Reconstruction methods to achieve optimal postoperative bowel function following low anterior resection for rectal cancer

After low anterior resection for rectal cancer, approximately 50% of patients experience defecatory malfunction such as multiple evacuations, urgency, and soiling. Since the neorectum is constructed with the remaining colonic segment, it can only substitute for the rectum to a limited extent. A straight anastomosis is most frequently used when the rectal remnant is sufficient, such as in high anterior resection. When the height of anastomosis is close to the anal sphincter, a J-pouch, a side-to-end, or a transverse coloplasty pouch are constructed to achieve better postoperative bowel function. The advantage of J-pouch reconstruction is not only the increased volume but also may be decreased motility when compared with straight reconstruction. In terms of postoperative function, the side-to-end and transverse coloplasty pouch have both been reported to exhibit similar functional results to J-pouch reconstruction. To obtain optimal functional results, pouch reconstruction should be considered, especially when the height of anastomosis is at the levator plane.     

Compression of a nasotracheal tube in the nasal cavity of a patient with craniofacial fibrous dysplasia

A 42-year-old woman with craniofacial fibrous dysplasia underwent osteoplasty of maxillary and mandibular bone. Preoperative CT images showed osteosclerosis and ground glass appearance of the right side of the skull including the orbit, temporal bone, paranasal sinus, and maxillary and mandibular bones, as well as hypertrophy of the nasal septum. Inhalation anesthesia was induced and 8.0-mmID polyvinyl chloride endotracheal tube was inserted via the left nostril with slight resistance. At emergence, a 10-Fr suction catheter could not be passed throgh the tube but an 8-Fr nasogastric tube could be passed. A part of the tube positioned in the nasal cavity was apparently compressed. Preoperative examination of the nasal cavity and nasal septum using CT or MRI may be desirable for nasotracheal intubation in the patients with craniofacial tumor, and the application of a spiral reinforced endotracheal tube may contribute to prevent such cases of airway obstruction in the nasal cavity.     

Right liver graft without middle hepatic vein reconstruction from a living donor

A case of adult-to-adult, living-donor liver transplantation using a right liver graft is described. In the donor operation, when the middle hepatic vein (MHV) was clamped after hepatic transection, reversed flow was detected in MHV tributaries by intraoperative color Doppler ultrasonography. Regurgitated flow in the clamped inferior right hepatic vein was also demonstrated. Portal flow remained hepatopetal during the procedure. Based on these ultrasonographic findings, neither the MHV tributaries nor the inferior right hepatic vein was reconstructed.     

Diverticulitis Causing a High Serum Level of Carbohydrate Antigen 19-9: Report of a Case

We report herein a rare case of diverticulitis causing a high serum level of carbohydrate antigen (CA) 19-9. A 52-year-old man was admitted to our hospital with lower abdominal pain. Laboratory data showed evidence of inflammation and a high serum level of CA 19-9 (370 U/ml). Computed tomography demonstrated thickening of the wall of the sigmoid colon. He was diagnosed as having diverticulitis of the sigmoid colon and was treated with antibiotics. Although his symptoms improved, the presence of a malignancy such as colorectal cancer could not be completely ruled out because of the persistently high serum level of CA19-9. A laparotomy was performed and the sigmoid colon was found to be adherent to the bladder. Under a diagnosis of diverticulitis, a sigmoidectomy was performed. Pathological examination revealed diverticulitis of the sigmoid colon, but there was no evidence of malignancy in the resected specimen. The serum CA19-9 level decreased to normal postoperatively and immunohistochemical staining revealed CA19-9 antigen in the cytoplasm of the diverticular epithelium. Therefore, a possible explanation for the high level of this tumor marker was diverticulitis of the sigmoid colon. Received: June 6, 2001 / Accepted: September 11, 2001     

Effect of Ventilatory Settings on Accuracy of Cardiac Output Measurement Using Partial CO2 Rebreathing

Background: Recently, a new device has been developed to measure cardiac output noninvasively using partial carbon dioxide (CO2) rebreathing. Because this technique uses CO2 rebreathing, the authors suspected that ventilatory settings, such as tidal volume and ventilatory mode, would affect its accuracy: they conducted this study to investigate which parameters affect the accuracy of the measurement.

Methods: The authors enrolled 25 pharmacologically paralyzed adult post-cardiac surgery patients. They applied six ventilatory settings in random order: (1) volume-controlled ventilation with inspired tidal volume (VT) of 12 ml/kg; (2) volume-controlled ventilation with VT of 6 ml/kg; (3) pressure-controlled ventilation with VT of 12 ml/kg; (4) pressure-controlled ventilation with VT of 6 ml/kg; (5) inspired oxygen fraction of 1.0; and (6) high positive end-expiratory pressure. Then, they changed the maximum or minimum length of rebreathing loop with VT set at 12 ml/kg. After establishing steady-state conditions (15 min), they measured cardiac output using CO2 rebreathing and thermodilution via a pulmonary artery catheter. Finally, they repeated the measurements during pressure support ventilation, when the patients had restored spontaneous breathing. The correlation between two methods was evaluated with linear regression and Bland-Altman analysis.

Results: When VT was set at 12 ml/kg, cardiac output with the CO2 rebreathing technique correlated moderately with that measured by thermodilution (y = 1.02x, R = 0.63; bias, 0.28 l/min; limits of agreement, -1.78 to +2.34 l/min), regardless of ventilatory mode, oxygen concentration, or positive end-expiratory pressure. However, at a lower VT of 6 ml/kg, the CO2 rebreathing technique underestimated cardiac out-put compared with thermodilution (y = 0.70x; R = 0.70; bias, -1.66 l/min; limits of agreement, -3.90 to +0.58 l/min). When the loop was fully retracted, the CO2 rebreathing technique overestimated cardiac output.     

Expression of connective tissue growth factor is increased in injured myocardium associated with protein kinase C beta2 activation and diabetes

Protein kinase C (PKC) beta isoform activity is increased in myocardium of diabetic rodents and heart failure patients. Transgenic mice overexpressing PKCbeta2 (PKCbeta2Tg) in the myocardium exhibit cardiomyopathy and cardiac fibrosis. In this study, we characterized the expression of connective tissue growth factor (CTGF) and transforming growth factor beta (TGFbeta) with the development of fibrosis in heart from PKCbeta2Tg mice at 4-16 weeks of age. Heart-to-body weight ratios of transgenic mice increased at 8 and 12 weeks, indicating hypertrophy, and ratios did not differ at 16 weeks. Collagen VI and fibronectin mRNA expression increased in PKCbeta2Tg hearts at 4-12 weeks. Histological examination revealed myocyte hypertrophy and fibrosis in 4- to 16-week PKCbeta2Tg hearts. CTGF expression increased in PKCbeta2Tg hearts at all ages, whereas TGFbeta increased only at 8 and 12 weeks. In 8-week diabetic mouse heart, CTGF and TGFbeta expression increased two- and fourfold, respectively. Similarly, CTGF expression increased in rat hearts at 2-8 weeks of diabetes. This is the first report of increased CTGF expression in myocardium of diabetic rodents suggesting that cardiac injury associated with PKCbeta2 activation, diabetes, or heart failure is marked by increased CTGF expression. CTGF could act independently or together with other cytokines to induce cardiac fibrosis and dysfunction.     

Cadaver fitting study of the DexAide right ventricular assist device

The DexAide right ventricular assist device (RVAD) has been developed to provide an implantable RVAD option to surgeons. The aim of this study was to determine the optimal cannula design and optimal implantation location of the DexAide RVAD in preparation for its clinical use. Separately, a HeartMate XVE left ventricular assist device (LVAD) and CorAide LVAD models were implanted into the preperitoneal and right thoracic space, and the anatomical fit of the DexAide RVAD was evaluated in five preserved human cadavers. The DexAide RVAD inflow cannula was inserted through the diaphragmatic surface of the right ventricle and the outflow was directed to the pulmonary artery. Right thoracic implantation of the DexAide RVAD provided an excellent fit with either the HeartMate or CorAide LVAD in all cadavers. The results of this study will guide improvements in the designs of cannulae and implantation of the DexAide RVAD in future clinical applications.     

Persistent local pain after posterior spine surgery for thoracic lesions

Many surgeons have investigated local pain associated with posterior spine surgery for cervical or lumbar lesions. However, little information is available concerning local pain after posterior thoracic spine surgery. This prospective study was, thus, performed to investigate the frequency and clinical features of local pain after posterior spine surgery for thoracic lesions. In 29 consecutive patients undergoing posterior spine surgery for various thoracic spinal disorders, local pain was investigated before and after surgery. In all 19 patients with preoperative back pain presumably due to thoracic lesions, pain was well alleviated after surgery. In contrast, 6 patients (21%) newly developed persistent shoulder angle pain after surgery, which resembled axial pain after cervical laminoplasty. In 5 of these 6 patients surgical exposure was extended to the cervicothoracic junction, whereas persistent shoulder angle pain was independent of disease etiologies and surgical procedure, and all of the 5 patients had no other etiologies of local pain such as surgical site infections, hardware failures, pseudoarthrosis, other metastasis, and vertebral fractures. These results suggest that dissection of muscle attachments to the cervicothoracic junction would play some part in the development of persistent local pain after posterior spine surgery for thoracic lesions, although surgical exposure of the zygapophysial joints at the cervicothoracic junction might be a possible source of postoperative shoulder pain. Therefore, to minimize such surgical complications, muscle insertions into the cervicothoracic junction should be preserved as far as possible.     

Intraoperative blood salvage during liver resection: a randomized controlled trial

OBJECTIVE: A randomized controlled trial was conducted to clarify the effectiveness of intraoperative blood salvage in reducing blood loss. BACKGROUND: Although reduction of central venous pressure (CVP) is thought to decrease blood loss during liver resection, no consistently effective and safe method for obtaining the desired reduction of CVP has been established. METHODS: Living liver donors scheduled to undergo liver graft procurement were randomly assigned to a blood salvage group, in which a blood volume equal to approximately 0.7% of the patient's body weight was collected before the liver transection, or a control group. The surgeons were blinded to the randomization results. The primary outcome measure was blood loss during liver parenchymal division. A multivariate analysis was also performed. RESULTS: Seventy-nine donors were allocated intraoperatively to the blood salvage group (n = 40) or the control group (n = 39). The amount of blood loss during liver transection was significantly smaller in the blood salvage group than in the control group (median loss during transection, 140 mL vs. 230 mL, P = 0.034). The CVP at the beginning of the liver parenchymal division was significantly lower in the blood salvage group than in the control group (median, 5 cm H2O vs. 6 cm H2O, P = 0.005). The results of a multivariate analysis revealed that intraoperative blood salvage offered the advantage of reduced blood loss during liver parenchymal division (adjusted OR, 0.31; 95% CI, 0.11-0.85, P = 0.025). CONCLUSION: Modest intraoperative blood salvage significantly and safely reduced blood loss during hepatic parenchymal transection.