved clinically. Some of the type III cases were reclassified type II, I and 0 and also one of the type II cases changed type I after the shunting operation. We conclude that the phase contrast cine MR imaging is a practically and clinically applicable technique for the quantitative measurement of the CSF flow.</P>

Doppler left ventricular (LV) inflow is reportedly affected by LV diastolic properties. We evaluated 48 subjects consisting of 27 patients with chronic mitral regurgitation (MR) and 21 patients with noncardiac disorders who received echocardiographic examinations. The deceleration rate divided by diastolic dimension (DR/Dd) derived from Doppler early diastolic LV inflow was correlated with the peak diastolic velocity divided by diastolic dimension (peak DV/Dd), a conventional index of LV diastolic function derived from the M-mode echocardiogram in the 48 patients, regardless of the presence of normal sinus rhythm or atrial fibrillation. LV diastolic function was then estimated by comparing perioperative echocardiographic examination and LV micro-and ultrastructural findings of biopsy specimens from 12 patients with MR who received mitral valve replacement. Fiber diameter, volume fraction of interstitial fibrosis (int. % Fib), and volume fractions of three intracellular components; the myofibrils (% MF), the sarcoplasmic reticulum (% SR) and the mitochondria (% MT), were measured in LV transmural biopsy specimens. DR/Dd was significantly correlated with peak DV/Dd before and after operation. Peak DV/Dd and DR/Dd were inversely correlated with int. % Fib and % SR, and were positively correlated with % MF. We subdivided the 12 MR patients according to their postoperative DR/Dd values as "recovered", and "non-recovered" based on their postoperative LV diastolic function. % MF was significantly lower in the 'non-recovered' group. Thus, DR/Dd can serve as an index of LV diastolic function. A decrease in % MF may inhibit the recovery of postoperative LV diastolic function.

Forty patients underwent coronary revascularization using bilateral internal thoracic artery (ITA) grafts between 1988 and 1992. A total of 111 coronary grafts were performed, or an average of 2.8 grafts per patient. Each patient received bilateral ITA grafts, and in 20 patients an additional 29 grafts were constructed with 18 autologous veins and 11 gastroepiploic arteries. The right ITA was grafted as a free graft in 20 patients. The ITA graft patency rate was 96 per cent (67/70) at the time of hospital discharge. The operative morbidity included 3 reoperations for bleeding, 1 perioperative myocardial infarction, 1 renal failure, 2 postcardiotomy shock, and 1 colon perforation. Two hospital deaths occurred; one due to colon perforation and the other due to postcardiotomy cardiogenic shock. One patient died of cerebral infarction 6 month after the operation. Thirty-four patients were in New York Heart Association functional class I, 2 were in class II and 1 was in class III. Cardiac function evaluated by echocardiography and scintigraphy showed significant improvement postoperatively. These data suggest that the use of bilateral ITA grafts is associated with an acceptable mortality and increases the versatility of arterial grafting.

A ten year follow-up study was made of 107 hips of 97 patients to find if derotation osteotomy affected the growth of the hip joint. The anteversion angles before and after treatment were measured in four groups classified according to treatment method: Pavlik harness, frog plaster, Colonna operation and derotation osteotomy. The difference in the angle was greatest in the derotation osteotomy group. However, no significant relation between the CE angles and the anteversion angles or the degree of derotation at the time of the follow-up study was found. The author concluded that the growth of the hip is not influenced by the extent of anteversion as much as was previously believed before.