Effectiveness of ultrasound-guided transversus abdominis plane block and rectus sheath block in pain control and recovery after gynecological transumbilical single-incision laparoscopic surgery.

PURPOSE: To evaluate the effectiveness of ultrasound-guided transversus abdominis plane (TAP) and rectus sheath (RS) blocks in pain management and recovery after gynecological single-incision laparoscopic surgery (SILS). MATERIALS AND METHODS: Abilateral TAP block (Group A, n = 9), bilateral TAP and RS blocks (Group B, n = 10), and a bilateral RS block (Group C, n = 9) with 40 ml ropivacaine per patient were conducted in 28 patients undergoing SILS for ovarian tumors. A pain score and walking distance in a 6-minute walk test (6MWT) were examined. RESULTS: Pain scores were significantly lower on postoperative day (POD) 3 than on POD 1 in Groups B (p = 0.03) and C (p = 0.02). The walking distance on POD 3 was comparable with that before surgery in Group C (p = 0.75), but shorter in Groups A (p = 0.004) and B (p = 0.02). CONCLUSIONS: The RS block alone was the most effective in relieving pain and accelerating general recovery after gynecological SILS.

[Huge left atrial myxoma masking the severity of mitral regurgitation; report of a case].

It is well known that mobile or large left atrial myxoma may lead to valve obstruction and insufficiency, and affect transmitral valve flow. A 50-year-old woman with a huge left atrial myxoma occluding the mitral valve was reported. The tumor was diagnosed by preoperative echocardiogram and mitral regurgitation was minimum. During the operation and after the myxoma resection, a severe mitral regurgitation, which was not observed during the preoperative echocardiogram, was noticed. Mitral valve defect was corrected by an annuloplasty ring, and the patient had an uneventful recovery. Our case suggests that careful evaluation of mitral valve during a myxoma resection operation is recommended.

In vitro percutaneous absorption of thiamine disulfide from a mixture of propylene glycol and fatty acid.

The in vitro percutaneous transport of thiamine disulfide (TDS), an oxidized dimer of thiamine, from propylene glycol through excised abdominal rat skin was studied. The application of saturated, long-chain fatty acids [stearic acid (18:0), myristic acid (14:0), and lauric acid (12:0)] as enhancers to the system was also studied. TDS permeated through rat skin from propylene glycol with a flux of 2.5 +/- 0.8 micrograms/cm2/min. The flux was enhanced 31 times by 12:0 and 1.4 times by 14:0 and was suppressed to 80% of its original value by 18:0. The absorption of TDS could not be explained by TDS permeating across a dialysis membrane, but the interaction between TDS and fatty acids may influence the system. The results show the possibility of developing a transdermal thiamine delivery system.

Protochlorophyllide and chlorophyll forms in dark-grown stems and stem-related organs.

Protochlorophyllide contents and the spectral properties together with photoactivities of native protochlorophyllide forms have been studied in dark-forced stems of 26 and epicotyls or hypocotyls of 9 plant species. The 77 K fluorescence emission spectra show that a form emitting at 629-631 nm is general in these organs. Besides this short-wavelength form, other protochlorophyllide forms emitting at 636, 645 and around 650-655 nm are found with various relative amplitudes. The pigment contents show good correlation with the ratio of short- to long-wavelength forms, i.e., the higher this ratio is, the less protochlorophyllide is detected. In addition to protochlorophyllide, several dark-grown plants also contain chlorophylls. In some cases only one chlorophyll form appears with emission maximum at 678-680 nm; other plants have forms characteristic of the fully developed photosynthetic apparatus (with maxima at 685, 695 and 730-740 nm). Flash illumination can transform only the 645 and 650-655 nm protochlorophyllide forms, the shorter-wavelength-emitting forms being inactive. Plant species with dominating 629-636 nm protochlorophyllide forms cannot accumulate chlorophyll on continuous illumination of natural intensity, and they became photodamaged. The structural or molecular background of the appearance of the different protochlorophyllide and chlorophyll forms and the reasons for their photosensitivity are discussed.

[Rupture of type III acute aortic dissection into the bilateral pleural space: report of a case].

Rupture of type III aortic dissection into the bilateral pleural space is very rare. A 62-year-old man was transferred to our department because of aortic dissection for emergency operation. computed tomography (CT) scan revealed rupture of type III aortic dissection into the bilateral pleural space. He underwent successful prosthetic graft replacement through left thoracotomy and removal of a massive amount of blood from the right pleural space by chest tube drainage. The postoperative course was uneventful after 2 days of respiratory support.

[Clinical study of warm heart surgery in emergent coronary artery bypass grafting].

Twenty-six nonrandomized patients undergoing emergent coronary artery bypass operation were assigned to either the cold group (traditional intermittent cold blood cardioplegia and slight hypothermic cardiopulmonary bypass (n = 7) or the warm group (intermittent warm blood cardioplegia and normothermic cardiopulmonary bypass) (n = 19). Preoperative variables were similar in both groups except the number of renal dysfunction patients were greater in the cold group. The time from removal of the aortic crossclamp to discontinuation of cardiopulmonary bypass was significantly shorter in the warm group and the incidence of heartbeat spontaniously converted to normal sinus rhythm after removal of the aortic crossclamp was higher in the warm group. The warm group showed good results concerning postoperative blood loss volume, change of base excess, time required for awakening and extubation. Significant differences were found in the hospital mortality rates between the groups (cold: 57.1%, warm: 5.3%). This study suggested a beneficial influence of warm heart surgery on postoperative hemodynamics, metabolic recovery and hospital mortality in emergent coronary artery bypass grafting.

[Concomitant lobectomy by video-assisted thoracic surgery and coronary artery bypass grafting: report of a case].

Successful simultaneous operation for cardiac and lung disease was performed in a 71-year-old man with lung carcinoma and ischemic heart disease. Chest CT scan revealed a mass in the right lower lobe and absence of mediastinal lymphadenopathy. Coronary angiography revealed significant stenosis of the left anterior descending artery, circumflex artery and right coronary artery. We performed concomitant video-assisted right lower lobectomy with mediastinal lymph node dissection as a form of less invasive surgery and triple coronary artery bypass grafting under cardiopulmonary bypass. Curative surgery for lung carcinoma and complete revascularization for ischemic heart disease were completed. The postoperative course was uneventful.

[A case report of total aortic arch replacement for distal aortic arch aneurysm in an octogenarian].

A 81-year-old man was admitted to our hospital because of hoarseness. Chest CT scan and aortogram showed distal arch aneurysm measuring 7.5 cm in diameter. Under deep hypothermia and selective cerebral perfusion, the distal aortic arch aneurysm was completely replaced with a woven Dacron graft with three limbs for the arch vessels. After the aortic cross clamp was released, severe low output syndrome (LOS) continued because of perioperative myocardial infarction. Then, a coronary artery bypass grafting (CABG) to the left anterior descending artery (LAD) was performed, after which the cardiopulmonary bypass was easily weaned under intra-aortic balloon counterpulsation (IABP) assistance. The postoperative course was uneventful. The perioperative myocardial infarction was thought to be induced by left coronary spasm, as comparison of the preoperative and postoperative coronary arteriograms showed no change.

[Video-assisted minithoracotomy versus conventional posterolateral thoracotomy for performing lobectomy of lung carcinomas].

This study was performed to evaluate the advantages of video-assisted minithoracotomy over conventional posterolateral thoracotomy for performing lobectomy of lung carcinomas. Thirty-two patients with clinical T1N0M0 non-small cell lung carcinoma underwent lobectomy with R2a mediastinal lymphadenectomy. Of these, sixteen patients underwent posterolateral thoracotomy (between April 1994 and November 1995: T group), and sixteen patients underwent video-assisted thoracic surgery (between December 1997 and April 1999: V group). No significant differences were found in the two groups with respect to the total number of mediastinal lymph nodes dissected (T group: 16.9 +/- 8.7. V group: 14.3 +/- 7.2) or operative time (T group: 182.3 +/- 48.8 min, V group: 174.9 +/- 28.8 min). The intraoperative blood loss was significantly less in the V group (T group: 222.3 +/- 107.1 ml, V group: 143.3 +/- 92.6 ml, p < 0.05), and the postoperative max CPK was also less (T group: 1,484 +/- 496, V group: 785 +/- 327, p < 0.0001). Duration of chest tube drainage (T group: 11.3 +/- 3.6 days, V group: 7.9 +/- 2.7 days) and the requirement of epidural analgesia (T group: 6.7 +/- 2.2 days, V group: 5.0 +/- 0.8 days) were less in the V group (p < 0.01), and the length of postoperative hospitalization as also shorter in the V group (T group: 26.3 +/- 8.3 days, V group: 20.6 +/- 4.1 days, p < 0.05). In conclusion, video-assisted minithoracotomy is less invasive than posterolateral thoracotomy for performing lobectomy of lung carcinomas, and has an advantage in that it improves the postoperative quality of life.

[A case of pure unroofed coronary sinus syndrome with persistent left superior vena cava].

A 36-year-old women with pure unroofed coronary sinus syndrome was reported. The anomalies of the cardiovascular system were absence of the coronary sinus, coronary sinus ASD and persistent left superior vena cava (PLSVC) draining into the left atrium. In this case, the PLSVC was ligated in the pericardium and the atrial septal defect was closed with a Dacron patch. There was no cerebral complication due to the increased intracranial pressure after ligation of the PLSVC. Postoperative coronary arteriography revealed absence of the coronary sinus in the venous phase.

[Total aortic arch graft replacement using a prosthetic graft with three branches for acute type A aortic dissection].

Between March 1991 and August 1991, six consecutive patients underwent the replacement of the both ascending aorta and total aortic arch using a prosthetic graft with three branches for acute type A aortic dissection involving the aortic arch. Preoperative complications included cardiac tamponade in 5 cases, aortic regurgitation in 2, and shock state in 3. All operations were performed with the aid of extracorporeal circulation, selective cerebral perfusion, and open aortic anastomosis within 3 days after the onset. One patient died of rupture of the aortic anastomosis secondary to mediastinitis two weeks after the operation. All patients gained their own consciousness after the operation without any serious cerebral complications. The present data suggest that acute type A aortic dissection involving the aortic arch could be treated by replacing both the ascending aorta and aortic arch using a prosthetic graft with three branches with an aid of the extracorporeal circulation, selective cerebral perfusion and open distal anastomosis.

[A case of bronchial mucoepidermoid carcinoma in a 7-year-old girl].

Mucoepidermoid carcinoma of the lung presenting in childhood is extremely uncommon. A 7-year-old girl was referred to our hospital with complaint of persistent cough and abnormal shadow on the chest roentgenogram. Bronchoscopic biopsy revealed a bronchial mucoepidermoid carcinoma and a left pneumonectomy was performed. The histopathological examination revealed intermediate grade malignancy without any metastasis in mediastinal lymph nodes. She is now doing well without any evidence of recurrence 2 years after the operation.

[Experience with re-cardiopulmonary bypass graft].

We report 14 consecutive patients who have undergone ReCABG during the last 7 years (1984-1990). There were 11 males and 3 females with a mean age of 56.8 years. All bypass conduits used were saphenous vein grafts. Angiographic indications for ReCABG included primary bypass graft failure, progressive coronary arteriosclerosis, and both of them. Successful ReCABG is mainly dependent on careful attention to special surgical technical considerations such as heart exposure especially in the existence of functioning bypass graft, cardiopulmonary bypass technique and myocardial protection and choice of available bypass conduits. We used arterial grafts in 6 cases (ITA in 4 and GEA in 2 cases). There was only one hospital mortality in our series. Symptomatic relief of angina pectoris was obtained in all surviving patients.

[A report of successful surgical management of right coronary artery to right atrium fistula forming giant aneurysms at the posterior wall of the right atrium].

A 52-year-old woman was diagnosed by echocardiography to have a fistula of the right coronary artery (RCA) and the right atrium (RA). Aortography demonstrated a remarkably dilated and undulating fistulous tract originating from the region corresponding to the orifice of the normal RCA. The fistulous tract detoured to the posterior wall of the RA, and forming 2 aneurysms there, opened to the RA. A RCA of normal size originating midway of the fistulous tract was also observed. The patient was operated on under cardio-pulmonary bypass. Aortocoronary saphenous vein graft to the RCA having normal diameter was performed, and the RCA was ligated in the proximal side of the anastomosis. The orifice of the fistulous tract from the aorta was closed with a patch and the entrances into the RA were also closed by pledgetted mattress sutures. The post operative course was uneventful and the patient is now doing well without any complaints.

[Mitral valvuloplasty for the repair of mitral valve prolapse due to tendon rupture of the posterior leaflet in a father and son--case reports].

The use of mitral valvuloplasty for the repair of mitral valve prolapse in members of a family has been reported only rarely. Patient 1 was a 71-year-old man, and patient 2 the son of patient 1 was a 47-year-old man. Both patients had a grade 3/4 mitral valve regurgitation due to tendon rupture of the posterior leaflet. The procedure was quadrangular resection of the posterior leaflet with annulorrhaphy and ring annuloplasty. The results were good in both cases. Histopathological analysis of a specimen resected from the mitral valve revealed myxomatous degeneration in both cases. These case reports suggest that there is a genetic basis for mitral valve prolapse.