[Partial penectomy for penile cancer in a centenarian man].

A 100-year-old man visited our hospital with a complaint of penile tumor formation with bleeding and pain. The tumor was 5cm in long diameter with an irregular surface, and extended from the glans via the coronal sulcus to the dorsal surface of the preputium. The clinical diagnosis was stage I penile cancer, and partial penectomy was performed. The pathological diagnosis was well-differentiated squamous cell carcinoma (pT1bcN0M0). To our knowledge, including foreign references, this is the oldest penile cancer patient in the literature. On discussing the operative course in very elderly patients, appropriate preoperative examination for circulatory and respiratory risks and evaluation of cognitive ability are considered essential. Although it is not difficult to conclude that only this operative procedure reveals enough radicality, we believe that it was the appropriate selection for relief of the patient's pain with full consideration of the invasiveness and risks.

Preoperative depression is a risk factor for postoperative short-term and long-term cognitive dysfunction in patients with diabetes mellitus.

PURPOSE: To identify whether the presence of preoperative depression in patients with diabetes mellitus is a risk factor for postoperative cognitive dysfunction after coronary artery bypass graft (CABG) surgery. METHODS: Data from 90 patients with diabetes mellitus undergoing elective CABG were analyzed. Hemodynamic data (arterial and jugular venous blood gas values) were measured during cardiopulmonary bypass. Preoperatively, all patients were given the 21-item Beck depression inventory to identify the presence of depression. In addition, all patients underwent a battery of neurological and neuropsychological tests the day before surgery, 7 days after surgery, and 6 months after surgery. RESULTS: The rate of cognitive dysfunction was 50% at 7 days and 23% at 6 months after surgery. Age, hypertension, presence of depression, duration of SjvO(2) ≤ 50%, ascending aorta atherosclerosis, diabetic retinopathy, and insulin therapy were independent predictors of short-term cognitive dysfunction, whereas HbA1c, diabetic retinopathy, insulin therapy, and presence of depression were independent predictors of long-term cognitive dysfunction. CONCLUSIONS: We found that the presence of depression preoperatively is associated with short-term and long-term postoperative cognitive dysfunction in patients with diabetes mellitus.

Differential effects of hyperventilation on cerebral blood flow velocity after tourniquet deflation during sevoflurane, isoflurane, or propofol anesthesia.

The purpose of this study was to compare the degree of increase in middle cerebral artery (MCA) blood flow velocity after tourniquet deflation when modulating hyperventilation during orthopedic surgery under sevoflurane, isoflurane, or propofol anesthesia. Twenty-four patients undergoing elective orthopedic surgery were randomly divided into sevoflurane, isoflurane, and propofol groups. Anesthesia was maintained with sevoflurane, isoflurane, or propofol administration with 33% oxygen and 67% nitrous oxide at anesthetic drug concentrations adequate to maintain bispectral values between 45 and 50. A 2.0-MHz transcranial Doppler probe was attached to the patient's head at the temporal window, and mean blood flow velocity in the MCA (V (mca)) was continuously measured. The extremity was exsanguinated with an Esmarch bandage, and the pneumatic tourniquet was inflated to a pressure of 450 mmHg. Arterial blood pressure, heart rate, V (mca) and arterial blood gases were measured every minute for 10 min after release of the tourniquet in all three groups. Immediately after tourniquet release, the patients' respiratory rates were increased to tightly maintain end-tidal carbon dioxide (PetCO(2)) at 35 mmHg. No change in partial pressure of carbon dioxide in arterial blood (PaCO(2)) was observed pre- and posttourniquet deflation in any of the three groups. Increase in V (mca) in the isoflurane group was greater than that in the other two groups after tourniquet deflation. In addition, during the study period, no difference in V (mca) after tourniquet deflation was observed between the propofol and sevoflurane groups. Hyperventilation could prevent an increase in V (mca) in the propofol and sevoflurane groups after tourniquet deflation. However, hyperventilation could not prevent an increase in V (mca) in the isoflurane group.

Effects of landiolol on left ventricular function during electroconvulsive therapy: a transthoracic echocardiographic study.

The purpose of this study was to examine the effects of landiolol on left ventricular (LV) systolic function, using transthoracic echocardiography, during electroconvulsive therapy (ECT). Fourteen patients undergoing ECT were studied. Bilateral ECT was performed after administration of thiopentone (2 mg/kg), succinylcholine (1 mg/kg), and initiation of assisted mask ventilation with 100% oxygen. Patients received a bolus injection of landiolol (0.125 mg/kg) or saline immediately after anesthetic induction and prior to electrical shock. LV systolic function was examined by transthoracic echocardiography prior to anesthetic induction, throughout the ECT procedure, and for 10 min after the seizure. Electrical shock resulted in a significant decrease in fractional area change (FAC) when compared with the awake condition in the control group [FAC when awake: 48 +/- 3%; 1 min after ECT: 38 +/- 4%*; 2 min after ECT: 36 +/- 4%*; 3 min after ECT: 40 +/- 3%*; mean +/- standard deviation, *p < 0.05 compared with awake]. Landiolol infusion stabilized systemic hemodynamics and LV systolic function. The study demonstrated that landiolol is a suitable agent to minimize hemodynamic changes and transthoracic echocardiographic variability after ECT.

Diabetic patients have an impaired cerebral vasodilatory response to hypercapnia under propofol anesthesia.

BACKGROUND AND PURPOSE: The purpose of this study was to examine the effects of diabetes mellitus and its severity on the cerebral vasodilatory response to hypercapnia. METHODS: Thirty diabetic patients consecutively scheduled for elective major surgery were studied. After induction of anesthesia, a 2.5-MHz pulsed transcranial Doppler probe was attached to the patient's head at the right temporal window, and mean blood flow velocity of the middle cerebral artery (Vmca) was measured continuously. After the baseline Vmca, arterial blood gases, and cardiovascular hemodynamic values were measured, end-tidal CO2 was increased by reducing ventilatory frequency by 2 to 5 breaths per minute. Measurements were repeated when end-tidal CO2 increased and remained stable for 5 to 10 minutes. RESULTS: Significant differences were observed in absolute and relative CO2 reactivity between the diabetes and control groups (absolute CO2 reactivity: control, 2.8+/-0.7; diabetes mellitus, 2.1+/-1.3; P<0.01; relative CO2 reactivity: control, 6.3+/-1.4; diabetes mellitus, 4.5+/-2.7; P<0.01, Mann-Whitney U test). Significant differences were also found between diabetic patients with retinopathy and those without retinopathy in absolute (P=0.002) and relative (P=0.002) CO2 reactivity, glycosylated hemoglobin (P=0.0034), and fasting blood sugar (P=0.01) (Scheffé's test, Mann-Whitney U test). There was an inverse correlation between absolute CO2 reactivity and glycosylated hemoglobin (r=0.69, P<0.001). CONCLUSIONS: Insulin-dependent diabetic patients have an impaired vasodilatory response to hypercapnia compared with that of the control group, and the present findings suggest that their degree of impairment is related to the severity of diabetes mellitus.

Epidural abscess in a patient with dorsal hyperhidrosis.

PURPOSE: To report the management of a patient who developed a lumbar epidural abscess when an epidural catheter was placed three years after a thoracic sympathectomy. The possible contribution of hyperhidrosis is discussed. CLINICAL FEATURES: A 62-yr-old male had compensatory hyperhidrosis in his back after thoracic sympathectomy. The patient, who suffered from thromboangeitis obliterans, underwent lumbar (L2-3) epidural catheterization in order to improve arterial circulation and ameliorate resting pain in his left leg. On the third day after catheterization, the patient complained of a dull pain in his back. Emergency magnetic resonance imaging revealed a 12-mm abscess in the epidural space. On the tenth day after catheterization, laminotomy at the 3-4 lumbar vertebrae and local drainage were performed. A 14-mm abscess was removed from the epidural space. The patient was discharged on day 21 after catheterization without any disability. CONCLUSION: Special precautions against infection may be necessary in patients with hyperhidrosis in the area where continuous epidural catheterization is attempted.