Association between postoperative pain and analgesic use in minimally invasive cardiac surgery.

BACKGROUND: This study aimed to investigate the effects of surgical methods on pain duration and oral analgesic administration in patients who underwent cardiac surgery using various minimally invasive methods. METHODS: We included 90 patients who underwent an anterior incision with costal cartilage transection, lateral incision without costal cartilage transection, or total endoscopic cardiac surgery using a lateral incision and no retractor. Oral analgesics were postoperatively administered upon patient request. All the patients were instructed to rate their pain during the daytime 3 and 7 days postoperatively. RESULTS: Between-group differences included surgical method, wound size, operation/cardiopulmonary bypass time/cardiac arrest time, and intraoperative fentanyl dose. No differences were found in sex, age, diabetes status, paravertebral block use, or blood loss. The number of postoperative days, postoperative analgesic use, and pain 3 days postoperatively demonstrated no difference. Pain ratings were most severe for the costal cartilage resection group and least severe for the total endoscopic cardiac surgery group 7 days postoperatively. Similarly, patients who underwent costal cartilage research exhibited the highest rate of analgesic use for 30 days postoperatively, whereas patients who underwent total endoscopic cardiac surgery demonstrated the lowest. CONCLUSIONS: We revealed significant between-group differences in pain prevalence and postoperative oral analgesic administration in patients who underwent cardiac surgery relative to the minimally invasive surgical method used.

[A case of bilobar multiple hepatocellular carcinoma in which complete remission was achieved by preoperative percutaneous isolated hepatic perfusion and subsequent hepatectomy].

We report a case of bilobar multiple hepatocellular carcinoma (HCC) successfully treated by preoperative percutaneous isolated hepatic perfusion(PIHP) and subsequent hepatectomy. A 77-year-old man with elevated serum PIVKA-II level and hepatomas was referred to our hospital. Abdominal dynamic computed tomography and gadoxetate disodium-enhanced magnetic resonance imaging demonstrated advanced HCCs: 11 tumors with a maximum tumor size of 4.8 cm diameter in the right lobe, and 1 tumor of 3.6 cm diameter in the left lobe. Curative resection was impossible due to insufficient liver function and due to the locations of the tumors. Therefore, we performed preoperative PIHP in order to control the multiple HCCs in the right lobe. This resulted in normalization of serum PIVKA-II level and complete necrosis of all tumors in the right lobe, as observed on dynamic computed tomography after 4 weeks of PIHP. Then, at 7 weeks after PIHP, we performed extended left lobectomy for residual tumor in the left lobe. Finally, complete remission was thought to have been achieved. The patient is alive 6 months after PIHP, without recurrence.

Recurrent Pulmonary Embolism Caused by Superficial Femoral Vein Aneurysm.

Venous aneurysms (VA), particularly superficial femoral VAs (SFVAs), are rare vascular lesions. A 65-year-old woman with a history of pulmonary embolism (PE), treated with tissue plasminogen activator and oral anticoagulation, was admitted to hospital for dyspnea. Enhanced computed tomography showed recurrent PE and right SFVA with a mural thrombus. The SFVA was not identified during the first PE. The PE was not massive and was treated with direct oral anticoagulants. The thrombus in the SFVA caused the PE, and surgical repair was performed to prevent further embolic events. Under general anesthesia, the SFVA was excised, and direct anastomosis was performed. PE recurrence, venous aneurysmal changes, and thrombosis were not noted at the 1-year follow-up.

Efficacy of left atrial plication for atrial functional mitral regurgitation.

OBJECTIVE: Atrial functional mitral regurgitation (AFMR) is caused by atrial fibrillation and left atrial enlargement. Our study aimed to evaluate the efficacy of left atrial plication (LAP) for AFMR. METHODS: Of 1164 mitral valve surgery patients at our hospital from January 2000 to May 2019, 22 patients underwent surgery for AFMR. Our retrospective analysis divided the patients with AFMR into two groups according to whether LAP was performed (LAP + group, n = 9; LAP - group, n = 13). Mitral valve angle (MV angle) (horizontal inclination of mitral valve) was measured by pre- and post-operative computed tomography scan. Individuals with type II mitral regurgitation, left ventricular ejection fraction of < 55%, males with left ventricular endo-diastolic dimension of > 60 mm and females with > 55 mm, aortic valve disease, mitral valve calcification, hypertrophic obstructive cardiomyopathy, and both "redo" and emergency cases were excluded. RESULT: Mitral valve replacement was performed in 6 patients and mitral ring annuloplasty in 16 cases. No recurrence of mitral regurgitation or structural valve deterioration occurred during the follow-up period. There were no hospital deaths; 3 deaths occurred during the follow-up period. Compared to the LAP - group, the LAP + group demonstrated a significantly greater decrease of MV angle (16.6 ± 8.1° vs. 1.2 ± 6.9°, p < 0.01) and left atrial dimension (18.4 ± 7.0 mm vs. 6.9 ± 14.6 mm, p = 0.02). CONCLUSIONS: Surgical results of AFMR were satisfactory. LAP may be appropriate for correcting the angle of a mitral valve tilted horizontally. More cases need to be considered in the future.

Chronic type B aortic dissection complicated by repetitive spinal cord ischaemia.

Chronic type B aortic dissection complicated by repetitive transient spinal cord ischaemia is rare. Reduced blood flow in the segmental arteries supplying the radicular arteries in the false lumen is the main cause of this pathology. Individual variations in spinal cord circulation are difficult to identify; therefore, the mechanisms of spinal cord ischaemia are poorly understood. We encountered a patient with chronic type B aortic dissection experiencing repetitive spinal cord ischaemia that finally led to spinal cord infarction. The patient recovered, except for mild monoparesis of the right leg. With the growth of the dissected aorta, we planned for surgical treatment to restore the blood supply in the spinal cord. The patient underwent thoraco-abdominal aortic repair using deep hypothermia, and favourable neurological results were achieved.

Langerhans cell histiocytosis of the skull on cytologic squash preparations.

We present a case in which a primary cytodiagnosis of Langerhans cell histiocytosis (LCH) of the skull was made using squash preparations. The patient, a 25-year-old male, presented with raised intracranial pressure and decreased visual acuity. Magnetic resonance imaging revealed a large skull lesion with osteolytic features in the left frontal bone. The patient underwent surgical resection by the extended basal frontal epidural approach. The squash preparation smears were cellular and demonstrated a mixed population of small, mature lymphocytes, eosinophils, and a high histiocytes content. The histiocytes occurred as isolated or loosely cohesive and clustered. They possessed abundant cytoplasm with rounded cell shape and had characteristic nuclear features, composed of fine chromatin and delicate nuclear membranes. The cytologic features of these histiocytes were consistent with Langerhans cells (LCs). A final impression of LCH of the skull was rendered. Subsequent histopathology confirmed the diagnosis. LCs reacted with both S-100 protein and CD1a immunohistochemically. The demonstration of Birbeck granules on electron microscopic study was also noted. Whenever squash preparation yields a mixed population of mature lymphocytes, eosinophils, and histiocytes, the cytologists should be aware of and consider LCH as a diagnostic possibility.

Persorption mechanisms of luminal antigenic particulates via apoptotic epithelial cells of intestinal villi into systemic blood circulation in orally immunized rats.

The possibility of persorption of prefixed bovine serum albumin-coated sheep erythrocytes (BSA-SEs) from mucous epithelial cells and its mechanisms were investigated in rats orally immunized by BSA for 14 consecutive days. On the day after the final oral immunization, the rats were duodenally perfused by BSA-SEs or non-coated SEs. BSA-SEs were also duodenally perfused in non-immunized rats. Thirty min after perfusion, BSA-SEs were significantly more engulfed by late-apoptotic-stage villous columnar epithelial cells in the orally immunized rats than those in other experiments. The specific antibody (SpAb) was detected on the surfaces of BSA-SEs in rats with oral immunization. In Peyer's patches of all animals, no SEs reached the follicle-associated epithelium, because of the close attachment of follicle-associated intestinal villi and the thick mucous layer. BSA-SEs were more frequently persorbed into portal blood in the orally immunized rats than in other rats. Small numbers of BSA-SEs or SEs were detected in the systemic blood of all animals. BSA-SEs were also histologically found in the blood vessels of the liver, but not in mesenteric lymph nodes. These findings suggest that sensitized antigenic particulates are taken up by late-apoptotic-stage villous columnar epithelial cells in the small intestine and are finally persorbed into the systemic blood circulation. The uptake of antigenic particulates might be mediated by its luminal SpAb.

Cytologic diagnosis of brain metastasis from hepatocellular carcinoma by squash preparation.

Hepatocellular carcinoma (HCC) metastasizes to the brain is rare instances. In published series and case reports of metastatic HCC, diagnosis of central nervous system metastases has been determined by histologic methods. We present a case of metastatic HCC of brain diagnosed by squash cytologic preparation. A 69-year-old male, HCV positive, suffering from post-hepatitic cirrhosis, initially diagnosed at age 68 with HCC presented with headaches of increasing frequency and severity. A computed tomography scan confirmed a 3-cm nodule in the right parietal lobe of the brain. Squash cytology was performed intraoperatively and preparations of a small tissue fragment resected from the mass showed medium-to-large-sized, well-cohesive clusters or sheets of uniform tumor cells. The tumor cells are highly cellular and contain solitary tumor cells in loose groupings as well as many fragments. They also appear somewhat bizarre and contain large, round, or ovoid nuclei with prominent nucleoli. Cytologic diagnosis of metastatic HCC was rendered reported and confirmed by a subsequent frozen section examination. To the best of our knowledge, this is the first reported case in which HCC was reported as brain metastasis, by using squash cytology. We suggest that intraoperative squash cytologic examination be viewed as a useful initial approach in the diagnosis of metastatic brain tumor.

The second best arterial graft to the left coronary system in off-pump bypass surgery: a propensity analysis of the radial artery with a proximal anastomosis to the ascending aorta versus the right internal thoracic artery.

OBJECTIVE: The second best arterial graft to the left coronary artery (LCA) system between the radial artery (RA) and the right internal thoracic artery (RITA) has been unknown. Moreover, a composite RA may be inferior to direct aorta-RA bypass grafting. The aim of the present study is to compare clinical outcomes between the RA anastomosed to the aorta and the RITA as a second arterial graft to the LCA. METHODS: A total of 805 patients received off-pump coronary arterial bypass grafting between 2000 and 2013. Of these patients, 232 received the bilateral internal thoracic arteries (BITA) and 152 received left internal thoracic arteries (LITA) + RA anastomosed to the aorta, following the inclusion criteria. Patients (1) received at least two arterial grafts in the LCA, (2) did not have renal insufficiency, and (3) did not receive composite RA grafts. A propensity score-matched analysis was performed, resulting in 118 matched pairs. RESULTS: There was no difference in operative mortality and stroke rate between the matched groups; however, the mean operation time was significantly shorter in the LITA + RA and the incidence of mediastinitis was lower in the LITA + RA (BITA: 2.5 %, LITA + RA: 0 %, p < 0.01). Kaplan-Meier cumulative mortality and freedom from cardiac events were similar. The long-term patency rates of the RITA and the RA were similar at 5 years (RITA: 78 %, RA: 84 %, p = 0.55). CONCLUSIONS: The RA anastomosed to the aorta appears to have good long-term outcomes, similar to the RITA as the second arterial graft. Furthermore, the choice of RA avoids sternal complications and shortens the operation time compared to the use of BITA.

Persorption of IgG-Fc-coated particulates from intestinal lumen into portal blood via villous columnar epithelial cells in rat small intestine.

Previously, the specific antibody-mediated persorption of antigenic molecules and particulates from the small-intestinal lumen into the peripheral blood was clarified in rats, but the intermediation of the receptor for the specific antibodies was not. In this study, the existence of receptor for the specific antibody was experimentally examined in the rat small intestine. Glutaraldehyde-fixed sheep erythrocytes (SEs) coated by Fc-fragments of IgG (IgG-Fc), (Fab')(2)-fragments of IgG (IgG-Fab) or bovine serum albumin (BSA), were injected into 3 jejunal loops each 2 cm in length in non-orally pre-immunized rats, respectively. Thirty minutes after the injection, IgG-Fc-coated SEs were significantly more engulfed by villous columnar epithelial cells than Fab- or BSA-coated SEs. The most frequent absorption sites were the intestinal villous apices. The IgG-Fc-coated SEs were adhered to the striated borders and were engulfed by villous columnar epithelial cells. IgG-Fc-coated SEs passing through the epithelial cells were also detected in the subepithelial blood capillaries just beneath the villous epithelium, but not in the connective tissue and the lymph vessels. These findings suggest that the absorption of luminal antigenic particulates is probably mediated by the Fc-receptor, and that the absorbed antigenic particulates are directly transferred to the hepatic portal blood by passing through the endothelium of the subepithelial blood capillaries.

Highly anaplastic extraventricular ependymoma arising in an adult, mimicking metastatic adenocarcinoma with heavy stromal inflammation and emperiporesis.

We report a case of extraventricular ependymoma arising in a 50-year-old woman that took an aggressive clinical course with recurrence three times. The initial tumor was a well-circumscribed nodule in the right temporal white matter measuring 2 cm in diameter. It showed variegated histological findings mimicking metastatic adenocarcinoma: an epithelioid arrangement of highly pleomorphic cells with pseudopapillary structures and perivascular pseudorosettes, and bizarre multinucleated giant cells with occasional emperiporesis surrounded by abundant mononuclear inflammatory cells, as well as a focal small area of conventional ependymoma. Emperiporesis and abundant mononuclear cell infiltration were not previously described in an ependymoma. The recurrent tumors predominantly showed an epithelioid pattern with frequent formation of astroblastoma-like pseudopapillary structures. Neoplastic cells were markedly atypical and had characteristic intracytoplasmic eosinophilic inclusion bodies. Much of the cells in both the initial and recurrent tumors showed a positive immunostaining for glial fibrillary acidic protein (GFAP) with accentuation to the cytoplasmic processes of the pseudorosettes and pseudopapillary structures. Epithelial membrane antigen (EMA) highlighted the epithelial differentiation of the tumor cells, while cytokeratin was completely negative. Although this tumor might be classified to at least WHO grade III from the histology and aggressive behavior, the exact grading is still controversial because of the rarity of such cases.