[Cytoreductive Surgery Performed Twice for Pseudomyxoma Peritonei with Pleural Extension of Mucinous Tumor].

Pseudomyxoma peritonei (PMP) is a condition characterized by production of a large amount of mucopolysaccharides by neoplastic epithelium, with intraabdominal cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) known to be viable treatment options. Pleural extension from an PMP is unusual and thought to be related to diaphragmatic perforation during surgery or transdiaphragmatic spreading of the disease through the lymphatic lacunae. Here, we report a patient with PMP with pleural extension of a mucinous tumor for whom CRS was performed twice. A 57-year-old female with PMP infiltrating the right chest cavity was scheduled for two separate CRS and hyperthermic chemotherapy procedures, because of the highly invasive characteristics of the surgery. For the first operation, we performed intra-abdominal surgery under general anesthesia combined with epidural anesthesia. To assess fluid and blood transfusion responsiveness, and reactions to vasoactive medication, we utilized an arterial pressure-based cardiac output monitor and central venous oximetry catheter. The second operation was performed 5 months later under general anesthesia with differential lung ventilation combined with epidural anesthesia. The operation and anesthesia for both surgical procedures were uneventful.

Measurement of blood pressure in a thalidomide-impaired patient who required ovarian cystectomy: A case report.

INTRODUCTION: Thalidomide was available for use over-the-counter between 1958 and 1962, and more than 300 thalidomide-impaired people have been confirmed in Japan. Currently, thalidomide-impaired people are nearing the age of 50 years and sometimes require medical treatment or surgery. However, a sphygmomanometer cannot be used to measure the blood pressure in some thalidomide-impaired people because of upper-limb shortening or hypoplastic defects. We encountered a patient with thalidomide-related upper limb defects who required abdominal ovarian cystectomy. PRESENTATION OF CASE: The patient was a 49-year-old woman (146.5cm, 35.9kg) with thalidomide-related upper-limb defects, but no dysplasia of the lower limbs, who underwent abdominal ovarian cystectomy. During the surgery, the patient's arterial blood pressure was monitored in her lower limbs by both non-invasive and invasive methods, and almost the same variations of the blood pressure between the invasive and non-invasive measurements were observed. DISCUSSION: Usually, blood pressure measurements are performed in a non-invasive manner in the upper limbs, however, such measurement could not be performed in the present case. There are few reports of measurement of the blood pressure or surgery under anaesthesia in thalidomide-impaired patients, and we report here that it was useful to measure the blood pressure in the lower limbs in the current patient. Invasive arterial pressure measurements showed almost the same changes as the non-invasive pressure measurements, although the systolic blood pressure was 10-20mmHg lower than the noninvasively measured systolic blood pressure. CONCLUSION: Non-invasive blood pressure measurements in the lower limbs might be useful in thalidomide-impaired patients requiring blood pressure monitoring, but further studies are required to validate this method.

Effect of invariant natural killer T cells with IL-5 and activated IL-6 receptor in ventilator-associated lung injury in mice.

Mechanical ventilation (MV) is well known to potentially cause ventilator-associated lung injury (VALI). It has also been reported recently that activation of invariant natural killer T (iNKT) cells is involved in the onset/progression of airway inflammation. We analyzed the roles of inflammatory cells, including iNKT cells, and cytokines/chemokines in a mouse model of VALI. C57BL/6 and Vα14(+)NKT cell-deficient (Jα18KO) female mice were subjected to MV for 5 hours. The MV induced lung injury in the mice, with severe histological abnormalities, elevation in the percentages of neutrophils in the bronchoalveolar lavage fluid (BALF), and increase in the number of iNKT cells in the lung. Jα18KO mice subjected to MV for 5 hours also showed lung injury, with decrease of the PaO2/FiO2 ratio (P/F ratio) and elevation of the levels of total protein, IL-5, IL-6, IL-12p40, and keratinocyte-derived cytokine (KC) in the BALF. Intranasal administration of anti-IL-5 monoclonal antibody (mAb) or anti-IL-6 receptor (IL-6R) mAb into the Jα18KO mice prior to the start of MV resulted in significant improvement in the blood oxygenation. In addition, the anti-IL-5 mAb administration was associated with a decrease in the levels of IL-5, IL-9, and IL-6R in the BALF, and anti-IL-6R mAb administration suppressed the mRNA expressions of IL-5, IL-6, IL-6R, and KC. These results suggest that iNKT cells may play a role in attenuating the inflammatory caused by ventilation through IL-5 and IL-6R.

[A case of large tracheoesophageal fistula after repair of the right discending aortic arch].

A 77-year-old woman with right aortic arch was diagnosed as aortic dissection (De Bakey IIIb) and hospitalized for conservative treatment. But, her respiratory condition deteriorated due to tracheal stenosis with aortic dissection. Surgical graft replacement of the descending aorta was performed to release tracheal stenosis. Six days after surgery, tracheoesophageal fistula (TEF) was noticed. The size of the fistula was 3 cm in diameter, located 3cm to the oral side from the carina and 23 cm from the incisors. Nineteen days after surgery, an esophageal stent was placed leading to temporary improvement of the respiratory status, but it aggravated again. Unfortunately, she died due to ventricular fibrillation 26 days after surgery. The case is extremely rare with dissection of the right aortic arch. Such a case is considered to be a high risk of TEF, and it is necessary to perform early preventive measures.

[Trends of HIV patients operated at International Medical Center of Japan].

BACKGROUND: HIV-infected patients are on the increase in Japan, and anti-HIV therapy improved their prognosis. It is expected that the number of operations in HIV patients will increase. METHODS: We surveyed the prevalence of HIV 30,188 patients operated at International Medical Center of Japan, a major, HIV/AIDS hospital, from 2001 to 2007. RESULTS: The number of HIV-positive cases was 389 in 7 years, and the prevalence of HIV seropositivity was 1.3% in total, 1.0% in scheduled, and 2.0% in emergent cases. The prevalence of male (2.0%) was higher than female (0.7%) patients and the prevalence was highest (9.2%) in male patients in their 30's. They were parallel with the HIV occurrence trend of Japan. The prevalence was the highest (2.4%) in the division of general surgery, as well as in obstetric and gynecology. The number of major surgery in HIV patients has been increasing. CONCLUSIONS: We assume that the perioperative management in each hospital has become more important. The annual trend of the number of the operations performed in HIV-positive patients at our hospital did not show annual changes.

Age-related differences in metoclopramide requirement for pain on injection of propofol.

OBJECTIVE: Pain on injection is still a major problem with propofol; metoclopramide effectively decreases this pain. The purpose of this study was to evaluate the influence of aging on metoclopramide requirement for propofol-induced pain. METHODS: In a randomised, double-blind manner, 120 patients, 60 younger (aged 20-40 years) and 60 older (aged 60-80 years) adults, received placebo (saline) or metoclopramide intravenously at two different doses (2.5mg and 5 mg) [younger group n = 20 each, older group n = 20 each], with venous occlusion for 1 minute, followed by administration of propofol 0.5 mg/kg into a dorsal hand vein. A blinded researcher asked the patient to assess the pain according to a pain score (0 = none, 1 = mild, 2 = moderate, 3 = severe) during injection of propofol. RESULTS: For younger patients, the incidence of propofol-induced pain was 30% in patients receiving metoclopramide 5mg (both p < 0.05), 70% in those receiving metoclopramide 2.5mg and 80% in those receiving placebo. The median pain score was lower in patients receiving metoclopramide 5mg (0) than in those receiving placebo (1.5) [p < 0.05]. For older patients, 15 patients (75%) complained of pain in the placebo group, compared with six (30%) in the metoclopramide 5mg group (p < 0.01) and seven (35%) in the metoclopramide 2.5mg group (p < 0.05). The median pain score was lower in patients receiving metoclopramide 5mg (0) [p < 0.01] or metoclopramide 2.5mg (0) [p < 0.05] than in those receiving placebo (1). CONCLUSION: This study showed that older patients require less metoclopramide, with venous occlusion for 1 minute, to reduce pain on injection of propofol than do younger patients.

Influence of aging on lidocaine requirements for pain on injection of propofol.

STUDY OBJECTIVE: To evaluate the influence of aging on lidocaine requirements for propofol-induced pain on injection. DESIGN: Prospective, randomized, double-blind, placebo-controlled study. SETTING: The study was undertaken at a University hospital. PATIENTS: 160 ASA physical status I and II adult patients scheduled for elective surgery with general anesthesia. INTERVENTIONS: Patients received placebo (saline) or lidocaine intravenously at three different doses (10, 20, or 40 mg), with venous occlusion for two minutes, followed by injection of propofol 0.5 mg/kg into a dorsal hand vein. MEASUREMENT AND MAIN RESULTS: Pain during injection of propofol was evaluated. For young patients, the frequency of propofol-induced pain was 70% in patients receiving lidocaine 10 mg (P = not significant); 50% in those receiving lidocaine 20 mg (P = not significant); and 30% in those receiving lidocaine 40 mg (P < 0.05), compared with placebo (80%). For elderly patients, 15 patients (75%) complained of pain in the placebo group, compared with 13 (65%) in the lidocaine 10 mg group (P = not significant); 5 (25%) in the lidocaine 20 mg group (P < 0.05); and 4 (20%) in the lidocaine 40 mg group (P < 0.05). CONCLUSIONS: A lidocaine dose of 40 mg for young patients and 20 mg for old patients, with venous occlusion for two minutes, is sufficient to reduce pain on injection of propofol.

Flurbiprofen axetil preceded by venous occlusion in the prevention of pain on propofol injection in the hand: a prospective, randomized, double-blind, vehicle-controlled, dose-finding study in Japanese adult surgical patients.

BACKGROUND: Pain on injection is still a major problem with propofol used for general anesthesia. A number of techniques for reducing propofol-induced pain on injection have been tried, with variable results. Flurbiprofen axetil, a prodrug of the nonsteroidal anti-inflammatory drug flurbiprofen, has been used for postoperative pain management but has not been studied for managing pain on injection of propofol when preceded with venous occlusion. OBJECTIVE: The present study was undertaken to examine the efficacy of flurbiprofen axetil for reducing pain on propofol injection in Japanese adult surgical patients. METHODS: This prospective, randomized, double-blind, vehicle-controlled, dose-finding study was conducted at the Department of Anesthesiology, University of Tsukuba Institute of Clinical Medicine, Tsukuba, Japan. Japanese patients aged 18 to 65 years scheduled to undergo elective surgery were eligible. Patients were randomized to receive flurbiprofen axetil IV at 1 of 3 doses (25, 50, or 75 mg), or vehicle (control group), preceded by manual venous occlusion with a rubber tourniquet for 2 minutes and followed by administration of 25% of the total calculated dose of propofol (2 mg/kg), injected into the largest vein of the hand through a 20-gauge IV cannula. During propofol injection, a researcher who was blinded to treatment assignment asked each patient about his or her pain at the injection site. Responses were scored on a 4-point scale (0 = none, 1 = mild, 2 = moderate, 3 = severe). Median pain intensity scores in each group were determined. Adverse effects (AEs) at the injection site (pain, edema, wheal, or inflammation) were monitored for up to 24 hours after surgery. RESULTS: A total of 120 patients (62 men, 58 women; mean [SD] age, 41 [12] years, mean [SD] height, 162 [8] cm; mean [SD] body weight, 58 [10] kg) were enrolled. Each treatment group comprised 30 patients. No significant between-group differences in demographic characteristics were found. A significantly higher proportion of patients in the control group (77%) experienced pain compared with the flurbiprofen axetil 50- and 75-mg groups (47% and 43%, respectively; both, P < 0.01). The median pain intensity scores were significantly lower in the flurbiprofen axetil 50- and 75-mg groups (both, 0 [no pain]) compared with controls (2 [moderate]; both, P < 0.01). The incidence and intensity of propofol-induced pain were statistically similar between the flurbiprofen axetil 25-mg and control groups. The incidence and intensity of pain associated with the injection of propofol were significantly lower in the flurbiprofen axetil 50- and 75-mg groups compared with the 25-mg group (incidence, 70% [both, P < 0.05]; median pain intensity score, 1 [mild] [both, P < 0.01]). No AEs were observed. CONCLUSION: In this study of Japanese adult surgical patients, flurbiprofen axetil at doses of 50 and 75 mg, preceded by venous occlusion for 2 minutes, was found to be effective in reducing propofol-induced pain on injection.

Effect of smoking on intraoperative sputum and postoperative pulmonary complication in minor surgical patients.

The effect of smoking for postoperative pulmonary complications (PPCs) in minor surgical patients who have an early recovery has not been evaluated. Smoking may also affect intraoperative sputum volume. We thus evaluated whether smoking had a relation to intraoperative sputum volume or PPCs in minor surgical patients. Smoking status was determined through the interviewer-assisted questionnaires. Intraoperative sputum volume was judged using the number of trials to suck up sputum from the trachea. Current and Ex-smokers were significantly more likely to have an increased intraoperative sputum volume when compared with Non-smokers (18.3% and 17.9% vs. 9.4%) although the relationship between smoking and PPCs was not demonstrated. In the multivariate models, Current and Ex-Smokers was identified as an independent risk factor of an increased intraoperative sputum volume (odds ratio, 2.7; 95% confidence interval, 1.6-4.6). The patients with < 2 months smoking cessation were more likely to have an increased intraoperative sputum volume. In conclusion, smoking is the risk factor of an increased intraoperative sputum volume, and preoperative smoking cessation > or = 2 months is recommended to reduce the risk of an increased intraoperative sputum volume, although the relationship between smoking and PPCs was not elucidated in minor surgical patients.