Influence of microcatheter length on flow rates of disposable infusion kits

BACKGROUND AND OBJECTIVE: Continuous spinal analgesia (CSA) offers considerable pain relief, and has been used in various procedures such as for surgery and cancer pain control. In Japan, portable and disposable infusion kits are increasingly employed for continuous epidural analgesia and CSA. In CSA, the use of a microcatheter is expected to reduce the incidence of spinal headache previously encountered with larger catheters. However, the flow rate of disposable infusion kits is reduced when used in conjunction with a microcatheter. METHODS: This study aimed to investigate the influence of catheter length on the flow rate of two different devices: 20- or 91-cm 28-G microcatheters connected to balloon- or syringe-type infusion pumps were examined (50 mL, 1 mL h(-1)). There were four groups each of 10 experiments: Group A: balloon-type infuser, 91 cm catheter; Group B: balloon-type infuser, 20 cm catheter; Group C: syringe-type infuser, 91 cm catheter; Group D: syringe-type infuser, 20 cm catheter. RESULTS: The mean flow rate in Group A was significantly less than that in Group B and the mean flow rate in Group C was significantly less than Group D (P < 0.05). CONCLUSION: These results indicated that the use of a shorter microcatheter achieves a better flow rate during CSA.     

Therapeutic strategy and outcome of stenting for subclavian and innominate artery occlusive disease

We performed stenting for the subclavian artery (SA) and innominate artery occlusive disease in 14 patients between April, 2000 and March, 2003. In 13 of 14 patients, good dilatation was obtained with stenting. In one patient with left SA occlusion, true lumen could not be detained from either proximal or distal sides of the occluded lesion, so stent deployment was not performed. From June, 2002, we performed stenting using combined femoral and brachial approaches in 6 of 8 patients. In patients in whom occlusive lesion existed in the proximal portion of the SA, it was useful strategy to create a "pull-through" system to stabilize the guiding catheter position in the aorta or the proximal portion of the SA, and to protect the vertebral artery (VA) with a balloon catheter. Post-operative morbidity was 0%. Restenosis was manifested in one patient (8%) two years after stent placement, and in-stent PTA was carried out. In stenting for the subclavian and innominate arteries, the pull-through system is considered useful for stabilization of the guiding catheter, and protection of the VA for prevention of distal embolism to the VA.     

Complications and diagnostic yield of stereotactic biopsy for the patients with malignant brain tumors

PURPOSE: The purpose of this study was to assess the complication risk rate and diagnostic yield in a series of 211 procedures performed by a consistent method at one institute. MATERIAL AND METHOD: Two hundred and one patients underwent 211 stereotactic biopsy procedures for diagnosis of malignant brain tumor at Niigata University between 1987-2001. Indication for stereotactic biopsy is decided on the following factors: 1) the patient is elderly or unsuitable for craniotomy; 2) the tumor location is in a deep, diffusing, multiple, eloquent site; 3) cytoreductive surgery is not needed to treat the suspected pathology. The specimen was obtained from the target point of CT scan by the aspiration method under local anesthesia except for in six patients who were children or needed operation for a VP shunt under general anesthesia. The lesion was located in 114 cases of cerebral hemisphere, in 44 cases of basal ganglia, in 11 cases of cerebellum and in 11 cases of spreading site. RESULT: Histological diagnosis was obtained in 188 of 211 procedures and the diagnostic yield was 93.5%. There were 104 high grade gliomas, 16 low grade gliomas, 5 germ cell tumors, 37 malignant lymphomas, 19 metastatic tumors and 13 negative/inconclusive biopsies. Sixteen patients incurred complications (7.6%). Four patients (1.6%) suffered intratumoral hemorrhage. Emergency craniotomy was performed in three patients and stereotactic aspiration of hematoma was carried out in one patient. Furthermore, of 12 complications, 9 occurred with the patient showing symptoms of worsening neurological deficit, 2 occurred with general convulsion and 1 occurred with severe facial pain. CONCLUSION: This study provided evidence that stereotactic biopsy was a safe and reliable tool for patients with unresectable malignant brain tumors.     

Circular myectomy for the treatment of congenital esophageal stenosis owing to tracheobronchial remnant

The management of the congenital esophageal stenosis is not well established. The authors present an infant with critical esophageal stenosis owing to tracheobronchial remnant. This lesion was managed successfully by circular myectomy of the esophageal wall without resection. An 1-year-old girl was referred for recurrent vomiting and dysphagia. An esophagogram showed an abrupt stenosis, and endoscopic ultrasonography showed cartilaginous tracheobronchial remnants within the esophageal wall. The extirpation of muscular layer, which contained cartilage, was attempted. Circular muscular layer was resected in 1 cm width leaving mucosal layer intact. Muscular layer was closed horizontally with absorbable sutures. The patient is free from the symptoms and eats normally 1 year after surgery. In case of short segmental stenosis owing to tracheobronchial remnant, this may be the preferred approach.     

Effect of postoperative chemotherapy on the serum alpha-fetoprotein level in hepatoblastoma

Purpose

It is generally accepted that postoperative chemotherapy does not affect the serum alpha-fetoprotein (AFP) level. The authors report on 3 patients who supposedly showed chemotherapy-related changes in their AFP levels after operation.

Methods

This study included 3 patients with hepatoblastoma (1 case of PRETEXT III and 2 cases of PRETEXT IV).

Results

One patient with PRETEXT III underwent a complete tumor resection, and the postoperative AFP level decreased until it reached the normal range. However, he consistently exhibited a transient, 2- to 3-fold increase in the AFP after each course of chemotherapy for 3 courses. The chemotherapy regimen had to be stopped because of drug-induced encephalopathy, but he has been followed up for 5 years without any evidence of recurrence, and his AFP level has also remained stable and in the normal range. Two patients with PRETEXT IV, who underwent a curative tumor resection, also showed similar chemotherapy-related changes in AFP levels. Both of these cases were observed only after the administration of routine postoperative chemotherapy instead of administering further high-dose chemotherapy. The AFP level remained stable for 17 months and 7 months after the cessation of chemotherapy in 2 cases, respectively.

Conclusions

Regarding the postoperative chemotherapy of hepatoblastoma, we have to pay close attention to both the AFP status during chemotherapy as well as the absolute AFP level.     

Increase in urinary leukotriene LTE4 levels in acute asthma: correlation with airflow limitation

BACKGROUND: Leukotrienes play a key role in the pathophysiology of chronic asthma. Activation of leukotriene pathways is accompanied by rises in detectable urinary levels of leukotriene E4 (LTE4). The relationship between urinary LTE4 levels and factors associated with acute asthma has not been determined. METHODS: Adults aged 15-54 years presenting with moderate to severe acute asthma were evaluated at emergency departments in 16 US sites. Forced expiratory volume in 1 second (FEV1) was measured during the first 60 minutes after arrival and at specified times until discharge or admission. Urine samples for measurement of LTE4 levels were obtained either on arrival at the study site and/or before discharge. Patients were seen 2 weeks later for follow up, at which time repeat FEV1 measurements and urine samples for LTE4 were obtained. RESULTS: One hundred and eighty four patients were evaluated; LTE4 results from both the acute and follow up periods were available for analysis in 146. Urinary LTE4 levels were increased during asthma exacerbations compared with levels obtained 2 weeks later (geometric means 111.7 and 75.6 pg/mg creatinine, respectively, mean percentage change -32.3; 95% confidence interval (CI) for the mean percentage change -39.6 to -24.3, p<0.001). The correlation between improvement in FEV1 and decline in LTE4 over the 2 week interval was significant (p<0.001, r=0.43). CONCLUSIONS: Activation of leukotriene pathways in acute asthma is correlated with the degree of airflow obstruction, and resolution of the asthma exacerbation is associated with a reduction in leukotriene levels.     

Procedures of Choice for Resection of Primary and Recurrent Liver Metastases from Colorectal Cancer

Although liver resection offers the only realistic chance of cure for patients with liver metastases from colorectal cancer, no consensus exists as to the procedure of choice for managing these tumors. Data from 193 patients who underwent hepatectomy for liver metastases from colorectal cancer and 26 of 193 patients who underwent repeat hepatectomy for recurrent metastases were collected. The suitability of resection was evaluated retrospectively based on known risk factors for recurrence and patterns of recurrence. On multivariate analysis, a positive surgical margin (SM+) was the only risk factor for recurrence after the initial resection (p < 0.01). SM+ (p < 0.01) and nonanatomic resection (p < 0·05) that was less than a sectionectomy (p < 0.05) were risk factors for recurrence after repeat hepatectomy. Multiple tumors (four or more) was the most common pattern of recurrence after initial hepatectomy, and recurrence close to the line of resection was most common after repeat hepatectomy. Based on tumor doubling times, recurrence after initial hepatectomy seemed to originate from the primary colorectal lesion, whereas recurrence after repeat hepatectomy was derived from a hepatic metastasis. Retrospective analysis suggests that hepatectomy with clear surgical margins is more important than anatomic resection for initial hepatectomy, and at least sectionectomy is necessary for repeat hepatectomy.