Inhaled olprinone improves contractility of fatigued canine diaphragm

Background. Diaphragmatic fatigue is implicated as a cause ofrespiratory failure. This study was undertaken to evaluate theeffects of inhaled olprinone, a newly developed phosphodiesteraseIII inhibitor, on the contractility of fatigued diaphragm indogs. Methods. Diaphragmatic fatigue was induced by intermittent supramaximalbilateral electrophrenic stimulation at a frequency of 20 Hzstimulation applied for 30 min. When fatigue was established,group I (n=8) received inhaled vehicle; group II (n=8) receivedinhaled olprinone 1 mg; group III (n=8) received inhaled olprinone2 mg. Diaphragmatic contractility was assessed by transdiaphragmaticpressure (Pdi, cm H₂O). Results. In the presence of fatigue, in each group, Pdi at low-frequency(20 Hz) stimulation decreased from baseline values (P<0.05),whereas Pdi at high-frequency (100 Hz) stimulation did not change.In groups II and III, during olprinone administration, Pdi atboth stimuli increased from fatigued values (20 Hz stimulation:group II (mean (SD)) 10.8 (1.0) to 12.5 (1.3), group III 10.9(1.7) to 15.0 (3.0); 100 Hz stimulation: group II 20.1 (1.9)to 22.6 (1.3), group III 20.6 (2.0) to 24.5 (2.0), P<0.05).The increase in Pdi was larger in group III than in group II(P<0.05). Conclusions. Inhaled olprinone produces a dose-dependent improvementin contractility of fatigued canine diaphragm. Br J Anaesth 2002; 88: 408–11     

Endoscopic submucosal dissection with a combination of small-caliber-tip transparent hood and flex knife is a safe and effective treatment for superficial esophageal neoplasias

Background  

Superficial esophageal neoplasias resected in piecemeal manner with endoscopic mucosal resection (EMR) sometimes recur locally, and additional treatments need to be developed. Efficacy and safety of endoscopic submucosal dissection (ESD) for esophageal neoplasias are not sufficiently demonstrated, so we conducted a retrospective study to evaluate the efficacy and safety of ESD for superficial esophageal neoplasias.     

Postpancreatoduodenectomy Hemorrhage Treated by Combined Transcatheter Arterial Embolization and Superior Mesenteric Artery to Iliac Artery Bypass: Report of a Case

Postpancreatectomy hemorrhage is a potentially life-threatening complication. We report herein our experience with a 65-year-old man with locally advanced pancreatic adenocarcinoma who underwent pancreatoduodenectomy with lymphadenectomy following neoadjuvant chemoradiotherapy. On postoperative day 45, he developed massive hematemesis. Angiography revealed active bleeding from the common hepatic artery, and transcatheter coil embolization of that vessel was successfully performed. On postoperative day 64, he again developed massive hematemesis. Angiography revealed active bleeding from the proximal superior mesenteric artery. Immediately after coil embolization of that vessel, bypass grafting between the superior mesenteric artery and the right common iliac artery was performed, using a greater saphenous vein graft. The combination of embolization and bypass grafting is an option for treatment of bleeding from the superior mesenteric artery in an emergent situation.Key words: Superior mesenteric artery, Bleeding, Bypass, Pancreatoduodenectomy, Postpancreatectomy hemorrhagePostpancreatectomy hemorrhage (PPH) is a rare but life-threatening complication, often associated with the presence of a pancreatic fistula or intraabdominal abscess.¹ The mortality associated with arterial bleeding after pancreatoduodenectomy is reportedly between 14.3% and 30.7%.^2–6 With recent advances in interventional radiology techniques, transcatheter arterial embolization (TAE) has become an alternative to surgical treatment.^3,5,7,8 However, it may be difficult to treat these patients with interventional radiology techniques alone, given their often unstable condition. In addition, the inappropriate use of TAE for arterial bleeding, especially after pancreatoduodenectomy, can lead to end-organ infarction and subsequent infection. We report herein our experience with a patient who had bleeding from the superior mesenteric artery (SMA) after pancreatoduodenectomy. This patient was successfully treated using SMA coil embolization followed by creation of an SMA-iliac artery bypass using a greater saphenous vein graft.     

Maximum stenosis of extracranial internal carotid artery: effect of luminal morphology on stenosis measurement by using CT angiography and conventional DSA.

PURPOSE: To assess the luminal morphology of the extracranial internal carotid artery at three-dimensional (3D) computed tomographic (CT) angiography and how this factor affects measurement of maximum carotid arterial stenoses at conventional intraarterial digital subtraction angiography (DSA). MATERIALS AND METHODS: Prospectively, conventional intraarterial DSA and 3D CT angiography were performed in 42 carotid arteries in 21 patients with suspected carotid artery disease. The longest axis length-perpendicular axis length (L/P) ratios of the arterial lumen on the cross-sectional images at the most stenotic area and distal nonstenotic area were analyzed by acquiring multiplanar reconstruction (MPR) images at 3D CT angiography. The maximum stenosis was measured at each modality with North American Symptomatic Carotid Endarterectomy Trial criteria. RESULTS: The L/P ratios in the most stenotic areas ranged from 1.0 to 3.2 (mean, 1.5 +/- 0.5 [SD]). The mean difference in maximum percentage of stenosis between the two modalities for L/P ratios of 2.0 or greater was significantly greater than that for L/P ratios of less than 1.5 (P < .05). Three carotid arteries with 70%-99% stenosis, with grades determined only with 3D CT angiography, had L/P ratios of 2.0 or greater. CONCLUSION: On MPR images at 3D CT angiography, the lumen of extracranial internal carotid artery stenosis showed a wide range of shapes. When a carotid artery has a high L/P ratio, the luminal morphology of the carotid artery stenosis may affect the assessment of maximum stenosis of the internal carotid artery at conventional DSA.     

Transcatheter arterial embolization for bone metastases from hepatocellular carcinoma

The objective of this study was to determine which of the following three methods is the most effective for the treatment of bone metastases from hepatocellular carcinoma (HCC): transcatheter arterial embolization (TAE); combination of TAE and external radiotherapy; or external radiotherapy alone. Thirty-nine metastatic bone lesions from HCC in 33 patients were retrospectively reviewed. Each lesion underwent either TAE alone (group A, n = 11), TAE followed by radiotherapy (group B, n = 17), or radiotherapy alone (group C, n = 11). They were evaluated on the following subjects: pain relief; improvement of daily activities; and complications. Each treatment was effective for pain relief (89-94%) and improvement of daily activities (73-82%). The mean time interval from the beginning of each treatment to the onset of initial pain relief was 4.7 days in group A, 4.8 days in group B, and 15 days in group C. Recurrence of the pain after the initial pain relief was noted in 75% in group A, 20% in group B, and 88% in group C. Pyrexia and local pain commonly occurred after TAE. In conclusion, TAE is effective in relieving pain immediately and in improving the patients' daily activities. The combination of TAE and radiotherapy is recommended for permanent pain relief.     

Prognosis of Japanese Metastatic Renal Cell Carcinoma Patients in the Cytokine Era: A Cooperative Group Report of 1463 Patients

Background

Incidence rate of renal cell carcinoma (RCC) differs among countries. The rates of Asian countries are lower than those of countries in North America or Europe but are exceptionally high in Japanese males. Approximately 30% of patients with RCC have metastasis at initial diagnosis, and another 30% have metastasis after nephrectomy. Clinical studies of risk factors in patients with metastatic RCC (mRCC) are mainly based on data from non-Asian patients.

Objectives

We aimed to investigate the prognosis of Japanese patients and their prognostic factors.

Design, setting, and participants

The subjects of this study were 1463 patients who were clinically diagnosed with RCC with metastasis in 40 Japanese hospitals between January 1988 and November 2002.

Measurements

The primary end point was overall survival calculated from first diagnosis of mRCC to death or last follow-up. We also investigated the relationship between survival and clinical features.

Results and limitations

The median overall survival time was 21.4 mo. The estimated survival rates at 1, 3, 5, and 10 yr were 64.2%, 35.2%, 22.5%, and 9.1%, respectively; they contrasted with data from the United States of 54%, 19%, 10%, and 6%, respectively for the same periods. A high percentage of patients had undergone nephrectomy (80.5%) and metastasectomy (20.8%), both of which were shown to prolong survival.

Conclusions

The median survival time in the present study was approximately twice as long as that of previous studies from North America or Europe. Early diagnosis of metastasis, nephrectomy, metastasectomy, and cytokine-based therapy seemed to improve the prognosis of RCC patients in the present study.     

Effect of synchronized intermittent mandatory ventilation on respiratory workload in infants after cardiac surgery

BACKGROUND: Synchronized intermittent mandatory ventilation (SIMV) is commonly used in infants and adults. However, few investigations have examined how SIMV reduces respiratory workload in infants. The authors evaluated how infants' changing respiratory patterns when reducing SIMV rate increased respiratory load. The authors also investigated whether SIMV reduces infant respiratory workload in proportion to the rate of mandatory breaths and which rate of SIMV provides respiratory workloads similar to those after tracheal extubation. METHODS: When 11 post-cardiac surgery infants aged 2-11 months were to be weaned with SIMV, the authors randomly applied five levels of mandatory breathing: 0, 5, 10, 15, and 20 breaths/min. All patients underwent ventilation with SIMV mode: pressure control ventilation, 16 cm H2O; inspiratory time, 0.8 s; triggering sensitivity, 0.6 l/min; and positive endexpiratory pressure, 3 cm H2O. After establishing steady-state conditions at each SIMV rate, arterial blood gases were analyzed, and esophageal pressure, airway pressure, and airflow were measured. Inspiratory work of breathing, pressure-time products, and the negative deflection of esophageal pressure were calculated separately for assisted breaths, for spontaneous breaths, and for total breaths per minute. Measurements were repeated after extubation. RESULTS: As the SIMV rate decreased, although minute ventilation and arterial carbon dioxide tension were maintained at constant values, spontaneous breathing rate and tidal volume increased. Work of breathing, pressure-time products, and negative deflection of esophageal pressure increased as the SIMV rate decreased. Work of breathing and pressure-time products after extubation were intermediate between those at a SIMV rate of 5 breaths/min and those at 0 breaths/min. CONCLUSION: When the load to breathing was increased progressively by decreasing the SIMV rate in post-cardiac surgery infants, tidal volume and spontaneous respiratory rate both increased. In addition, work of breathing and pressure-time products were increased depending on the SIMV rate.     

Prostatic carcinoma presenting as neck lymph node metastases: report of two cases]

We report two cases of prostatic carcinoma presenting as neck lymph node metastases. Case 1: A 56-year-old man was admitted to our hospital with the chief complaint of left lower abdominal pain. A lymph node was palpable on the left side of the neck swollen. Rectal examinations revealed prostatic stony-hard mass. Computed tomography showed a swollen neck and paraaortic lymph nodes on the left side. PSA level was 380 ng/ml. Transperineal prostatic biopsy revealed moderately differentiated adenocarcinoma, and neck lymph node biopsy also revealed metastatic adenocarcinoma. We diagnosed him with prostatic carcinoma stage D2 (LYM). He underwent hormonal therapy (TAB) but died 13 months later. Case 2: A 66-year-old man was admitted to our hospital with the chief complaint of a large palpable mass on the left side of the neck. Resection of this mass revealed metastatic adenocarcinoma. Rectal examination revealed no malignant lesions, but the PSA level was high, 1,700 ng/ml. Transperineal prostatic biopsy revealed moderately differentiated adenocarcinoma. Computed tomography revealed paraaortic and pelvic lymph node metastases and bone scintigram revealed abnormal uptake, bone metastases. We diagnosed him with prostatic carcinoma stage D2 (LYM OSS). We performed bilateral testectomy followed by hormonal therapy (TAB). The lymph node metastases disappeared after 4 months of therapy.     

Endoscopic submucosal dissection and preoperative assessment with endoscopic ultrasonography for the treatment of rectal carcinoid tumors

Background

Rectal carcinoid tumors 10 mm in diameter or smaller located within the submucosal layer can be cured by local excision including endoscopic treatment. But complete resection of these tumors with endoscopic polypectomy is difficult. This study aimed to evaluate the usefulness of endoscopic submucosal dissection (ESD) and endoscopic ultrasonography (EUS) for the treatment of rectal carcinoid tumors.

Methods

In this study, 22 rectal carcinoid tumors in 21 patients were evaluated with EUS and treated using ESD from January 2004 to December 2008.

Results

The mean size of the resected tumors was 6.1 mm (range, 2.0–10 mm) on histopathologic evaluations. When the sizes of the tumors shown by EUS and histopathologic evaluation were compared, the mean values were not significantly different. All the tumors were located within the submucosal layer, and the accuracy of the preoperative depth determination with EUS was 100% (22/22). The mean duration of the ESD procedure was 37 min (range, 20–71 min). The overall rate of en bloc resection with ESD was 100% (22/22). Although postoperative bleeding occurred in two cases (9%), both cases were successfully managed by endoscopic hemostasis. No perforation or recurrence was observed during the mean follow-up period of 30 months (range, 7–66 months).

Conclusions

Endoscopic submucosal dissection and preoperative assessment with EUS are effective for treating rectal carcinoid tumors and enabling en bloc resection.