Tube or tubeless: an anesthetic strategy for upper airway surgery

Since the patient’s airway is shared between an anesthesiologist and a surgeon, airway management during upper airway surgery can be challenging. Beyond the conventional method of general anesthesia, high-flow nasal oxygenation (HFNO) has recently been used as a key technique for tubeless anesthesia. HFNO provides humidified, heated oxygen up to 70 L/min, which promises improved oxygenation and ventilation, allowing for prolonged apneic oxygenation. In previous physiological and clinical studies, HFNO has been demonstrated that tubeless anesthesia safely provide an uninterrupted surgical field during laryngeal surgeries. Although tubeless anesthesia remains uncommon, it can be a good alternative to conventional anesthesia if an anesthesiologist and a surgeon select appropriate patients together with sufficient experience. A safe strategy for tubeless anesthesia, along with appropriate backup plans, including endotracheal intubation and high-frequency jet ventilation, should be considered for upper airway surgery.

Chondrocutaneous posterior auricular artery perforator free flap for single-stage reconstruction of the nasal tip: a case report

Full-thickness nasal tip reconstruction is a challenging process that requires provision of ample skin and soft tissue, and intricate cartilage structure that maintains its architecture in the long term. In this report, we describe reconstruction of a full-thickness nasal tip and ala defect using a posterior auricular artery perforator based chondrocutaneous free flap. The flap consisted of two lay ers of skin covering conchal cartilage, and was based on a perforating branch of the posterior auricular artery. A superficial vein was secured at the posterior margin. The donor perforator was anastomosed to a perforating branch of the lateral nasal artery. The superficial vein was connected to a superficial vein of the surrounding soft tissue. The donor healed well after primary closure. The flap survived without complications, and the contour of the nasal rim was sustained at follow-up 6 months later. As opposed to combined composite reconstructions using a free cartilage graft together with a small free flap or pedicled nasolabial flap, the posterior auricular artery perforator free flap encompasses all required tissue types, and is similar in contour to the alar area. This flap is a useful option in single-stage reconstruction of nasal composite defects.

A propeller superficial transverse cervical artery perforator flap for defect coverage of the submental area: a case report

Reconstruction of submental defects is a challenge that needs to be approached carefully, since many important anatomical structures are located in this small space. Both aesthetic and functional outcomes should be considered during reconstruction. In this report, we describe a case where a superficial branch of the transverse cervical artery (STCA) perforator propeller flap was applied for coverage of the submental area. An 85-year-old woman presented with a 3-cm ovoid mass on her submental area. We covered the large submental defect with a STCA rotational flap in a 180° propeller pattern. The flap survived well without any complications at 1 year of follow-up. A STCA propeller flap is a useful surgical option in reconstruction for defect coverage of the submental area.

Cardiopulmonary Bypass Strategies to Maintain Brain Perfusion during Lung Transplantation in a Patient with Severe Hypercapnia

Herein, we report a case of lung transplantation in a patient with profound preoperative hypercapnia, focusing on the cardiopulmonary bypass strategy used for brain perfusion during the operation. We applied the pH-stat method for acid-base regulation, and thereby achieved the desired outcome without any neurologic deficit.

Cardiopulmonary Bypass Strategies to Maintain Brain Perfusion during Lung Transplantation in a Patient with Severe Hypercapnia / 대한흉부외과학회지

Herein, we report a case of lung transplantation in a patient with profound preoperative hypercapnia, focusing on the cardiopulmonary bypass strategy used for brain perfusion during the operation. We applied the pH-stat method for acid-base regulation, and thereby achieved the desired outcome without any neurologic deficit.

Intraoperative Neurophysiologic Testing of the Perigastric Vagus Nerve Branches to Evaluate Viability and Signals along Nerve Pathways during Gastrectomy

PURPOSE: The perigastric vagus nerve may play an important role in preserving function after gastrectomy, and intraoperative neurophysiologic tests might represent a feasible method of evaluating the vagus nerve. The purpose of this study is to assess the feasibility of neurophysiologic evaluations of the function and viability of perigastric vagus nerve branches during gastrectomy. MATERIALS AND METHODS: Thirteen patients (1 open total gastrectomy, 1 laparoscopic total gastrectomy, and 11 laparoscopic distal gastrectomy) were prospectively enrolled. The hepatic and celiac branches of the vagus nerve were exposed, and grabbing type stimulation electrodes were applied as follows: 10–30 mA intensity, 4 trains, 1,000 µs/train, and 5× frequency. Visible myocontractile movement and electrical signals were monitored via needle probes before and after gastrectomy. Gastrointestinal symptoms were evaluated preoperatively and postoperatively at 3 weeks and 3 months, respectively. RESULTS: Responses were observed after stimulating the celiac branch in 10, 9, 10, and 6 patients in the antrum, pylorus, duodenum, and proximal jejunum, respectively. Ten patients responded to hepatic branch stimulation at the duodenum. After vagus-preserving distal gastrectomy, 2 patients lost responses to the celiac branch at the duodenum and jejunum (1 each), and 1 patient lost response to the hepatic branch at the duodenum. Significant procedure-related complications and meaningful postoperative diarrhea were not observed. CONCLUSIONS: Intraoperative neurophysiologic testing seems to be a feasible methodology for monitoring the perigastric vagus nerves. Innervation of the duodenum via the celiac branch and postoperative preservation of the function of the vagus nerves were confirmed in most patients. TRIAL REGISTRATION: Clinical Research Information Service Identifier: KCT0000823

Severe hypoxemia during carinal resection in the lateral position under one-lung ventilation of a non-dependent lung: a case report / 대한마취과학회지

During one-lung ventilation (OLV) in the lateral position, the dependent, ventilated lung receives more blood flow than the non-dependent, non-ventilated lung owing to gravity, improving the match of ventilation and perfusion. Conversely, in the rare clinical situations when OLV is applied to the non-dependent lung, arterial oxygenation can get worse due to considerable shunt flow to the dependent non-ventilated lung. We report a case of severe hypoxemia during carinal resection under OLV of a non-dependent lung. In this case, OLV had to be applied to the non-dependent lung in the lateral position because the bronchus of the non-dependent lung was anastomosed with the trachea, whereas the bronchus of the dependent lung had already been resected for carinal resection. The subsequent hypoxemia resulting from the shunt flow to the dependent non-ventilated lung was treated successfully by ligating the pulmonary artery of the dependent lung.

Endovascular Treatment of 429 Anterior Communicating Artery Aneurysms Using Bare-Platinum Coils : Clinical and Radiologic Outcomes at the Long-term Follow-up

OBJECTIVE: We reviewed the feasibility, safety and efficacy as well as the clinical outcome and long-term angiographic results of endovascular treatment (EVT) of the anterior communicating artery (ACoA) aneurysms. METHODS: A total of 429 ACoA aneurysms in 426 patients were treated using coil embolization between March 1996 and October 2010 in a single institution. Pretreatment aneurysmal features were checked using angiogram. We had usually used tailored steam shaped microcatheter according to individual angiographic architectures. Immediate postembolization outcomes were evaluated using an angiographic outcome scale and clinical evaluation was performed using the Glasgow Outcome Scale (GOS). RESULTS: Postembolization angiograms demonstrated total occlusion of aneurysm in 290 of 429 (67.6%) aneurysms, neck remnant in 80 (18.6%) and body filling in 59 (13.8%). Dome direction and aneurysm angle was not associated with initial angiographic outcomes. The procedure-related morbidity rate was 0.9% (4 of 429). Clinical and imaging follow-up more than 6 months were available in 382 (89.0%) patients with a mean of 26.2 months. Overall rate of major recanalization was 7.9% (30 of 382) and all of them were retreated without complications. At the last follow-up, 233 (99.2%) of 235 patients had GOS of 5 in unruptured group, and 152 (79.5%) of 191 patients showed good clinical outcomes (GOS of 4 or 5) in ruptured group. CONCLUSION: Tailored steam shaping of the microcatheter is vital to achieve good angiographic outcomes regardless of aneurysmal direction. EVT is feasible and safe for most ACoA aneurysms with acceptable immediate and long-term outcomes.

Transection of a Coopdech bronchial blocker tip during bronchial resection for right upper lobectomy: a case report / 대한마취과학회지

A bronchial blocker (BB) is preferred for lung separation in patients with difficult airways. However, BBs, unlike double-lumen tubes, must be placed in the bronchus of the lung being operated on, hence can be damaged by surgical manipulation. Intubation was unexpectedly difficult in this male patient, so a Coopdech BB was placed in the right mainstem bronchus through a single-lumen tracheoscopic ventilation tube for a thoracoscopic right upper lobectomy. During the bronchial resection, however, the distal tip of the BB was transected and pinched in the staple line, so the staple line was partially opened, and the BB was withdrawn into the trachea. The opened bronchial stump was sutured manually under apnea without conversion to an open thoracotomy, and there was no significant air leakage through the suture line. This case underlines the importance of frequently evaluating the position of a BB during lung surgery.

Preoperative Embolization of Cerebellar Hemangioblastoma with Onyx: Report of Three Cases / 신경중재치료의학

Hemangioblastoma is a benign and highly vascular tumor. Complete surgical resection of highly vascular tumor such as hemangioblastoma may be challenging due to excessive bleeding. Preoperative embolization of these lesions may decrease the intraoperative blood loss and facilitate excision. We report three cases of cerebellar hemangioblastomas that were embolized using Onyx.

A Self-expanding Nitinol Stent (Enterprise) for the Treatment of Wide-necked Intracranial Aneurysms: Angiographic and Clinical Results in 40 Aneurysms

OBJECTIVE: Self-expanding stents are increasingly used for the treatment of complex intracranial aneurysms. The purpose of this study was to evaluate the usefulness and safety of a self-expanding nitinol stent (Enterprise) in the treatment of wide-necked intracranial aneurysms. METHODS: This was a retrospective study of 39 patients with 40 wide-necked intracranial aneurysms who were enrolled in a single-center registry of patients treated with the Enterprise between June 2009 and December 2011. Thirty patients were asymptomatic, four had cerebrovascular accident sequelae, and five had suffered subarachnoid hemorrhage. One aneurysm had reopened after prior coil embolization, while 39 had not been treated. Clinical charts, procedural data, and angiographic results, including both immediate post-procedural angiograms and follow-up imaging, were reviewed. RESULTS: The mean neck size of the aneurysms was 5.58 mm (range 3-15.1 mm). Embolization was successful in all patients. There were five procedure-related events. There were no fatalities, but one procedure-related morbidity was noted. The immediate angiographic results included eight complete occlusions (20%), six remnant necks (15%), and 26 remnant sacs (65%). At angiographic follow-up (mean: 11.3 months), out of 18 of the aneurysms treated with stent-assisted coiling, there were 13 (72.2%) complete occlusions, four (22.2%) remnant necks, and one recanalization (5.6%). CONCLUSION: Stent-assisted coiling using the Enterprise is effective for the treatment of wide-necked intracranial aneurysms. Further angiographic and clinical follow-up investigation will be needed for evaluation of the long-term outcomes.

Risus Sardonicus in Multiple System Atrophy

No abstract available.

Unsuspected intravascular migration of a thoracic epidural catheter in a thoracotomy patient: A case report

Thoracic epidural analgesia is the most effective method of managing post-thoracotomy pain. However, the catheter may be misplaced into the intrapleural, intercostal, subarachnoid, or intravascular space. Intravascular misplacement of a catheter can be detected by aspiration of blood or administration of a test dose of local anesthetic; however, these methods may result in a false-negative response. Moreover, a catheter placed in the epidural space may migrate into a blood vessel during the intraoperative period. Thus, the location of the catheter tip should always be determined before local anesthetic is administered. We report a case of intraoperative intravascular migration of a thoracic epidural catheter in a 32-year-old male who underwent left thoracotomy.

Preoperative Aspirin Resistance does not Increase Myocardial Injury during Off-pump Coronary Artery Bypass Surgery

We performed a prospective cohort trial on 220 patients undergoing elective off-pump coronary artery bypass surgery and taking aspirin to evaluate the effect of aspirin resistance on myocardial injury. The patients were divided into aspirin responders and aspirin non-responders by the value of the aspirin reaction units obtained preoperatively using the VerifyNow(TM) Aspirin Assay. The serum levels of troponin I were measured before surgery and 1, 6, 24, 48 and 72 hr after surgery. In-hospital major adverse cardiac and cerebrovascular events, graft occlusion, the postoperative blood loss and reexploration for bleeding were recorded. Of the 220 patients, 181 aspirin responders (82.3%) and 39 aspirin non-responders (17.7%) were defined. There were no significant differences in troponin I levels (ng/mL) between aspirin responders and aspirin non-responders: preoperative (0.04 +/- 0.08 vs 0.03 +/- 0.06; P = 0.56), postoperative 1 hr (0.72 +/- 0.87 vs 0.86 +/- 1.10; P = 0.54), 6 hr (2.92 +/- 8.76 vs 1.50 +/- 2.40; P = 0.94), 24 hr (4.16 +/- 13.44 vs 1.25 +/- 1.95; P = 0.52), 48 hr (2.15 +/- 7.06 vs 0.65 +/- 0.95; P = 0.64) and 72 hr (1.20 +/- 4.63 vs 0.38 +/- 0.56; P = 0.47). Moreover, no significant differences were observed with regard to in-hospital outcomes. In conclusion, preoperative aspirin resistance does not increase myocardial injury in patients undergoing off-pump coronary artery bypass surgery. Postoperative dual antiplatelet therapy might have protected aspirin resistant patients.

Comparison of the Effects of Postoperative Continuous Plus Bolus Patient-Controlled Analgesia and of Bolus Patient-Controlled Analgesia in Children / 대한마취과학회지

BACKGROUND: Patient-controlled analgesia has been used with increasing frequency to provide postoperative pain relief for children. We compared the effects of continuous plus bolus patient-controlled fentanyl analgesia with those of bolus patient-controlled fentanyl analgesia. METHODS: One hundred and thirty four children (aged 3-8 yr) undergoing orthopedic surgeries received one of two analgesic regimens of fentanyl based patient-controlled analgesia (PCA); bolus infusion of 0.4microgram/kg with a 15 minute lock-out interval (group B) or continuous (0.2microgram/kg/hr) and bolus infusion (0.2microgram/kg) with a 15 minute lock-out interval (group C). We compared the two groups in terms of degree of analgesia, sedation and nausea. RESULTS: Analgesic effects were better in group B at 1 and 2 hours after surgery. The incidence of sedation in group C was greater than in group B at 1 and 2 hours after surgery, and the groups were similar in terms of the incidences of nausea. CONCLUSIONS: We concluded that bolus infusion of fentanyl in children did not increase the incidence of side effects and that it was associated with a better analgesic effect than continuous and bolus fentanyl infusion.

Anatomical Basis for Supraclavicular Central Venous Catheterization Assessed by Three-Dimensional Computed Tomography / 대한마취과학회지

BACKGROUND: The current study aimed at elucidating the anatomical basis for a supraclavicular approach for central venous catheterization using three-dimensional computed tomography (3D-CT). METHODS: Retrospective review of CT images from 60 adult patients with normal body build was performed using 3D-CT reconstruction. Right-sided approach was assumed, and the skin entry point was decided as a point above the subclavian vein at the supraclavicular fossa. Measured parameters were; angles of the clavicle (Aclv) and the subclavian vein (Ascv) to the coronal plane, the distance from the clavisternomastoid angle to the skin entry point (Dse), the optimal angle of needle insertion (Ains) targeting the confluence between the internal jugular vein and the subclavian vein, the distance from the skin entry point to the confluence (Dconf), and the diameter of the confluence (Dia). Descriptive statistics were performed for the measured values. Correlation test was performed between Ascv and Aclv. RESULTS: Measured values were; Aclv = 8.0 degrees, Ascv = 5.7 degrees, Dse = 12.5 mm, Ains = 40 degrees, Dconf = 20.5 mm, and Dia = 18.1 mm. Ascv demonstrated positive correlation with corresponding Aclv (r = 0.494, P < 0.001). CONCLUSIONS: Optimal guideline for the supraclavicular approach can be provided via 3D-CT investigation. Forty degrees of needle direction to the sagittal plane and parallel to the posterior surface of the clavicle, at 1.3 cm posterior to the clavisternomastoid angle insures proper puncture of the confluence without anticipated complications.

Whole Lung Lavage and Extracorporeal Membrane Oxygenation in a Patient with Pulmonary Alveolar Proteinosis and Lung Cancer / 대한마취과학회지

Pulmonary alveolar proteinosis is characterized by accumulation of surfactant phospholipids and proteins within alveoli of the lungs. Sequential whole lung lavage is an accepted modality for treatment of pulmonary alveolar proteinosis. Generally, the degree of hypoxemia is tolerable while only one lung is being ventilated and the other is being lavaged. However, one patient became severely hypoxemic when one lung ventilation was performed through the left lung because of R-to-L shunt due to the lung cancer in the left lower lobe. Therefore, whole lung lavage on the right lung was successfully performed, while utilizing venovenous extracorporeal membrane oxygenation.

Reflex Epilepsy Provoked by Mental Activities Mainly Associated with Use of the Hands / 대한간질학회지

There have been very few reports on reflex seizures induced by writing. Complex precipitating behaviors such as calculation, writing, copying of complicated figure, and spatial construction have been recognized as triggering factor of epileptic seizures. We report a case of a patient with a very unusual form of complex reflex epilepsy in which seizures are usually induced by writing or spatial construction. Neurological examination was normal and brain magnetic resonance imaging showed mild brain atrophy without focal lesion. During long-term video-EEG monitoring, she was instructed to write a letter with the right hand. About 20 minutes after writing, she experienced similar aura and motion arrest and then showed an elevation of bilateral upper extremities like myoclonic jerk followed by generalized tonic clonic seizure. On ictal EEG, spike and wave complexes appeared from both centroparietal region followed by 10 Hz rhythmic activities for 20 seconds. Interictal EEG was normal. Ictal-interictal subtraction image of brain SPECT (99mTc-HMPAO) showed hyperperfusion in the middle frontal gyrus and precentral gyrus of left frontal lobe and superior and inferior frontal gyrus of right frontal lobe. We suggest that this reflex epilepsy might be originated from both central areas with maximum on the left side. Oxcarbazepine was effective in controlling this reflex epileptic seizure.