Anticoagulant therapy in a pregnant patient with prosthetic mitral valve-emergency for caesarian section and postoperative bleeding

Pregnant patients with prosthetic valve need anticoagulation therapy during pregnancy to prevent stuck valve. Regarding the thrombosed valve, there is a dilemma between anticoagulation to prevent further thrombus formation and postoperative bleeding after caesarian section until valve replacement surgery. A 35-year-old woman in her 34th weeks of pregnancy with a thrombus on prosthetic mitral valve was scheduled for emergency caesarian section under general anesthesia. Anticoagulation therapy with heparin was started after admission to the intensive care unit targeting the range between 70-100 second of activated partial thromboplastin time to prevent further thrombus formation. Heparin was administered intravenously (25,000 units per day), but APTT was kept over 110 seconds. Abdominal wall hematoma was detected by percutaneous echo next day and surgery for removal of hematoma was performed. Mitral valve replacement surgery was performed on the postoperative third days successfully. Postoperative anticoagulation therapy with heparin should be started carefully in consideration of physiological change of clotting ability after the termination of pregnancy.     

Total calcanectomy in a patient with a giant cell tumor

Total en-bloc calcanectomy was performed in a 36-year-old male patient with a giant cell tumor in his right calcaneus. A year after surgery, the patient had no complaints, and a good functional result was obtained. He was able to return to his work. No local or metastatic recurrences were encountered.     

Primary mediastinal hyalinizing spindle cell tumor with giant rosettes

We describe herein a unique case of primary mediastinal hyalinizing spindle cell tumor with giant rosettes that occurred in a 41-year-old man. The clinical and pathologic features together with a brief review of the literature are reported.     

Anesthetic management of a patient with a giant ovarian tumor

We reported a case of a giant ovarian tumor weighing 30 kg removed successfully. Anesthesia was induced with the patient in the lateral decubitus, and the surgery was started with this position. While the tumor was abraded, hemodynamics was almost stable. The patient recovered without any postoperative complications. Anesthetic management for cases of a giant ovarian tumor is discussed.     

A patient with a huge posterior mediastinal tumor and ST-segment depression in electrocardiogram

A 68-year-old woman had felt a chest and back pain for 3 months. Gradually her symptom became aggravated, and she felt severe dyspnea in supine position and dysphagia combined with superior vena cava syndrome. A huge posterior mediastinal tumor was revealed and her esophagus was severely narrowed on the chest MRI. Therefore, emergency tumor resection was scheduled under general anesthesia. Anesthesia was induced by midazolam (2 mg) with the patient in the right lateral position. After gas exchange and oxygenation were comfirmed by pulse oximetry reading and clinical signs, she was slowly turned to supine position. But, suddenly, ST-segment depression and low amplitude developed in electrocardiogram and systolic blood pressure was depressed to below 60 mmHg. Therefore, she was rapidly retuned to right lateral position, and ST-segment and systolic blood pressure recoverd. On the next time, although she was slowly turned to the right semi-lateral position, there was almost no circulatory failure. A bronchial tube was intubated in her left bronchia under bronchoscope. We should remember that the preparation of percutaneous cardiopulmonary support (PCPS) should be considered as a means of protection against cardiovascular collapse or airway obstruction perioperatively.     

Anesthetic management of a patient with a giant ovarian tumor complicated with cerebral palsy

The anesthetic management of a patient with a giant ovarian tumor (16.5kg) was reported. The patient was a 32 year old female with cerebral palsy and severe mental retardation. The management of anesthesia in this case including induction of anesthesia, intra-operative hypotension due to removal of tumor and post operative pulmonary complication, should be considered carefully. Especially, the monitoring of central venous pressure was essential, because the venous return fluctuates markedly depending on the surgical procedure. Patient had no premedication. Anesthesia was induced with halothane, nitrous oxide and oxygen by mask with the monitoring of ECG, and radial arterial as well as central venous pressure. Following easy tracheal intubation, bronchospasm occurred, which induced multifocal PVC's. This PVC turned to bigeminy and treatment with such drug as lidocaine was not effective. Anesthesia was maintained with enflurane, nitrous oxide and oxygen. Bigeminy disappeared 5 minutes after discontinuing enflurane anesthesia. Post-operative course was uneventful. The merit of slow induction method with halothane, nitrous oxide and oxygen has not been proved in this special case.     

Long-term survival of a patient with giant cell glioblastoma. Case report

The authors report on a patient who had undergone resection of a left-sided temporal giant cell glioblastoma at the age of 69 years and who survived for more than 17 years. This man had not undergone postoperative radiotherapy or adjuvant chemotherapy. He died at the age of 86 years without clinical evidence of tumor recurrence. Histologically, the lesion was characterized by highly pleomorphic tumor cells (including bizarre multinucleated giant cells) with high mitotic activity, large necroses, and prominent mononuclear infiltration. A point mutation in the TP53 tumor suppressor gene (c.524G>A; R175H) and no epidermal growth factor receptor gene amplification were revealed on molecular genetic analysis. No diagnostic chromosomal imbalances were identified on comparative genomic hybridization, although the average ratio profile for chromosome 10 indicated loss of 10p15 in a subpopulation of tumor cells. This patient is exceptional because tumor resection, probably in conjunction with a marked antitumor immune response, apparently resulted in eradication of the lesion.     

Custom-made wrist prosthesis in a patient with giant cell tumor of the distal radius

Introduction

Treatment for giant cell tumors of the distal radius is challenging when motion is to be preserved. As standard wrist prostheses typically do not achieve favorable results, we treated a 36-year-old man with giant cell tumor of the distal radius with a new, custom-made implant.

Methods

A custom-made wrist prosthesis with a long shaft was designed according to the patient’s X-ray findings. After complete tumor resection, the prosthesis was subsequently implanted into the distal radius without complications.

Results

Two months after surgery, range of motion was 30°-0-25° for extension/flexion, 10°-0-5° for ulnar/radial abduction, 80°-0-0 for pronation/supination, complete range of motion for the fingers, and a grip strength of 6 kg. Two years after surgery, implant position was still correct and range of motion was 45°-0-10° for extension/flexion, 10°-0-20° for ulnar/radial abduction, and 80°-0-10° for pronation/supination. Grip strength was 16 kg, and DASH score was 25 compared to 39 before surgery. The patient returned to work as a craftsman.

Conclusion

Custom-made wrist prostheses could become a practical option in patients with large defects of the distal radius who desire to preserve wrist motion.     

A successfully resected case of giant malignant mediastinal germ cell tumor

A 14-year-old male was admitted for complaints of dyspnea and cough. Chest radiography revealed a huge mass in the right lung field. The serum alpha fetoprotein (AFP) level was elevated to 1,251 ng/ml. Histological findings of the specimens obtained by needle biopsy revealed a mature teratoma with non-seminoma. After 2 courses of chemotherapy [cisplatin (CDDP) and etoposide (VP-16)], serum AFP level decreased to 25 ng/ml, and the tumor was resected with pericardium (the tumor size was 14 x 10 x 20 cm). Two courses of chemotherapy were administered again postoperatively with normalization of serum AFP level. The patient has no sign of recurrence of the tumor.     

Anterior mediastinal presentation of a giant angiomyolipoma

Angiomyolipomas are benign, solitary, noninvasive lesions that most often arise in the kidney. Extrarenal manifestations of these tumors include the skin, oropharynx, the abdominal wall, retroperitoneum, gastrointestinal tract, heart, lung, liver, uterus, penis, and spinal cord. We report a patient with a giant angiomyolipoma located in the anterior mediastinum. We believe this is the seventh reported case of mediastinal angiomyolipoma and the largest reported by size. It is the second reported lesion to arise in the anterior mediastinum. Distinction from other pulmonary or thoracic masses relies on the appreciation of the unique and characteristic histologic features of these mediastinal angiomyolipomas. We conclude that, although rare, angiomyolipoma should be considered in the differential diagnosis of a mediastinal tumor.     

Immediate surgical rescue for mediastinal compression by giant metastatic lung tumor

Mediastinal compression by a large metastatic lung tumor is a life-threatening condition and needs immediate decompression. We performed palliative surgical rescue for 2 patients aged 42 and 30 years with these conditions, and were able to control their symptoms. Patients were free of symptoms soon after the operation. Palliative surgical rescue can relieve the symptoms immediately and improve the general condition dramatically. We think that surgical rescue is worthwhile, especially for younger patients.     

Reexpansion pulmonary edema after removal of a giant thoracic tumor associated with long-time lung collapse and mediastinal shift

A 64-year-old woman was admitted to our hospital for removal of a thoracic tumor. Chest X-ray and computed tomography demonstrated a giant thoracic tumor occupying the right thorax, with the right lung almost completely collapsed and the mediastinum shifted to the left. Her preoperative pulmonary function studies revealed %vital capacity of 30%, and her oxyhemoglobin saturation was 92% (room air). Anesthesia was maintained with sevoflurane and fentanyl. The trachea was intubated with an armored tube because of severe tracheal shift. Operation was performed in the supine position. A Swan-Ganz catheter was inserted from the right femoral vein under fluoroscopy with stand-by of percutaneous cardiopulmonary support. The tumor was removed segmentally, and her right lung was inflated gradually. Two hours after removal of the tumor, PaO2 decreased to 74.2 mmHg (FIO2 1.0), and a large amount of sputum was suctioned subsequently. We suspected re-expansion pulmonary edema (RPE) and administered steroid with frequent tracheal suctioning. The patient was transferred to ICU without extubation. Postoperative X-ray demonstrated diffuse alveolar infiltrates over the right lung field. The patient was followed by respiratory management and body fluid management with diuretic drugs. The trachea was extubated on the following day, and her postoperative recovery was uneventful thereafter. We should consider the occurrence of RPE at removal of the giant thoracic tumor.