[Acute hospital collaboration with the region].

The palliative care team of Tokai University Hospital began its activities in 2004. After several changes in its organization, the activities of the palliative care team have become well known, and this department has become very active. Palliative care at our hospital has now broadened its scope and now includes both inpatients and outpatients. Initially, the patients primarily consisted of terminal-stage cancer patients, but in recent years patients who are being treated for cancer have also been included in the palliative care department. In terms of our collaboration with the region, the health care providers responsible for palliative care are making continued efforts to establish good relationships through regular scheduled palliative care training workshops and study sessions. Regional collaborations with oncologists is the ultimate/primary goal. As an educational institution we conduct clinical practical training and clinical training in core hospitals and private practices with medical students and junior resident physicians. However, few of these training institutions are home-care-supporting clinics or home-care-supporting hospitals. It remains unclear whether medical students and resident physicians are involved in home care. Knowledge of palliative care has gradually increased among the health care providers at our hospital. However, the dissemination of knowledge about home care among medical students, resident physicians, and oncologists is found to be lacking; hence, we have made this our goal. Another goal of ours would be to train existing physicians to equip them with knowledge and experience necessary for dealing with home care.

[Rectal tenesmus due to tumor invasion into the pelvic cavity responding favorably to antiarrhythmic drug therapy].

We experienced 3 patients(Cases 1, 3, and 4)with pelvic tumor-related rectal tenesmus showing favorable responses to antiarrhythmic drugs. Based on this experience, we administered antiarrhythmic drugs preferentially to 2 others with tumor derived rectal tenesmus(Cases 2 and 5), and again obtained favorable responses. These 5 patients(1 man, 4 women)were 28-89(mean 58)years of age. The primary lesion was cervical cancer in 3 patients, ovarian cancer in 1, and bladder cancer in 1. In the 3 with cervical cancer, the tumor had directly infiltrated the rectum and vulva. The patient with ovarian cancer had a residual tumor in the Douglas pouch postoperatively. The patient with bladder cancer had undergone total cystectomy and urinary diversion using an ileal conduit at another institution. All 5 patients complained of a frequent desire to defecate without feces(rectal tenesmus). Their rectal tenesmus was attributed to pelvic neurological dysfunction around the rectum. Drug therapy was initiated with oral mexiletine hydrochloride(Mexitil)150 mg in 3 divided doses in 4 patients and with continuous infusion of intravenous lidocaine 2%(Xylocaine)500mg/day in the other(Case 2). None had adverse reactions; all 5 experienced palliation of symptoms and improved quality of life.

Assessment of dyspnea in terminally ill cancer patients: role of the thoracic surgeon as a palliative care physician.

BACKGROUND: Many cancer patients suffer from rapidly-progressing dyspnea that is difficult to relieve. METHODS: The subjects were 26 patients who had dyspnea that was difficult to relieve. The Numeric Rating Scale was used to evaluate their dyspnea. For all patients, the cause of the dyspnea was investigated by CT and x-rays. RESULTS: The principal causes of the dyspnea were pleural effusion that increased daily, complications from pneumonia, massive ascites, multiple metastatic lung tumors and atelectasis, recurrent laryngeal nerve paralysis and narrowing secondary airway compression. Dyspnea was caused by a variety of conditions that overlapped over time, intensifying patients' discomfort. Among 14 patients for whom we recommended treatment with sedation, only 8 of them consented. Among the patients who were treated with sedation, the median interval between the exacerbation of dyspnea and death was 16 days; among non-sedated patients it was 18 days. CONCLUSIONS: Palliative care physicians who specialize in the respiratory system can, to some extent, predict the occurrence of rapidly progressive dyspnea in cancer patients. It is important to explain the methods of relieving dyspnea to the patient, the patient's family, and the oncologist early, so that decisions on how to manage dyspnea can be made in advance.

[A case of pain management using transdermal fentanyl patches for peritoneal carcinomatosis in a patient with small intestine stoma].

We experienced a patient with an ileal artificial anus who suffered from abdominal pain caused by peritoneal dissemination of ovarian cancer, for which slow-release oxycodone was ineffective, but fentanyl patch proved effective. The patient was a 28-year-old female who developed abdominal pain caused by peritoneal dissemination on postoperative day 60 after radical hysterectomy and colostomy. For pain relief, administration of 10-mg slow-release oxycodone and 180-mg loxoprofen sodium was begun. When the dose was increased to 25 mg on postoperative day 240, the slow-release oxycodone in its original form was confirmed in feces from the artificial anus.When the same drug was changed to a fentanyl patch(12. 5 mg/hr), the pain was relieved. A palliative care doctor needs much knowledge regarding the changes in the patient's body with the progress and treatment of cancer, in addition to the drug mechanism.

Ten cases of palliation of cancer pain with morphine.

OBJECTIVE: With the discovery of novel opioids in recent years, it has become feasible to alleviate various forms of cancer pain. If the characteristics of individual opioids are exploited depending on pain-related factors in cancer patients may yield satisfactory pain relief with a low incidence of adverse reactions. METHODS: This study involved 10 patients (5 male and 5 female) with cancerous abdominal pain, for whom the original opioid regimen was switched to morphine alone or continued in combination with morphine. The primary disease was gastric cancer in 5 patients, and uterine cervix, ovary cancer, leukemia, malignant pleuroperitoneal mesothelioma, and colon cancer in 1 patient each. Pain assessment was carried out using the Numerical Rating Scale. RESULTS: In all the 10 cases, the opioid administered first was fentanyl; the pain relief was inadequate. Satisfactory pain relief was achieved in all patients by switchover to morphine alone or by concomitant administration of morphine with fentanyl. CONCLUSION: Enhanced gastrointestinal motility accounts, at least in part, for cancerous abdominal pain. Further, this kind of pain can be relieved by suppression of gastrointestinal motility with morphine.

[The university hospital palliative care team's approach to the transfer of end-stage cancer patients from hospital care to home medical care].

The palliative care team's roles are to provide a symptom relief to cancer patients, help them accept their medical conditions, and offer advice regarding the selection of appropriate medical treatments to suit their needs. Seeking the comfort of their homes, patients prefer a home care of superior medical care provided at hospitals. In 2008, 25 of the end-stage cancer patients at hospitals were expressed their desires to have a home medical care, and 10 of them were allowed to do so. We considered the following contributing factors that a patient should have for a smooth transition from hospital care to home medical care: (1) life expectancy of more than 2 months, (2) no progressive breathing difficulties experienced daily, (3) good awareness of medical condition among patients and families, (4) living with someone who has a good understanding of the condition, (5) availability of an appropriate hospital in case of a sudden change in medical requirements, and (6) good collaboration between emergency care hospitals, home physicians, and visiting nurses. To treat the end-stage cancer patients at home, there is a need for information sharing and a joint training of physicians specialized in cancer therapy, palliative care teams, home physicians, and visiting nurses. This would ensure a sustainable "face-to-face collaboration" in community health care.

Resection and stapling technique for wide-based giant bullae in video-assisted thoracic surgery using a new end-stapler.

In video-assisted thoracic surgery (VATS), stapling resection for wide-based giant bullae requires a large-volume reduction of normal lung parenchyma and is technically difficult because of the lack of holding and stapling ability of the end stapler for the thick lung parenchyma. A new end-stapler device, the Echelon 60 Endopath stapler (60-mm stapling), has a long, strong anvil and a wide jaw aperture and is able to easily hold thick lung parenchyma. This device is able to divide with precise stapling over a long incision. In VATS management for two recent cases of broad-based giant bullae, this new device was used instead of suture closure and easily achieved stapled closure after excision of the bulla wall. This method prevents large-volume reduction of normal lung and enables an easy, fast, and reliable suture along a precise stapling line.

Simultaneous bilateral spontaneous pneumothorax with pleural window communicating with bilateral pleural spaces.

A pleural window communicating between bilateral pleural cavities is a serious condition in patients with pneumothorax, allowing air to leak from the affected lung into the contralateral pleural cavity and resulting in bilateral spontaneous pneumothorax. We treated a patient with a history of right-sided bullectomy for simultaneous bilateral spontaneous pneumothorax that subsequently recurred. A pleural window (1 cm long) was detected in the mid-mediastinum, and direct suture closure with localized pleural abrasion using argon beam coagulation on the circumference of the lesion was performed at video-assisted thoracoscopic surgery.

New-model ultrasonically activated shears for hemostatic sectioning during video-assisted thoracic surgery.

During video-assisted-thoracic surgery (VATS), bleeding limits the field of view and requires frequent exchange of surgical instruments through ports, complicating the surgical procedure. The poor video view also increases the risk of vessel injury. Attention must be paid to hemostasis to achieve safe, smooth VATS. The Harmonic Scalpel (HS) is able to grasp and divide tissues while sealing small vessels, which often cause bleeding during electrocautery, and lymphatic vessels. We obtained experience using a new model of HS, which appears effective for separating membranous or streak adhesions, cutting pulmonary parenchyma, and dividing lymphatic tissues. Compared to previous models, it allows superior handling during VATS. Tissue holding with this HS is greatly improved.