[A Case of Synchronous Papillary Thyroid Cancer and Breast Ductal Cancer].

Occurrences of thyroid cancer and breast cancer metachronously or synchronously are common for women. Explanations for these associations include detection bias, shared hormonal risk factors, and genetic susceptibility, but the etiology behind specific associations is not elucidated well. The importance of the relationship between breast and thyroid cancer will continue to become evident and physicians should be aware of this association in caring for thyroid and breast cancer survivors. We report a case of synchronous papillary thyroid cancer and breast ductal cancer.

Effectiveness of frailty screening and perioperative team management of colectomy patients aged 80 years or more.

BACKGROUND: We aimed to clarify usefulness of the modified Frailty Index 11 (mFI-11) for assessing risk of postoperative complications (POCs) and effectiveness of perioperative management team (POMT) intervention for improving postoperative status of frail aged patients requiring colorectal cancer (CRC) surgery. METHODS: We compared, retrospectively, surgical outcomes among 151 consecutive CRC surgery patients aged ≥80 years. Patients were grouped by mFI-11 scores and by POMT intervention (vs. no POMT intervention). RESULTS: POCs were more prevalent, postoperative stays were longer, and discharge status was poorer among high-risk (mFI-11 ≥ 3/11) patients without POMT intervention than among low-risk (mFI-11 ≤ 2/11) patients (p = 0.04, p = 0.02, p < 0.01). Multiple POCs occurred less frequently and performance of activities of daily living was better for high-risk patients with (vs. those without) POMT intervention (p = 0.04, p = 0.03). CONCLUSION: POMT intervention appears beneficial for frail aged patients scheduled for CRC surgery.

Improving laser cooling efficiencies of Yb-doped yttrium aluminum garnet by utilizing non-resonant anti-Stokes emission at high temperatures.

Laser cooling in solids has been demonstrated, and cooling from room temperature to cryogenic temperatures has so far been the main focus of research. However, operation at high temperatures can be advantageous. We propose that laser cooling of Yb-doped yttrium aluminum garnet ceramic discs is enhanced above 300 K. Photoluminescence (PL) spectra is evidence that the phonon-assisted energy transfer from resonant states, which exhibit a narrow PL peak, to inhomogeneously distributed energy states becomes stronger at higher temperatures. This results in an enhanced non-resonant anti-Stokes PL at high temperatures. The ideal cooling efficiency determined from the PL spectrum at 470 K is 1.7 times higher than that at 300 K.

[A Case of Cardiopulmonary Arrest due to Difficult Mask Ventilation and Difficult Laryngoscopy in the Ward after Operation: A Case Report].

A 77-year-old man with paroxysmal atrial fibrillation and hypertrophic obstructive cardiomyopathy was scheduled for cervical laminoplasty. He was predicted difficult mask ventilation combined with difficult laryn- goscopy (CICV) because of short thyromental distance. After induction of general anesthesia, we attempted tracheal intubation using McGRATHO and Gum-elastic Bougie and the intubation was successful. After opera- tion, in ward, atrial fibrillation occurred. Because anti- arrhythmic agents were not effective, cardioversion was planned. While under sedation, his breathing stopped. The attending physician could not ventilate with mask and intubate with Macintosh laryngoscope. The patient went into cardiopulmonary arrest After successful intubation using McGRATH? and Gum- elastic Bougie by anesthesiologist The attending physi- cian did not recognize CICV. We should convey infor- mation of CICV surely and perform education about difficult airway management.

[The Influence of Preoperative Oral Carbohydrate Administration on Perioperative Blood Sugar Levels and Patients' Satisfaction].

BACKGROUND: After introducing preoperative oral carbohydrate as a part of enhanced recovery after surgery (ERAS) protocols, we assessed the influence of carbohydrate administration on the perioperative blood sugar levels (BS), the variation of vital signs and patients' satisfaction. METHODS: After IRB's approval and obtaining patients' consent, patients were divided into two groups; taking carbohydrate (Group AW) or not (Group NAW). Anesthesia was induced and maintained with total intravenous anesthesia using propofol, remifentanil and rocuronium. We measured BS six times during perioperative period. We also compared blood pressures and heart rates during induction of anesthesia. Moreover, we carried out questionnaire surveys about degree of satisfaction for ERAS among patients and nurses. RESULTS: Heart rates were significantly higher in Group AW (P < 0.05), but there were no significant difference in blood pressures or BS between the groups. Patients in Group AW had more anxiety for surgeries (P = 0.003), but more than 85% of patients and nurses were satisfied with carbohydrates. CONCLUSIONS: The carbohydrate administration had little influence on the perioperative vital signs. However, we gained high reputations from patients and paramedics.

[Safety and economics of fondaparinux administration in the laparoscopic surgery].

BACKGROUND: The factor Xa inhibitor, fondaparinux was used for prevention of venous thromboembolism in the clinical setting. We evaluated the antithrombotic effect, complications and economic aspects of this agent in the patients undergoing laparoscopic surgery. METHODS: Forty one patients scheduled for laparoscopic abdominal surgery were divided into two groups. In group F (N = 33), patients received once-daily subcutaneous injection of fondaparinux (2.5 mg x day(-1)) for 4 postoperative days. In group E (N = 8), patients did not receive therapy. In group F, general anesthesia with transversus abdominis plane (TAP) block was administered during surgery, and general anesthesia with epidural anesthesia was performed in group E. We evaluated incidence of DVT (deep vein thrombosis), abnormal bleeding, other postoperative complications, and economic benefit to the hospital. RESULTS: In both groups, no patient developed DVT Abnormal bleeding was observed in 7 patients of group E. Postoperative complications and pain were not different between the two groups. The revenue in group F was 34,434 yen/patient lower than that of group E due to Japanease insulance system. CONCLUSIONS: No patients developed DVT and severe complications of fondaparinux after laparoscopic abdominal cancer surgery. However, revenue to the hospital decreased 34,434 yen/patient by use of analgestic method. We must consider cost-benefit in use of fondaparinux.

[Reliability of a less-invasive cardiac output monitor in the perioperative period of a patient with severe dilated cardiomyopathy].

Recently, various less-invasive cardiac output monitors are used for a variety of cases. We used FloTrac system for a patient with severe dilated cardiomyopathy (LVDd/Ds = 75/62 mm, EF = 22%) and recognized its limitation. A 52-year-old woman underwent left partial mastectomy. There were no significant events during the operation. In the ICU, she developed symptoms of low output state, but we could not detect any significant changes on Vigileo Monitor. Arterial pressure-based cardiac output (APCO) measurement with FloTrac is based on the patient's characteristics, blood pressure waveform and basic data stored in Vigileo Monitor. Its accuracy is worse with arterial wave artifact, compromise of the arterial catheter, aortic regurgitation, intense peripheral vasoconstriction, irregular pulse and severe cardiac hypofunction. Thus, its reliability is influenced by various conditions, especially in critically ill patients. FloTrac system is very useful for the management of cardiocirculatory dynamics, but we should be familiar with its limitations.

[Hypertrophic cardiomyopathy].

A 68-year-old woman with severe cardiac dysfunction due to dilated phase of hypertrophic cardiomyopathy was diagnosed with sigmoid cancer and scheduled for high anterior resection. Preoperative left ventricular ejection fraction (EF) was 16% by transthoracic echocardiography. After placement of an epidural catheter at the T12-L1 interspace, and artery catheters in the left radial artery for invasive blood pressure monitoring and in the right femoral artery for stand-by IABE general anesthesia was induced by midazolam, fentanyl and sevoflurane, and maintained with sevoflurane. Analgesia was obtained by epidural administration of 1% lidocaine and 0.2% ropivacaine. A central venous catheter was placed in the right internal jugular vein through which dobutamine was infused throughout the operation. Cardiac function monitored by transesophageal echocardiography showed EF of 9% just after insertion. After arbitrary administration of phenylephrine and landiolol, the operation and anesthesia were completed without serious problems. However, congestive heart failure worsened on postoperative day 2, and was improved by increasing dobutamine and by administration of milrinone.

[Parental presence is a useful method for smooth induction of anesthesia in children: a postoperative questionnaire survey].

BACKGROUND: Parental presence during induction of anesthesia (PPIA) is widely practiced to prevent preoperative anxiety in children. However, some previous studies described parental presence is less effective than sedative premedication. The purpose of this investigation is to determine whether PPIA is not an effective prevention of preoperative anxiety using a postoperative questionnaire survey to parents. METHODS: PPIA was performed for 72 children (aged 1-15 years old) during one year. No patients received sedative premedication before surgery. We evaluated degree of anxiety before induction of anesthesia with four-point scale, 1: exciting and crying before entering surgical room, 2: exiting and crying on a surgical bed, 3: agitated, crying, not exciting, 4: calm. After surgery, we executed a questionnaire survey to parents concerning degree of anxiety and satisfaction. RESULTS: Ninty percent of parents accepted PPIA and all parents wanted PPIA next time if their children undergo surgery again. Younger age and frequency of surgery were associated with anxiety during induction in children (P<0.05). On the other hands, children above ten years of age did not want PPIA so much. CONCLUSIONS: PPIA has beneficial effects against preoperative anxiety in both children and parents.

[Perioperative management of patients with drug-eluting coronary stents presenting for non-cardiac surgery].

After the approval of the drug-eluting coronary stent in Japan in 2004, Japanese cardiologists took the benefit of this new technology to improve the post percutaneus coronary intervention complication of restenosis. Post market studies of drug-eluting coronary stent are becoming available. Unfortunately, many of the results indicate the risk of late stent thrombosis. The chance of stent thrombosis seems elevated when a patient is without antiplatelet medication, dehydrated and in a stressed state. Operation puts the patient in such adverse conditions that might render him to thrombo-producting state. As the use of drug-eluting stent becomes popular, the management of those patients in operative settings becomes inevitable. In this paper, we reviewed the medical records of 20 patients for surgery with drug-eluting coronary stents in our hospital. Time intervals between stent placement and surgery were: less than 90 days (2 cases), less than 180 days (3 cases), less than one year (8 cases), more than one year (7 cases). There was no stent thrombosis in the perioperative period. We did not take precautionary steps for stent thrombosis in the perioperative period, except in two cases where operations were performed recently (One patients received heparin and the other patients received aspirin and cilostazol). None of patients had excessive blood loss. However, many reports suggest the increasing risk of stent thrombosis in patients with the drug-eluting coronary stents presenting for non-cardiac surgery. They also suggest that, in contrast to bare metal stent, there may be no association between the risk of stent thrombosis and time intervals from stent placement to surgery. We should pay more attention to management of patients with drug-eluting coronary stents presenting for non-cardiac surgery.

[Anesthetic management for patients with compromised left ventricular function due to coronary artery disease in non-cardiac surgery].

BACKGROUND: As the number of patients suffering from coronary artery disease (CAD) increases, anesthetic management for these patients become more common than the past. But no established management strategies have been proven beneficial. METHODS: We reviewed all anesthetic management records of seven patients with compromised LV function (EF<30% or FS<30%) for CAD in our hospital, who had undergone non-cardiac operations. RESULTS: Three cases were brain surgeries and four cases were abdominal surgeries. In all cases, central venous catheters were placed before induction of general anesthesia. After inotropic agents were started through central venous catheters, patients went through induction with midazolam, fentanyl and propofol without any trouble. In three cases of abdominal surgeries, pulmonary artery catheters were placed. And in five cases, artery catheters were placed in the femoral arteries, so that, in case of cardiac shock, we could start IABP without delay. In one case, we experienced shock during operation, but without IABP, the patient recovered with pharmacological support. No patient died of cardiac cause during the hospital stay for the procedure. CONCLUSIONS: We reported anesthetic management of seven patients with compromised left ventricular function for CAD in non-cardiac surgery. However, as the reports of anesthetic management in patients with compromised left ventricular function in non-cardiac surgery is few, further study will be required.

Caudal epidural anesthesia administered intraoperatively provides for effective postoperative analgesia after total hip arthroplasty.

STUDY OBJECTIVE: To investigate the use of caudal epidural anesthesia for postoperative pain after total hip arthroplasty. DESIGN: Prospective study. SETTING: University-affiliated hospital. PATIENTS: 32 (4 men and 28 women) patients, aged 49 to 89 years, scheduled for total hip arthroplasty for osteoarthritis of the hip. INTERVENTIONS AND MEASUREMENTS: Patients were allocated to three groups: lumbar epidural anesthesia (EA group; n = 16) or caudal epidural anesthesia (CA group; n = 16) groups, which were case-matched according to patient demographics. Nine patients received general anesthesia only (GA group). We evaluated the level of postoperative pain using a 100-mm Visual Analog Scale (VAS) recorded at 3, 6, 9, 12, and 24 hours after surgery. MAIN RESULTS: Total requirement of diclofenac sodium suppositories was significantly larger in the GA group than in the EA or CA groups (444 +/- 302 vs 188 +/- 124 and 145 +/- 130 mg). The number of days requiring analgesics was significantly prolonged in the GA group compared with the EA or CA groups (14 +/- 9 vs 4 +/- 3 and 4 +/- 4 days). These items were similar between the EA group and the CA group. All VAS values for pain, rest, and movement in the postsurgical period over 24 hours were significantly higher in the GA group than in either the EA or CA groups. CONCLUSIONS: Caudal epidural anesthesia provides effective postoperative analgesia similar to lumbar epidural anesthesia.

[Influence of age-related complications on clinical outcome in patients with surgical repair of atrial septal defect].

BACKGROUND: The influence of perioperative characteristics on postoperative outcome has been obscure in the adult patients with atrial septal defect (ASD). This study was designed to investigate whether perioperative patient profiles and complications will contribute to postoperative outcome following surgical closure of ASD in adult patients. METHODS: Subjects were 39 (17 male and 22 female) ASD patients, aged 16 to 69 years (mean 53 +/- 15) who were scheduled for surgical repair of isolated secundum ASD between 1999 to 2003. All patients were evaluated for circulatory characteristics using echocardiography and cardiac catheterization. Postoperative complications were evaluated by examining duration of postoperative oxygen requirement, postoperative duration until first ambulation, intubation and hospital stay after surgery. RESULTS: In elderly group (over 50 years of age), preoperative %FEV1.0, preoperative oxygen index and creatinine clearance were lower compared with those of younger group (under 50 years of age) (P=0.0309, P= 0.0341 and P= 0.0112, respectively). Moreover, elderly group showed longer duration of oxygen requirement compared with younger group (3 +/- 5 days and 2 +/- 1 days; P=0.0273). Age and change of the left ventricular diastolic diameter (LVDd) affected the incidence of postoperative arrhythmia (P=0.0195 and P=0.0204). Preoperative oxygen index and %VC affected long term intubation (P=0.0201 and P=0.0363). TAP, smoking and pulmonary hypertension affected long term oxygen supply (P=0.0070, 0.0349 and 0.0355). Only %VC affected postoperative duration until first ambulation (P = 0.0219). Delirium and postoperative oxygen index affected the length of hospitalization (P=0.0072 and 0.0188). CONCLUSIONS: Respiratory function was important in short-term outcomes in the patients with ASD. In addition, preoperative small LVDd was a useful predictor for postoperative atrial fibrillation.

[Anesthetic management for video-assisted extended thymectomy of patients with myasthenia gravis].

BACKGROUND: Thymectomy is one of therapeutic modalities for patients with myasthenia gravis. Since 1998, we have performed video-assisted extended thymectomy, which is much less invasive than traditional method. However, its optimal perioperative management has not been established. METHODS: From April 1998 to December 2003, 40 patients with myasthenia gravis underwent video-assisted extended thymectomy in our hospital. Anesthesia was maintained with propofol, sevoflurane and epidural anesthesia. No muscle relaxant was used. Operations were performed in supine position and required differential lung ventilation of both sides in turn for manipulation. A central venous catheter was inserted in the femoral vein to prepare for unexpected bleeding or other hemodynamic changes. RESULTS: Seven patients presented hypoxemia under differential lung ventilation and needed bilateral lung ventilation or addition of CPAP to nondependent lung. Unexpected bleeding from the left innominate vein occurred in two patients and required median sternotomy. Severe hypotension caused by compression of the heart during operation was observed in twenty-one patients. Extubation in the operating room was successful in all patients except one with severe bulbar paralysis before preoperative period. CONCLUSIONS: It is important to examine both surgical techniques of video-assisted surgery and physiological features of myasthenia gravis for anesthetic management of video-assisted extended thymectomy.

[Preoperative evaluation, anesthetic management and postoperative complications of athetotic type cerebral palsy patients undergoing laminoplasty].

BACKGROUND: The patients with athetotic type cerebral palsy need to have their necks fixed for preventing worsening of their symptoms during surgery. Cervical fixation with a halo vest leads to difficult tracheal intubation and possibility of aspiration. Therefore careful perioperative management is necessary, especially for respiratory complications. However, since it is difficult on the patients with cerebral palsy to perform spirogram correctly, their preoperative respiratory functions are hard to be evaluated. METHODS: We evaluated the relationships between preoperative condition and postoperative complications in 50 athetotic type cerebral palsy patients who had undergone laminoplasty. In addition, we also compared them with non-cerebral palsy patients for laminoplasty without a halo vest. RESULTS: The patients with cerebral palsy showed lower preoperative ADL score, severer symptoms of myelopathy, and decreased %VC in spirogram. We found all of these were related to prolonged postoperative recovery of ADL and longer hospitalization. Two patients with cerebral palsy suffered from aspiration pneumonia after operation, whereas any non-cerebral palsy patients had no remarkable complications. CONCLUSIONS: Careful perioperative management is necessary for cerebral palsy patients undergoing laminoplasty, especially for prevention of aspiration pneumonia.

[Thoracoscopic surgery for spontaneous pneumothorax and its anesthetic considerations].

BACKGROUND: Incidence of spontaneous pneumothorax (SPT) is increasing recently. Video-assisted thoracic surgery (VATS) is, at present, accepted generally as a procedure of choice for surgical treatment of SPT. This study was designed to investigate whether pre-operative complications and epidural anesthesia contribute to post-operative outcome following VATS for SPT. METHODS: From 1999 to 2002, 88 patients (78 men and 10 women, ranging in ages from 18 to 86, with an average age of 42 years) presented with SPT and received VATS at the Osaka Police Hospital. We evaluated the relationship between peri-operative risk factors and post-operative outcome after VATS for SPT. RESULTS: Age and epidural analgesia contributed to post-operative pain (P=0.0268 and P=0.0165, respectively). Moreover, old age and long duration of surgery extended a hospitalization period (P=0.0002, r2=0.393 and P=0.0394, r2=0.224, respectively). In addition, old age contributes to post-operative pneumonia (P=0.0405). The patient with history of smoking had prolonged duration of surgery (P=0.0040) and oxygen supply after surgery (P=0.0312). CONCLUSIONS: VATS for SPT is less invasive and contribute to short hospitalization. However, VATS also requires general anesthesia with one-lung ventilation. From our study, peri-operative careful management is necessary in a patient with old age and a habit of smoking.

Diabetes attenuates the hemodynamic stabilizing effects of oral clonidine during off-pump coronary artery bypass surgery.

STUDY OBJECTIVE: To investigate the influence of diabetes mellitus on the hemodynamic-stabilizing effect of clonidine during off-pump coronary artery bypass (OPCAB) surgery. DESIGN: Prospective study. SETTING: Public, university-affiliated hospital. PATIENTS: 40 patients (32 male, 8 female) scheduled for OPCAB surgery. INTERVENTIONS AND MEASUREMENTS: Patients were divided into equal groups of diabetic and nondiabetic patients. All patients were given 150 microg oral clonidine 1 hour before induction. Anesthesia was induced and maintained with fentanyl, propofol, and sevoflurane. Propranolol was administered intermittently to maintain an adequate heart rate (HR; 50 to 70 bpm). Preoperative demographic data (fasting blood glucose concentration and hemoglobin A1c), dose of intraoperative drugs (propofol and propranolol), and outcome data (duration of intubation and duration of hospital stay after surgery) were analyzed. MAIN RESULTS: In the diabetic and nondiabetic groups, the mean (+/-SD) plasma glucose values were 7.8 +/- 2.3 mmoL. L(-1) and 5.4 +/- 0.7 mmoL. L(-1), respectively (p < 0.05), and the mean (+/-SD) HbA1c values were 7.1 +/- 1.3% and 5.2 +/- 0.4%, respectively (p < 0.05). The mean propofol infusion rate was 2.8 +/- 0.9 mg. kg(-1). h(-1) in diabetic patients and 3.1 +/- 1.0 mg. kg(-1). h(-1) in nondiabetics (NS, p > 0.05). The total requirement for propranolol was 5.1 +/- 2.4 mg in diabetic patients and 1.6 +/- 1.1 mg in nondiabetics (p < 0.05). CONCLUSIONS: Diabetes attenuates the hemodynamic stabilizing effects of preanesthetic oral clonidine in the clinical setting.

[A case of intractable bone fracture pain due to metastasis of carcinoma treated with continuous epidural infusion using ropivacaine].

A 62-yr-old man presented with intractable pain due to sciatic and iliac bone fractures with metastasis of carcinoma. We treated this symptom using epidural infusion of ropivacaine over 8 weeks. He developed no complications related to epidural infusion of ropivacaine. Continuous epidural infusion of ropivacaine is useful for the management of pain from invasive carcinoma.

Fluid management and postoperative respiratory disturbances in patients with transthoracic esophagectomy for carcinoma.

STUDY OBJECTIVE: To investigate whether intraoperative fluid management contributes to postoperative respiratory disturbances in esophagectomy for carcinoma. DESIGN: Retrospective study. SETTING: Operating room and postanesthetic care unit of the cancer center. PATIENTS: From 1997 to 2000, 112 ASA physical status I, II, and III patients with primary carcinoma of the esophagus undergoing transthoracic esophagectomy. INTERVENTIONS AND MEASUREMENTS: As of 1998, we altered fluid management during esophagectomy to save intraoperative fluid administration. Then, we investigated postoperative respiratory disturbances after esophagectomy in the period from 1998 to 2000 (late period) compared with the period from 1997 to 1998 (early period). We also investigated the relationship between perioperative risk factors and postoperative respiratory disturbances. The need for frequent (>10) bronchoscopic suctioning of sputum during postoperative period, the need for tracheostomy, and failure in the removal of endotracheal tube (ETT) (extubation) on the first postoperative day (1 POD) were investigated for respiratory disturbances after surgery. MAIN RESULTS: Intraoperative volume balance decreased more so in the late period compared with early period (p < 0.0,001). The need for tracheostomy, bronchoscopic suctioning, and extubation failure on 1 POD were more frequent in the early period than in the late period (p = 0.0083, p = 0.0319, and p = 0.0024, respectively). The hospital recovery period after surgery was shortened during the late period (p = 0.032). Intraoperative volume balance affected the need for tracheostomy and frequent bronchoscopy postoperatively. CONCLUSIONS: Careful intraoperative fluid administration may decrease postoperative respiratory disturbances.

Continuous epidural, not intravenous, droperidol inhibits pruritus, nausea, and vomiting during epidural morphine analgesia.

PURPOSE: To investigate whether continuous epidural droperidol and intravenous (IV) intraoperative droperidol inhibit pruritus and postoperative nausea and vomiting (PONV) during epidural morphine analgesia. DESIGN: Randomized, double-blinded, controlled study. SETTING: Metropolitan cancer center. PATIENTS: 120 ASA physical status I and II patients undergoing thoracic or abdominal surgery with general anesthesia combined with epidural anesthesia. INTERVENTIONS: Patients received an intraoperative epidural injection of 2 mg morphine hydrochloride, followed postoperatively by a continuous epidural infusion of morphine hydrochloride 4 mg/day for 4 days. Patients were randomly allocated to four groups: Group A = control group, Group B = intraoperative single IV injection of droperidol (2.5 mg), Group C = postoperative continuous epidural droperidol infusion (2.5 mg/day), and Group D = intraoperative IV injection of droperidol (2.5 mg) and postoperative continuous epidural droperidol infusion (2.5 mg/day). MEASUREMENTS AND MAIN RESULTS: The frequency and severity of pruritus and PONV in each group were evaluated during the postoperative period. Continuous epidural infusion of droperidol significantly reduced the frequency and severity of pruritus and PONV induced by epidural morphine without causing significant side effects. Intraoperative single IV injection of droperidol was effective for PONV (p < 0.05) but not for pruritus. CONCLUSION: Postoperative epidural droperidol infusion significantly decreased both the frequency and severity of pruritus and PONV during postoperative continuous epidural morphine analgesia. IV intraoperative droperidol significantly reduced the frequency and the severity of PONV but not pruritus.