Results of unilateral adrenalectomy in subclinical Cushing's syndrome due to adrenocorticotropic hormone‐independent macronodular adrenal hyperplasia

Adrenocorticotropic hormone (ACTH)‐independent bilateral adrenocortical macronodular adrenocortical hyperplasia (AIMAH) is a rare cause of Cushing's syndrome (CS). Traditionally, bilateral adrenalectomy with subsequent lifetime steroid replacement has been considered to be the treatment of choice. In the present study, we evaluated the long‐term results of unilateral adrenalectomy in subclinical CS (SCS) due to AIMAH, with regard to the main laboratory and clinical abnormalities. Two patients with confirmed SCS due to AIMAH underwent unilateral laparoscopic adrenalectomy to reduce the cortisol‐secreting tissue. These procedures were successfully conducted in both cases without open conversion, and no surgery‐related morbidity occurred. In both cases, the size of the remaining adrenal gland appeared quite stable, and neither of the patients showed a Cushingoid appearance. Unilateral adrenalectomy achieved satisfactory and prolonged control of cortisol secretion, and also reduced the risk of metabolic disorders and cardiovascular disease after surgery. It can be a safe and effective treatment for SCS due to AIMAH, while maintaining the patient's quality of life.     

Dose effects of propofol on hemodynamic and cytokine responses to endotoxemia in rats

Purpose Our previous studies have demonstrated that propofol inhibits hypotension, metabolic acidosis, and cytokine responses and reduces mortality in endotoxemic rats. The purpose of this study was to elucidate whether these beneficial effects of propofol on hemodynamics and cytokine responses were dose related.Methods Forty-eight rats were divided at random among four equal groups: groups S, M, and L received intravenous propofol administration (5, 10, and 20mg·kg^–1·h^–1, respectively) immediately after endotoxin (Escherichia coli endotoxin; 15mg·kg^–1, i.v.) was given. Group E received endotoxin alone. We assessed hemodynamics and plasma cytokine [tumor necrosis factor (TNF)- and interleukin (IL)-6] concentrations for 5h following endotoxin injection.Results Systolic arterial pressure (SAP) was significantly higher at 4 and 5h in groups S and M than in group E (P < 0.05), although SAP decreased progressively in all groups. Endotoxin injection increased the TNF- and IL-6 concentrations in all groups. The increase in TNF- concentrations at 2h was significantly lower in group M than in group E (P < 0.05). On the other hand, the increase in IL-6 concentration at 5h was significantly lower in groups M and L than in group E (P < 0.05).Conclusion The effects of propofol on blood pressure and cytokine responses were influenced by the dose of propofol, although the relationship did not follow simple linearity.     

Effect of flumazenil on recovery from sevoflurane anesthesia in children premedicated with oral midazolam before undergoing herniorrhaphy with or without caudal analgesia

Purpose Oral midazolam is frequently used to treat children, but its effect on recovery from anesthesia is controversial. This study was designed to evaluate the effect of flumazenil on reversal of midazolam during recovery from sevoflurane-induced anesthesia in children who underwent caudal analgesia compared to those who did not.Methods A series of 60 children 1–8 years of age, with an American Society of Anesthesiologists (ASA) physical status of 1 or 2, who were scheduled to undergo herniorrhaphy were randomly assigned to one of four groups: group 1, control/placebo; group 2, control/flumazenil; group 3, caudal/placebo; group 4, caudal/flumazenil. After oral administration of midazolam 0.5 mg · kg⁻¹, anesthesia was induced and maintained with sevoflurane and nitrous oxide in oxygen via a face mask with spontaneous ventilation. The time from the discontinuation of anesthetics to emergence was recorded, and at the time of discharge from the operating room each patient’s recovery characteristics were assessed using a three-point scale.Results Emergence from anesthesia was significantly less agitated in the group of children who underwent caudal analgesia without flumazenil compared to the other three groups. Flumazenil shortened the time to emergence regardless of the application of caudal analgesia, and caudal analgesia delayed the time to emergence regardless of flumazenil administration.Conclusion Caudal analgesia and avoiding the use of flumazenil synergistically resulted in the emergence from anesthesia in a less agitated state for children who underwent herniorrhaphy after oral midazolam premedication.This study was presented in part at the International Anesthesia Research Society’s 77th Clinical and Scientific Congress, New Orleans, March 22, 2003     

The detection of cerebral hypoperfusion with bispectral index monitoring during general anesthesia

We describe a patient in whom the bispectral index (BIS) decreased to 0 during surgery. A 42-yr-old man with chronic renal failure was scheduled to undergo construction of an arteriovenous shunt. He had a history of acute cerebral hemorrhage. An intracranial hematoma had been removed a month earlier with almost complete neurological recovery. He had uncontrolled hypertension. His systolic blood pressure was 180 mm Hg before anesthesia induction. Anesthesia was induced with 100 mg of propofol and 3% sevoflurane. After laryngeal mask insertion, anesthesia was maintained with nitrous oxide 60% in oxygen and sevoflurane. BIS decreased to near 0 on 2 occasions: after anesthesia induction and shortly after the start of the surgery. His systolic blood pressure decreased to 110 mm Hg and BIS increased when his blood pressure was increased to 130-140 mm Hg. The decrease in BIS was suspected to be the result of decreased cerebral blood flow. The systolic blood pressure of 110 mm Hg (mean blood pressure, 80 mm Hg) was probably less than the lower limit of autoregulation. Although BIS has some limitations as a cerebral monitor, it was useful for detecting possible cerebral hypoperfusion in this case.     

The number of metastatic lymph nodes: a promising prognostic determinant for gastric carcinoma in the latest edition of the TNM classification

Background: The number of metastatic regional lymph nodes determines the new pN categories in the 5th edition of the TNM classification.

Study Design: Our retrospective study was conducted to compare the new method of defining lymph node status with the conventional classification, consisting of the anatomic extent of lymph node metastases, a well-established prognostic factor. The study was based on clinical data for 493 patients with gastric carcinomas who underwent potentially curative operations and had histologically confirmed nodal metastases. These patients were stratified into 1) n categories according to the Japanese Classification of Gastric Carcinoma, 2) the new pN categories, and 3) the pN categories determined by the number of metastatic perigastric nodes resected by standard D1 gastrectomy. Survival data were analyzed for each group.

Results: The number of metastatic nodes after D2 lymphadenectomy reflected prognosis well and was shown by multivariate analysis to be a strong independent prognostic factor. When the classification was performed limited to the metastatic perigastric nodes, stage migration was evident, but the variable remained competent as a prognostic indicator.

Conclusions: The number of metastatic nodes is a promising determinant in the new international stage classification.     

Haemodynamic effects of induction of general anaesthesia with propofol during epidural anaesthesia

PURPOSE: To clarify whether propofol administration during thoracic or lumbar epidural anaesthesia intensifies the haemodynamic depression associated with epidural anaesthesia. METHODS: Patients (n = 45) undergoing procedures of similar magnitude were randomly divided into three study groups: a control group (n = 15) receiving general anaesthesia alone and two study groups undergoing thoracic (n = 15) and lumbar epidural anaesthesia (n = 15) before induction of general anaesthesia. All patients received 2 mg.kg-1 propofol at a rate of 200 mg.min-1, followed by a continuous infusion of 4 mg.kg-1.hr-1. Mean arterial blood pressure (MAP) and heart rate (HR) were measured at baseline, three minutes after induction, and one minute after tracheal intubation in all three groups and at 20 min after epidural anaesthesia was established in the thoracic and lumbar groups. RESULTS: Following epidural anaesthesia, MAP decreased from 94 +/- 14 (SD) at baseline to 75 +/- 11 mmHg (P < 0.0001) in the thoracic group and from 92 +/- 12 to 83 +/- 15 mmHg in the lumbar group. After propofol administration, MAP decreased further in the thoracic group to 63 +/- 9 mmHg (P = 0.0077) and to 67 +/- 10 mmHg (P = 0.0076) in the lumbar group. The MAP following propofol induction in the thoracic group (P < 0.0001) and in the lumbar group (P = 0.0001) was lower than MAP in the control group (81 +/- 9 mmHg). HR decreased only in response to thoracic epidural anaesthesia (P = 0.0066). CONCLUSION: The hypotensive effects of propofol are additive to those of epidural anaesthesia, resulting in a profound decrease in mean arterial pressure.     

Slit diaphragm dysfunction in proteinuric states: identification of novel therapeutic targets for nephrotic syndrome

Several recent studies have demonstrated that the slit diaphragm of the glomerular epithelial cell (podocyte) is the structure likely to be the principal barrier in the glomerular capillary wall. Nephrin identified as a gene product mutated in congenital nephrotic syndrome located at the outer leaflet of plasma membranes of the slit diaphragm. The anti-nephrin antibody is capable of inducing massive proteinuria, which indicates that nephrin is a key functional molecule in the slit diaphragm. Expression of nephrin was reduced in glomeruli of minimal change nephrotic syndrome. Some recent studies demonstrated that podocin, CD2-associated protein and NEPH1 are also functional molecules in the slit diaphragm, and their expressions are altered in membranous nephropathy and also in focal glomerulosclerosis. These observations suggested that the alteration of the molecular arrangement in the slit diaphragm is involved in the development of proteinuria in several kinds of glomerular diseases. Recent studies of our group have demonstrated that type 1 receptor-mediated angiotensin II action reduced the expression of the slit diaphragm-associated molecules and that type 1 receptor blockade ameliorated proteinuria by preventing the function of angiotensin II on the slit diaphragm. By the subtraction hybridization techniques using glomerular cDNA of normal and proteinuric rats, we detected that synaptic vesicle protein 2B and ephrin B1 are involved in the maintenance of the barrier function of the slit diaphragm. Presented at the 36th Eastern Regional Meeting of the Japanese Society of Nephrology.     

Impact of internal biliary drainage after pancreaticoduodenectomy

Background  Bile acid has an important role in protecting immune systems related to gut-associated lymphoid tissue. This study was designed to evaluate the effects of internal biliary drainage after a pancreaticoduodenectomy (PD) on postoperative nutrition and complications in a randomized study. Methods  The authors compared the morbidity, mortality, and postoperative nutritional status of 46 patients who had a hepaticojejunostomy (HJ) with a stented external biliary drainage (group E) or with a non-stented internal biliary drainage (group I) after a PD. Results  Systemic infection was recognized in four patients in group E, while no patients in group I. Transthyretin at postoperative 28 days in group I was 15.6 ± 6.2, higher than that in group E. Retinol-binding protein at postoperative 28 days in group I was 2.6 ± 1.0 and also higher than that in group E. Conclusion  HJ with no-stented internal biliary drainage was not associated with systemic infections and mortality, but showed the possibility of improving nutritional status.     

Living donor liver transplantation for biliary atresia complicated by situs inversus: technical highlights.

Living-donor liver transplantation (LDLT) has become an established technique to treat children with end-stage liver disease. Biliary atresia (BA), one of the most common indications for liver transplantation in children, can be associated with situs inversus (SI). In the past, the presence of SI has been considered to be an absolute contraindication for liver transplantation because of the technical difficulties. Recently, some reports of successful diseased-donor liver transplantation in patients with BA complicated by SI have been published; however, few reports of that with LDLT exist. The technical difficulties involved with LDLT for such cases have not been described. Herein, we present 4 successful cases of LDLT for BA with SI. Complex anomalies associated with SI, such as a hepatic artery arising from the supraceliac aorta, a preduodenal portal vein, and absence of the retrohepatic inferior vena cava, increase the technical difficulties involved with the operation. Additional caution is required in LDLT because a living-donor graft has short vessels and the availability of vascular grafts from the donor is limited. In conclusion, LDLT for BA complicated by SI can be managed successfully with technical modifications and scrupulous attention. This series represents the largest reported group of patients with BA complicated by SI who underwent a successful LDLT procedure.