Use of perioperative ureteral stent in abdominal aortic aneurysm with retroperitoneal fibrosis - A report of two cases -.

Retroperitoneal fibrosis is associated with fibroblast proliferation due to inflammatory changes in adipose/fibrous tissue. Given that aortic dilation in abdominal aortic aneurysm can cause compression of the ureter, abdominal aortic aneurysm complicated by retroperitoneal fibrosis is likely to result in urinary tract obstruction. Accordingly, close attention to changes in perioperative urine volume is warranted when operating on patients with abdominal aortic aneurysm complicated by retroperitoneal fibrosis. We have recently performed laparotomies on two cases of abdominal aortic aneurysm complicated by retroperitoneal fibrosis. In the first case, surgery was performed without the placement of a ureteral stent. The patient developed postrenal acute renal failure caused by postoperative urinary retention. In the second case, ureteral stent placement in advance enabled perioperative management without complications. The clinical course of these cases suggests that, in laparotomy with concomitant retroperitoneal fibrosis, preoperative ureteral stent placement can prevent postoperative complications in the renal and urinary systems.

Human atrial natriuretic peptide attenuates renal ischemia-reperfusion injury.

BACKGROUND: Acute kidney injury (AKI) is common in the intensive care unit, and one of its primary causes is renal ischemia-reperfusion (I/R) injury. Human atrial natriuretic peptide (hANP) exerts various pharmacologic effects, including renal protection. In the present study, we evaluated the renal protective effect of hANP in a rat model of renal I/R. MATERIALS AND METHODS: Male Wistar rats were divided into three groups that received the following treatments: induction of renal I/R (I/R group); continuous intravenous injection of hANP followed 30 min later by induction of renal I/R (hANP+I/R group); and sham treatment (control group). Rats were sacrificed after 60 min of ischemia and 24 h of reperfusion or sham treatment. To evaluate the renal protective effects if hANP, serum blood urea nitrogen (BUN) and creatinine (Cre) concentrations were determined, kidneys were histologically assessed, and serum biomarkers of oxidative stress were evaluated. In addition, antimycin A (AMA)-stimulated RAW264.7 cells were treated with hANP to assess its antioxidant effects. RESULTS: Serum BUN and Cre levels were elevated in the I/R group; however, these increases were significantly inhibited in the hANP + I/R group. Similarly, kidney tissue damage observed in the I/R group was attenuated in the hANP + I/R group. In vitro, AMA-stimulated cells treated with hANP showed reduced reactive oxygen species activity compared to cells treated with AMA alone. CONCLUSIONS: Our findings indicate that hANP may be effective in the treatment of various types of I/R injuries.

Age-dependent responses to renal ischemia-reperfusion injury.

BACKGROUND: The incidence of acute kidney injury (AKI) in the elderly population has steadily increased in recent years. Functional recovery after AKI is also impaired in the elderly; however, the mechanism underlying these age-related differences is not well understood. In the present study, we assessed kidney morphology, function, and oxidative stress in young and aged rats after renal ischemia and reperfusion. MATERIALS AND METHODS: Young (6- to 7-wk-old) and aged (60- to 65-wk-old) male Wistar rats were divided into four groups based on age and treatment: renal ischemia-reperfusion in young rats (young IR); renal ischemia-reperfusion in aged rats (aged IR); sham treatment in young rats (young control), and sham treatment in aged rats (aged control). Rats were sacrificed 24 h after treatment, serum blood urea nitrogen (BUN) and creatinine (Cre) concentrations were determined, and kidney tissue histology and 8-hydroxydeoxyguanosine (8-OHdG) levels were evaluated. RESULTS: After ischemia-reperfusion, serum BUN, and Cre levels were higher in aged rats than in young rats. Reperfusion-induced kidney damage and kidney tissue 8-OHdG levels were also more severe in the aged IR group. Moreover, plasma antioxidant potential was lower in aged IR rats than in young IR rats. CONCLUSIONS: Aged rats exhibited reduced antioxidant potential and increased oxidative stress after ischemia-reperfusion. Our findings demonstrate that aged rats experience more severe reperfusion-induced injuries compared with young rats.

Remifentanil and glucose suppress inflammation in a rat model of surgical stress.

PURPOSE: Postoperative stress produces an inflammatory response. Recent studies have shown that narcotic analgesics suppress the immune system. Nutritional management during perioperative care has also been reported to affect inflammation. We therefore examined whether remifentanil or glucose administration could ameliorate postsurgical inflammatory responses using a rat model of surgical stress. METHODS: We divided male Wistar rats randomly into five groups: (1) control, (2) sevoflurane+lactated Ringer's solution, (3) sevoflurane+lactated Ringer's solution with 1% glucose, (4) sevoflurane+remifentanil+lactated Ringer's solution, and (5) sevoflurane+remifentanil+ lactated Ringer's solution with 1% glucose. In all groups, serum samples were obtained at various time points after surgery, and secreted cytokine concentrations were determined. In addition, we assessed the activation of protein kinase B (Akt) and forkhead/winged helix box class O (FOXO3), which play a role in gluconeogenesis/stress responses. RESULTS: Surgical stress increased the serum concentrations of tumor necrosis factor-α and interleukin-6. Groups receiving remifentanil with anesthesia showed an attenuated inflammatory response. The inflammatory response was also reduced by administering 1% glucose. Furthermore, 1% glucose induced Akt and FOXO3 phosphorylation in the quadriceps femoris muscle 12 h after surgery. CONCLUSIONS: Anesthesia based on remifentanil and perioperative administration of lactated Ringer's solution containing 1% glucose may be able to control inflammatory responses caused by surgical stress.

Anti-inflammatory effects of perioperative intensive insulin therapy during cardiac surgery with cardiopulmonary bypass.

PURPOSE: Recent studies have reported that controlling blood glucose with insulin can suppress systemic inflammation. In the present study, we evaluated how perioperative intensive insulin therapy (IIT) influences the inflammatory response in an artificial pancreas during cardiac surgery with cardiopulmonary bypass. METHODS: We randomly divided the patients undergoing cardiac surgery with cardiopulmonary bypass into two groups: an IIT group (n = 13) and a conventional treatment (CT) group (n = 12). For the IIT group, blood glucose control was initiated with an artificial pancreas at initiation of surgery. Blood glucose was maintained at 100 mg/dl until 24 h postoperatively. Blood samples were collected to determine changes in serum cytokine levels over time. RESULTS: Patients' characteristics did not differ significantly between groups. Blood glucose levels were significantly higher in the CT group after surgery. Serum levels of tumor necrosis factor-α, interleukin-6, and high-mobility group box 1 were higher in the CT group than in the IIT group. CONCLUSIONS: Use of IIT in the artificial pancreas during the perioperative period significantly decreased the inflammatory response. Moreover, we did not find evidence of hypoglycemia in those treated with IIT. This suggests that use of IIT in an artificial pancreas can be safe and effective for critically ill patients.

Catecholamine-resistant shock and hypoglycemic coma after cardiotomy in a patient with unexpected isolated ACTH deficiency.

Isolated adrenocorticotropic hormone (ACTH) deficiency is an extremely rare disease in which ACTH-producing cells of the pituitary gland are selectively damaged. The resulting decline in ACTH production and secretion results in chronic secondary adrenocortical insufficiency. The patient in this case did not present with adrenal insufficiency symptoms prior to surgery. However, after cardiotomy under extracorporeal circulation, the patient lapsed into a catecholamine-resistant shock and hypoglycemic coma. Acute adrenal insufficiency was strongly suspected, and the patient was diagnosed with isolated ACTH deficiency after careful examination. Because the demand for cortisol increases after highly invasive surgeries, cortisol supplementation therapy is essential for patients with complications from isolated ACTH deficiency. There is a high risk of a lethal outcome when surgery is carried out without a diagnosis, as in this case. Therefore, cortisol must be supplemented without delay when acute adrenal insufficiency is suspected during the perioperative period.

Cepharanthine exerts anti-inflammatory effects via NF-κB inhibition in a LPS-induced rat model of systemic inflammation.

BACKGROUND: Systemic inflammatory response syndromes involving sepsis continue to have extremely high mortality rates. Inflammation is difficult to control when it spreads throughout the body and often progresses into multiple organ dysfunction, eventually leading to death. Cepharanthine (CE) is a plant alkaloid that possesses bioactive properties, with various known actions. In the present study, we investigated protective effects of CE in a lipopolysaccharide (LPS)-induced systemic inflammatory response model and examined underlying mechanisms. MATERIALS AND METHODS: We intravenously administered LPS (7.5 mg/kg) to male Wistar rats after intraperitoneal injections of either physiologic saline (LPS group) or CE (10 mg/kg; CE + LPS group), or 2 h before intraperitoneal injection of CE (post-CE + LPS group). We then compared changes in serum cytokine and nitrogen oxide levels over time, and performed histologic examinations of the lungs and liver in each group. Using mouse macrophage RAW264.7 cells, we determined the effect of CE on LPS-induced cytokine secretion into the cell culture medium, as well as NF-κB activity. RESULTS: The increase in LPS-induced cytokine levels in rat serum was significantly inhibited by CE treatment; this effect was also seen in the post-CE + LPS group. In addition, we observed histologic improvements with CE co-treatment. In vitro, CE inhibited NF-κB activation by inhibiting the IKK pathway. CONCLUSIONS: These results suggest that CE exerts protective effects, at least in part, via NF-κB inhibition. CE may thus be a potential agent for treating systemic inflammatory response syndromes such as sepsis.

Cepharanthine improves renal ischemia-reperfusion injury in rats.

BACKGROUND: Acute renal damage has numerous causes, including renal ischemia-reperfusion injury. Due to its diverse actions, cepharanthine is used to treat many acute and chronic diseases, including pit viper bites, alopecia areata, and leucopenia in radiation therapy. In this study, we examined whether cepharanthine provides a renal-protective effect in a renal ischemia-reperfusion model. MATERIALS AND METHODS: Male Wistar rats were divided into four groups that received the following treatments: induction of renal ischemia-reperfusion (I/R group); subcutaneous injection of cepharanthine (10 mg/kg) followed 1 h later by induction of renal ischemia-reperfusion (Cepha + I/R group); subcutaneous injection of cepharanthine (10 mg/kg) (Cepha group); and subcutaneous injection of saline followed 1 h later by sham treatment (control group). Rats were sacrificed 24 h after renal ischemia-reperfusion or sham treatment. Serum blood urea nitrogen (BUN) and creatinine (Cre) concentrations were determined, histologic examination was performed, and oxidative stress was evaluated in kidney tissue. In addition, antimycin A (AMA)-stimulated RAW264.7 cells were treated with cepharanthine to determine its antioxidant effects. RESULTS: Serum BUN and Cre levels were increased in the I/R group; however, these increases were significantly inhibited in the Cepha + I/R group. Similarly, kidney tissue damage observed in the I/R group was attenuated in the Cepha + I/R group. In vitro, cells treated with both cepharanthine and AMA showed reduced reactive oxygen species activity compared with cells treated with AMA alone. CONCLUSIONS: Our findings suggest that cepharanthine may be effective in the treatment of various types of ischemia-reperfusion injuries.

Total parenteral-nutrition-mediated dendritic-cell activation and infiltration into the small intestine in a rat model.

PURPOSE: Total parenteral nutrition (TPN) is commonly carried out in the clinical setting. However, effects of TPN on the immune system, including dendritic cells (DC), are not well understood. The purpose of this study was to determine whether TPN affects DC activation and infiltration into the intestinal barrier. METHODS: Male Wistar rats were given conventional nutrition (CN) or TPN for 7 days. DCs were visualized by immunohistochemistry. Levels of nucleotide-binding oligomerization domain protein 2 (NOD2) and high-mobility group box 1 (HMGB1) protein were assessed by Western blot. RESULTS: The number of DCs at the small intestinal barrier was significantly increased in the TPN group (9.2 ± 3.1 cells/microscopic field) compared with the CN group (0.5 ± 0.6 cells/microscopic field; p < 0.05), as were protein expression levels of NOD2 and HMGB1. CONCLUSION: These results suggest that TPN increases activation and infiltration of DCs into the small intestine, potentially involving an increase in NOD2 and HMGB1 levels in the small intestine.

The effect of landiolol on cerebral blood flow in patients undergoing off-pump coronary artery bypass surgery.

PURPOSE: To examine the effect of landiolol on cerebral blood flow in patients with normal or deteriorated cardiac function. METHODS: Thirty adult patients who were diagnosed with angina pectoris and who underwent elective off-pump coronary artery bypass surgery were studied. Patients were divided into two groups, one with a preoperative left ventricular ejection fraction (EF) of 50% or higher (normal EF group; n = 15) and the other with an EF of less than 50% (low EF group; n = 15). The mean cerebral blood flow velocity (Vmca) and pulsatility index (PI) in the middle cerebral artery were recorded using transcranial Doppler ultrasonography (TCD). Individual hemodynamic data were obtained using a pulmonary arterial catheter. RESULTS: In both groups, landiolol produced a significant decrease in heart rate (HR), which then returned to baseline 15 min after administration was completed. A significant decrease in mean arterial pressure occurred in the low EF group, but the decrease was within 30% of the baseline. In the normal EF group, there was no decrease in cardiac index (CI), whereas in the low EF group, CI significantly decreased along with the decrease in HR. There were no significant differences in Vmca and PI between the two groups. CONCLUSION: Continuous administration of landiolol at a dose of 0.04 mg/kg/min after 1 min rapid i.v. administration at a dose of 0.125 mg/kg/min decreases HR without causing aggravation of CBF during treatment of intraoperative tachycardia in patients with normal and deteriorated cardiac function.

[Anesthesia management of geriatric patients with arterial pressure-based cardiac output monitoring FloTrac sensor for emergency surgery].

In cases of emergency surgery for geriatric patients, immediate anesthesia induction and careful intraoperative management is necessary without sufficient preoperative information. We report anesthesia management of a 96-year and a 90-year old patients with FloTrac sensor which is an arterial pressure-based cardiac output monitoring device and is able to manage critical patients effectively and safely during anesthesia.

[Landiolol does not affect bispectral index scale in off-pump coronary artery bypass surgery in patients under fast-track cardiac anesthesia].

BACKGROUND: We evaluated the effect of landiolol, a novel ultra-short-acting receptor-selective blocker, on bispectral index scale (BIS). METHODS: Ten patients scheduled for off-pump coronary artery bypass (OPCAB) surgery under fast-track cardiac anesthesia were analyzed. Anesthesia was maintained with appropriate additional administration of fentanyl (total dose: 10-15 microg x kg(-1)) and vecuronium under inhalation of a mixture of oxygen, air and sevoflurane (less than 2%). Landiolol was administered continuously for 5 min, when the heart rate (HR) was 80 or more per minute and the BIS values were kept between 40-60. HR, mean arterial pressure (MAP), cardiac index (CI) and BIS values were recorded at 4 time points (after induction of anesthesia, before administration of landiolol, immediately before comple- tion of administration, and 15 minutes after completion of administration). RESULTS: HR decreased significantly by landiolol administration, but there were no significant changes in MAP, CI and BIS. CONCLUSIONS: This study suggests that landiolol does not affect BIS in OPCAB surgery patients under fast-track cardiac anesthesia.

[Pneumothorax during retroperitoneoscopic nephrectomy: a case report].

A 54-year-old female patient was scheduled for retroperitoneoscopic nephrectomy. Anesthesia was induced with propofol and maintained with nitrous oxide/sevoflurane and epidural anesthesia. One hour after the start of the surgery, arterial oxygen saturation suddenly decreased from 99% to 94%. Because her oxygenation gradually improved and hemodynamics was stable, the operation was continued. After the end of the surgery, left pneumothorax was found on a chest X ray. The patient was extubated following thoracocentesis that had improved her pneumothorax and oxygenation. There is no report of pneumothorax in retroperitoneoscopic nephrectomy, as far as we know, although several cases have been reported in laparoscopic nephrectomy. We must be careful of pneumothorax in both laparoscopic and retroperitoneoscopic nephrectomy.