Critical aspiration pneumonia during induction of anesthesia in elective abdominal surgery: a case report.

BACKGROUND: We experienced the critical aspiration pneumonia during induction of anesthesia in elective abdominal surgery which standard fasting period was complied with. CASE PRESENTATION: A 64-year-old male was scheduled for gastrojejunostomy because of gastrointestinal obstruction. He fasted from the night before surgery. General anesthesia was induced, and cricoid pressure was applied during intubation. However, he vomited huge amount of gastric contents. The scheduled surgery was performed without surgical complications, and postoperatively respiratory management, including mechanical ventilation with prone positioning, was performed in high care unit. He was extubated on postoperative day 2. He was discharged from the hospital on POD 25. CONCLUSION: The standard fasting period can prevent aspiration pneumonia in most cases. However, even in elective cases without abdominal symptoms, we consider that massive-volume gastric residual contents, especially in susceptible cases. We suggest that point-of-care gastric ultrasonography be performed in suspicious cases before induction of anesthesia.

Three-Dimensional Fixation: Pathological Protocol Following Pancreaticoduodenectomy with Portal Vein Resection for Pancreatic Cancer.

BACKGROUND: Although existing histopathologic protocols for pancreatic cancer have been standardized, the relevance between prognosis and resection margin clearance is still controversial. Reconstruction of specimens as in situ to appropriately assess the margin is desirable in these protocols. METHODS: The three-dimensional fixation protocol defined specimen handling of pancreaticoduodenectomy (PD) with portal vein (PV) resection. The superior mesenteric artery (SMA) margin of the specimen was tidily fixed around an artificial SMA as if in an in situ setting. In this prospective study, patients undergoing PD with PV resection for pancreatic cancer in 2016 were enrolled. To evaluate the feasibility of the three-dimensional fixation protocol, the SMA margin distance and PV involvement of tumor assessed by computed tomography (CT) were compared with those assessed by pathology. RESULTS: Thirty-three patients with/without preoperative chemotherapy were enrolled. The entire cohort did not present with high-quality diagnostic assessment of the medial margins around SMA and PV (correct estimation, 58% and 73%, respectively). In contrast, in 16 patients undergoing upfront surgery, the concordance value of the SMA margin, which assesses the agreement between CT and pathology measures, was 0.48 (moderate agreement). The PV involvement examined by imaging was significantly associated with that by pathology (P = 0.013). CONCLUSIONS: The three-dimensional fixation protocol was applicable to all cases undergoing PD with PV resection. Focusing on the patients with upfront surgery demonstrated the feasibility of accurate pathological assessment of medial margins. We propose this protocol as a promising standard for the assessment of true surgical margin status.

Hyalinizing clear cell carcinoma of the bronchial glands: presentation of three cases and pathological comparisons with salivary gland counterparts and bronchial mucoepidermoid carcinomas.

Hyalinizing clear cell carcinoma of the bronchial glands is a very rare tumor. Since only five reports describing six tumors have been published to date, only a little is known about specific histologic findings and clinical features. Because of its rarity, hyalinizing clear cell carcinoma has not been described in the latest WHO classification of pulmonary tumors yet. Here we present three cases of bronchial hyalinizing clear cell carcinomas, confirmed by both fluorescence in situ hybridization (FISH) and RT-PCR, focusing on histologic and immunohistochemical characteristics in a comparison with three cases of salivary gland origin. In addition, we compared immunohistochemical features with bronchial mucoepidermoid carcinoma, a lesion that needs to be taken into account in differential diagnosis of hyalinizing clear cell carcinoma. All our bronchial hyalinizing clear cell carcinoma cases were surgically resected. Histologically, tumor cells showed clear to eosinophilic cytoplasm with hyalinizing stroma in various proportions, resembling those of salivary gland origin. Immunohistochemically, tumor cells were positive for CK7, CK5/6, p40, p63, and ATF1, while they were negative for TTF1, Napsin A, HMB45, and SOX10. The CK5/6 staining pattern varied in mucoepidermoid carcinomas, while that of hyalinizing clear cell carcinoma was uniformly positive. FISH revealed EWSR1-ATF1 fusion, and RT-PCR with sequencing confirmed specificity of the chimeric gene for hyalinizing clear cell carcinoma. Clinically, bronchial hyalinizing clear cell carcinoma was characterized by occurrence in the fourth to sixth decades, no link with smoking history, and a predilection for the right lung, in line with previous reports. In summary, our study confirmed that the bronchial hyalinizing clear cell carcinoma is a histologically and genetically identical tumor to that of salivary gland origin, and that gene rearrangement analysis can play a critical role in distinction from mucoepidermoid carcinoma.

Skene's gland adenocarcinoma with intestinal differentiation: A case report and literature review.

Adenocarcinoma of Skene's gland (the female homolog to the male prostate) is extremely rare, with only a few cases reported. We present a case of Skene's gland adenocarcinoma with intestinal differentiation. The patient was a 69-year-old Japanese woman who was operated on for a recurrent tumor of the external ostium of the urethra. Histopathologically, the tumor showed glandular and cribriform patterns with a signet-ring cell component in a mucus lake. Immunohistochemically, the tumor cells were positive for prostate specific acid phosphatase (PSAP), and AMACR, and negative for Nkx3.1 or prostate specific antigen (PSA). Although in situ lesion could not be discovered, positive immunostainings for Nkx3.1, PSAP, and androgen receptor in the remaining paraurethral glands around the tumor indirectly but strongly suggest that the tumor had originated from Skene's gland. This tumor also showed intestinal differentiation as suggested histologically and by positive immunostainings for CDX2, MUC2, and CK20, along with negative immunostaining for CK7. It is often very difficult to identify the origin of a female urethral carcinoma. In such cases, immunohistochemical features can be an essential clue to the origin. We therefore present this instructive case with a literature review.

Two cases of thoracic epidural neurolysis after local anesthetic titration in cancer patients.

Two patients who underwent thoracic epidural neurolysis after titration using local anesthetic are reported. Case 1 suffered serious back and epigastric pain arising from metastasis of lung cancer and Case 2 was not relieved right chest pain by costal metastasis from urethral cancer only by morphine. Block therapies improve the patients' quality of life if these underwent in opioid resistant pain or moving pain. Among them subarachnoid neurolytic blockage or epidural continuous blockage are usually selected in terminal stage. Subarachnoid blockage is potent but usually induces paresthesia and hypesthesia and patient has to keep lateral position under affected site intraoperatively. Epidural block is easy to treat but is difficult to continue because of infection and decrement of efficacy attributed adhesion of epidural space, stress arose from immobilization. We operate epidural neurolytic blockage for these patients and they were relieves from pain without suffer from the side effect.