Effect of a selective neutrophil elastase inhibitor on early recovery from body water imbalance after transthoracic esophagectomy.

The objective of the study was to evaluate the efficacy of sivelestat, a selective neutrophil elastase inhibitor, on body fluid balance after transthoracic esophagectomy. Esophagectomy with elective lymphadenectomy may induce excessive release of neutrophil elastase, which then promotes vascular permeability and an excessive water shift from the intravascular space to the peripheral compartment. Body fluid imbalance after esophagectomy often leads to circular instability, a decrease of urine output, and a delay in the shift to a diuretic state. The study was designed as a case-control study with a historical control group. A retrospective analysis was performed to examine our hypothesis that sivelestat improves abnormal body fluid retention and prevents subsequent pulmonary complications. To reveal the direct influence of sivelestat on the postoperative course, we avoided using steroids or other diuretic agents. Eighty-eight patients who underwent thoracic esophagectomy with extended lymphadenectomy from 2000 to 2008 were divided into two groups: those treated from 2003 to 2008, who all received postoperative administration of sivelestat (n=60); and those treated from 2000 to 2002, who did not receive sivelestat and were used as the control group (n=28). Both groups received fluid management using the same protocol. The time to reach a diuretic state, time until extubation of the tracheal tube, and development of delayed respiratory dysfunction were compared between the groups using univariate and multivariate analysis. The time until a shift to a diuretic state was significantly shorter after treatment with sivelestat (p<0.0001) and with a shorter operation time (p<0.0001). The tracheal tube was extubated significantly earlier in the sivelestat group (p<0.0001) and the incidence of delayed respiratory dysfunction was also significantly lower (p=0.0028) in this group. Multivariate logistic regression analysis showed that a delay in a shift to a diuretic state was a strong independent risk factor for the time to tracheal extubation (odds ratio 2.539, p=0.0056) and occurrence of delayed respiratory dysfunction (odds ratio 1.989, p=0.0104). Sivelestat treatment was not independently associated with reduced pulmonary complications, but the diuretic state was strongly regulated by sivelestat treatment (odds ratio 0.044, p=0.0003). Thus, administration of sivelestat has a beneficial influence on recovery from body water imbalance through a more rapid return to a diuretic state after esophagectomy, which contributes to prevention of subsequent pulmonary complications.

[Thyroid dysfunction in children with chronic renal failure]. / Alteraciones de la función tiroidea en niños con insuficiencia renal crónica.

OBJECTIVES: To determine the frequency and type of thyroid dysfunction in children with chronic renal failure (CRF) in peritoneal dialysis (PD) or hemodialysis (HD); and to establish the accuracy of the presence of goiter to identify patients with CRF and thyroid dysfunction. PATIENTS AND METHODS: This is a cross-sectional study performed in a tertiary pediatric medical care center. CRF patients younger than 17 years old, with more than three months in PD or HD were included. All patients were assessed regarding their growth and sexual development; thyroid dysfunction was evaluated by serum concentration of thyrotropin (TSH), thyroxine (T4L) and triiodothyronine (T3T). RESULTS: 50 patients were included, 25 were male, and mean age was 12 years old. There were 14 (28%) patients with thyroid dysfunction; nine had subclinical hypothyroidism, three patients had euthyroid sick syndrome and two primary hypothyroidism. Thirteen patients had goiter: seven had thyroid dysfunction and in six patients the thyroid function was normal. The sensitivity of goiter to detect thyroid dysfunction was 50% and the specificity was 83.3%. The two patients with the greatest delay in their growth were hypothyroid. CONCLUSIONS: Given that the high frequency of thyroid dysfunction in children with CRF, these patients need a systematic screening, in order to improve their quality of care.

[Effect of the treatment of hyperthyroidism on the course of exophthalmos]. / Influencia del tratamiento del hipertiroidismo en el curso del exoftalmos.

The exophthalmos evolution in hyperthyroid patients was investigated: twenty patients were randomly assigned to treatment with radioiodine (group I followed 2-162 months) and 20 to treatment with thyroidectomy (group II followed 2-158 months). There was no correlation of sex age and follow up with exophthalmos evolution. In group I, exophthalmos improved in one patient (5%), did not change in ten (50%) and worsened in nine (45%). In group II it got better in six (30%), did not change in seven (35%) and got worse in seven (35%). The differences between the two groups were not statistically significant (p greater than 0.05). The postsurgical thyroid gamma-gram with one mCi of I-131 in group II showed absence of thyroid tissue in nine patients (45%) and remainders of the gland in 11 (55%) and apparently this did not influence the post treatment evolution. The length of pretreatment evolution did not influence the evolution post treatment. In summary, there was no correlation between exophthalmos evolution and kind of treatment in Graves' disease.

[Quantitative changes of hepatic microcirculation and mitochondrial function after splenectomy in liver cirrhosis rats].

To evaluate the potential risk of splenectomy for patients with cirrhotic liver. I measured quantitative time-course changes of portal pressure (PP), and hepatic tissue blood flow (TBF) by hydrogen clearance method and adenine nucleotides by HPLC in a rat model. Intraperitoneal thioacetamide injection (200mg/kg x 30) produced histologically proven cirrhotic liver (TAAs) as well as increasing the spleen weight and PP compared to controls. PP and TBF simultaneously decreased on the 1st postoperative day (POD) after splenectomy in TAAs, whereas controls showed no changes in these parameter after splenectomy. Although PP of TAAs remained decreased until the 7th POD after splenectomy, their TBF gradually increased between the 2nd and 7th PODs returning to the baseline value. Recovery of ATP or energy charge after their decrease on the 1st POD was delayed in TAAs. Splenectomy in TAAs enhanced the deterioration of energical metabolism. Splenectomy in cirrhotic rats resulted in an additional postoperative risk.

[A pharyngeal carcinoma after resection of a upper esophageal web].

Dysphagia suddenly progressed in a 69-year-old woman who had a 50-year history of intermittent difficulty in swallowing solid food. A thick circumferential who in the upper esophagus was extensive enough to be the cause of dysphagia. There was another thin semicircular web in the pharynx. Bouginage resulted in only 6-months relief of symptoms, and the same esophageal who was reformed with the same severe symptoms 3 years later. Surgical resection of the esophageal web was performed. Extensive pharyngeal carcinoma was found 4 years after surgery. She died of heart failure during combination therapy of irradiation and chemotherapy.

A new technique using free ileocaecal patch transplantation for secondary voice restoration after total laryngectomy.

SUMMARY: We introduce our newly designed voice restoration technique, which uses free ileocaecal patch transplantation for patients who have undergone prior total laryngectomy. Two women received ileocaecal patch transplantation for secondary voice restoration after total laryngectomy. In order to make the tracheoesophageal shunt for speech, a new orifice on the anterior wall of the hypopharynx had to be opened, which was closed at the time of laryngectomy. The hypopharyngeal orifice was covered by a free caecal patch harvested from an ileocaecal segment. Then, a tracheoesophageal shunt was created by anastomosing the terminal ileum of the patch and the remnant of the cervical trachea. Expiratory air was diverted into the pharynx through the ileum of the transplanted graft when the tracheostoma was closed by digital occlusion. Aspiration through an oesophagotracheal shunt in swallowing was prevented by the ileocaecal valve on the patch. Both patients began to speak up to 4 weeks after surgery without requiring training or difficult practice to achieve initial phonation and to be able to swallow without aspiration. The advantages of our procedure are (1) it can be carried out at the time of laryngectomy and also at secondary voice restoration after earlier laryngectomy; (2) the graft contains an ileocaecal valve that prevents aspiration through the shunt and also functions as a vibrating device to produce voice; (3) our procedure can be adapted to individuals whose tracheostoma is detached from the oesophagus and becomes contraindicated for a voice prosthesis. We believe that our newly designed procedure is a unique and useful alternative, especially for secondary voice restoration after prior total laryngectomy.