[Safety of Pancreaticoduodenectomy in Patients of Advanced Age and Our Efforts to Prevent Postoperative Pneumonia]

With the aging of society, surgical patients are becoming older. The same trend can be seen in patients undergoing highly invasive operations, such as pancreaticoduodenectomy(PD). The risk of postoperative complications is reportedly higher in patients of advanced age, and postoperative pneumonia occurs at particularly high frequency. We investigated the safety of PD in patients of advanced age with a focus on the prevention of postoperative pneumonia. In total, 223 patients underwent PD at our department from January 2015 to December 2020. We compared various parameters between older patients(≥80 years of age, n=32)and younger patients(<80 years of age, n=191). Although older patients had lower nutrition scores, there was no significant difference in the incidence of postoperative complications between the two groups. Three older patients who were undergoing swallowing rehabilitation by a speech-language therapist did not develop postoperative pneumonia. However, one patient who did not receive swallowing rehabilitation developed postoperative pneumonia. Based on these findings, we plan to incorporate swallowing evaluation before postoperative oral intake into the clinical pathway and introduce speech-language therapy intervention in patients of advanced age.

Preoperative serum CA19-9 predicts postoperative pancreatic fistula in PDAC patients: retrospective analysis at a single institution

Background

Postoperative pancreatic fistula (POPF) is a critical complication of pancreatectomy in patients with pancreatic ductal adenocarcinoma (PDAC). Recent papers reported that serum carbohydrate antigen (CA)19-9 levels predicted long-term prognosis. We investigated whether preoperative serum CA19-9 levels were associated with POPF in PDAC patients.

Methods

This cohort study was conducted at a single institution retrospectively. Clinicopathologic features were determined using medical records.

Results

Among of 196 consecutive patients who underwent pancreatectomy against PDAC, 180 patients whose CA19-9 levels were above the measurement sensitivity, were registered in this study. The patients consisted of 122 patients who underwent pancreaticoduodenectomy and 58 patients who underwent distal pancreatectomy. Several clinicopathological factors, including CA 19-9 level, as well as surgical factors were determined retrospectively based on the medical records. Patients with high CA19-9 levels had a significantly higher incidence of POPF than those with low levels (43.9 vs. 13.0%, P < 0.0001). The receiver operating characteristic curves calculated that the cutoff CA19-9 value to predict POPF was 428 U/mL. CA19-9, BMI, curability, and histology were statistically significant risk factors for POPF by univariate analysis. Multivariate analysis showed that CA19-9 and BMI levels were statistically significant independent risk factors for POPF. CA19-9 levels were correlated with both histology and curability. Disease free survival and overall survival of patients with higher levels of CA19-9 were significantly shorter than that of patients with lower levels of preoperative serum CA19-9.

Conclusions

In patients undergoing pancreatectomy for PDAC, higher preoperative CA19-9 levels are a significant predictor for POPF.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-022-01825-3.

What are the factors predictive of postoperative complications in patients with colorectal cancer undergoing stenting as a bridge to surgery?

OBJECTIVE

Using a self-expanding metal stent as a bridge to surgery (BTS) is considered a reasonable strategy for patients with acute malignant large bowel obstruction. Since postoperative complications have a negative impact on patient survival, we aim to clarify the predictors of complications in patients undergoing BTS using a self-expanding metal stent.

METHODS

We conducted a retrospective review of 61 patients with colorectal cancer (CRC) who underwent stenting as a BTS at our institution. We analyzed the association of postoperative complications with clinicopathologic, surgical, and patient factors, and with the prestenting or preoperative laboratory data.

RESULTS

Both postoperative complications in general and severe complications were significantly associated with a longer stenotic-section length (p = 0.007 and p = 0.003), lower preoperative hemoglobin levels (p < 0.001 and p = 0.081), and lower prestenting hemoglobin levels (p = 0.006 and p = 0.042). Multivariate logistic regression analysis showed that lower prestenting (<13.0 g/dl) and preoperative (<11.5 g/dl) hemoglobin levels were independent predictive factors for postoperative complications (odds ratio [OR]: 4.15; 95% confidence interval [CI]: 1.07-18.90; p = 0.040; and OR: 4.93; 95% CI: 1.35-20.28; p = 0.016). A stenotic-section length of 5.0 cm or greater was predictive of severe complications (OR: 25.67; 95% CI: 1.95-1185.00; p = 0.011).

CONCLUSIONS

Our data suggest that lower hemoglobin levels before stenting and a longer length of the stenotic section of bowel might predict postoperative complications in patients with CRC undergoing BTS for obstruction.

A case of right hepatic duct entering cystic duct successfully treated by laparoscopic subtotal cholecystectomy through preoperatively placed biliary stent

BACKGROUND

Laparoscopic cholecystectomy is a well-established surgical procedure and is one of the most commonly performed gastroenterological surgeries. Therefore, strategy for the management of rare anomalous cystic ducts should be determined.

CASE PRESENTATION

A 56-year-old woman was admitted to our hospital owing to upper abdominal pain and diagnosed with acute cholecystitis. Magnetic resonance cholangiopancreatography suspected that several small stones in gallbladder and the right hepatic duct drained into the cystic duct. Endoscopic retrograde cholangiopancreatography confirmed the cystic duct anomaly, and an endoscopic nasobiliary drainage catheter (ENBD) was placed at the right hepatic duct preoperatively. Intraoperative cholangiography with ENBD confirmed the place of division in the gallbladder, and laparoscopic subtotal cholecystectomy was safely performed.

CONCLUSIONS

The present case exhibited rare right hepatic duct anomaly draining into the cystic duct, which might have caused biliary tract disorientation and bile duct injury (BDI) intraoperatively. Any surgical technique without awareness of this anomaly preoperatively might insufficiently prevent BDI, and preoperative ENBD would facilitate safe and successful surgery.

Laparoscopic surgery for two patients with strangulated transomental hernias

Background

Transomental hernias are a rare type of internal hernia. We report two cases of successful cases of laparoscopic repair. One required laparotomy due to concern for intestinal viability.

Case presentation

The first patient was a 67-year-old man who presented with abdominal pain and vomiting. He had no history of laparotomy or abdominal injury. Computed tomography suggested small bowel obstruction and possible intestinal strangulation. Emergent laparoscopy found approximately 200 cm of small bowel was strangulated around the greater omentum. The strangulation was released laparoscopically, but because of the color of the strangulated bowel, laparotomy was performed to evaluate viability. The involved portion of intestine was not resected. The patient experienced transient postoperative paralytic ileus and was discharged on postoperative day 14. The second patient was a 56-year-old man who presented with abdominal pain. Abdominal computed tomography revealed dilatation of the small intestine and a closed loop suggesting ileus due to intestinal strangulation. An emergency laparoscopy found a transomental hernia, and the strangulation was released laparoscopically. Recovery was uneventful, and the patient was discharged on postoperative day 6.

Conclusion

Transomental hernia can be successfully treated laparoscopically. In cases where bowel viability is a concern, laparotomy should not be hesitated.

Single incision laparoscopic surgery (SILS) for Meckel's diverticulum

A 65-year-old male patient presented with a chief complaint of abdominal pain. Abdominal computed tomography (CT) showed slight intestinal dilation and obstruction of the upper right quadrant of the small intestine, while ectopic gastric mucosal scintigraphy revealed abnormal accumulation in agreement with the CT-identified structure. The cause of bowel obstruction was diagnosed as Meckel’s diverticulum; the patient was referred for surgery. A small laparotomy was performed with a 35-mm skin incision to the center of the navel. Once a lap disk was attached, a laparoscope was inserted to visualize the abdominal cavity. The small intestine that includes the structure was pulled out from the umbilicus to the outside of the peritoneal cavity and partially resected. On the pathological tissue findings, the patient was diagnosed with Meckel’s diverticulum. We report our experience with single-lap laparoscopic surgery for a case of intestinal obstruction caused by Meckel’s diverticulum and review pertinent literature.

Hypogenesis of right hepatic lobe in a laparoscopic cholecystectomy for acute gallstone cholecystitis: A case report

Hypogenesis or agenesis of right hepatic lobe is a rare abnormality and is generally associated with gallbladder and biliary tract abnormalities. Cases of biliary injury following cholecystectomy have been reported in patients with agenesis of right hepatic lobe because the anatomical anomalies complicate the surgical approach. We report a case of laparoscopic cholecystectomy in a patient with hypogenesis of right hepatic lobe. A 92-year-old male patient was admitted to our hospital with fever and right lower abdominal pain with suspected acute appendicitis. Abdominal computed tomography revealed gallstones with acute cholecystitis and hypogenesis of right hepatic lobe. He underwent laparoscopic cholecystectomy with the left semilateral decubitus position. The patient's postoperative course was uneventful. In conclusions, some patients with liver lobe hypoplasia do not present with the typical symptoms of acute cholecystitis due to dislocation of the gallbladder. The left semilateral decubitus position with modified placement of port sites is useful for laparoscopic cholecystectomy in patients with hypogenesis of right hepatic lobe.

Significance of lymph node metastasis in pancreatic neuroendocrine tumor

PURPOSE

Pancreatic neuroendocrine tumor (PNET) is relatively rare and has a generally better prognosis than does pancreatic cancer. However, as its prognosis in patients with lymph node metastasis (LNM) is unclear, lymph node dissection for PNET is controversial. Our study aimed to clarify the significance of LNM in PNET.

METHODS

We retrospectively examined 83 PNET patients who underwent pancreatic resections with lymph node dissection at Kumamoto University Hospital, Saiseikai Kumamoto Hospital, and Kumamoto Regional Medical Center from April 2001 to December 2014. Their clinicopathological parameters were analyzed by the absence or presence of LNM, and with regard to the disease-free survival (DFS) and overall survival (OS). A predictive score of LNM was also made using the age, tumor size, primary tumor location, and tumor function.

RESULTS

Although the 5-year OS was 74.8% for LNM⁺ and 94.6% for LNM^- (P = 0.002), LNM was not an independent risk factor for the OS in a multivariate analysis. However, tumors larger than 1.8 cm were found to be an independent prognostic factor, and the cut-off value for the predictive score was 1.69.

CONCLUSIONS

Although LNM was not an independent prognostic factor, lymph node dissection is recommended for patients whose predictive score is larger than 1.69.

Prognostic factor of distal bile duct cancer (DBDC) and ampullary cancer (AC) after pancreatoduodenectomy

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Background: Ampullay cancer (AC) is relatively good prognosis in the biliary tract cancer. Such as LN metastasis, pancreatic invasion is a prognostic factor in AC. On the other hand, Distal bile duct cancer (DBDC) is somewhat good prognosis in the biliary tract cancer. Such as ductal resection margin positive is a prognostic factor in DBDC. There are few papers considered to both difference. Therefore, we conducted this study to examine the difference of AC and DBDC. Methods: To evaluate Cancer-Specific Survival (CaSS), Recurrence-Free Survival (RFS) and prognostic factors after pancreatoduodenectomy (including pylorus-preserving pancreatoduodenectomy: PPPD, subtotal stomach-preserving pancreatoduodenectomy: SSPPD) based on a series of 80 patients of AC and 36 patients of DBDC from 1996 to 2015. We reviewed and analyzed the clinicopathologic data, recurrence and survival. Results: Five years CaSS and RFS of AC were 72.3% and 72.5%. In univariate analysis, pancreatic invasion, R1or R2 resection, duodenal invasion and lymph node metastasis are significantly poor prognosis. In multivariate analysis, pancreatic invasion and R1or R2 resection are poor prognostic factors (pancreatic invasion, p = 0.0012, hazard ratio (HR) 5.65 [confidence interval (CI) 1.92-19.5 95%], R1or R2 resection, p = 0.0043, HR 6.22 [CI 1.68-40.2 95%]). On the other hand, five years CaSS and RFS of DBDC were 35.8% and 46.8%. In univariate analysis, pancreatic invasion (+) ≥ 5 mm in depth, and duodenal invasion are significantly poor prognosis. In multivariate analysis, duodenal invasion is the only poor prognostic factors (p = 0.0227, HR 2.90 [CI 1.16-7.39 95%]). Conclusions: DBDC is considerable poor prognosis compared with AC. Lymph node metastasis is not prognostic factor depends on D2 LN dissection in AC, than pancreatic invasion. Cancer cells invaded pancreatic parenchyma in AC; pancreatic invasion may be the most important prognostic factor by biology-like pancreatic cancer. Duodenal invasion in DBDC was prognostic factor reflects the degree of development of the cancer beyond pancreatic parenchyma. Further clinicopathological and biological studies are needed to confirm our findings.

Significance of lymph node metastasis in pancreatic neuroendocrine tumors

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Background: Pancreatic neuroendocrine tumor (PNET) is uncommon, and its prognosis is generally better than that of pancreatic cancer. Although some PNET patients have lymph node metastasis, its effect on their prognosis is unclear, lymph node dissection for PNET is controversial. Our study aimed to clarify the significance of lymph node metastasis in PNET. Methods: We retrospectively examined 83 PNET patients who underwent pancreatic resections at Kumamoto University Hospital, Saiseikai Kumamoto Hospital and Kumamoto Regional Medical Center from April 2001 to December 2014. We excluded NET G3 from them. Their clinicopathological parameters were analyzed by the absence or presence of lymph node metastasis, and with regard to disease-free survival (DFS) and overall survival (OS). Results: Although 5-year DFS was lymph node metastasis group: 73.3%, and no lymph node metastasis group: 85.0% (P = 0.474); and 5-year OS was lymph node metastasis: 91.7% and no lymph node metastasis: 96.2% (P = 0.055), lymph node metastasis was not an independent risk factor for DFS or OS in multivariate analysis. However, tumors larger than 1.8 cm were found to be an independent prognostic factor. Conclusions: Although lymph node metastasis was not an independent prognostic factor, tumors larger than 1.8 cm were an independent prognostic factor, and warrant lymph node dissection for PNET patients with tumors of this size.

Prognostic factor of carcinoma of the ampulla of vater after surgery

270

Background: General rules for biliary tract cancer in Japan were revised and Stage of biliary tract cancer was compliant with the seventh UICC. Carcinoma of the Ampulla Vater (CAV) is relatively good prognosis among the biliary tract cancer, such as lymph node metastasis, pancreatic invasion and perineural invasion has been reported to be prognostic factors. We investigated the validity of TNM-Stage by examining the prognostic factors from the outcome of resection experienced. Methods: To evaluate prognostic factors after surgery based on a series of 70 patients of CAV from 1996 to 2014. Twenty-eight patients received pancreatoduodenectomy (PD), 25 patients received pylorus-preserving pancreatoduodenectomy (PPPD) and 17 patients received subtotal stomach-preserving pancreatoduodenectomy (SSPPD). We reviewed and analyzed the clinicopathologic data, surgical outcomes, recurrence and survival. Results: Actuarial disease-specific survival (DSS) was 65 % at five years. In univariate analysis, pancreatic invasion, lymph node metastasis and duodenal invasion are significantly poor prognosis. In multivariate analysis, pancreatic invasion is the only poor prognostic factor (p = 0.0023, hazard ratio (HR) 5.31 [confidence interval (CI) 1.77-18.9 95%]); lymph node metastasis and duodenal invasion are not significantly different (p = 0.0672 and 0.8769, respectively). Also, in the study of relapse risk factors, pancreatic invasion and lymph node metastasis are significantly different. In TNM-Stage II, those of T3N0, 1 are poor prognosis than T1, 2N1 (p = 0.0334). Conclusions: Pancreatic invasion is an independent poor prognostic and recurrence risk factor. The Stage of Japanese Society of Biliary Surgery has reflect prognosis than TNM-Stage in carcinoma of the Ampulla Vater.

Unusual biliary myoepithelial carcinoma in liver-case report and immunohistochemical study

Myoepithelial carcinoma is a well-known tumor of salivary gland, representing 1% of all salivary gland tumors. They have also been reported in other sites as skin/soft tissue, breast and lung. This paper reports a rare case of primary myoepithelial carcinoma in the liver, as well as discusses the findings of immunohistochemistry. The clinical manifestations, imaging characteristics, and histopathological changes of myoepithelial carcinoma in this case were described. The patient was a 33 years old female presented with a cystic tumor in the right lobe of the liver. As the liver tumor increased in size within six months, malignant neoplasm was suspected and thus anterior hepatic segmentectomy was performed. The mass composed of glandular-like structures and trabecular sheets of spindled shaped cells and epithelioid cells which were positive for myoepithelial markers. The tumor recurred within one year, in the left lobe of the liver and partial left lobe lobectomy was performed. The tumor resected showed similar histology to the primary tumor. Three months later, another recurrence was noted for which radiofrequency ablation was performed. This report presents a recurrent case of myoepithelial carcinoma in the liver and suggests the possibility of biliary origin of such tumor.

Statins inhibit tumor progression via an enhancer of zeste homolog 2-mediated epigenetic alteration in colorectal cancer

While statin intake has been proven to reduce the risk of colorectal cancer (CRC), the mechanism of antitumor effects and clinical significance in survival benefits remain unclear. Statin-induced antiproliferative effects and its underlying mechanism were examined using six CRC cell lines. Statins except pravastatin showed antiproliferative effects (simvastatin ≥ fluvastatin > atorvastatin) even though both of simvastatin and pravastatin could activate mevalonate pathways, suggesting the statin-mediated antiproliferative effects depended on non-mevalonate pathway. Indeed, statin induced p27(KIP1) expression by downregulation of histone methyltransferase enhancer of zeste homolog 2 (EZH2), which acts as an epigenetic gene silencer. Additionally, the use of simvastatin plus classII histone deacetylase (HDAC) inhibitor (MC1568) induced further overexpression of p27(KIP1) by inhibiting HDAC5 induction originated from downregulated EZH2 in CRC cells and synergistically led to considerable antiproliferative effects. In the clinical setting, Statin intake (except pravastatin) displayed the downregulated EZH2 expression and inversely upregulated p27(KIP1) expression in the resected CRC by immunohistochemical staining and resulted in the significantly better prognoses both in overall survival (p = 0.02) and disease free survival (p < 0.01) compared to patients without statin intake. Statins may inhibit tumor progression via an EZH2-mediated epigenetic alteration, which results in survival benefits after resected CRC. Furthermore, statin plus classII HDAC inhibitor could be a novel anticancer therapy by their synergistic effects in CRC.

Colonic perforation due to colorectal cancer: predicting postoperative organ failure with a preoperative scoring system and selecting the optimal surgical method based on the prognosis

PURPOSE

The purpose of this study was to predict the postoperative organ derangement before surgery and to select the optimal surgical methods for a perforation due to colorectal cancer.

METHODS

The Mannheim Peritonitis Index (MPI) was used to determine the preoperative status and Sequential Organ Failure Assessment (SOFA) score for postoperative status, retrospectively.

RESULTS

There were 25 cases of colorectal cancer-related colon perforation. These patients were classified as having a preoperative MPI ≤ 29 or ≥ 30 and the mean postoperative SOFA scores were 2.30 ± 2.45 and 7.93 ± 3.45 (p = 0.0002), respectively. Seven of 20 patients who underwent tumor resection received a bowel anastomosis without a stoma. The MPI of these seven patients was low (23.1 ± 7.47) and there were no severe postoperative organ disorders (SOFA score 1.86 ± 2.26). Eighteen of the 25 patients had no distant metastasis. Eight of these 18 patients underwent lymph node (LN) dissection, including intermediate LNs, while the other 10 cases only had the pericolic/perirectal LNs dissected. The average preoperative MPI was 23.9 ± 7.68 and 32.8 ± 5.77, and the postoperative SOFA scores were 3.75 ± 3.01 and 7.10 ± 5.34, respectively.

CONCLUSION

The MPI could be used to predict postoperative organ disorders and thus represents a useful index that can be used to determine the optimal surgical methods.

Safety and short-term therapeutic effects of miriplatin-lipiodol suspension in transarterial chemoembolization (TACE) for hepatocellular carcinoma

AIM

To determine the safety and usefulness of a novel anticancer drug, miriplatin, in transarterial chemoembolization (TACE) for unresectable hepatocellular carcinoma.

PATIENTS AND METHODS

Patients (n=115) who underwent TACE with miriplatin-lipiodol suspension (miriplatin group), and control patients (n=131) who underwent TACE with cisplatin-lipiodol suspension (CDDP group) took part in this study.

RESULTS

The overall incidence of adverse events was significantly lower in the miriplatin group. The percentage of patients attaining treatment effect 4 in both groups was not significantly different. The proportion exhibiting a >50% decrease in positive tumor markers following TACE was significantly greater in the CDDP group for alpha-fetoprotein, but not significantly different for des-gammma-carboxy prothrombin.

CONCLUSION

Miriplatin-lipiodol suspension was associated with reduced intensity of adverse events and had comparable short-term therapeutic effects to cisplatin-lipiodol suspension, thereby indicating its usefulness in TACE.

Germinal center-associated nuclear protein (GANP) has a phosphorylation-dependent DNA-primase activity that is up-regulated in germinal center regions

Antigen stimulation induces a rapid proliferation of B cells for expansion of specific B cell clones and their further differentiation into antibody-producing cells in germinal centers of T-dependent antigen-immunized mice. Previously, we identified a 210-kDa germinal center-associated nuclear protein (GANP) that is up-regulated selectively in germinal centers and carries an MCM-binding domain in the carboxyl-terminal side. In addition, here, we found a region (from 414 to 550 aa) in GANP molecule that is slightly similar to the known DNA-primase component p49. The recombinant GANP fragment covering this region synthesizes RNA primers for extension by DNA polymerase I with single-stranded DNA templates in vitro. GANP DNA-primase activity is controlled by phosphorylation at Ser(502) that is induced by CD40-mediated signaling in vitro and in the germinal center B cells stimulated with antigen in vivo. Overexpression of ganp cDNA in Daudi B cells caused the increased DNA synthesis more than the levels of the mock-transfectants. These evidences suggested that the novel DNA-primase GANP is involved in regulation of cell proliferation of antigen-driven B cells in germinal centers.

Sevoflurane protects stunned myocardium through activation of mitochondrial ATP-sensitive potassium channels

We sought to determine the hemodynamic and cardioprotective effects of sevoflurane in canine stunned myocardium. Forty-nine dogs were allocated to one of seven groups (n = 7 for each). In six separate groups, dogs received vehicle, glibenclamide (a nonselective adenosine triphosphate-dependent potassium [K(ATP)] channel antagonist) (0.3 mg/kg IV) or 5-hydroxydecanoic acid (a mitochondrial K(ATP) channel antagonist) (5 mg/kg IV) in the presence or absence of 1 minimum alveolar concentration (1 MAC) sevoflurane. In an additional group, dogs received 1 MAC sevoflurane with hemodynamic correction. Regional myocardial contractility was evaluated with segment shortening. Measurements were made before and during 15-min ischemia and 90-min reperfusion. Recovery of segment shortening 90 min after reperfusion was significantly improved in the dogs anesthetized with sevoflurane either with or without hemodynamic correction (70.1 +/- 4.2 and 75.9 +/- 3.1% of baseline, respectively), whereas the recovery was poor in control and glibenclamide or 5-hydroxydecanoic acid pretreated dogs (33.3 +/- 4.3, 33.8 +/- 6.8, and 45.0 +/- 5.5% of baseline, respectively). Regional myocardial perfusion showed no significant difference among groups. The results indicate that sevoflurane has a cardioprotective effect mediated through activation of mitochondrial K(ATP) channels and independent of coronary blood flow or reduction in cardiac work.

IMPLICATIONS

Sevoflurane exerts a cardioprotective effect that is mediated via activation of adenosine triphosphate-sensitive potassium channels in ischemic canine hearts.

Interaction of isoflurane and cromakalim, a KATP channel opener, on coronary and systemic haemodynamics in chronically instrumented dogs

BACKGROUND

Although isoflurane has been shown to cause coronary and systemic vasodilation through KATP channel activation, the interaction of KATP channel openers and isoflurane has not been fully investigated. The present study was carried out to determine the haemodynamic actions of cromakalim, a KATP channel opener, under the conscious state and during isoflurane anaesthesia in chronically instrumented dogs.

METHODS

Fourteen dogs were chronically instrumented to measure systemic and coronary haemodynamics. Each dog was randomly assigned to receive doses of either cromakalim, 4 and 10 microg x kg(-1) i.v., or isoflurane, 2.1% end-tidal (1.5 MAC), plus cromakalim, 4 and 10 microg x kg(-1) i.v.

RESULTS

Cromakalim dose-relatedly decreased mean arterial pressure and systemic vascular resistance and increased coronary blood flow in both conscious and anaesthetized states. With isoflurane, the duration of effects of cromakalim were prolonged. Isoflurane exerted an additive effect on the increase in coronary blood flow induced by a low-dose cromakalim, whereas it did not influence the effect of a high-dose cromakalim. The maximum rate of increase in left ventricular pressure and segment shortening were increased by cromakalim in the conscious state but unchanged during isoflurane anaesthesia.

CONCLUSION

The results suggest that the coronary vasodilating effects of isoflurane and cromakalim are basically additive until cromakalim exerts the maximal effect, and that the action of cromakalim on the coronary vasculature is prolonged by isoflurane.

A novel nuclear phosphoprotein, GANP, is up-regulated in centrocytes of the germinal center and associated with MCM3, a protein essential for DNA replication

Antigen (Ag) immunization induces formation of the germinal center (GC), with large, rapidly proliferating centroblasts in the dark zone, and small, nondividing centrocytes in the light zone. We identified a novel nuclear protein, GANP, that is up-regulated in centrocytes. We found that GANP was up-regulated in GC B cells of Peyer's patches in normal mice and in spleens from Ag-immunized mice. GANP-positive cells appeared in the light zone of the GC, with coexpression of the peanut agglutinin (PNA) (PNA)-positive B220-positive phenotype. The expression of GANP was strikingly correlated with GC formation because Bcl6-deficient mice did not show the up-regulation of GANP. GANP-positive cells were mostly surrounded by follicular dendritic cells. Stimulation with anti-micro and anti-CD40 induced up-regulation of ganp messenger RNA as well as GANP protein in B220-positive B cells in vitro. GANP is a 210-kd protein localized in both the cytoplasm and nuclei, with a homologous region to Map80 that is associated with MCM3, a protein essential for DNA replication. Remarkably, GANP is associated with MCM3 in B cells and MCM3 is also up-regulated in the GC area. These results suggest that the up-regulation of GANP might participate in the development of Ag-driven B cells in GCs through its interaction with MCM3.

[Monitored anesthesia care for a patient with malignant pheochromocytoma]

Monitored anesthesia care (MAC) is being increasingly used in the 1990s for a wide variety of diagnostic and therapeutic procedures. The primary objective in providing MAC is to ensure patients' comfort and safety, whether in the operating room or in other places. We experienced MAC for a patient with pheochromocytoma. A 63-year-old man with hepatic metastasis of malignant pheochromocytoma, received transcatheter arterial embolization (TAE) in the angiographic room. Hypertension and ventricular arrhythmia occurred during the hepatic arterial embolization. However, we successfully controlled the hemodynamic changes using phentolamine and propranolol under the close monitoring. He showed an uneventful recovery during postoperative period except for mild hypotension on the third day which needed temporary norepinephrine infusion.

Comparative analysis of systemic and coronary hemodynamics during sevoflurane- and isoflurane-induced hypotension in dogs

We studied the effects of sevoflurane on myocardial contractility and systemic and coronary hemodynamics, as compared with the effects of isoflurane in dogs under the same cardiac work conditions. Sixteen mongrel dogs were anesthetized with alpha-chloralose. Heart was paced at 100 beats/min after producing a complete atrioventricular (A-V) block. Controlled hypotension to a mean arterial pressure (MAP) of 60 mm Hg was induced and maintained by inhalation of either anesthetic, lasting for 60 min. Measurements were made at baseline, 15 min (T1), and 60 min (T2) after starting hypotension, and 30 min after discontinuing equihypotension (T3). Although left ventricular systolic segment shortening (%SS) decreased approximately 20% in both groups, cardiac output (CO) decreased only in sevoflurane during equihypotension (-27.6% at T2). Sevoflurane decreased the coronary blood flow (CBF; -34.8% at T2) with no significant change of coronary vascular resistance (CVR), whereas isoflurane produced a significant decrease in CVR resulting in no change of CBF despite of decreased coronary perfusion pressure (-37.4% at T2). These systemic and coronary vascular effects were continued even at T3. In conclusion, myocardial depressant effects were comparable between sevoflurane and isoflurane. Both systemic and coronary vasodilatory effects of isoflurane are greater than those of sevoflurane.

Malignant pheochromocytoma with multiple hepatic metastases treated by chemotherapy and transcatheter arterial embolization

A 62-year-old Japanese male developed multiple hepatic metastases two years after resection of pheochromocytoma of the right adrenal gland. Transcatheter arterial embolization (TAE) was performed for the purpose of the treatment of hepatic metastases resistant to 27 cycles of combined chemotherapy consisting of cyclophosphamide, vincristine, and dacarbazine. After TAE, the hepatic metastatic lesions decreased in size and hypertension passed its crisis. The present case suggests the utility of TAE for multiple hepatic metastases under careful blood pressure monitoring.

[Endoscopic resection of the thoracic sympathetic trunk for the treatment of frequent syncopal attack of idiopathic long QT syndrome]

A 22 year old man was diagnosed as having Jervell and Lange-Nielsen syndrome (JLNS), which includes a prolonged QTc, congenital neural deafness, and syncopal attacks or sudden death. In spite of medication with beta blocker, syncopal attack increased in frequency since his sister suddenly had died of JLNS. Because left stellate ganglion block improved the QTc dispersion, left cardiac sympathectomy was scheduled under the video-assisted thoracic surgery. After the premedication with midazolam, anesthesia was induced with thiamylal, and maintained with nitrous oxide, sevoflurane, and fentanyl. Serious arrhythmias were not observed throughout the perioperative period. Sympathetic trunk was successfully resected from the top of 1st ganglion to the bottom of 4th ganglion of left thoracic sympathetic trunk. Horner's sign did not appear after the surgery. Although the shortening of QTc was not significant, QTc dispersion during exercise was improved, and syncopal attack was not observed until 6 months after the surgery.

Carbachol, norepinephrine, and hypocapnia stimulate phosphatidylinositol turnover in rat tracheal slices

BACKGROUND

The intracellular mechanisms involved in the alpha-adrenoceptor- or hyperventilation-induced bronchoconstriction remain unknown. Because there is a direct relationship between phosphatidylinositol (PI) metabolism and airway smooth muscle contraction induced by muscarinic agonists, the authors examined the effects of carbachol (CCh), norepinephrine (NE), and hypocapnia on PI turnover in the airway smooth muscle.

METHODS

Rat tracheal slices were incubated in Krebs-Henseleit solution containing LiCl and [3H]myo-inositol in the presence of NE, CCh, or neither. The PCO2 in the solution was 36 +/- 3 mmHg (normocapnia), 19 +/- 2 mmHg (moderate hypocapnia), or 5 +/- 2 mmHg (severe hypocapnia), respectively. [3H]inositol monophosphate (IP1) formed was counted with a liquid scintillation counter.

RESULTS

Basal IP1 formed was greater at severe hypocapnia than at normocapnia. Norepinephrine- and CCh-induced IP1 formation were also greater at hypocapnia than at normocapnia.

CONCLUSIONS

These results indicate that CCh, NE, and hypocapnia stimulate PI turnover in the airway smooth muscle, which would cause bronchoconstriction, and hypocapnia also augments NE- and CCh-induced PI turnover, which could cause worsening of exercise-induced asthma and vagotonic asthma, respectively.

[Interaction of cardiovascular effect of calcium channel blocking drugs and those of inhalation anesthetics in humans]

The hemodynamics in the patients undergoing craniotomy was studied to evaluate the interaction of cardiovascular effects of calcium blocking drugs (nicardipine NCR or diltiazem DL) and those of inhalation anesthetics (0.6% isoflurane Iso or 0.9% sevoflurane Sevo). (Group I = NCR alone, Group II = NCR+Iso, Group III = NCR+Sevo, Group IV = DL alone, Group V = DL+Iso, Group VI = DL+Sevo) Anesthesia was maintained with neuroleptanesthesia (N2O 60%). A 30% reduction in systolic blood pressure was achieved and this was maintained for 60 minutes in each groups. The following effects were observed during induced hypotension. 1) Heart rate increased in the group I and II, but decreased in the group IV, V and VI. 2) Cardiac output increased in the group I and II, but significantly decreased in the group VI. 3) Systemic vascular resistance and left ventricular stroke work decreased in all the groups. 4) Pulmonary vascular resistance decreased slightly in all the groups. 5) Cardiac arrhythmias were observed in 4 cases of the group IV and VI. These results suggest that the presence of Iso or Sevo at low concentrations does not have a marked effect on the pharmacologic action of NCR or DL in humans.

[Differential lung ventilatory management during bronchoplasty]

We compared two methods of respiratory managements during bronchoplasty surgery. In one lung ventilation group (OLV-G), 10 patients were ventilated with Broncho-cath tube or Univent tube. On another 10 patients, ventilation was performed with Univent tube following insertion of bronchial blocker into main bronchus of dependent lung. Dependent lung was then ventilated using high frequency jet ventilation (HFJV) through bronchial blocker superimposed with low tidal volume IPPV (selective HFJV, S-HFJV-G). Oxygenation index (O.I.) of S-HFJV-G was significantly higher than that of OLV-G when bronchus was open. These phenomena might have occurred through prevention of pulmonary blood flow shift to the non-dependent lung when S-HFJV was used.

[Investigation of limulus test during and after cardiopulmonary bypass. Part II. Effect of washing of the bypass circuit]

Previously we reported the presence of Limulus positive substance (LPS) in blood and urine for several days following cardiopulmonary bypass (CPB), and foreign particles in the primining fluids. The purpose of this study was to evaluate the effect of washing of the CPB circuit on appearance of LPS and to define the nature of it. Semi-quantitative Limulus test was performed in patients using washed CPB circuit (n = 54) and without washing (n = 41). LPS in the blood were negative in all patients before CPB. LPSs in the priming fluids did not disappear after washing, however the amounts of it in the blood were significantly lower than those without washing. Especially at second postoperative day. Limulus test were positive in 10% of patients with washed CPB circuit and 60% of those without it (p less than 0.01), and all the urine samples of patients with washed CPB circuit were negative to Limulus test at 1st postoperative day. The number of foreign particles decreased in parallel with the smaller pore size of the filter. Since reactions of Pregell to ethylene oxide gas, ethylene chlorohydrin and ethylene glycol were negative, ethylene oxides did not seem to be the LPS. These results indicate the superiority of employment of washed CPB circuit with micropore filter. However, further exploration is still mandatory to elucidate the LPSs.

[Investigation of Limulus test during and after cardiopulmonary bypass--analysis of Limulus positive substance and particles in the cardiopulmonary bypass circuit]

Patients undergoing heart surgery with cardiopulmonary bypass (CPB) frequently have positive Limulus test without any remarkable signs of endotoxemia. CPB circuit could be one of the possible causes of this phenomenon, but the exact mechanism has not been studied. Accordingly, a prospective study was made in 41 patients undergoing heart surgery with CPB. Limulus test were performed on the samples of priming fluids of CPB including the plasma and urine of those patients during and after surgery. Besides the Limulus test, the CPB fluids were analysed by the false positive test. Microscopic examinations were carried out on the priming fluids before and after using a 40 microns filter during recirculation without washing the CPB circuit and the fluid from a 4 microns filter been washed by 2000 ml of Martose-10 in order to find out the presence of any foreign particles in the CPB circuit. The size and the number of particles were measured by coulter counter. The studies revealed the following facts, 1) Limulus test; most of the samples from priming fluids (31/35), plasma circulating the CPB (36/36), urine during CPB (22/25) and plasma (34/35) and urine (21/30) just after the surgery revealed positive. However, only 4 samples from plasma at 3POD and 2 samples from urine at 2POD revealed positive, 2) false positive test of the samples from priming fluids was negative meaning the Limulus positive substances are not endotoxin, 3) under microscopic analysis and coulter counter, there were about 40 particles over 50 microns per ml of priming fluids before washing the CPB circuit.(ABSTRACT TRUNCATED AT 250 WORDS)

[The effect of nitroglycerin ointment on cardiovascular functions in hypertensive patients during emergence from anesthesia]

The present study was designed to investigate the effect of nitroglycerin (TNG) ointment to attenuate the cardiovascular response of hypertensive patients during emergence from anesthesia compared with the effects of TNG infusion and nifedipine instillation in the nose. In addition, plasma TNG concentration was measured in the TNG ointment group and TNG infusion group. TNG 30 mg in ointment reduced the arterial pressure during extubation without producing hypotension and tachycardia. There was no significant difference in plasma TNG concentration between TNG ointment group and TNG infusion group each receiving 0.3 micrograms.kg-1.min-1. The study suggests that TNG ointment is useful for regulation of arterial pressure in hypertensive patients during emergence from anesthesia.