Unique Learning System for Uterine Artery Embolization for Symptomatic Myoma and Adenomyosis for Obstetrician-Gynecologists in Cooperation with Interventional Radiologists: Evaluation of UAE From the Point of View of Gynecologists Who Perform UAE.

STUDY OBJECTIVE: To evaluate a unique learning system for uterine artery embolization (UAE) and examine its feasibility and clinical outcomes for the treatment of symptomatic uterine leiomyomas and adenomyosis when performed by obstetrician-gynecologists in cooperation with interventional radiologists (IVRs). DESIGN: Retrospective study (Canadian Task Force classification II-2). SETTING: University hospital. PATIENTS: One hundred seventy-three patients who underwent UAE for symptomatic leiomyomas and adenomyosis. INTERVENTIONS: We examined the medical records of patients who underwent UAE for symptomatic uterine leiomyomas and adenomyosis at our department between 2003 and 2012 using our learning system for UAE for obstetrician-gynecologists in cooperation with IVRs. The charts of all patients were reviewed, and data on etiologic factors, past medical history of leiomyomas and adenomyosis, symptoms, details of UAE, and clinical outcomes after UAE were extracted. MEASUREMENTS AND MAIN RESULTS: A total of 173 patients who underwent 177 UAEs were identified, including 4 patients who underwent embolization twice because of primary treatment failure or symptom recurrence. During the study period, 2 gynecologists successfully acquired endovascular skills. The technical success rate was 97.7% (174 of 177). The duration of fluoroscopy in procedures performed by obstetrician-gynecologists who acquired endovascular skills was not significantly different from that in procedures performed by IVRs at our institution; however, this duration was significantly longer in procedures performed by obstetrician-gynecologists who did not have sufficient experience with our learning protocol for UAE because of inadequate live observation of UAEs performed by skilled IVRs. Complications that necessitated discontinuation of the procedure occurred in 2.3% of cases (4 of 177). The clinical outcomes were similar to those reported in previous studies. Adverse events after UAE included myeloid passages in 7.0% (11 of 158), infections in 2.5% (4 of 158), vaginal discharge in 2.5% of patients with leiomyomas (4 of 158), and vaginal discharge in 7.1% of patients with adenomyosis (1 of 14). All the adverse events were adequately treated by the obstetrician-gynecologists themselves. The timing of hysterectomy due to complications or recurrence of symptoms after UAE varied widely. CONCLUSION: UAE performed by obstetrician-gynecologists in cooperation with radiologists can be achieved safely and successfully with acceptable clinical outcomes. Live observation of the procedure performed by skilled IVRs is essential to improving the skills and reducing the fluoroscopic time of obstetrician-gynecologists.

[Anesthetic Management of a Patient with May-Hegglin Anomaly].

We report the case of a 52-year-old woman with May-Hegglin Anomaly (MHA) and a platelet count of 1.9 x 10(4) x mm(-3). She was scheduled to undergo abdominal total hysterectomy and adnexectomy with uterine fibroids. Anesthesia was maintained by inhalation of sevoflurane (1.5%), continuous intravenous infusion of remifentanil (0.2-0.3 µg x kg(-1) x min(-1)), intermittent intravenous infusion of fentanyl (35 µg), and the transversus abdominis plane block with 20 ml of 0.375% ropivacaine. The amount of bleeding during surgery was 150 ml and her postoperative course was uneventful. MHA is a rare hematological disorder inherited as an autosomal dominant trait that is characterized by thrombocytopenia, giant platelets, and inclusion bodies in the granulocytes. A decrease in platelet count is detectable with a blood test But function of platelets is generally normal. Anesthesiologist should understand the characteristics of MHA, and administer anesthetics without giving platelets.

Leiomyoma treatment by uterine artery embolization using gelatin sponge prepared by the pumping method.

Uterine leiomyoma, a benign tumor, may be treated with drugs, albeit surgical resection is more common. The present study aimed to evaluate the treatment of leiomyoma cases by uterine artery embolization (UAE) using a gelatin sponge prepared by the pumping method. The results of 700 leiomyoma cases treated by UAE in the outpatient department were evaluated. UAE was performed by injecting gelatin sponge prepared by the pumping method into the uterine artery. Among 700 cases, effective cases were 680 (97.2%), ineffective cases were 18 (2.8%) and impossible cases for UAE were 2 (0.2%). Retreatment was required in 23 cases (3.3%). Complication events designated by the Society of Interventional Radiology Clinical Practice Guidelines occurred in 31 cases (4.4%): 1 case showed permanent adverse sequelae, 4 cases required major therapy with a prolonged hospitalization (>48 h) and 10 patients required therapy with minor hospitalization (<48 h). The remaining 16 cases required nominal or no therapy. Follow-up of patients was performed for 599 cases for an average period of 1.2±0.9 years, ranging between 1 month and 6 years. Pregnancy after UAE was observed in 12 cases/15 cycles. Thus, the findings indicate that UAE using gelatin sponge prepared by the pumping method applied to outpatients is a safe and useful treatment procedure.

[Management of one lung ventilation with bronchial blocker catheter for a patient with tracheobronchopathia osteochondroplastica].

Tracheobronchopathia osteochondroplastica is a rare benign disease, with difficult airway for intubation because the trachea and bronchia are narrow and transformed. We experienced one lung ventilation for a patient with the lung cancer associated with the tracheobronchopathia osteochondroplastica. The Coopdech bronchial blocker is a device for one lung ventilation. We could actually manipulate the blocker balloon very easily and maintain complete one lung ventilation maintaining SpO2 well. Coopdech bronchial blocker is useful for one lung ventilation in a patient with difficult airway such as tracheobronchopathia osteochondroplastica.

[Management for the removal of dopamin-secreting pheochromocytoma].

Incidence of dopamin-secreting pheochromocytoma is very rare. We reported managment of anesthesia for the removal of dopamin-secreting pheochromocytoma. A 46-year-old woman was diagnosed with pheochromocytoma, but lacking clinical symptoms. Plasma and urinary dopamine levels were remarkably elevated, but other catecholamine levels were within normal limits. She underwent left adrenalectomy. Plasma dopamine was measured before during and after the adrenalectomy. Blood pressure was not related to plasma dopamine levels.

[Management of maternal tetanus contracted by an obstetric procedure].

A 34-year-old woman from the Philippines showed difficulty in opening the mouth. She had no wounds in the last one mouth, but was treated with an obstetric procedure after stillbirth 16 days before in the Philippines. She showed trismus, rigidity and muscle pain, but no muscle spasms, dyspnea and autonomic dysfunction. In this case, it is supposed that the obstetric procedure is the origin of the injury. In Japan, this is the first report of maternal tetanus.

[Tracheal intubation for two patients with lingual tonsil hyperplasia and prospect of difficult airway management].

Lingual tonsil hyperplasia is rare, but may cause difficult or inpossible tracheal intubation. We experienced two cases of tracheal intubation for lingual tonsil hyperplasia. A 71-yr-old man was scheduled for resection and biopsy of symptomatic hypertrophied lingual tonsils. In this patient, we performed oro-tracheal intubation by rigid laryngoscopy from left oral angle, because left hypertrophied lingual tonsils are smaller than those on the right side. A 44-yr-old man was scheduled for resection of symptomatic hypertrophied lingual tonsils after lingual tonsillitis. In this patient, we performed nasotracheal intubation using fiberoptic bronchoscopy with assist of jaw-lift and tongue-extension. When an anesthesiologist can predict the abnormality of lingual tonsils, these methods might be recommended for difficult airway and intubation. However, it is necessary to prepare a difficult airway management set including laryngeal mask airway, intubating laryngeal mask airway, fiberoptic bronchos-copy and transcutaneous tracheotomy set. And most important is preliminary evaluation of airway and cautious planning of tracheal intubation.

[A case of cor triatriatum diagnosed by echocardiography on pre-anesthetic examination].

A 69-year-old man was planned for elective surgery of the lumbar vertebral disk herniation. We performed a pre-anesthetic examination. He had a mild cardiomegaly (CTR = 55%) on chest X-ray examination, and ST-T change on electrocardiogram. His electrocardiogram showed negative T wave in III and aVF, ST elevation in I, aVL, V1-3, and flat T wave in V5-6. But he was without any symptoms of chest occlusion. He had no other abnormal laboratory data and abnormality in physical examination. We did echocardiography on him and cor triatriatum was diagnosed. The flow from the accessory chamber was 0.44 m.s-1. There were no abnormalities in the reflux of the pulmonary vein. We managed him under general anesthesia for operation, and took care to prevent right heart failure. There were no complications in peri-operative period. It was very important to perform pre-anesthetic examination by anesthetic specialist. Echocardiogram is useful for pre-anesthetic examination, if cardiovascular disease is suspected by chest symptom, electrocardiogram or chest X-ray examination.

[Pulmonary embolism in three surgical patients despite prophylactic measures].

Pulmonary embolism after surgery became a major problem in Japan recently. From the year 2000, we started the prophylaxis against pulmonary embolism in orthopedic or gynecological surgical patients with some risk factors of pulmonary embolism. But we experienced three cases of pulmonary embolism although two of them had received subcutaneous heparin after surgery. We consider that prophylactic measures are recommended for the patient with risk factors of pulmonary embolism. Pulmonary embolism should be considered when surgical patients complain of abnormality such as chest pain.