[Decision to avoid general anesthesia on 3 cases with anterior mediastinal masses].

We report 3 cases of anterior mediastinal masses in which we avoided providing general anesthesia for a biopsy and a central venous catheter placement. In all cases, chest X-rays on admission showed mediastinal mass ratio (MMR) greater than 44% and thoracic computed tomographic scans demonstrated cross sectional area (CSA) of the trachea 60% less than expected and the main stem bronchi narrowing. We made a decision not to provide general anesthesia, considering the risk of airway obstruction after induction of general anesthesia. In case 1, a 6-year-old boy, preoperative corticosteroid therapy relieved respiratory complaints without improvement of MMR and %CSA. On hospital day 3 the patient developed airway obstruction during induction of anesthesia and the surgery was postponed. After 3 days of additional chemotherapy MMR decreased to 34% and %CSA increased to 94%. On day 6 surgery under general anesthesia was performed safely. In case 2, a 15-year-old boy presented with MMR 44% and %CSA 48% and left bronchial stenosis and underwent surgery under local anesthesia. In case 3, a 3-year-old boy, preoperative corticosteroids and chemotherapy improved MMR 67% to 34% and %CSA 60% to 95%. On day 8 of admission a biopsy was performed under general anesthesia uneventfully. We emphasize not only clinical signs but also radiological signs are important to evaluate the safety in induction of general anesthesia for the management of the cases of anterior mediastinal masses.

[Case of a schizophrenic patient refusing emergent operation for ovarian torsion].

We report a case of a schizophrenic patient who rejected an emergent operation for ovarian torsion. A 48-year-old woman with ovarian torsion strictly turned down emergent surgery against the recommendation of her gynecologist, who could not communicate with her. In response to his request, a psychiatrist examined and diagnosed her as schizophrenia. Therefore, she was transferred to our hospital for management in closed wards. She was so paranoiac and self-defensive that we, the psychiatrist, the gynecologist, and the anesthesiologist, could not obtain informed consent for the operation from her. Because this was an emergent and life-threatening case, we attempted anesthesia and surgery with the consent of her mother and uncle. First, we took her not directly to the operating room but to ICU to relieve her anxiety and fear. Then, we intubated her under sedation and analgesia. Finally, we took her to the operating room and started the operation. Anesthesia was maintained with 1.5-2.0% sevoflurane and fentanyl (total 9 microg x kg(-1)). The operation was uneventful and she was retransferred to ICU with the tracheal tube in place. Next day she was extubated and left ICU. She was informed by her psychiatrist of the fact that the operation had been performed. Fortunately, her mental status and postoperative course was generally stable.