Search

Background: The McGRATH® MAC (McGRATH) laryngoscope is a newly developed video device, which enables us to perform tracheal intubation minimally invasive. The aim of this study is to evaluate and com- pare the hemodynamic changes triggered by intuba- tion using either the McGRATH or the Macintosh laryngoscope., Methods: Thirty-seven patients, between 20 and 42 years of age with ASA status I or II, were randomly assigned to two groups : the McGRATH (n=19) or the Macintosh laryngoscope (n=18). Anesthesia was induced with fentanyl 2 μg · kg⁻¹, propofol 2 mg · kg⁻¹, sevoflurane 2%, and rocuronium 0.6 mg · kg⁻¹. We recoded the hemodynamic changes (blood pressure, heart rate) every minute up to 5 minute after intuba- tion. We also recoded the time needed to complete the tracheal intubation. In all cases, the same certified anesthesiologist performed tracheal intubation. Data were presented as mean ± SD. Statistical analyses were performed using the t-test for comparisons of the patients' demographic data, blood pressure, and heart rate between groups., Results: There were no significant differences in two groups regarding age, weight, height, and sex. Comparing the average time needed to complete the tracheal intubation, the McGRATH group took longer than Macintosh group (40.5 ± 15.3 seconds vs. 29.4? 4.73 seconds, P=0.01). There was no significant differ- ence in blood pressure and heart rate just before tra- cheal intubation. The McGRATH laryngoscope had a significantly lower value than the Macintosh laryngo- scope in systolic pressure (101.2?7.9 vs. 111 ?16.8 mmHg, P=0.03) and heart rate (71.5?9.9 vs. 79.7? 12.3 mmHg, P=0.02) at one minute after tracheal intu- bation., Conclusions: The McGRATH laryngoscope is less invasive for hemodynamic parameters than the Macin- tosh laryngoscope. These findings suggest that the McGRATH laryngoscope may enable us to perform tracheal intubation less invasively.

A 57-year-old man was admitted to our hospital because of low-grade fever and pain in the right hypochondrium. Abdominal ultrasonographic (US) examination revealed a hyperechoic mass in the body of the gallbladder. The wall of the gallbladder towards the fundus was markedly thickened, while the wall near the gallbladder neck showed no abnormality. Power Doppler and contrast-enhanced CT of the abdomen revealed absence of blood flow in the fundic wall of the gallbladder, however, a contrast-enhanced image of the entire wall was obtained by contrast US, although the blood flow to the fundus was decreased. Torsion of the gallbladder was diagnosed and laparoscopic cholecystectomy was performed. The gallbladder was found to be a wandering gallbladder, Gross I type, and slight counterclockwise torsion was found at the neck of the gallbladder. We report a case of partial torsion of the gallbladder neck, in which the details of the ischemic hemodynamic changes could be observed by contrast-enhanced US.

We observed improvements in two cases of chronic atelectasis through use of nasal continuous positive airway pressure (nCPAP). Case 1 suffered from middle lobe syndrome accompanied by chronic atelectasis resistant to medical treatment. Case 2 suffered from respiratory failure caused by chronic atelectasis and airway infection complications thereof following a total pneumonectomy and post-pneumonectomy syndrome. The patient was placed on artificial ventilation, and atelectasis was improved by maintaining PEEP and airflow to the atelectatic region. Following extubation we obtained good pneumatization using nCPAP. nCPAP has been reported as effective not only in cases of sleep apnea, but also for cardiogenic pulmonary edema and post-operative atelectasis; we believe it holds great promise for chronic atelectasis as well.

We encountered 4 cases of hepatic peribiliary cysts (HPBC) in our hospital. Two were asymptomatic, one was complicated by a choledocholithiasis, and one by cholangitis and sepsis. Based on a review of the 38 cases of HPBC clinically diagnosed in Japan, the main problem associated with this disease seemed incorrect preoperative diagnosis leading to an unnecessary hepatectomy. Another problem was concomitant cholangitis, which tended to recur and in some cases needed aggressive treatment using drainage.

The outcome of multiple injures freqently depends on the priority of treatments, and the decision as to the procedures and timing of primary care is extremely important. We studied the patients with multiple trauma whounderwent emergency endovascular treatment for facial hemorrhage related to external carotid arterial injury. The subjects are 5 patients who underwent embolization of the external carotid artery by an endovascular approach among patients with multiple traumas who were brought to our hospital by ambulance. In these patients, the vital signs on arrival, interval between injury and intravascular surgery, type of brain injury, type and grade of concurrent injury and outcome were studied. Three patients showed hemorrhagic shock on arrival, and 1 patient showed hemorrhagic shock immediately after arrival. The mean interval between injury and endovascular surgery was 3.9 hours. All patients had skull base fracture, and abnormal intracranial lesions on initial CT including 4 focal injuries and 1 diffuse injury. Moderate to severe thoracic/abdominal injuries were noted in 3 patients. In the remaining 2 patients, there was no trauma in the thoracic or abdominal regions. Intraperitoneal hemorrhage with splenic injury was observed in 3 patients. In 3 of 4 patients died by hemorrhagic shock because of the delay of endvascular treatments. In trauma patients with persistent hemorrhage, emergency endovascular treatment should be considered as a primary survey for initial treatment without delay under intensive conservative treatment.

We report a case of posterior fossa meningioma extending into the cervical jugular vein, which was successfully resected. A 57-year old male with ataxia and mild hypogeusia was admitted to our hospital. MRI demonstrated a well-circumscribed large posterior fossa mass with extracranial extension through the internal jugular vein. Two-staged surgical treatment was then performed. The mass in the posterior fossa was removed at the first operation. The tumor was invading into the sigmoid sinus which was filled with tumor. The second operation for extracranial mass was performed 1 month later. Transcervically, the internal jugular vein obstructed by tumor was successfully removed. The post-operative course was uneventful and histopathological examination revealed the fibrous meningioma in the posterior fossa, but the intravenous portion of the tumor showed more atypical findings. Such a case is quite uncommon and the mechanism of tumor extension with different histological features is discussed.

We report a case of localized ischemia of the sternocleidomastoid muscle (SCM) occurring after occipital artery embolization of a dural arteriovenous fistula (dAVF). A 45-year-old man presented intracerebral hemorrhage from a dAVF at the left transverse-sigmoid sinus. The dAVF had a high flow fistula from the left occipital artery (OA). Endovascular therapy was carried out one month later. Transarterial embolization of the OA was carried out prior to the transvenous approach to decrease the shunt flow. During obliteration of the proximal portion of the OA with fiber platinum coils and polyvinyl alcohol particles, the patient reported severe neck pain. The fistula was successfully embolized after transvenous packing of the left sigmoid sinus with detachable coils. The neck pain persisted for one week and disappeared after conservative treatment. T2-MR imaging 3 days after the embolization showed a hyperintensity in the left SCM. This ischemic lesion was probably induced by occlusion of the muscular branch of the OA. We discuss this common but rarely reported complication of OA embolization.

A 55-year-old female patient was scheduled for laparoscopic adrenal surgery. In the operating room, anesthesia was induced with propofol and maintained with nitrous oxide/sevoflurane and epidural anesthesia. The operation was completed uneventfully. After tracheal extubation, Spo2 decreased suddenly from 98 to 92% and chest auscultation revealed weaker breathing sound on the left side. Left pneumothorax and pneumomediastinum were noticed on a chest X-ray. The pneumothorax in this case was thought to have been caused by passage of insufflation gas through the retroperitoneum to the mediastinum and thoracic cavity or by a minor injury of diaphragm. Although pneumothorax complication in laparoscopic surgery is rare, the frequency of its occurrence in laparoscopic adrenal surgery appears to be higher than other laparoscopic operations and may be due to the organ's location in the retroperitoneum near the diaphragm. Attention should be paid to the possibility of pneumothorax occurring during laparoscopic adrenal surgery even if there is no apparent surgical injury.

Background: Diaphragmatic function is impaired after abdominal surgery. We investigated the effect of continuous extradural infusion of bupivacaine on diaphragmatic function after upper abdominal surgery using respiratory inductive plethysmography (RIP)., Methods: Ten healthy patients for upper abdominal surgery were divided into two groups; the first group of patients with continuous extradural infusion of morphine (group 1) and the second group of patients with continuous extradural infusion of morphine and bupivacaine (group 2)., Results: On the first day after surgery, there was no significant difference between the visual analogue scale scores in the two groups. Abdominal contribution to tidal volume (VAB/VT) in group 1 was significantly decreased compared to that of the pre-operative value. VAB/VT in group 2 was significantly higher than that in group 1., Conclusions: Continuous extradural infusion of bupivacaine improves diaphragmatic function after upper abdominal surgery.

A 22-year-old man was admitted to our ICU for treatment of fat embolism syndrome complicated with multiple bone fractures. Acute respiratory distress syndrome developed, and the patient received steroid therapy. During the steroid therapy, symmetrical proximal muscle weakness of all four limbs without sensory abnormalities and autonomic nervous system dysfunction developed. Cerebrospinal fluid showed albuminocytologic dissociation. Blood examination showed herpes simplex virus and cytomegalovirus infection. The patient was diagnosed as having Guillain-Barré syndrome, but he recovered completely one month after admission. It is thought that the prolonged steroid therapy for acute respiratory distress syndrome in this case induced viral infection that might have caused Guillain-Barré syndrome.

A 70-year-old woman was admitted to our hospital because of an aneurysm of the ascending aorta. The patient underwent replacement of the ascending aorta with an interposition graft under cardiopulmonary bypass. IntRaoperative transesophageal echocardiographic examination showed regional wall motion abnormality of the inferior and inferior septum segments. Emergency coronary artery bypass graft surgery was performed. Post-operative coronary angiography revealed mechanical compression of the right coronary artery due to the surgical procedure. Transesophageal echocardiographic examination is useful for evaluation of myocardial ischemia during surgical repair of aortic aneurysms.

Tongue swelling after surgery is a rare but potentially lethal postoperative complication. This is a case report of a 62-yr-old patient who developed tongue swelling after intraoperative monitoring by transesophageal echocardiography. The patient underwent replacement of the descending aorta with an interposition graft under cardiopulmonary bypass. A transesophageal echocardiography (TEE) probe was inserted after the induction of general anesthesia. Surgery and anesthesia were uneventful. After the surgical procedure, the TEE probe was removed. At that time, marked swelling of the tongue was noted. However, there was no diffuse edema in the neck, face, supraglottic structures or the larynx. The tongue swelling was thought to have been caused by local mechanical compression of the tongue with the TEE probe. The tongue returned to normal size the next day. Care should be taken to prevent the occurrence of this complication during and after TEE examination under general anesthesia.

We examined clinical features and outcomes of mechanically ventilated patient (n = 11) retrospectively who had developed acute respiratory failure during treatments with immunosuppressive drugs. The mean APACHE II score was 22.6, and the mean lung injury score was 2.9. In eight patients chest X-ray and computed tomography showed interstitial pneumonia. Fungus and/or cytomegalovirus were isolated most often from patients with interstitial pneumonia. Observed mortality (72.7%) was significantly (P < 0.001) higher than predicted mortality (45.1%) in the APACHE II score. Patients, who were complicated with septic shock caused by fungus infection, showed poor mortality. These results suggest that the fungus and cytomegalovirus infections might be associated with poor prognosis in patients with acute respiratory failure during treatment with immunosuppressive drugs.

We report a case with radical neck clipping following incomplete embolization with coils and imperfect neck clipping. A 43-year-old woman suffered from a subarachnoid hemorrhage (Hunt & Hess Grade IV) due to the rupture of a left paraclinoid internal carotid aneurysm on 28 October, 1996. Neck clipping of the aneurysm was performed at day 1. Follow-up angiogram at 2 weeks after surgery showed however a small residual aneurysm. The second angiogram 1.5 months later showed the growth of the residual aneurysm. The residual part of the aneurysm was then treated with endovascular embolization using interlocking detachable coils (IDC), resulting in incomplete occlusion of the aneurysm. The direct surgical clipping of the residual aneurysm was performed via Dolenc approach. A fenestrated clip was applied to the partial embolized aneurysm, when the aneurysmal wall was ruptured between the occluded part of the aneurysm and the residual dome. The fenestrated clip was then reapplied successfully under temporary occlusion of the parent artery. Because of the stenosis of the parent artery, STA-MCA anastomosis was then performed. Postoperative recovery of the patient was uneventful and postoperative angiogram showed stenosis of the parent artery with patent bypass flow. The patient was discharged without complications. Technical problems in neck clipping following incomplete embolization with coils are discussed.

We investigated the effect of epidural buprenorphine on diaphragmatic function using respiratory inductive plethysmography (RIP) in seven healthy patients after upper abdominal surgery. After surgery, changes of rib cage contribution to tidal volume (%RC) increased significantly from 25.3 +/- 7.3 (mean +/- SD) to 50.7 +/- 14.8% (P < 0.05). After the injection of epidural buprenorphine, visual analogue scale (VAS) score decreased significantly from 8.3 to 3.3 (P < 0.05). But, %RC was unchanged compared to the value before the injection. These results indicate that pain relief by epidural buprenorphine does not improve diaphragmatic function after upper abdominal surgery.

We investigated hemodynamic and blood gas changes in eight patients undergoing femoral neck prosthetic replacement. We measured blood pressure, heart rate, pulmonary artery pressure, cardiac output and blood gas before packing bone cement with a cement gun and 5, 10, and 15 min after the insertion of the prosthesis. Significant increases in mean pulmonary artery pressure, and arterial PCO2 were observed, but there were no significant changes in mean arterial pressure, cardiac output, or arterial PaO2. These pulmonary circulatory and blood gas alterations suggested that pulmonary embolism or pulmonary vasospasm had been brought about by the insertion of the prosthesis, but this did not result in systemic changes in the patients in this study. In conclusion, it is recommended to monitor circulatory and respiratory changes closely to detect pulmonary embolism during femoral neck prosthetic replacement using a cement gun.

Continuous thoracic epidural anesthesia (T4/5) using 4-5 ml.h-1 of 1.5% lidocaine with 1:200,000 epinephrine and inhaled anesthesia using nitrous oxide, oxygen and sevoflurane were performed in two patients, (40 and 22 yr-old females) with myasthenia gravis. This combined anesthetic technique provided muscle relaxation for endotracheal intubation and optimal operating conditions, including muscle relaxation and stability of hemodynamics during transsternal thymectomy. Further, continuous epidural anesthesia using 4 ml.h-1 of 0.25% bupivacaine provided postoperative pain relief without other analgesics and stable postoperative respiratory conditions. In conclusion, we confirm the benefits of this technique which provides not only safe and stable conditions during the surgery, but also an improved comfort for patients in the postoperative period following transsternal thymectomy for myasthenia gravis.

Pulmonary eosinophilia is a disease entity which is characterized by an increase of eosinophils in the bronchoalveolar lavage fluid or in tissue. While there are several disease states encountered in pulmonary eosinophilia, some have a definite cause and diagnosis, while others are of unknown etiology. The diagnosis of idiopathic eosinophilic pneumonia is given when other pulmonary eosinophilia with known cause and diagnosis are excluded. Simple pulmonary eosinophilia and chronic eosinophilic pneumonia are well established disease entities, but recent papers have clarified a new concept of acute eosinophilic pneumonia. In this article, the clinical features of three idiopathic eosinophilic pneumonias simple pulmonary eosinophilia as a self-limiting lung infiltrates, chronic eosinophilic pneumonia as a disease with longstanding symptoms requiring steroids administration and a tendency to relapse, and acute eosinophilic pneumonia as an acute respiratory distress which responds dramatically to steroids administration and without relapse after discontinuation of therapy are discussed.

A forty-one-year-old male who was found to have lung carcinoid tumor showed clinical features of Cushing syndrome. At the age of 38 years during a regular check-up, a chest roentgenogram showed multiple nodular shadows in the bilateral lung, and he was admitted to hospital. By open lung biopsy, he was diagnosed as having malignant carcinoid or small cell carcinoma of the lung. The abnormal lung shadows did not respond to chemotherapy (CDDP + VDS). The clinical course after discharge was uneventful until the age of 41 years, when he was readmitted to our hospital because of brain metastasis. Physical examination revealed moon face and central obesity. Plasma ACTH level was high and dexamethasone suppression test showed no cortisol suppression on 8 mg dexamethasone administration. Therefore, it was thought that the patient had ACTH producing ectopic tumor which led to Cushing syndrome. We measured the molecular weight of ACTH by column chromatography and found he had a big ACTH (molecular weight about 22,000). Reexamining him clinically and histologically, we concluded that the patient had atypical carcinoid tumor in the lung which might produce ACTH causing Cushing syndrome with metastasis to the brain.

The authors report a case with esophageal cancer who had undergone a non-curative resection and showed a recurrence. Treatment with only oral 5'-DFUR resulted in complete response. This was followed by oral ftorafur, and the case has remained complete response for 40 months. It is rare to obtain such an effect in esophageal cancers by oral and sole administration of a drug in the 5-FU class. Our experience with this case is described.

Successful surgical treatment of aortic arch aneurysm ruptured into the left lung was reported. The patient was a 74-year-old man suffering from recurrent hemoptysis. Computed tomography and aortic angiography demonstrated a giant aortic arch aneurysm. Emergency operation was performed. Arch reconstruction by a Dacron graft was performed with hypothermic circulatory arrest. The post operative course was uneventful and there was no evidence of cerebral complication. In the emergency operation for ruptured aortic arch aneurysm, hypothermic circulatory is very useful method for cerebral protection.

A 33-year-old man with a 6-month history of rhinitis and bronchial asthma was referred to our hospital with polyarthralgia, severe anemia, hypoxemia, mononeuropathy multiplex, and renal insufficiency with hematuria. Marked eosinophilia was observed in his sputum, peripheral blood, and bronchoalveolar lavage fluid (BALF). In addition, his sputum contained many hemosiderin-laden macrophages, indicative of pulmonary hemorrhage. His chest roentgenogram on admission showed diffuse ground grass appearance. High resolution computed tomography (HRCT) demonstrated diffuse high density areas throughout the lung fields and characteristic irregularity and enlargement of the peripheral pulmonary arteries. His general condition rapidly deteriorated, but dramatically improved with oral steroid administration, and his major symptoms disappeared within a few days. Examination of the biopsied lung tissue revealed unequivocal evidence of pulmonary angitis with marked eosinophilic infiltration and perivascular granulomas. Bone marrow biopsy showed hyperplasia of eosinophilic leukocytes in contrast to the low cellularity. Suppression of erythroid hemopoiesis was thought to be the primary cause for his rapidly progressive anemia. Serum anti-GBM antibody titer returned to within the normal range soon after the initiation of steroid therapy.

Delayed diagnosis in two cases of congenital duodenal obstruction was discussed. Case 1. Ten-month-old baby girl with Down's syndrome was admitted to the hospital because of vomiting of milk. Wall-like obstruction was found in the second part of duodenum. Case 2. One-year-old boy infant with Down's syndrome showed a stack of coin in the duodenum on admission. Wall-like obstruction was found in the second part of duodenum. Diagnosis of duodenal obstruction is sometimes delayed in Down's syndrome. Symptom such as vomiting and growth retardation might be ignored in a child with Down's syndrome. A large hole was found in the center of the obstruction in both cases; 4 mm in diameter in case 1, 3 mm in case 2. Papilla of Vater opened at the anal side of the obstruction. These structural particularities played a role in making symptom of duodenal obstruction obscure. Mural obstruction of duodenum was observed in both cases. The obstructions were, in shape, similar to the membraneous stenosis of the duodenum. However, they were not membranes but walls as thick as 4-5 mm. Wall-like duodenal obstruction has not been reported in the literature. It can not be concluded whether mural obstruction in our cases is a new subtype of duodenal obstruction or not.

For the purpose of carrying out an objective evaluation of the clinical efficacy and safety of cefotetan (CTT), a new cephamycin-type injectable antibiotic, in the treatment of complicated urinary tract infections, cefmetazole (CMZ) was employed as the control drug in a comparative study performed by the double-blind method. CTT was administered in a dose of 0.5 g or 1 g, while CMZ was used in a dose of 1 g; both of these drugs were administered by intravenous drip infusion twice a day for 5 days. The total number of treated cases was 393; 105 patients in the CTT 1 g group, 97 patients in the CTT 2 g group, and 96 patients in the CMZ 2 g group. The judgment of the clinical effects of these 3 therapeutic regimens was carried out in accordance with the criteria for evaluation of clinical efficacy of antimicrobial agents on UTI (2nd edition). The results are as follows. With regard to the overall efficacy of the drug treatments, the calculated efficacy rates were 54.3% in the CTT 1 g group, 63.9% in the CTT 2 g group and 52.1% in the CMZ 2 g group. The differences between these efficacy rates were not statistically significant. Regarding the efficacy of the treatments in terms of the bacteriuria, the bacterial cultures were seen to become negative in 40% of the cases in the CTT 1 g group, 54.6% of the CTT 2 g group and 42.7% of the CMZ 2 g group. Again, there were no statistically significant differences between the groups. Concerning the efficacy of the drugs against pyuria, by combining the cases found to be normalized and those seen to show improvement, the improvement rates were calculated to be 41.9% for the CTT 1 g group, 37.1% for the CTT 2 g group, and 37.5% for the CMZ 2 g group. These pyuria improvement rates show no statistically significant differences, respectively. The incidences of occurrence of side effects and laboratory test abnormalities thought to be caused by the drug therapy were as follows; 1.5% and 5.3% in the CTT 1 g group, 1.5% and 3.1% in the CTT 2 g group and 0% and 6.9% in the CMZ 2 g group. There were no significant differences between the groups. Based on the above clinical results, it can be concluded that, in the treatment of complicated urinary tract infections, we can expect CTT to provide the same therapeutic efficacy as CMZ when its dosage is the same or even half thereof. In addition, the safety of CTT is equal to that of CMZ. Therefore, CTT is concluded to be a useful drug.

Gentamicin 40 mg was intramuscularly admininistered two times daily to 15 patients with complicated urinary tract infections. The results are as follows 1. The clinical efficacy of gentamicin was excellent in 12 cases (80.0%), good in 2 cases (13.3%) and null in 1 case (6.7%). The effective rate was 93.3%. 2. Bacteria disappeared in 16 strains (84.2%), colonized in 3 strains (15.8%) out of 19 isolates. 3. BUN, GOT and GPT values were determined before and after GM administration, and no significant abnormal finding attributable to GM was observed in this clinical study.

Patients with chronic complicated urinary tract polymicrobial infections due to Pseudomonas aeruginosa and other bacteria were treated with cefsulodin using cefotiam or cefmenoxime as a concomitant drug. Each drug was given to the patients in daily dose of 1 or 2 g by drip infusion twice a day for 5 to 16 days. The results were as follows: Overall clinical efficacy was excellent in 7 cases (44%), moderate in 6 cases (38%) and poor in 3 cases (19%), the effectiveness rate being 81.3%. Bacteriologically, 38 strains (88.4%) were eradicated, 1 strain decreased and 4 strains unchanged out of the 43 clinical isolates from the patients. No side effects and no abnormalities of laboratory findings were observed.

Unlabelled: Recently, the scintigram with 99mTc-labeled compounds has been routine procedure, because of it's ideal physical characteristics. The short physical half life of six hours, the absence of beta emission, and the gamma rays of 140 keV permit the administration of large amount of radioactivity. For scintigram of deep or large organ, the absorption of 99mTc gamma-rays by bone and soft tissue should not be negligible. For example, bone scintigram with 99mTc-phosphorous compounds shows different pictures depending upon the anterior and the posterior views, because of it's rather lower energy. Therefore, the linear attenuation coefficient and the half value layer of bone and soft tissue were measured with 99mTc gamma-rays and others (197Hg, 203Hg, 131I, 198Au, 85Sr)., Results: 1) The linear attenuation coefficient of 99mTc gamma-rays was: bone -0.240 cm-1, acrylite -0.173 cm-1, Mix D -0.155 cm-1. 2) The half value layer of 99mTc gamma-rays was: bone -2.89 cm, acrylite -3.98 cm, Mix D -4.47 cm. It was concluded that the lower photon energy of 99mTc was influenced by bone and soft tissue, but it appeared to be most suitable for the present imaging devices. Therefore, pictures of multiple views are necessary in case of the scintigram was 99mTc-labeled compounds.

We have constructed compensating screens which have different sensitivities for the pulmonary hilum and mediastinum in contrast to the lung. With these screens the regions of the mediastinal and retrocardiac areas are simultaneously displayed with optimal contrast on postero-anterior (PA) chest radiographs. The potential clinical use of compensating screens was evaluated in 67 patients for visibility of the anatomical structures in comparison with conventional screens. Confidence test was used to compare the detectability of the various anatomical structures of the chest. The chest radiographs obtained with compensating screens improved visibility of the anatomical structures including the tracheal bifurcation, right and left main bronchus, and paraesophageal line.