[Hypercapnea during thoracoscopic surgery under regional anesthesia].

A 23-year-old woman was supposed to undergo thoracoscopic surgery for the 10th pneumothorax that accompanied histiocytosis X. The past history included Lylle's disease, asthma, myocarditis, drug-induced leucocytopenia and bronchitis obliterans. The preoperative arterial blood gas analysis under receiving O2 at rate of 2 l.min-1 via a nasal cannula revealed normal values. General anesthesia and intubation with a double-lumen endotracheal tube would have been preferable, but regional anesthesia was chosen because of her medical history and positive results of the skin tests for vecuronium, pancronium, diazepam and midazolam. During the first 10 min of thoracoscopic procedure, her respiration became rapid and shallow and she was restless and comatose. The operation was cancelled. Arterial blood gas analysis under receiving O2 at rate of 4 l.min-1 via a face mask revealed: pH 7.025, PaO2 113.8 mmHg, PaO2 244.8 mmHg, HCO3- 29.7 mEq.l-1, BE-5.6, and O2 saturation 99.1%. Manual artificial ventilation with a mask and bag was initiated. Her spontaneous respiration and consciousness recovered in next 30 min. The postoperative course was uneventful. Tachypnea, caused from anxiety, dyspnea and stimulation of irritant receptors in the airway, were considered to be responsible for the event. The duration of inspiration became shorter as tachypnea developed, that made the tidal volume to decrease and hypercapnea ensued.

[Anesthetic management of a Paget's disease patient complicated with Parkinson disease].

Paget's disease is a metabolic disorder of unknown etiology characterized by excessively rapid remolding of bone. We report a case of Paget's disease complicated with Parkinson syndrome. A 69-year-old female patient was scheduled for ventriculo-peritoneostomy due to hydrocephalus. Her manifestations included disability to walk, slight deafness and muscular rigidity of limbs, without symptom of intracranial hypertension. After induction of anesthesia with thiopental and vecuronium, tracheal intubation with Macintosh laryngoscope was attempted but failed because mouth opening was restricted to only 3 cm. Again with Bullard laryngoscope, she was successfully intubated. During neurosurgical operation, the anesthesia was maintained with low concentration of isoflurane (under 0.3%), nitrous oxide and oxygen. The surgery was completed without adverse events such as disorder of autonomic nervous system. However 6-days after operation, ventilatory arrest occurred due to bronchial obstruction with sputum. Immediately, re-intubation was performed without any sequela and tracheostomy was also performed. In conclusion, as reported previously, intubation and postoperative pulmonary dysfunction should be carefully taken care of, and Bullard laryngoscope was useful for this patient.

[Surgical treatment of renal cell carcinoma with tumor thrombus in inferior vena cava].

Removal of renal cell carcinoma (RCC) extended into the inferior vena cava (IVC) can be a difficult operation. Between 1941 and 1989, 110 RCC patients were treated with radical operation and examined for tumor thrombus histopathologically. Twenty nine (26.3%) patients had invasion into the returning vein of tumor (Stage Vla), 12 (10.9%) in renal vein (stage Vlb) and the remaining 4 (3.6%) into IVC (stage V2). In one patient who had surgery under extracorporeal circulation, a thrombus was extended into the right atrium. In the remaining three patients, the RCC was confined to a small portion of the IVC and operated by caval sleeve resection. Radical operation in such patients free of any distant metastasis, may raise the survival rate.

[Evaluation of combined resection of aortic wall in lung cancer invaded aorta].

Left pneumonectomy with combined resection of aortic wall was performed for three patients with lung cancer invaded aorta. In clinical and pathological examination, the following results were obtained. 1: In all three cases, metastasized subaortic lymphnodes invaded to medial wall of the descending aorta. 2: Microscopically, invasion of aortic wall was limited to the adventitia adjacent to the muscle layer. We think that the resection of whole layer of the aortic wall was preferable. 3: The resections of aortic wall were performed under partial clamp of aorta in one case, and under total clamp with the use of cardiopulmonary bypass in two cases. If the area of invasion is wide, total clamp was recommended. 4: Two patients died of recurrent disease 56 months and 20 months after surgery. In the other one, postoperative empyema was occurred. He died of bleeding from the suture line of Dacron patch to the aortic wall three months postoperatively. Covering of the bronchial stump and the patch of the aorta should be considered to prevent postoperative empyema.

Extracorporeal circulation influence on plasma atrial natriuretic peptide concentration in cardiac surgery patients.

An attempt was made to clarify the change of plasma human atrial natriuretic peptide (hANP) concentration before, during, and after cardiac surgery in heart failure with extracorporeal circulation. Plasma hANP concentration did not significantly decrease during total aortic cross clamping (ACC) with complete clamping of the superior and inferior vena cavae. This finding may be explained by the suppression of endopeptidase activities and the response of hANP receptors due to the low body temperature. Plasma hANP concentration strongly increased from 56.6 +/- 8.4 to 208.9 +/- 40.7 pg/ml (n = 5) by the release of total ACC. This strong increase of hANP in the plasma may occur due to the rapid increase of atrial pressure from zero to 12.5 mm Hg caused by releasing the total ACC. The molecular form of plasma hANP obtained after the release of total ACC was alpha-hANP alone, which was estimated by gel permeation chromatography and reverse HPLC.

Implication of Ia-positive bone marrow interstitial stem cells in the induction of unresponsiveness to canine renal allografts.

The removal from stored autologous host bone marrow of a monocytoid cell population by exposure to methylprednisolone is associated with successful introduction of unresponsiveness to renal allografts in irradiated recipients reconstituted with such treated marrow. The eliminated cells are a prominent component of the canine long bone marrow interstitium and share a number of important properties with dendritic cells (DC), including size and shape; poor or nonadherence to plastic or glass surfaces; negative staining for neutral esterase, acid phosphatase, or peroxidase; nonphagocytic; Ia positive, but negative for IgG or IgM; ability to act as accessory cells in augmenting the intensity of allogeneic mixed-lymphocyte reactions. Both cell types are of bone marrow origin and are susceptible to steroids in vitro. The results suggest that the bone marrow interstitial cells identified in the course of this study may be enriched with populations of canine dendritic cell precursors and dendritic cells at various stages of differentiation. The detection of a receptor site for Helix promatia on the surface of such cells may be of usefulness in their further characterization and in the analysis of their precise role in the modulation of allogeneic unresponsiveness.

Postoperative left ventricular function in patients with mitral stenosis. The effect of commissurotomy and valve replacement on left ventricular systolic function.

Preoperative and postoperative left ventricular cineangiograms of 26 patients with mitral stenosis (MS) were analyzed to calculate left ventricular end-diastolic volume (EDV), end-systolic volume (ESV), stroke volume (SV), ejection fraction (EF) and systolic regional wall motion. Nine patients underwent commissurotomy (OMC group) and 17 patients underwent mitral valve replacement (MVR group). In both groups, postoperative EDV, SV and EF tended to increase, while ESV remained unchanged. In the OMC group, systolic wall motion of the left ventricle was found to be improved postoperatively, whereas systolic wall motion in the MVR group was found to be impaired postoperatively. The latter finding was assumed to be due to excision of the papillary muscles and chordae tendineae. Preservation of these structures is likely to be important for better postoperative functional recovery of the left ventricle.

Enhanced resistance to the effects of hypothermic ischemia in the preserved canine kidney.

Addition of trifluoperazine (TFP), a powerful calmodulin inhibitor to Collins' flush solution has exerted a significant protective effect on the cold-preserved kidney, with successful autotransplantation of 80% of preserved kidneys (4 of 5) after 72 hr of storage. In contrast, use of Collins' solution alone resulted in successful autotransplantation of only 33% (2 of 6) of kidneys after a similar period of preservation. In an attempt to analyze the significance of this result, the microcirculation of preserved kidneys was studied with injections of technetium-labeled microspheres into the kidneys, followed by study with a noninvasive radionuclide scintiphotography (RNS) technique that does not interfere with subsequent transplantation of the kidney. Such studies demonstrate that prolonged cold preservation after flush-cooling with Collins' solution is associated with a progressive deterioration of the integrity of the microcirculation, resulting in poor flow to the renal cortex. In contrast, when TFP is added to the Collins' solution, there are uniform increases in renal cortical flow in kidneys stored for 48 and 72 hr, with preservation of the integrity of the renal microcirculation. Biological testing shows a clear-cut correlation between these observations and the capacity of the tested kidneys to sustain life after retransplantation. Further experiments suggest that the decreases observed in cortical flow in kidneys preserved in the cold for 72 hr are a consequence of cellular swelling, and not of a vasospastic response. The data support the conclusion that TFP exerts its protective effect on the basis of its membrane stabilizing capacity as a calmodulin inhibitor, and not through direct vasodilatation.

Scintigraphic evaluation of the viability of cold-preserved kidneys before transplantation.

Renal microcirculation studies utilizing microspheres can provide a highly reliable index of the viability of preserved kidneys. We describe a noninvasive method that permits subsequent transplantation of each tested kidney. Fresh canine kidneys were removed and perfused with either Collins' solution or Collins' solution with 5 mg/l of trifluoperazine (TFP), and preserved at 4 degrees to 6 degrees C in their respective perfusates for 5, 24, 48, or 72 hr. At the end of each period, the preserved kidney was perfused with 50,000 Tc-99m-labeled microspheres. Uniform cortical activity occurred in all kidneys preserved for 5 hr, with moderate decreases in cortical activity at 24 hr. Kidneys perfused with Collins' solution showed progressively decreasing cortical flow with sparse cortical activity after 72 hr. In kidneys perfused with Collins' solution containing TFP, however, cortical flow remained relatively well preserved at 48 and 72 hr. Direct correlation between viability of the cortical microcirculation and the capacity of the corresponding kidney to sustain life upon retransplantation into the original host was observed.