A comparative study of degree of colorectal distention with manual air insufflation or automated CO2 insufflation at CT colonography as a preoperative examination

Objectives

The purpose of this study was to compare the degree of colorectal distention between manual insufflation using room air and automatic insufflation using carbon dioxide for computed tomography colonography performed as a preoperative examination for patients with colon cancer.

Materials and methods

Participants comprised 200 patients who underwent computed tomography colonography immediately after colonoscopy from October 2011–2012. The first 100 patients were examined using manual insufflation, and the remaining 100 patients were examined using automated insufflation. Two radiologists independently assessed colorectal distention using a 4-point scale in six segments: cecum, ascending colon, transverse colon, descending colon, sigmoid colon, and rectum. Mean scores of the two radiologists were used to analyze whether any differences existed between techniques in terms of the degree of distention per segment.

Results

Mean distention values for the colonic lumen were better using the automated technique than with the manual technique in both positions (p < 0.05). In segments, distention was significantly better using the automated technique than using the manual technique in the sigmoid and descending colon for prone patients, and in all segments for supine patients.

Conclusions

Automated carbon dioxide insufflation offered significantly improved colorectal distention scores compared to manual room air insufflation.     

Factors predicting mortality in emergency abdominal surgery in the elderly

ABSTRACT: OBJECTIVE: This study aimed to investigate clinical features of abdominal emergency surgery in elderly patients, and to determine factors predicting mortality in these patients. METHODS: The study population included 94 patients aged 80 years or older who underwent emergency surgery for acute abdominal diseases between 2000 and 2010. Thirty-six patients (38.3%) were male and fifty-eight patients (61.7%) were female (mean age, 85.6 years). Main outcome measures included background of the patient's physical condition (concomitant medical disease, and performance status), cause of disease, morbidity and mortality, and disease scoring system (APACHE II, and POSSUM). Prognostic factors affecting mortality of the patient were also evaluated by univariate analysis using Fisher's exact test and Mann- Whitney U-test, and by multivariate analysis using multiple logistic regression analysis. RESULTS: Of the 94 patients, 71 (75.5%) had a co-existing medical disease; most patients had hypertension (46.8%). The most frequent surgical indications were acute cholecystitis in 23 patients (24.5%), followed by intestinal obstruction in 18 patients (19.1%). Forty-one patients (43.6%) had complications during hospital stay; the most frequent were surgical site infection (SSI) in 21 patients (22.3%) and pneumonia in 12 patients (12.8%). Fifteen patients died (overall mortality, 16%) within 1 month after operation. The most common causes of death were sepsis related to pan-peritonitis in 5 patients (5.3%), and pneumonia in 4 patients (4.3%). Multiple logistic regression analysis showed that time from onset of symptoms to hospital admission and the POSSUM scoring system could be prognostic factors for mortality. CONCLUSIONS: Mortality in elderly patients who underwent emergency surgery for acute abdominal disease can be predicted using the disease scoring system (POSSUM) and on the basis of delay in hospital admission. Keywords.     

Gene expression profile of renal proximal tubules regulated by proteinuria

BACKGROUND: Proximal tubules activated by reabsorption of protein are thought to play significant roles in the progression of kidney diseases. Thus, identification of genes related to proteinuria should provide insights into the pathological process of tubulointerstitial fibrosis. METHOD: Gene expression profiles were constructed by means of direct sequencing procedures to identify genes induced in the mouse kidney proximal tubules (PT) exposed to proteinuria. RESULTS: By comparing the gene expression of control PT to that of disease model PT, the abundantly expressed genes in control PT were down-regulated presumably because of potentially toxic effects of proteinuria. From the more than 1000 up-regulated genes, an immunity related gene, thymic shared antigen-1 (TSA-1), and a novel gene, GS188, were selected for further characterization. The increased expression of TSA-1, a member of the Ly-6 family, and of GS188 in response to proteinuria was confirmed by Northern analysis, immunohistochemistry, in situ hybridization and laser microdissection along with real-time PCR analysis. Full length cloning of GS188 identified it as a family member of LR8 that was reported to express predominantly in fibroblasts. CONCLUSIONS: The gene expression profiles showed that the expression patterns in PT were changed dramatically by proteinuria. The profiles include novel genes that should be further characterized to aid the understanding of the pathophysiology of progressive kidney diseases.     

Propofol Increases Pulmonary Artery Smooth Muscle Myofilament Calcium Sensitivity: Role of Protein Kinase C

Background: Vascular smooth muscle tone is regulated by changes in intracellular free Ca2+ concentration ([Ca2+]i) and myofilament Ca2+ sensitivity. These cellular mechanisms could serve as targets for anesthetic agents that alter vasomotor tone. This study tested the hypothesis that propofol increases myofilament Ca2+ sensitivity in pulmonary artery smooth muscle (PASM) via the protein kinase C (PKC) signaling pathway.

Methods: Canine PASM strips were denuded of endothelium, loaded with fura-2/AM, and suspended in modified Krebs- Ringer's buffer at 37[degrees]C for simultaneous measurement of isometric tension and [Ca2+]i.

Results: The KCl (30 mm) induced monotonic increases in [Ca2+]i and tension. Verapamil, an L-type Ca2+ channel blocker, attenuated KCl-induced increases in [Ca2+]i and tension to an equal extent. In contrast, propofol attenuated KCl-induced increases in [Ca2+]i to a greater extent than concomitant changes in tension and caused an upward shift in the peak tension-[Ca2+]i relation. Increasing extracellular Ca2+ in the presence of 30 mm KCl resulted in similar increases in [Ca2+]i in control and propofol-pretreated strips, whereas concomitant increases in tension were greater during propofol administration. The Ca2+ ionophore, ionomycin (0.1 [mu]m), increased [Ca2+]i to approximately 50% of the value induced by 60 mm KCl. Under these conditions, propofol (10, 100 [mu]m) caused increases in tension equivalent to 11 +/- 2 and 28 +/- 3% of the increases in tension in response to 60 mm KCl, whereas [Ca2+]i was slightly decreased. Similar effects were observed in response to the PKC activator, phorbol 12-myristate 13-acetate (PMA, 1 [mu]m). Specific inhibition of PKC with bisindolylmaleimide I before ionomycin administration decreased the propofol- and PMA-induced increases in tension and abolished the propofol- and PMA-induced decreases in [Ca2+]i. Selective inhibition of Ca2+-dependent PKC isoforms with Go 6976 also attenuated propofol-induced increases in tension.     

Management of adrenal metastasis from hepatocellular carcinoma

Purpose: Although the adrenal gland is a common site of extrahepatic metastasis from hepatocellular carcinoma (HCC), there are no definitive guidelines for the treatment of adrenal metastasis. This study examines the effectiveness of various treatments for this disease. Methods: We retrospectively analyzed 20 patients treated for adrenal metastasis of HCC by adrenalectomy (n = 13), transarterial chemoembolization (TACE), or percutaneous ethanol injection therapy (PEIT) (n = 7). Results: There were no significant differences in cumulative survival rates between patients given adrenalectomy and those given TACE or PEIT, either after completing treatment for primary HCC or after the first treatment for adrenal metastasis. Six of seven patients with tumor thrombi in the inferior vena cava (IVC) from adrenal metastasis underwent adrenalectomy combined with intracaval thrombectomy, five of whom survived for more than 1 year after surgery, and two of whom are still alive without any recurrence more than 3 years after surgery. PEIT showed good results for small adrenal metastasis. Conclusion: These findings suggest that therapeutic modalities should be chosen according to the clinical features of each individual, including the size of the metastatic tumor, whether there is invasion into the IVC, the function of the remaining liver, and the existence of intra- and/or nonadrenal extrahepatic lesions. Furthermore, intracaval tumor thrombectomy could be indicated for patients with IVC thrombus if they are suitable candidates for surgery. Received: July 9, 2001 / Accepted: July 2, 2002 Reprint requests to: Y. Shimahara     

New Pancreatic Duct-Invagination Anastomosis Using UltrasonicDissection for Nonfibrotic Pancreas with a Nondilated Duct

Nonfibrotic pancreases with a nondilated duct are susceptible to pancreatic fistula or leakage following pancreaticoduodenectomy. We developed a novel pancreatic duct-invagination anastomosis using an ultrasonic dissector and applied this technique to 14 consecutive pancreaticoduodenectomies and 1 segmental pancreatectomy for otherwise normal pancreases. With the aid of an ultrasonic dissector, even branch pancreatic ducts were skeletonized, ligated securely, and divided during pancreatic transection. Moreover, the main duct was exposed (> 1 cm) easily by ultrasonic dissection and a small-caliber pancreatic tube was inserted into the duct on the stump. Subsequently, pancreatic duct invagination could be easily done through a 10 G intravenous catheter passed through the gastrointestinal tract. The main duct was anchored to the adjacent serosa, but any pancreatic parenchymal sutures, possibly leading to internal laceration and/or parenchymal ischemia particularly in soft nonfibrotic pancreases, were avoidable during the procedures. All the anastomoses were done within 10 minutes. Only 1 patient (6.7%)developed pancreatic fistula, which resolved spontaneously in 21 days postoperatively. Neither anastomotic leakage nor remnant pancreatitis was seen in this series. Although a prospective, randomized study is needed, this technique may contribute to reduced morbidity after pancreaticoduodenectomy for a nonfibrotic pancreas with a nondilated main duct.     

Anesthesia protocols for early vitrectomy in former preterm infants diagnosed with aggressive posterior retinopathy of prematurity

Aggressive posterior retinopathy of prematurity (ROP) can, if left untreated, rapidly progress to total retinal detachment within 1–2 weeks. Early surgical intervention with vitrectomy has been attempted to treat and prevent further retinal detachment. We investigated the anesthetic management of 29 infants with aggressive posterior ROP undergoing early vitrectomy. Postmenstrual age at surgery ranged from 35 to 47 weeks (median 41). Weight ranged from 1408 to 3478 g (median 1875). All infants underwent general anesthesia with fentanyl and sevoflurane. Mean surgical and anesthetic times were 88.6 and 143.6 min, respectively. In two patients, vitrectomy was postponed for one week due to enteric perforation in one patient and meningitis in the other, because the anticipated perioperative risk was deemed high. There were no intraoperative complications, except in one patient who developed pulmonary edema following upper airway obstruction. All patients survived to be discharged from NICU or transferred to the referring hospital. In all cases, complete or partial retinal reattachment was successfully achieved. Early vitrectomy for aggressive posterior ROP may be effective despite associated perioperative risks. As this condition progresses rapidly, prompt preoperative organization, including anesthetic planning, is important and useful. Anesthesiologists can play an important role in the perioperative management of such high-risk infants.