Management of non-cerebral malperfusion complicating acute type A dissection

雑誌掲載タイトル：Management of noncerebral malperfusion complicating acute type A dissectionVital organ malperfusion in acute type A aortic dissection is associated with worse outcomes, especially when multiple organ systems are involved, and when coronary or mesenteric malperfusion is present. To achieve the two goals of central aortic repair and adequate and timely reperfusion, mechanism and organ-specific strategy in the methods and sequence of repair should be considered. For dynamic aortic malperfusion, reperfusion can be quickly achieved by femoral artery perfusion, and the fenestrated frozen elephant trunk operation, in which the proximal end of device is secured to zone 1 or 2 and distal 1 or 2 supra-aortic vessels are preserved by fenestration of the fabric, seems optimal as a method of central aortic repair. For coronary malperfusion, percutaneous coronary intervention before central aortic repair may have a role. However, it should be kept in mind that the door-to-unloading time is also important to reduce the area of myocardial infarction, and retrograde cardioplegia is not distributed to most of the right ventricle, which can be critical when right coronary malperfusion is present. Static mesenteric malperfusion should be addressed first, and second look laparotomy should not be hesitated after central aortic repair. The use of a hybrid operating room may be an optimal solution to achieve both goals.journal articl

Altered fasting and postprandial plasma ghrelin levels in patients with liver failure are normalized after liver transplantation

[Abstract] Context Anorexia is a problem of paramount importance in patients with advanced liver failure. Ghrelin has important actions on feeding and weight homeostasis. Experimental data exist, which suggest that ghrelin could protect hepatic tissue. Both fasting and post-oral glucose tolerance test (OGTT) ghrelin concentrations are controversial in liver cirrhosis and are unknown after liver transplantation. Objective Our aim was to study fasting ghrelin concentrations and their response to an OGTT in liver failure patients before and after liver transplantation. Design and methods We included 21 patients with severe liver failure studied before (pretransplantation, PreT) and 6 months after liver transplantation (posttransplantation, PostT), and 10 age- and body mass index-matched healthy or overweight subjects as the control group (Cont). After an overnight fast, 75 g of oral glucose were administered; glucose, insulin, and ghrelin were obtained at baseline and at times 30, 60, 90, and 120 min. Results Fasting ghrelin (median and range, pg/ml) levels were lower in PreT: 539 (309–1262) than in Cont: 643 (523–2163), P=0.045. Fasting ghrelin levels increased after liver transplantation, 539 (309–1262) vs 910 (426–3305), for PreT and PostT respectively, P=0.001. The area under the curve (AUC) of ghrelin (pg/ml min) was lower in PreT: 63 900 (37 260–148 410) than in Cont: 76 560 (56 160–206 385), P=0.027. The AUC of ghrelin increased in PostT, 63 900 (37 260–148 410) vs 107 595 (59 535–357 465), for PreT and PostT respectively, P=0.001. Fasting levels and the AUC of ghrelin were similar in PosT and Cont. Conclusions Decreased fasting and post-OGTT ghrelin levels in liver failure patients were normalized after liver transplantation.Instituto de Salud Carlos III; PI051024Instituto de Salud Carlos III; PI070413Xunta de Galicia; PS07/12Galicia. Consellería de Innovación, Industria e Comercio; PGIDT05PXIC91605PNGalicia. Consellería de Economía e Industria; INCITE08ENA916110E

Arterio-jugular Differences in Serum S-100β Proteins in Patients Receiving Selective Cerebral Perfusion

Purpose The early increase in serum S100β after cardiopulmonary bypass (CPB) seems to be derived from an extracerebral source. To exclude contamination, we investigated the arterio-jugular differences in S100β levels in patients receiving selective cerebral perfusion (SCP). We also evaluated the brain-protective effect of SCP by comparing the arterial S100β levels with those in patients undergoing coronary artery bypass grafting (CABG). Methods We measured arterial and jugular venous levels of S100β in ten patients undergoing aortic arch repair with SCP for up to 12h postoperatively (SCP group). We also measured arterial levels of S100β in nine patients undergoing CABG (CPB group). Results There was no incidence of hospital death or stroke. The arterial levels of S100β in both groups were comparable and peaked just after the conclusion of CPB. The arterial and jugular venous levels of S100β were almost equivalent. The arterio-jugular differences in S100β levels were negligible, even in our SCP-group patient with postoperative delirium, who had a peak value three times higher than the other patients. Conclusions The arterio-jugular differences in S100β did not clarify the origin of their increase. Thus, measuring the jugular venous levels of S100β in patients without postoperative clinical neurological deterioration would be of little benefit. However, SCP seems to protect the brain against S100β release as effectively as conventional CPB

Acetylcholine regulates ghrelin secretion in humans

Ghrelin secretion has been reportedly increased by fasting and energy restriction but decreased by food intake, glucose, insulin, and somatostatin. However, its regulation is still far from clarified. The cholinergic system mediates some ghrelin actions, e.g. stimulation of gastric contractility and acid secretion and its orexigenic activity. To clarify whether ghrelin secretion undergoes cholinergic control in humans, we studied the effects of pirenzepine [PZ, 100 mg per os (by mouth)], a muscarinic antagonist, or pyridostigmine (PD, 120 mg per os), an indirect cholinergic agonist, on ghrelin, GH, insulin, and glucose levels in six normal subjects. PD increased (P < 0.05) GH (change in area under curves, mean +/- SEM, 790.9 +/- 229.3 microg(*)min/liter) but did not modify insulin and glucose levels. PZ did not significantly modify GH, insulin, and glucose levels. Circulating ghrelin levels were increased by PD (11290.5 +/- 6688.7 pg(*)min/ml; P < 0.05) and reduced by PZ (-23205.0 +/- 8959.5 pg(*)min/ml; P < 0.01). The PD-induced ghrelin peak did not precede that of GH. In conclusion, circulating ghrelin levels in humans are increased and reduced by cholinergic agonists and antagonists, respectively. Thus, ghrelin secretion is under cholinergic, namely muscarinic, control in humans. The variations in circulating ghrelin levels induced by PD and PZ are unlikely to mediate the cholinergic influence on GH secretion

Laparoscopic splenectomy for a wandering spleen complicating gastric varices: report of a case

Wandering spleen is a rare clinical entity, and its chronic torsion of the vascular pedicle result in splenic vein occlusion leading to gastric varices. Here, we present a case of wandering spleen complicating gastric varices in a 40-year-old female. Three-dimensional CT (3D-CT) clearly showed the disruption of the splenic vein at the origin of the vascular pedicle and collateral development of the gastric varices. The patient was electively treated with laparoscopic splenectomy. Difficulty of prediction of the splenic vein recanalization to improve the varices was the reason for the use of splenectomy versus splenopexy. The varices were successfully diminished 3 months after the surgery. After review of cases of complicating gastric varices in the literatures, splenectomy is still a secure way to treat an adult patient with wandering spleen with complicating gastric varices

Functional brain isolation technique for stroke prevention in thoracic endovascular aortic repair

To prevent embolic stroke during thoracic endovascular aortic repair, we have adopted the brain isolation technique since June 2014 in nine selected high risk patients (9/134: 6.7%) having ulcerated or protruding atheromas within the proximal aorta. Cardiopulmonary bypass was used to prevent aortic atheromas from entering the brain. We used a heparin-coated closed-loop cardiopulmonary bypass system incorporating a soft reservoir bag with 1 mg/kg heparin to minimize the disadvantages of extracorporeal circulation. The bypass graft (right axillary-left carotid-left axillary) was used as an arterial inflow in patients undergoing zone-1 landing (n=8), while peripheral cannulation into three brachiocephalic arteries was employed in the remaining patient. Initial pump flow was set at 1.3 L/min/m2, and native cardiac output was reduced by adjusting the reservoir bag volume. Aortography was performed to confirm non-visualization of the arch vessels before catheter manipulation. There was no mortality and one solitary left cerebellar infarction.journal articl

Changes in appetite, energy intake, body composition and circulating ghrelin constituents during an incremental trekking ascent to high altitude

Purpose Circulating acylated ghrelin concentrations are associated with altitude-induced anorexia in laboratory environments, but have never been measured at terrestrial altitude. This study examined time course changes in appetite, energy intake, body composition, and ghrelin constituents during a high-altitude trek. Methods Twelve participants [age: 28(4) years, BMI 23.0(2.1) kg m−2] completed a 14-day trek in the Himalayas. Energy intake, appetite perceptions, body composition, and circulating acylated, des-acylated, and total ghrelin concentrations were assessed at baseline (113 m, 12 days prior to departure) and at three fixed research camps during the trek (3619 m, day 7; 4600 m, day 10; 5140 m, day 12). Results Relative to baseline, energy intake was lower at 3619 m (P = 0.038) and 5140 m (P = 0.016) and tended to be lower at 4600 m (P = 0.056). Appetite perceptions were lower at 5140 m (P = 0.027) compared with baseline. Acylated ghrelin concentrations were lower at 3619 m (P = 0.046) and 4600 m (P = 0.038), and tended to be lower at 5140 m (P = 0.070), compared with baseline. Des-acylated ghrelin concentrations did not significantly change during the trek (P = 0.177). Total ghrelin concentrations decreased from baseline to 4600 m (P = 0.045). Skinfold thickness was lower at all points during the trek compared with baseline (P ≤ 0.001) and calf girth decreased incrementally during the trek (P = 0.010). Conclusions Changes in plasma acylated and total ghrelin concentrations may contribute to the suppression of appetite and energy intake at altitude, but differences in the time course of these responses suggest that additional factors are also involved. Interventions are required to maintain appetite and energy balance during trekking at terrestrial altitudes

Usefulness of a temporary shunt by cannulation during superior vena cava combined resection

Superior vena cava invasive thoracic malignancy requires combined resection of the superior vena cava to achieve en bloc resection of the involved structures with negative margins. The superior vena cava combined resection requires the creation of collateral circulation from the head to the heart before performing the combined resection. Even for a short time, total superior vena cava clamping without a procedure is unsafe and should be avoided. We will present a surgical resection with superior vena cava reconstruction, involving a temporary extrathoracic shunt from the left brachiocephalic vein to the right auricle using a venous return cannula. This is an optional technique for convenient and safe superior vena cava combined resection. It provides an excellent intrathoracic surgical view by venous return via the unilateral brachiocephalic vein, with the advantages of being a simple procedure requiring short surgical time.journal articl

Patency of separate tube grafts for intercostal artery reconstruction: Size and length matter

Objectives. Low patency is a major concern when using separate tube grafts for intercostal artery reconstruction. We aimed to elucidate the optimal size and length of grafts from the patency and computational fluid dynamics. Methods. The patency, size, and length of separate tube grafts were evaluated in 41 patients. Computational fluid dynamics simulation was performed in a model derived from a patient with a patent 12-mm graft of 15mm in length, with 2 simulation models with a smaller (8-mm) or longer (30-mm) graft. Results. A total of 49 grafts were used for intercostal artery reconstruction. There was 1 in-hospital death and 2 spinal cord injuries. The patency rate, which could be evaluated in 46 grafts, was 63% (29/46). It was 71% (24/34) in thoracoabdominal aortic replacement and 42% (5/12) in descending aortic replacement. Among 14 patients in whom all grafts were occluded, no patients developed spinal cord injury. All grafts longer than 25mm were occluded (n=5). Eight- and 10-mm grafts showed better patency than 12-mm grafts in thoracoabdominal aortic replacement (p=0.008), when grafts were shorter than 25mm. Computational fluid dynamics simulation revealed vortical flow within the 12-mm graft, which did not reach the intercostal orifice, while helical flow was maintained throughout the cardiac cycle within the 8-mm graft. Conclusions. Eight- and 10-mm grafts seemed better than 12-mm grafts, and grafts should be kept shorter than 25mm. Computational fluid dynamics simulation may shed light on the issue of optimal intercostal artery reconstruction technique.journal articl