Hemodynamic and catecholamine responses during tracheal intubation using a lightwand device (Trachlight) in elderly patients with hypertension

Purpose.Tracheal intubation using a lightwand device (Trachlight) should minimize hemodynamic change by avoiding direct-vision laryngoscopy. We evaluated hemodynamic and catecholamine responses during tracheal intubation using a Trachlight in elderly patients with hypertension.Methods.Twenty-six hypertensive patients aged over 65 years undergoing orthopedic surgery were randomly divided into two groups, group L (n = 13) and group T (n = 13). Anesthesia was induced with fentanyl (2g·kg^–1) and propofol (1.5mg·kg^–1), and then muscle relaxation was obtained with vecuronium (0.15mg·kg^–1). The trachea was intubated with either a Macintosh laryngoscope (group L) or a Trachlight (group T). Hemodynamics, plasma catecholamine concentrations, and arterial blood gases were measured before the induction of anesthesia (T0), before tracheal intubation (T1), immediately after tracheal intubation (T2), and 3min after tracheal intubation (T3).Results.The intubation time was shorter in group T than in group L (12.6 ± 1.7 vs 23.5 ± 2.9s, mean ± SE; P 0.01). Compared with the preinduction (T0) value, systolic blood pressure (SBP) showed a significant decrease at T1 and T3 in group L and at T1, T2, and T3 in group T. The heart rate (HR) and plasma norepinephrine (NE) concentration showed no change in either group throughout the time course, whereas the plasma epinephrine (E) concentration showed a significant decrease at T2 and T3 in both groups. The mean values of the rate-pressure product (RPP: HR × SBP) were less than 15 000 after tracheal intubation in both groups. There was no significant difference in hemodynamic or catecholamine responses between groups at any point. No patient had ischemic ST-T changes in either group.Conclusion.A lightwand has no advantage over a laryngoscope in terms of hemodynamic and plasma catecholamine responses to tracheal intubation in elderly patients with hypertension, despite a shorter intubation time.     

Tissue factor antisense oligonucleotides prevent renal ischemia-reperfusion injury

BACKGROUND: Tissue factor (TF) expression is induced on macrophages and endothelial cells during the immune response. We designed an antisense (AS) phosphorothioate oligodeoxynucleotide (ODN) to specifically inhibit the expression of rat TF to study the effects of the AS ODN on renal ischemia-reperfusion injury in the rat. METHOD: AS-1 ODN for TF was delivered intravenously to inhibit the expression of TF in endothelial cells. After 8 hr, the right kidney was harvested and the left renal artery and vein were clamped. The kidney was reperfused after 90 min of ischemia, and rats were killed at 0, 1.5, 5, 12, and 24 hr after reperfusion. TF expression was analyzed by immunohistochemical staining using monoclonal antibody. RESULTS: In the untreated ischemic group, 0 of 20 rats survived beyond day 3. However, treatment with AS-1/TF led to 12 of 20 rats surviving beyond day 4. TF was detected on distal tubular epithelial cells, endothelial cells, and blood vessels but not on necrotic and proximal tubular epithelial cells. The necrotic area extended and encompassed nearly all of the ischemic kidney within 12 hr after reperfusion. The necrotic area and the grade of TF staining were more significantly reduced in the AS-1/TF-treated group than in the control group. Furthermore, fluorescein isothiocyanate-labeled AS-1/TF was significantly intense in tubular epithelial cells 8 hr after intravenous administration. CONCLUSIONS: The results indicate that AS-1/TF inhibited the ischemia-reperfusion injury of the kidney. Microcirculatory incompetence resulting from microthrombus may cause the formation and development of necrosis.     

Surgery for pulmonary metastases from colorectal cancer

OBJECTIVE: Several investigators have analyzed prognostic factors of surgical treatment for pulmonary metastases from colorectal cancer, but the results remain inconclusive. This study was performed to determine the prognostic implications of the prethoracotomy serum level of carcinoembryonic antigen (CEA) in relation to the postthoracotomy recurrent pattern among patients with this disease. METHODS: A retrospective analysis of prognostic factors was undertaken in 100 patients who had consecutively undergone initial surgical resection for pulmonary metastases of colorectal origin. RESULTS: The overall 3- and 5-year survival rates were 62.2% and 49.4%, respectively. Univariate analysis revealed that the prethoracotomy serum CEA level and operative curability were strongly associated with prognosis, while in multivariate analysis, only the prethoracotomy serum CEA level was a significant prognostic indicator. Patients with a high level of prethoracotomy serum CEA more frequently exhibited recurrence in extrathoracic sites, especially in the brain. CONCLUSION: Before thoracotomy for pulmonary metastases from colorectal cancer, the serum CEA level was the most useful prognostic factor. Patients with elevated serum CEA level should undergo a careful prethoracotomy systemic survey and postthoracotomy follow-up for extrathoracic metastases, in particular brain metastases, and an appropriate combined therapeutic modality should be considered.     

Characterization of K-ras gene mutations in association with mucinous hypersecretion in intraductal papillary-mucinous neoplasms

Background/Purpose Intraductal papillary-mucinous neoplasms (IPMNs) of the pancreas have a favorable prognosis. However, invasive ductal carcinomas of the pancreas show a rapid progression. The aim of this study was to investigate gene mutations in pure pancreatic juice from IPMN patients and to define these genetic mutations in relation to the histopathological and clinical features of IPMNs. Methods Twenty-two patients with IPMN, 21 patients with ductal carcinoma, and 20 patients with normal pancreas or chronic pancreatitis were recruited for this study. We measured the main pancreatic duct’s largest diameter and the maximum size of a dilated branch was assessed by ultrasonography or endoscopic ultrasonography. Pure pancreatic juice was collected and was investigated for K-ras, p16, and p53 mutations. Results Mutant K-ras gene was detected in 13 of the 22 patients (59.1%) with IPMNs. Different kinds of mutations were detected in the same patient in 4 cases. In the 13 patients with mutant K-ras gene, the diameter of the most dilated part of the main pancreatic duct was 2–8 mm (average, 4.5 mm) and in 7 patients with wild-type K-ras gene, the diameter was 2–5 mm (average, 2.7 mm). There was a significant difference in the diameter of the main pancreatic duct between patients with and without the mutant K-ras gene (P = 0.0323). Conclusions The incidence of K-ras mutation may be associated with the hypersecretion of mucin.     

Pancreatic schwannoma: Report of a case

Among pancreatic neoplasms, pancreatic schwannoma is quite rare. We report a case of solitary pancreatic schwannoma, plus a literature review of this tumor. A 71-year-old woman was diagnosed by abdominal ultrasonography as having a pancreatic tumor and was hospitalized in our department at Kumamoto University Hospital on January 26, 2006. Abdominal computed tomography, magnetic resonance imaging, and endoscopic ultrasonography all showed this tumor, which was located in the body of the pancreas, to have cystic and solid components, and with a septum in the cystic part of the lesion. The tumor, preoperatively identified as a mucinous cystic neoplasm, was clearly separated from the normal pancreatic parenchyma. We performed a spleen-preserving distal pancreatectomy with a lymph node dissection on February 7, 2006. A histopathological examination of the resected specimen by means of hematoxylin and eosin revealed the tumor to consist of two parts: one with a compact spindle cell pattern (Antoni type A), and the other showing degeneration of fat (Antoni type B). We also found positive results for immunohistochemical staining for S-100 and vimentin. These findings confirmed the tumor’s classification as a pancreatic schwannoma.     

Changes of D-dimer after total hip arthroplasty in patients with and without intraoperative heparin

Introduction Marked activation of thrombosis is common in patients undergoing total hip arthroplasty, especially during reaming of the femur and after insertion of the femoral prosthesis. This suggests that management designed to minimize deep vein thrombosis and fatal pulmonary embolism after total hip arthroplasty should be focused on the period during insertion of the femoral component. In some previous studies, a low dose of heparin administered intraoperatively was shown to suppress the formation of fibrin. Objective The present study was performed to evaluate the influence of intraoperative heparin administration on the D-dimer level and on the prevention of pulmonary embolism after total hip arthroplasty. Material/methods A total of 22 and 26 consecutive patients respectively underwent total hip arthroplasty with and without intraoperative administration of unfractionated heparin. Postoperatively, all patients wore knee-high elastic stockings and were fitted with calf-to-thigh intermittent pneumatic compression devices. Active ankle flexion and extension exercises were commenced as soon as motor function recovered. None of the 48 patients received prophylactic anticoagulants postoperatively. Results There was a significant difference of the mean D-dimer level on the 1st day between the patients with and without intraoperative administration of heparin (8.9 ± 6.6 vs. 15.7 ± 12.7, P < 0.05). Although there were no patients with symptomatic deep venous thrombosis and pulmonary embolism, asymptomatic pulmonary embolism was detected by pulmonary perfusion scintigraphy in three patients who did not receive intraoperative heparin. The operative blood loss and postoperative drainage were similar in both groups and no bleeding complications were observed. In conclusion, we recommend a safe and inexpensive regimen comprising 1,000 U of intravenous unfractionated heparin intraoperatively, postoperative pneumatic compression, and early active mobilization for prevention of thoromboembolic complications after total hip arthroplasty.     

The Number of Metastatic Lymph Nodes is a Significant Risk Factor for Bone Metastasis and Poor Outcome After Surgery for Linitis Plastica-type Gastric Carcinoma

BACKGROUND: Linitis plastica-type gastric carcinoma remains a disease with poor prognosis despite an aggressive surgical approach. Although a prominent pattern of disease failure is peritoneal carcinomatosis, some patients experience rapid disease progression without signs of the peritoneal disease. METHODS: Clinicopathologic data from 178 patients with linitis plastica-type gastric cancer operated on between 1991 and 2000 were analyzed. Survival stratified by curability of surgery, pN stage, and patterns of failure were evaluated by using the Kaplan-Meier method, and chi(2) test was used to evaluate correlation between the number of metastatic lymph nodes in terms of pN categories and the incidence of various patterns of metastasis and recurrence. Cox regression hazard model was used to identify independent prognostic factors. RESULTS: R0 resection was performed only among 82 patients (46% of those who underwent laparotomy). Node metastasis was frequent with only 22 patients classified as pN0. Peritoneal carcinomatosis was observed in 131 patients and was the commonest pattern of recurrence. Bone metastasis, found in 13 patients, was associated with poor outcome, and its incidence was significantly correlated with the number of metastatic nodes. pT4 status and pN3 status were identified as significant independent prognostic determinants. CONCLUSION: Treatment strategy for the linitis plastica should in general combine surgery with aggressive treatment directed toward peritoneal disease. However, patients with >16 metastatic nodes more often are associated with bone metastasis than those with modest nodal involvement and suffer from poor prognosis.     

Radiofrequency ablation with hand-assisted laparoscopic surgery for the treatment of hepatocellular carcinoma in the caudate lobe

OBJECTIVE: To assess the feasibility and safety of radiofrequency ablation (RFA) with hand-assisted laparoscopic surgery (HALS) for hepatocellular carcinoma (HCC) in the caudate lobe with severe liver dysfunction. SUMMARY BACKGROUND DATA: HCC in the caudate lobe remains one of the most difficult locations where various treatments tend to pose problems regarding the optimal surgical approach. The technique of HALS has thus been proposed as a useful method for performing a safe RFA therapy. For this study, we assessed the feasibility and safety of RFA with HALS for the treatment of HCC in the caudate lobe with liver dysfunction. PATIENTS AND METHODS: Between July 1999 and February 2005, 5 patients who suffered from HCC in the caudate lobe were indicated for RFA. The percutaneous puncture was difficult and all patients have severe liver dysfunction with viral chronic hepatitis. Therefore, RFA was assisted by an inserted hand through a minimal skin incision under laparoscopic inspection. An intraoperative endoscopic ultrasound examination was performed before RFA to determine the tumor region. The hand-assisted minimal dissection around the caudate lobe was required to detect tumor and avoid injuries of other tissues. RFA for HCC was performed using a cooled-tip (Radionics Inc, Burligton, MA) connected to a RF generator under the programmed cyclic impedance. RESULTS: The surgical procedures consisted of 5 RFA to tumors in the caudate lobe with HALS, which was performed safely, and a postoperative computed tomography scan revealed a sufficient ablation in all patients. There was no operative mortality but 1 patient had minor bile leakage, which was treated conservatively, and all patients recovered and thus were eventually discharged. One patient had local recurrence after 3 months, 3 patients had tumor recurrences in another segment after 6 months. At a mean follow-up 32.2 months, all patients were still alive. CONCLUSIONS: RFA with HALS is considered to be a safe and feasible technique for HCC in the caudate lobe with liver dysfunction.     

The prevalence of intrinsic subtypes and prognosis in breast cancer patients of different races

A recent report indicated that a high prevalence of basal-like breast tumors (estrogen receptor [ER]-negative, progesterone receptor [PR]-negative, human epidermal growth factor receptor [HER] 2-negative, and cytokeratin 5/6-positive and/or HER1-positive) could contribute to a poor prognosis in African American women with breast cancer. It has been reported that Japanese women with breast cancer have a significantly better survival rate than other races in the USA. These findings suggest that breast cancers in Japanese women have favorable biological characteristics. To clarify this hypothesis, we conducted a cohort study to investigate the prevalence of intrinsic subtypes and prognosis for each subtype in 793 Japanese patients. This study revealed a very low prevalence (only 8%) of basal-like breast tumors with aggressive biological characteristics in Japanese patients. Survival analysis showed a significantly poorer prognosis in patients with basal-like tumors than in those with luminal A tumors (ER- and/or PR-positive, and HER2-negative) with favorable biological characteristics. These findings support the hypothesis that breast cancers in Japanese women have more favorable biological characteristics and a better prognosis than those in other races. In conclusion, the prevalence of basal-like breast tumors could influence the prognosis of breast cancer patients of different races. The prevalence of intrinsic subtypes should be taken into account when analyzing survival data in a multi-racial/international clinical study.