[Thoracic Endovascular Aortic Repair for Stanford Type B Acute Aortic Dissection with Right Leg Malperfusion:Report of a Case].

We report a case of complicated Stanford type B acute aortic dissection with malperfusion to the right leg. The patient received conservative treatment in a previous hospital. However, he complained of pain in the right leg, which had been gradually turning pale. The patient was diagnosed with complicated Stanford type B acute aortic dissection with right leg malperfusion and was transferred to our hospital for treatment. Thoracic endovascular aortic repair (TEVAR) to close the entry to the distal aortic arch was performed, and we embolized the left subclavian artery to prevent type Ⅱ endoleak and to extend the stent-graft landing zone. We implanted a bare stent into the right external iliac artery to enlarge its true lumen. The patient was discharged from our hospital 22 days postoperatively. After the operation, computed tomography( CT) scan showed an aortic false lumen remodeling.

Japanese surgical resource utilization in 2016.

PURPOSE: The purpose of this paper is to examine from the viewpoint of resource utilization the Japanese surgical payment system which was revised in April 2016. DESIGN/METHODOLOGY/APPROACH: The authors collected data from surgical records in the Teikyo University electronic medical record system from April 1 till September 30, 2016. The authors defined the decision-making unit as a surgeon with the highest academic rank in the surgery. Inputs were defined as the number of medical doctors who assisted surgery, and the time of operation from skin incision to closure. An output was defined as the surgical fee. The authors calculated each surgeon's efficiency score using output-oriented Charnes-Cooper-Rhodes model of data envelopment analysis. The authors compared the efficiency scores of each surgical specialty using the Kruskal-Wallis and the Steel method. FINDINGS: The authors analyzed 2,558 surgical procedures performed by 109 surgeons. The difference in efficiency scores was significant (p = 0.000). The efficiency score of neurosurgery was significantly greater than obstetrics and gynecology, general surgery, orthopedics, emergency surgery, urology, otolaryngology and plastic surgery (p<0.05). ORIGINALITY/VALUE: The authors demonstrated that the surgeons' efficiency was significantly different among their specialties. This suggests that the Japanese surgical reimbursement scales fail to reflect resource utilization despite the revision in 2016.

Continuous erector spinae plane block for pain management of an extensive burn.

Damage from extensive burn injury requires pain management that effectively treats the entire affected area. An erector plane (ESP) block has been reported to anesthetize a wide range of spinal nerves. In this time, the continuous ESP block was an effective analgesic for acute pain management for the extensive damage.

Rocuronium pharmacodynamic models for published five pharmacokinetic models: age and sex are covariates in pharmacodynamic models.

PURPOSE: Equilibration rate constant is necessary to calculate effect-site concentration, which is useful to control drug effect. We developed pharmacodynamic models for published five compartmental pharmacokinetic models published by Wierda, Szenohradszky, Cooper, Alvarez-Gomez, and McCoy. METHODS: We used 3848 train-of-four ratios from 15 male and nine female patients (21-76 years; 44-93 kg body weight; 148-181 cm height; and 17.3-29.8 kg/m2 body mass index) as pharmacodynamic measures, which were collected at the start of 0.6 mg/kg rocuronium administration until the end of the surgery. Effect compartment was assumed to be connected to central compartment of the pharmacokinetic model with equilibration rate constant (ke0). Sigmoid Emax model was fitted to describe the relationship between train-of-four ratio and effect-site concentration. Age, sex, and body mass index were assessed as possible covariates of the following model parameters: ke0, effect-site concentration for half of maximum effect, and the steepness of the effect-site concentration versus effect relationship. RESULTS: The duration of neuromuscular monitoring was 69 (37-129) [median (range)] min. All pharmacodynamic models included age and three included sex as significant covariates. Ke0 values ranged between 0.0820 and 0.247 depending on the pharmacokinetic model. The time-courses of the effect-site concentration were similar among the pharmacodynamic models for Wierda, Cooper, and Alvarez-Gomez pharmacokinetic models, which were lower than that for the Szenohradszky pharmacokinetic model. CONCLUSION: Each pharmacodynamic model with the corresponding pharmacokinetic model can be described the time course of rocuronium effect appropriately. The required effect-site concentration of rocuronium for a pharmacodynamic effect was depending on the applied models.

Efficiency of inpatient orthopedic surgery in Japan: a medical claims database analysis.

Purpose The purpose of this paper is to determine the characteristics of healthcare facilities that produce the most efficient inpatient orthopedic surgery using a large-scale medical claims database in Japan. Design/methodology/approach Reimbursement claims data were obtained from April 1 through September 30, 2014. Input-oriented Banker-Charnes-Cooper model of data envelopment analysis (DEA) was employed. The decision-making unit was defined as a healthcare facility where orthopedic surgery was performed. Inputs were defined as the length of stay, the number of beds, and the total costs of expensive surgical devices. Output was defined as total surgical fees for each surgery. Efficiency scores of healthcare facilities were compared among different categories of healthcare facilities. Findings The efficiency scores of healthcare facilities with a diagnosis-procedure combination (DPC) reimbursement were significantly lower than those without DPC ( p=0.0000). All the efficiency scores of clinics with beds were 1. Their efficiency scores were significantly higher than those of university hospitals, public hospitals, and other hospitals ( p=0.0000). Originality/value This is the first research that applied DEA for orthopedic surgery in Japan. The healthcare facilities with DPC reimbursement were less efficient than those without DPC. The clinics with beds were the most efficient among all types of management bodies of healthcare facilities.

[Successful Awake Intubation with Airway Scope? for a Difficult Airway Patient with Enormous Angioma Protruding out of the Mouth].

A 48-year-old man (165 cm, 53 kg), was scheduled for an angioma resection. The tumor was so large that together with tongue, grew from the buccal region to the lower jaw and protruded out of the mouth. Mouth opening was only 2.5-finger-width. Expected as a case of difficult airway, we planned awake intubation using Airway Scope® (AWS) and gum-elastic bougie while maintaining spontaneous ventilation according to the difficult airway algorithm of American Society of Anes- thesiologists. Although fiberscope (FB) is a common choice for awake intubation, it requires proficient skills. In addition, as the distal end of endo-tracheal tube cannnot be visualized by FB, the angioma might be damaged during the intubation. Instead, AWS can visualize the tip of the tube without displacing oropha- ryngeal tissue and it is unlikely to damage the tumor because of a tube guide groove on the inner side of the AWS blade. We experienced successful awake intuba- tion with AWS for a patient with difficult airway due to an enormous angioma protruding out of the mouth.

Surgeons' efficiency change is a major determinant of their productivity change.

Purpose - The sustainability of the Japanese healthcare system is in question because the government has had a huge fiscal debt. Despite an enormous effort to cut the deficit, our healthcare expenditure is increasing every year because of the rapidly aging population. One of the solutions for this problem is to improve the productivity of healthcare. The purpose of this paper is to determine the factors that change surgeons' productivity in one year. Design/methodology/approach - The authors collected data of all surgical procedures performed at Teikyo University Hospital from April 1 through September 30 in 2014 and 2015, and computed the surgeons' Malmquist index (MI), efficiency change (EC) and technical change (TC) using non-radial and non-oriented Malmquist model under the constant returns-to-scale assumptions. The authors then divided the surgeons into two groups; one whose productivity progressed and the other whose productivity regressed. These two groups were compared to identify factors that may influence their MI. Findings - The only significant difference between the two groups was ECs (p < 0.0001). The other factors, such as TC, experience, surgical volume, emergency cases, surgical specialty, academic ranks, medical schools and gender, were not significantly different between the two groups. Originality/value - EC is a major determinant of surgeons' productivity change. The best way to improve surgeons' productivity may be to enhance their efficiency regardless of their surgical volume and personal backgrounds.

[Anesthetic Management of Cesarean Section in a Pregnant Woman with Advanced Tongue Cancer].

It is very difficult to decide the best time to deliver the baby for a pregnant woman with advanced cancer. We experienced the perioperative and perinatal management of a 39-year-old pregnant woman with advanced tongue cancer. The cancer had already metastasized to the lung and lymph nodes. Furthermore a recurrent thumb-sized tumor was found in her mouth. She had firmly desired to discontinue all anticancer treatment for protecting the fetus. On the other hand, her family could not accept her determination yet. Therefore the medical team was organized with doctors and co-medicals from multiple departments such as gynecology, pediatrics, radiology, oncology, midwife, psychotherapy and anesthesiology. After several conferences including herself and family, finally cesarean section was scheduled for the 30th gestational week. Prepared for unexpected emergency delivery, airway stenosis was ruled out by fiberoptic laryngoscopy and the consent for emergency tracheostomy was obtained. The operation was performed successfully under spinal anesthesia without any severe troubles. Medical care as a team from early phase enabled elaborate observation and preparation through the perioperative and perinatal period. Furthermore, it was efficient to provide satisfaction to the patient and her family as well.

The Japanese Surgical Reimbursement System Fails to Reflect Resource Utilization.

The goal of this study was to examine the current Japanese surgical payment system from the viewpoint of resource utilization. We collected data from surgical records in Teikyo University's electronic medical record system from April 1 through September 30, 2013. We defined the decision-making unit as a surgeon with the highest academic rank in the surgery. Inputs were defined as: 1) the number of medical doctors who assisted surgery and 2) the time of operation from skin incision to closure. An output was defined as the surgical fee. We calculated each surgeon's efficiency score using the output-oriented Banker-Charnes-Cooper model of data envelopment analysis. We compared the efficiency scores of each surgical specialty using the Kruskal-Wallis and Steel methods. We analyzed 2,825 surgical procedures performed by 103 surgeons. The difference in efficiency scores was significant (P = 0.0001). The thoracic surgeons were the most efficient and were more efficient than plastic, obstetric and gynecologic, urologic, otorhinolaryngologic, orthopedic, general, and emergency surgeons (P < 0.05). We demonstrated that surgeons' efficiency in operating rooms was significantly different among surgical specialties. This suggests that the Japanese surgical reimbursement scales fails to reflect resource utilization.

Resource utilization in surgery after the revision of surgical fee schedule in Japan.

PURPOSE: The purpose of this paper is to examine whether the current surgical reimbursement system in Japan reflects resource utilization after the revision of fee schedule in 2014. DESIGN/METHODOLOGY/APPROACH: The authors collected data from all the surgical procedures performed at Teikyo University Hospital from April 1 through September 30, 2014. The authors defined the decision-making unit as a surgeon with the highest academic rank in the surgery. Inputs were defined as the number of medical doctors who assisted surgery, and the time of operation from skin incision to closure. An output was defined as the surgical fee. The authors calculated surgeons' efficiency scores using data envelopment analysis. FINDINGS: The efficiency scores of each surgical specialty were significantly different (p=0.000). ORIGINALITY/VALUE: This result demonstrates that the Japanese surgical reimbursement scales still fail to reflect resource utilization despite the revision of surgical fee schedule.

[MAC for Pediatric Examinations].

MAC is often required for pediatric examinations outside of operating room. It is difficult to conduct MAC for pediatric population safely. In Japan, most MAC for pediatric examinations are not conducted by anesthesiologists but pediatricians. Following practices in other countries, Japan Pediatric Society, Japanese Society of Pediatric Anesthesiology and Japanese Society of Pediatric Radiology collaborated to establish the first Japanese guideline for pediatric sedation: Proposals about sedation for MRI examinations in 2013. This proposal consists of six parts; 1. informed consent 2. pre-sedation patient assessment, 3. back-up team for emergency, 4. pre-sedation NPO, 5. patient monitoring, and 6. post-sedation care. Anesthesiologists are expected to play supervisor roles of sedation operation to make the sedation environment safe, even though they can not conduct sedation by themselves.

Effect of surgeon experience on technical efficiency.

Surgeon experience certainly improves their technical efficiency although it also causes physiological changes with aging. The authors hypothesized that surgeons' technical efficiency improves with increasing experience up to a point where it then decreases, which is a concave relationship. The authors collected data from all the surgical procedures performed at University Hospital from April through September in 2013-19. The dependent variable was defined as surgeons' technical efficiency scores that were calculated using output-oriented Charnes-Cooper-Rhodes model of data envelopment analysis. Inputs were defined as (1) the number of assistants and (2) the duration of surgical operation. The output was defined as the surgical fee for each surgery. Surgeon experience was defined as the number of years since medical school graduation. Five control variables were selected: surgical volume, gender, academic rank, surgical specialty, and the year of surgery. Multiple regression analysis using pooled and random-effects Tobit models was performed for our panel data. Totally 20,375 surgical procedures performed by 264 surgeons in 42 months were analyzed. The coefficients of experience and the square of experience were not significantly different from zero. The other coefficients were also insignificant. Surgeons' technical efficiency does not have a concave relationship with experience.

The effects of short interactive animation video information on preanesthetic anxiety, knowledge, and interview time: a randomized controlled trial.

BACKGROUND: We designed an interactive animated video that provides a basic explanation-including the risks, benefits, and alternatives-of anesthetic procedures. We hypothesized that this video would improve patient understanding of anesthesia, reduce anxiety, and shorten the interview time. METHODS: Two hundred eleven patients scheduled for cancer surgery under general anesthesia or combined general and epidural anesthesia, who were admitted at least 1 day before the surgery, were randomly assigned to the video group (n = 106) or the no-video group (n = 105). The patients in the video group were asked to watch a short interactive animation video in the ward. After watching the video, the patients were visited by an anesthesiologist who performed a preanesthetic interview and routine risk assessment. The patients in the no-video group were also visited by an anesthesiologist, but were not asked to watch the video. In both groups, the patients were asked to complete the State-Trait Anxiety Inventory and a 14-point scale of knowledge test before the anesthesiologist's visit and on the day of surgery. We also measured interview time. RESULTS: There was no demographic difference between the 2 groups. The interview time was 34.4% shorter (video group, 12.2 ± 5.3 minutes, vs. no-video group, 18.6 ± 6.4 minutes; 95% confidence interval [CI] for the percentage reduction in time: 32.7%- 44.3%), and knowledge of anesthesia was 11.6% better in the video group (score 12.5 ± 1.4 vs. no-video group score 11.2 ± 1.7; 95% CI for the percentage increase in knowledge: 8.5%-13.9%). However, there was no difference in preanesthetic anxiety between the 2 groups. CONCLUSION: Our short interactive animation video helped patients' understanding of anesthesia and reduced anesthesiologists' interview time.

Papillary muscle sandwich plasty for the treatment of functional mitral valve regurgitation.

We evaluated the availability of original "sandwich plasty" for the treatment of functional mitral regurgitation (FMR) associated with ischemic heart disease (IHD) and aortic valve disease (AVD). Forty-three patients were reviewed, including 27 IHD patients and 16 AVD patients. Preoperatively severe FMR was detected in 14 patients, moderate FMR in 26, and mild FMR in 3. The papillary muscle heads of anterior leaflets and posterior leaflets were approximated using Teflon-pledgeted 3-0 Ticron sutures at anterolateral and posteromedial commissural portions. After surgery, residual moderate FMR was observed in 1 patient and mild FMR in 3 patients. Tenting height of the mitral valve significantly decreased. FMR free rates 2 years after surgery were 93% among IHD patients and 83% in AVD patients. "Sandwich plasty" was simple and effective for the treatment of functional FMR caused by tethering effects due to left ventricular dilatation.

[Robot assisted tumor resection of an asymptomatic right atrial intracardiac lipoma; report of a case].

Primary cardiac tumors are relatively rare. No therapeutic guidelines have been established for the surgical indications of such cases. This creates therapeutic dilemmas, especially when the patient is asymptomatic. We describe the robot-assisted resection of an asymptomatic right atrial lipoma. A 63-year-old female was diagnosed to have a round mobile lipoma, measuring 27 mm in diameter in the right atrium near the junction with the inferior vena cava (IVC). Although she was asymptomatic, a surgical resection was indicated since the lipoma could cause an embolism or IVC obstruction due to its morbidity and potential to enlarge. Surgery was performed using the da Vinci Surgical System. A right-sided approach was used through 4 ports. The tumor was resected with a small portion of the right atrial wall. The total operation time was 214 minutes, and the total pump time was 84 minutes. The operation was performed while the heart was beating.

Equality of Surgical Fee Schedule in Japan: A Retrospective Observational Study.

The authors had previously demonstrated that the Japanese surgical fee schedule had been unequal among surgical specialties in spite of its biannual revisions. This study examined how the degree of inequality of the fee schedule changed by estimating Gini coefficients for efficiency scores computed from data envelopment analysis. All the surgeries at Teikyo University Hospital in 2013 to 2018 were candidates used for the analysis of efficiency and equality of fee schedule. Inputs were defined as (1) the number of assistants, and (2) the duration of operation. An output was defined as the surgical fee. Each surgeon's efficiency score was calculated using data envelopment analysis. Using the medians of efficiency scores in each surgical specialty, the authors inferred Gini coefficients and their standard errors in each year and in each surgical fee schedule. The authors analyzed 16 307 surgical procedures during the study period of 2013 to 2018. There was no statistically significant difference in the Gini coefficients between the years and between the surgical fee schedules (P > .05). It was demonstrated that the degree of inequality of the Japanese surgical fee schedule remained constant from 2013 through 2018.