Association between preoperative lumbar skeletal muscle index and postoperative nausea and vomiting in patients undergoing pylorus-preserving pancreatoduodenectomy: a retrospective study.

BACKGROUND: Sarcopenia is associated with postoperative complications; however, its impact on the quality of postoperative recovery, such as postoperative nausea and vomiting (PONV) and pain, remains unclear. We investigated the association of preoperative lumbar skeletal muscle mass index (LSMI) with PONV, postoperative pain, and complications. METHODS: Medical records of 756 patients who underwent pylorus-preserving pancreatoduodenectomy (PPPD) were retrospectively reviewed. The skeletal muscle areas were measured on abdominal computed tomography (CT) images. LSMI was calculated by dividing the skeletal muscle area by the square of the patient's height. We analyzed the correlations between preoperative LSMI calibrated with confounding variables and PONV scores, PONV occurrence, pain scores, rescue analgesic administration, postoperative complications, and length of hospital stay. RESULTS: The median (1Q, 3Q) LSMI was 47.72 (40.74, 53.41) cm2/m2. The incidence rates of PONV according to time period were as follows: post-anesthesia care unit, 42/756 (5.6%); 0-6 h, 54/756 (7.1%); 6-24 h, 120/756 (15.9%); 24-48 h, 46/756 (6.1%); and overall, 234/756 (31.0%). The incidence of PONV was inversely correlated with LSMI 24-48 h post-surgery and overall. LSMI and PONV scores were negatively associated 6-24 h and 24-48 h post-surgery. There was no association between LSMI and postoperative pain scores, rescue analgesic administration, complications, or length of hospital stay. CONCLUSIONS: Preoperative LSMI was associated with PONV in patients undergoing PPPD. Therefore, LSMI measured on preoperative abdominal CT can be a predictive indicator of PONV. Appropriate PONV prophylaxis is necessary in patients with low LSMI before PPPD.

A Simple Risk Scoring System for Predicting the Occurrence of Aspiration Pneumonia After Gastric Endoscopic Submucosal Dissection.

BACKGROUND: Aspiration pneumonia after endoscopic submucosal dissection (ESD) is rare, but can be fatal. We aimed to investigate risk factors and develop a simple risk scoring system for aspiration pneumonia. METHODS: We retrospectively reviewed medical records of 7833 patients who underwent gastric ESD for gastric neoplasm under anesthesiologist-directed sedation. Candidate risk factors were screened and assessed for significance using a least absolute shrinkage and selection operator (LASSO)-based method. Top significant factors were incorporated into a multivariable logistic regression model, whose prediction performance was compared with those of other machine learning models. The final risk scoring system was created based on the estimated odds ratios of the logistic regression model. RESULTS: The incidence of aspiration pneumonia was 1.5%. The logistic regression model showed comparable performance to the best predictive model, extreme gradient boost (area under receiver operating characteristic curve [AUROC], 0.731 vs 0.740). The estimated odds ratios were subsequently used for the development of the clinical scoring system. The final scoring system exhibited an AUROC of 0.730 in the test dataset with risk factors: age (≥70 years, 4 points), male sex (8 points), body mass index (≥27 kg/m2, 4 points), procedure time (≥80 minutes, 5 points), lesion in the lower third of the stomach (5 points), tumor size (≥10 mm, 3 points), recovery time (≥35 minutes, 4 points), and desaturation during ESD (9 points). For patients with total scores ranging between 0 and 33 points, aspiration pneumonia probabilities spanned between 0.1% and 17.9%. External validation using an additional cohort of 827 patients yielded AUROCs of 0.698 for the logistic regression model and 0.680 for the scoring system. CONCLUSIONS: Our simple risk scoring system has 8 predictors incorporating patient-, procedure-, and sedation-related factors. This system may help clinicians to stratify patients at risk of aspiration pneumonia after ESD.

Immunomodulatory Effects of Perioperative Dexmedetomidine in Ovarian Cancer: An In Vitro and Xenograft Mouse Model Study.

BACKGROUND: The surgical stress response (SSR) causes immunosuppression which may cause residual tumor growth and micrometastasis after cancer surgery. We investigated whether dexmedetomidine affects cancer cell behavior and immune function in an ovarian cancer xenograft mouse model. METHODS: The effect of dexmedetomidine on cell viability and cell cycle was assessed using SK-OV-3 cells at drug concentrations of 0.5, 0.1, 5, and 10 µg mL-1. BALB/c nude mice were used for the ovarian cancer model with the Dexmedetomidine group (n=6) undergoing surgery with dexmedetomidine infusion and the Control group (n=6) with saline infusion for 4 weeks. Natural killer (NK) cell activity, serum proinflammatory cytokines, and cortisol were measured at predetermined time points and tumor burden was assessed 4 weeks after surgery. RESULTS: Dexmedetomidine had no effect on cell viability or cell cycle. Following a sharp decrease on postoperative day (POD) 1, NK cell activity recovered faster in the Dexmedetomidine group with significant difference vs. the Control group on POD 3 (P=0.028). In the Dexmedetomidine group, cortisol levels were lower on POD 3 (P=0.004) and TNF-α levels were lower at 4 weeks after surgery (P<0.001) compared to the Control group. The Dexmedetomidine group showed lower tumor burden at 4 weeks vs. the Control group as observed by both tumor weight (P<0.001) and the in vivo imaging system (P=0.03). CONCLUSIONS: Dexmedetomidine infusion may improve ovarian cancer surgery outcome by suppressing the SSR and stress mediator release. Further studies are needed to elucidate the mechanisms by which dexmedetomidine acts on cancer and immune cells.

Effect of Dexmedetomidine on Biochemical Recurrence in Patients after Robot-Assisted Laparoscopic Radical Prostatectomy: A Retrospective Study.

The usage of dexmedetomidine during cancer surgery in current clinical practice is debatable, largely owing to the differing reports of its efficacy based on cancer type. This study aimed to investigate the effects of dexmedetomidine on biochemical recurrence (BCR) and radiographic progression in patients with prostate cancer, who have undergone robot-assisted laparoscopic radical prostatectomy (RALP). Using follow-up data from two prospective randomized controlled studies, BCR and radiographic progression were compared between individuals who received dexmedetomidine (n = 58) and those who received saline (n = 56). Patients with complete follow-up records between July 2013 and June 2019 were enrolled in this study. There were no significant between-group differences in the number of patients who developed BCR and those who showed positive radiographic progression. Based on the Cox regression analysis, age (p = 0.015), Gleason score ≥ 8 (p < 0.001), and pathological tumor stage 3a and 3b (both p < 0.001) were shown to be significant predictors of post-RALP BCR. However, there was no impact on the dexmedetomidine or control groups. Low-dose administration of dexmedetomidine at a rate of 0.3-0.4 µg/kg/h did not significantly affect BCR incidence following RALP. In addition, no beneficial effect was noted on radiographic progression.

Predictive models for chronic kidney disease after radical or partial nephrectomy in renal cell cancer using early postoperative serum creatinine levels.

BACKGROUND: Several predictive factors for chronic kidney disease (CKD) following radical nephrectomy (RN) or partial nephrectomy (PN) have been identified. However, early postoperative laboratory values were infrequently considered as potential predictors. Therefore, this study aimed to develop predictive models for CKD 1 year after RN or PN using early postoperative laboratory values, including serum creatinine (SCr) levels, in addition to preoperative and intraoperative factors. Moreover, the optimal SCr sampling time point for the best prediction of CKD was determined. METHODS: Data were retrospectively collected from patients with renal cell cancer who underwent laparoscopic or robotic RN (n = 557) or PN (n = 999). Preoperative, intraoperative, and postoperative factors, including laboratory values, were incorporated during model development. We developed 8 final models using information collected at different time points (preoperative, postoperative day [POD] 0 to 5, and postoperative 1 month). Lastly, we combined all possible subsets of the developed models to generate 120 meta-models. Furthermore, we built a web application to facilitate the implementation of the model. RESULTS: The magnitude of postoperative elevation of SCr and history of CKD were the most important predictors for CKD at 1 year, followed by RN (compared to PN) and older age. Among the final models, the model using features of POD 4 showed the best performance for correctly predicting the stages of CKD at 1 year compared to other models (accuracy: 79% of POD 4 model versus 75% of POD 0 model, 76% of POD 1 model, 77% of POD 2 model, 78% of POD 3 model, 76% of POD 5 model, and 73% in postoperative 1 month model). Therefore, POD 4 may be the optimal sampling time point for postoperative SCr. A web application is hosted at https://dongy.shinyapps.io/aki_ckd . CONCLUSIONS: Our predictive model, which incorporated postoperative laboratory values, especially SCr levels, in addition to preoperative and intraoperative factors, effectively predicted the occurrence of CKD 1 year after RN or PN and may be helpful for comprehensive management planning.

Prediction of hypotension after postural change in robot-assisted laparoscopic prostatectomy using esophageal Doppler monitoring: a prospective observational trial.

Postural change from a steep Trendelenburg position to a supine position (T-off) during robot-assisted laparoscopic prostatectomy (RALP) induces a considerable abrupt decrease in the mean arterial pressure (MAP). We investigated the variables for predicting postural hypotension induced by T-off using esophageal Doppler monitoring (EDM). One hundred and twenty-five patients undergoing RALP were enrolled. Data on the MAP, heart rate, stroke volume index (SVI), cardiac index, peak velocity, corrected flow time, stroke volume variation, pulse pressure variation, arterial elastance (Ea), and dynamic arterial elastance were collected before T-off and at 1, 3, 5, 7, and 10 min after T-off using EDM. MAP < 60 mmHg within 10 min after T-off was considered to indicate hypotension, and 25 patients developed hypotension. The areas under the curves of the MAP, SVI, and Ea were 0.734 (95% confidence interval [CI] 0.623-0.846; P < 0.001), 0.712 (95% CI 0.598-0.825; P < 0.001), and 0.760 (95% CI 0.646-0.875; P < 0.001), respectively, with threshold values of ≤ 74 mmHg, ≥ 42.5 mL/m2, and ≤ 1.08 mmHg/mL, respectively. If patients have MAP < 75 mmHg with SVI ≥ 42.5 mL/m2 or Ea ≤ 1.08 mmHg/mL before postural change from T-off during RALP, prompt management for ensuing hypotension should be considered.Trial registration: NCT03882697 (ClinicalTrial.gov, March 20, 2019).

Quality of Recovery of Patients Who Underwent Curative Pancreatectomy: Comparison of Total Intravenous Anesthesia Versus Inhalation Anesthesia Using the QOR-40 Questionnaire.

BACKGROUND: There has been increasing attention on the subjective recovery of patients undergoing cancer surgery. Total intravenous anesthesia (TIVA) and inhaled anesthesia with volatile anesthetics (INHA) are safe and common anesthetic techniques. Currently, TIVA and INHA have only been compared for less invasive and less complex surgeries. This prospective randomized trial aimed to compare the quality of recovery between TIVA and INHA in patients undergoing pancreatoduodenectomy (PD) or distal pancreatectomy (DP) using the Quality of Recovery (QOR)-40 questionnaire. METHODS: We enrolled 132 patients who were randomly assigned to either the desflurane (DES) (INHA, balanced anesthesia with DES and remifentanil infusion) or TIVA (effect-site target-controlled infusion of propofol and remifentanil) groups and completed the QOR-40 questionnaire postoperatively. RESULTS: The mean global QOR-40 score on postoperative day 3 was significantly higher in the TIVA group than in the DES group. In the PD group, the total QOR-40 score was significantly higher in the TIVA group than in the DES group. Moreover, the TIVA group had significantly higher scores in the physical comfort and psychological support QOR-40 dimensions than the DES group. CONCLUSION: TIVA provides better quality of recovery scores on POD 3 for patients undergoing curative pancreatectomy. CLINICAL TRIAL REGISTRATION NUMBER: NCT03447691.

Hemimandibular hyperplasia treatment with condylectomy and orthodontic camouflage treatment using miniplate.

A 13-year-old growing female patient presented with hemimandibular hyperplasia of the right side, Class III hypodivergent skeletal pattern, and severe facial asymmetry. Corrective surgery was deferred until her growth had been completed. When the patient was 16 years old, a low condylectomy was performed on the hyperplastic side of her mandible to prevent its progressive condylar hyperplasia, while simultaneous orthodontic camouflage treatment was performed with the intrusion of the maxillary right posterior teeth using temporary skeletal anchorage devices without additional orthognathic surgery. A low condylectomy caused anterior and lateral open bite after the downward and backward movement of the chin, which improved Class III appearance. The intrusion of the maxillary right posterior teeth followed by compensating extrusion of the mandibular posterior teeth contributed to improve the patient's facial asymmetry with correction of the transverse occlusal plane and lip canting. After 30 months of treatment, an acceptable esthetic outcome and functional occlusion were achieved. The treatment results were well maintained for 1-year retention.

Effect of volatile and total intravenous anesthesia on syndecan-1 shedding after minimally invasive gastrectomy: a randomized trial.

This study aimed to compare the effects of volatile anesthesia and total intravenous anesthesia (TIVA) on syndecan-1 shedding in patients with gastric cancer undergoing minimally invasive gastrectomy. Patients were randomly assigned to either the Volatile (n = 68) or the TIVA (n = 68) group. Anesthesia was maintained with sevoflurane/remifentanil or propofol/remifentanil in the Volatile and TIVA groups, respectively. Serum syndecan-1 was evaluated at pre-operation, end of operation, and postoperative day (POD) 1. Inflammatory markers including white blood cell (WBC) count, neutrophil-to-lymphocyte ratio (NLR), and C-reactive protein (CRP), were also measured at pre-operation, end of operation, and POD 1, 2, 3, and 5. The TIVA group showed significantly lower levels of syndecan-1 at the end of the operation compared to the Volatile group; however, no difference was seen between the groups at POD 1. The WBC count and NLR were significantly lower in the TIVA group at the end of the operation than the Volatile group, but there were no differences between the groups at POD 1, 2, 3, and 5. CRP levels were similar between the groups at all time points. In conclusion, despite TIVA being superior to volatile anesthesia in protecting endothelial glycocalyx during the operation, both did not prevent postoperative syndecan-1 shedding after gastrectomy.Clinical trial registration number: NCT04183296 (ClinicalTrial.gov, 03/12/2019).

Transhepatic Tract Embolisation After Biliary Intervention Using n-Butyl Cyanoacrylate and Autologous Blood: A Retrospective Analysis of 42 Patients.

PURPOSE: We evaluated the safety and efficacy of transhepatic tract embolisation after a biliary intervention using n-butyl cyanoacrylate (NBCA) and autologous blood. MATERIALS AND METHODS: Between January 2017 and December 2018, 42 consecutive patients (mean age: 71 ± 15 years, 24 men) with malignant (n = 26) or benign (n = 16) biliary obstructions underwent percutaneous biliary intervention followed by tract embolisation within 2 weeks. Forty-six transhepatic tracts (4 bilateral) in 42 patients were embolised using a NBCA and lipiodol mixtures (1:1-1:2 ratios) after intraductal infusion of peripherally obtained autologous blood. The indwelling catheter diameters were 8.5-14 Fr. The median interval between percutaneous biliary drainage and tract embolisation was 10 days (range 3-14 days). Glue-cast formation via fluoroscopy and immediate complications were reviewed retrospectively in medical records. Follow-up data (median: 135, range 11-720 days) including computed tomography (CT) images (n = 17) were evaluated for delayed complications and glue-cast formation. RESULTS: Successful glue-cast formations were achieved in all 46 tracts. No patients experienced haemorrhage, and only one patient had external bile leakage. Eight patients complained of abdominal pain (numerical scale ≤ 5) immediately after embolisation, which was controlled by analgesics. Two patients had transient fever. Segmental (n = 11) or sub-segmental (n = 6) glue-cast patterns were identified along the transhepatic tract by follow-up CT. No biliary obstructions were caused by inadvertent glue spread. Fragmented glue was detected outside the stent in one patient. CONCLUSION: Transhepatic parenchymal tract embolisation with NBCA and autologous blood is a safe and feasible method for preventing bile leakage. LEVEL OF EVIDENCE: Level 4, Case Series.

Image similarity evaluation of the bulk-density-assigned synthetic CT derived from MRI of intracranial regions for radiation treatment.

OBJECTIVE: Various methods for radiation-dose calculation have been investigated over previous decades, focusing on the use of magnetic resonance imaging (MRI) only. The bulk-density-assignment method based on manual segmentation has exhibited promising results compared to dose-calculation with computed tomography (CT). However, this method cannot be easily implemented in clinical practice due to its time-consuming nature. Therefore, we investigated an automatic anatomy segmentation method with the intention of providing the proper methodology to evaluate synthetic CT images for a radiation-dose calculation based on MR images. METHODS: CT images of 20 brain cancer patients were selected, and their MR images including T1-weighted, T2-weighted, and PETRA were retrospectively collected. Eight anatomies of the patients, such as the body, air, eyeball, lens, cavity, ventricle, brainstem, and bone, were segmented for bulk-density-assigned CT image (BCT) generation. In addition, water-equivalent CT images (WCT) with only two anatomies-body and air-were generated for a comparison with BCT. Histogram comparison and gamma analysis were performed by comparison with the original CT images, after the evaluation of automatic segmentation performance with the dice similarity coefficient (DSC), false negative dice (FND) coefficient, and false positive dice (FPD) coefficient. RESULTS: The highest DSC value was 99.34 for air segmentation, and the lowest DSC value was 73.50 for bone segmentation. For lens segmentation, relatively high FND and FPD values were measured. The cavity and bone were measured as over-segmented anatomies having higher FPD values than FND. The measured histogram comparison results of BCT were better than those of WCT in all cases. In gamma analysis, the averaged improvement of BCT compared to WCT was measured. All the measured results of BCT were better than those of WCT. Therefore, the results of this study show that the introduced methods, such as histogram comparison and gamma analysis, are valid for the evaluation of the synthetic CT generation from MR images. CONCLUSIONS: The image similarity results showed that BCT has superior results compared to WCT for all measurements performed in this study. Consequently, more accurate radiation treatment for the intracranial regions can be expected when the proper image similarity evaluation introduced in this study is performed.

Is breast asymmetry caused by volume differences in women with pectus excavatum?

This study determined the breast volumes of female patients with pectus excavatum that led to asymmetry and hypoplasia compared with normal women. This retrospective study enrolled 13 patients diagnosed with pectus excavatum and 13 normal women, randomly selected from a healthcare centre (n = 26), between January 2012 and December 2014. We measured breast volumes (n = 52) based on chest computed tomography (CT) of all patients using Image J software and divided them into four groups according to the side and presence of pectus excavatum. The mean volumes of the right and left breasts of patients with pectus excavatum were 209 ± 64 mL and 218 ± 67 mL, respectively, with no significant difference between the two groups (P = 0.736). The mean volumes of the right and left breasts of normal women were 415 ± 197 mL and 439 ± 197 mL, respectively, with no significant difference between the two groups (P = 0.754). The breasts of patients with pectus excavatum were significantly smaller than those of normal women (P < 0.001). Both breasts of patients with pectus excavatum were similar in size but were smaller than the breasts of normal women. Skeletal correction for breast asymmetry correction, followed by breast augmentation for breast hypoplasty correction, with a one- or two-step approach may be useful to improve the aesthetics of breast deformities in women with pectus excavatum.

A small Askin's tumor presenting with early onset of chest pain.

Most primitive neuroectodermal tumor of the chest wall destroy the rib, chest wall muscles, diaphragm, and lung or extend into the spinal compartment, resulting in a large-sized tumor and symptoms. In contrast, we recently encountered a rare case of Askin's tumor presenting with early-onset chest pain despite the small size. After resection of the tumor and adjuvant chemotherapy, the patient remains disease-free over 3 years of follow-up.

Significance of low-dose radiation distribution in development of radiation pneumonitis after helical-tomotherapy-based hypofractionated radiotherapy for pulmonary metastases.

Hypofractionated radiotherapy (HRT) is now commonly used for pulmonary malignancies, since a tumoricidal dose can be accurately delivered to the target without a consequential dose to adjacent normal tissues. However, radiation pneumonitis (RP) is still a major problem after HRT. To determine the significant parameters associated with developing RP, we retrospectively investigated data from patients with lung metastases treated with HRT using helical tomotherapy. A total of 45 patients were included in the study and the median age was 53 years old. The median prescriptive doses were 50 Gy to the internal target volume and 40 Gy to the planning target volume in 10 fractions over 2 weeks. RP was diagnosed by chest X-ray or computed tomography after HRT, and its severity was determined by CTCAE version 4.0. The incidence of symptomatic RP was 26.6%. Univariate analysis indicated that mean lung doses, V5, V10, V15, V20 and V25 were associated with the development of symptomatic RP (P < 0.05). However, multivariate analysis indicated that only V5 was associated with the development of symptomatic RP (P = 0.019). From the ROC curve, V5 was the most powerful predictor of symptomatic RP, and its AUC (area under curve) was 0.780 (P = 0.004). In addition, the threshold value of V5 for the development of symptomatic RP was 65%. A large distribution of low-dose radiation resulted in a higher risk of lung toxicity. So, to prevent symptomatic RP, it is recommended that the V5 be limited to <65%, in addition to considering conventional dosimetric factors. However, further clinical study must be undertaken in order to confirm this result.

Bronchiectasis in active tuberculosis.

BACKGROUND: Bronchiectasis in tuberculosis (TB) is usually considered chronic traction bronchiectasis associated with healed scars. However, bronchiectasis can occasionally be seen in active TB. PURPOSE: To evaluate prevalence, appearance, and changes of bronchiectasis associated with active TB on computed tomography (CT). MATERIAL AND METHODS: A total of 391 patients with active TB who had undergone CT scans at the time of diagnosis were included in the study. Active TB was diagnosed when the sputum or the sample obtained by bronchoalveolar lavage tested positive using an acid-fast bacillus (AFB) smear test, polymerase chain reaction (PCR) test, or an AFB culture. The CT scans were reviewed focusing on bronchiectasis within consolidations or nodules. Cases with bronchiectasis beyond the consolidation or nodules were excluded from the study to exclude pre-existing traction bronchiectasis. The prevalence and appearance (cylindrical, varicose, cystic, and presence of focal erosion) of bronchiectasis and its time-dependent changes were analyzed. In addition, the presence of the feeding bronchus sign was checked. Here, the feeding bronchus sign was defined as a CT finding where the cavity communicates with the dilated airway. RESULTS: In 100 (25%) of the 391 patients, bronchiectasis was present within consolidations or nodules on CT. The shape of the bronchiectasis was cylindrical in all patients and focal erosions were revealed in 75 patients (75%). Nine patients had both cylindrical and varicose forms of the bronchiectasis. The feeding bronchus sign was observed in 42 patients (42%). Follow-up CT was performed on 19 of 100 patients. The bronchiectasis had progressed in 11 patients (58%), improved in four patients (21%), remained unchanged in one patient (5%), and could not be determined in the remaining three patients (16%). In nine patients, CT images prior to diagnosis were available, and in all these cases, bronchiectasis was newly developed. CONCLUSION: Bronchiectasis can be seen within active inflammation in one-fourth of active TB on CT. In association with active inflammation, bronchiectasis is mostly cylindrical with focal erosions, occasionally accompanied by the feeding bronchus sign.

Hypofractionated radiotheapy using helical tomotherapy for advanced hepatocellular carcinoma with portal vein tumor thrombosis.

BACKGROUND: We want to evaluate the efficacy of helical tomotherapy (HT) for treating advanced hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT). METHODS: We treated 35 patients for unresectable HCC combined with PVTT in whom other treatment modalities were not indicated. The tumor thrombi involved the main trunk of the portal vein in 18 patients (51.4%) and the first or second order branches in 17 patients (48.6%). A median dose of 50 Gy (range: 45-60 Gy) was delivered in 10 fractions. Capecitabine was given concomitantly at a dose of 600 mg/m2 twice daily during radiotherapy. RESULTS: The responses were evaluated via computed tomography. There was a complete response (CR) in 5 patients (14.3%), partial response (PR) in 10 patients (28.6%), stable disease (SD) in 18 patients (51.4%) and progressive disease (PD) in 2 patients (5.7%). The Child-Pugh classification (A vs B) and the Japan integrated staging (JIS) score (2 vs 3) were statistically significant parameters that predicted the response of PVTT (p = 0.010 and p = 0.026, respectively). The median survival, one and two year survival rate of all patients was 12.9 months, 51.4% and 22.2%, respectively. The patients with tumor thrombi in the main portal trunk showed statistically inferior overall survival than patients with tumor thrombi in the portal vein branches (9.8 versus 16.6 months, respectively, p = 0.036). The responders' median survival was 13.9 months, double 6.9 months as the median survival of the non-responders. No radiation induced liver disease or treatment related mortality was not appeared. CONCLUSIONS: Hypofractionated radiotherapy with HT was effective not only for tumor response but also for survival in the advanced HCC patients with PVTT. And stricter patient selection by Child-Pugh classification and JIS score may maximize the potential benefits of this treatment.

Re-irradiation of unresectable recurrent head and neck cancer: using Helical Tomotherapy as image-guided intensity-modulated radiotherapy.

PURPOSE: Re-irradiation (re-RT) is considered a treatment option for inoperable locoregionally recurrent head and neck cancer (HNC) after prior radiotherapy. We evaluated the efficacy and safety of re-RT using Helical Tomotherapy as image-guided intensity-modulated radiotherapy in recurrent HNC. MATERIALS AND METHODS: Patients diagnosed with recurrent HNC and received re-RT were retrospectively reviewed. Primary endpoint was overall survival (OS) and secondary endpoints were locoregional control and toxicities. RESULTS: The median follow-up period of total 9 patients was 18.7 months (range, 4.1 to 76 months) and that of 3 alive patients was 49 months (range, 47 to 76 months). Median dose of first radiotherapy and re-RT was 64.8 and 47.5 Gy10. Median cumulative dose of the two courses of radiotherapy was 116.3 Gy10 (range, 91.8 to 128.9 Gy10) while the median interval between the two courses of radiation was 25 months (range, 4 to 137 months). The response rate after re-RT of the evaluated 8 patients was 75% (complete response, 4; partial response, 2). Median locoregional relapse-free survival after re-RT was 11.9 months (range, 3.4 to 75.1 months) and 5 patients eventually presented with treatment failure (in-field failure, 2; in- and out-field failure, 2; out-field failure, 1). Median OS of the 8 patients was 20.3 months (range, 4.1 to 75.1 months). One- and two-year OS rates were 62.5% and 50%, respectively. Grade 3 leucopenia developed in one patient as acute toxicity, and grade 2 osteonecrosis and trismus as chronic toxicity in another patient. CONCLUSION: Re-RT using Helical Tomotherapy for previously irradiated patients with unresectable locoregionally recurrent HNC may be a feasible treatment option with long-term survival and acceptable toxicities.

Incidence of venous air embolism during myomectomy: the effect of patient position.

PURPOSE: Venous air embolism (VAE) is characterized by the entrainment of air or exogenous gases from broken venous vasculature into the central venous system. No study exists regarding the effect of patient positioning on the incidence of VAE during abdominal myomectomy. The purpose of this study was to assess the incidence and grade of VAE during abdominal myomectomy in the supine position in comparison to those in the head-up tilt position using transesophageal echocardiography. MATERIALS AND METHODS: In this study, 84 female patients of American Society of Anesthesiologist physical status I or II who were scheduled for myomectomy under general anesthesia were included. Patients were randomly divided into two groups: supine group and head-up tilt group. Transesophageal echocardiography images were videotaped throughout the surgery. The tapes were then reviewed for VAE grading. RESULTS: In the supine group, 10% of the patients showed no VAE. Moreover, 10% of the patients were classified as grade I VAE, while 50% were categorized as grade II, 22.5% as grade III, and 7.5% as grade IV. In the head-up tilt group, no VAE was detected in 43.2% of the patients. In addition, 18.2% of the patients were classified as grade I VAE, 31.8% as grade II, and 6.8% as grade III; no patients showed grade IV. VAE grade in the head-up tilt group was significantly lower than that in the supine group (p<0.001). CONCLUSION: The incidence and grade of VAE in the head-up tilt group were significantly lower than those in the supine group during abdominal myomectomy.

Carbon dioxide embolism during laparoscopic surgery.

Clinically significant carbon dioxide embolism is a rare but potentially fatal complication of anesthesia administered during laparoscopic surgery. Its most common cause is inadvertent injection of carbon dioxide into a large vein, artery or solid organ. This error usually occurs during or shortly after insufflation of carbon dioxide into the body cavity, but may result from direct intravascular insufflation of carbon dioxide during surgery. Clinical presentation of carbon dioxide embolism ranges from asymptomatic to neurologic injury, cardiovascular collapse or even death, which is dependent on the rate and volume of carbon dioxide entrapment and the patient's condition. We reviewed extensive literature regarding carbon dioxide embolism in detail and set out to describe the complication from background to treatment. We hope that the present work will improve our understanding of carbon dioxide embolism during laparoscopic surgery.