From the viewpoints of early respiratory stabilization and intensive care unit disposition without any complications, surgical rib fixation is a sufficiently acceptable procedure not only for flail chest but also for repair of severe multiple rib fractures.

No abstract

The pharmacokinetics of intravenously administrated cisplatin and etoposide were studied in a patient with seminoma (stage IIIA) receiving hemodialysis for chronic renal failure. The treatment schedule was as follows: 7 mg/m2 of cisplatin at day 1, 3, 5; 14 mg/m2 of cisplatin at day 2, 4; 70 mg/m2 of etoposide at day 1-5; hemodialysis at day 2, 4. After the treatment myelosuppression was very strong. So the patient were received another treatment of smaller doses of cisplatin and etoposide in three courses. The other schedule was as follows: 14 mg/m2 of cisplatin at day 1, 3, 5; 35 mg/m2 of etoposide at day 1-5; hemodialysis at day 1, 3, 5. The area under the blood concentration-time curve (AUC) of free-cisplatin was 6.82 micrograms.hr/ml in first course, 4.07 micrograms.hr/ml in second course. The peak concentration of peripheral blood free-cisplatin was 0.58 microgram/ml in first course, 0.43 microgram/ml in second course. The AUC of etoposide was 241.9 micrograms.hr/ml in first course, 216.9 micrograms.hr/ml in second course. After treatment CR was observed and there was no recurrence for five years. In conclusion, it was considered that cisplatin and etoposide could be given to the patient receiving hemodialysis for chronic renal failure and smaller doses should be given to prevent side effects.

In redo coronary artery bypass grafting (CABG) procedures, the patent left internal thoracic artery (LITA) graft is at risk of reentry injury when it adheres to the sternum. 1 We herein report a new approach to dissect the LITA graft from the sternum using video-assisted thoracoscopic surgery (VATS) through the left hemithorax. CLINICAL SUMMARYA 63-year-old man was referred to undergo redo CABG for newly developed class 3 angina. The patient had undergone first-time CABG with a LITA to the left anterior descending coronary artery (LAD), a left radial artery graft to the obtuse marginal artery, and the right gastroepiploic artery to the posterior descending artery 8 years before his presentation in our department. The current coronary angiogram showed 90% stenosis of the LITA graft and occlusion of the right gastroepiploic artery. The radial artery graft was patent. The native LAD was totally occluded, so that the blood supply to the whole anterior wall was completely dependent on the diseased LITA graft. Redo double CABG was recommended for the patient.Preoperative computed tomography showed the LITA graft crossing the sternal midline and adherence to the manubrium (Figure 1). To avoid injury to the patent LITA graft, we planned to do a presternotomy dissection of the LITA graft from the sternum by VATS.General anesthesia was induced, and a double-lumen endotracheal tube was inserted. The patient was placed in a supine position, and the left arm was abducted. A camera port was created in the fifth intercostal space in the anterior axillary line (Figure 2, A). A thoracoscope was carefully inserted. There were minimal adhesions in the left side of the thorax. The LITA graft was immediately identified under

Stenosis of the subclavian artery proximal to the origin of the internal mammary artery (IMA) used for coronary artery bypass grafting may produce flow reversal (steal syndrome) and cause myocardial ischemia. We present three cases of subclavian artery stenosis proximal to the IMA before and after CABG. The first case developed symptomatic myocardial ischemia resulting from a variant of coronary-subclavian steal syndrome. The second case had asymptomatic subclavian artery stenosis proximal to the IMA used for CABG. In the third case we planned to perform CABG using the left IMA to treat cardiac ischemia. All of the patients were successfully treated by stent placement without the use of a protection device. In the first and second cases, cardiac ischemia did not appear during balloon inflation of the subclavian artery and no embolic complication occurred. In the third case, CABG was performed six months after stenting. Subclavian artery stenting is a valid alternative to surgical treatment to restore the flow to the IMA before or after CABG.