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Purposes : Pancreatoduodenectomy (PD) was performed for 6 periampullary cancer patients by using methods verified by quality randomized controlled trials (RCT) in a low-volume center (LVC). The purpose of this study was to verify the clinical results. Methods : No-touch pylorus-resecting pancreatoduodenectomy (PrPD), antecolic gastrojejunostomy, pancreatico-jejunostomy with a lost stent tube to the main pancreatic duct, and early removal of a prophylactic drain were performed. Results : The drain could be removed 4 days after opera- tion, and no pancreatic fistula was observed in all cases. Solid food could be started on POD4 after removing the drain. Furthermore, postoperative systemic chemotherapy could be started earlier. Conclusion : Although we have only a few PD cases a year in our institution, PD can be conducted safely without complications by using the methods verified by quality RCTs. J. Med. Invest. 62 : 188-194, August, 2015

Purposes : The purpose of this study was to verify the outcome of the emergency one stage resection and anastomosis procedure for patients with obstructed colorectal cancer. Methods : An emergency one stage resection and anastomosis procedure was performed for 40 patients with obstructive colorectal cancer. The outcome was verified and compared dividing into two groups. 17 patients under the age of 70 in (Group A), 23 patients 70 years and over in (Group B). Results : The operative mortality rate in both groups was 0%. As a result, postoperative complications were not significantly different between the two groups. The overall survival rate after a 5-year period in both groups was 41.8%, regarding all patients and the survival curves for the two groups, was not significantly different. The 5 year survival rate in stage II or III showed no differences between the two groups. Conclusion : The one-stage resection and anastomosis of the large bowel could be applied safely to emergency patients, which in turn allows for excellent shortterm operative results in both groups mentioned. This particular procedure should be positively enforced, even in elderly patients in their 70’s.

SOPHAGEAL PACING can provide a reliable method for controlling heart rate, but transesophageal ventricular pacing is often unsuccessful in children. The authors achieved transesophageal ventricular pacing in 2 infants without difficulty, and transesophageal atrial pacing in 1 child by using the transesophageal echocardiography (TEE) probe as a guide. CASE REPORTS Case 1 A 3-day-old newborn boy (weight 1,838 g) underwent emergency implantation of a permanent pacemaker. Immediately after the patient was delivered by cesarean section because of fetal bradycardia, he was intubated and mechanically ventilated. An electrocardiogram (ECG) showed complete atrioventricular block with a heart rate (HR) of 44 beats/min. Echocardiography showed aortic regurgitation, tricuspid regurgitation, pulmonary hypertension, and a left ventricular ejection fraction of 49%. Continuous intravenous infusions of dopamine, 5 g/kg/min, and isoproterenol, 0.06 g/kg/min, were administered. When the patient arrived at the operating room, his HR was about 50 beats/min. Anesthesia was induced and maintained with intravenous fentanyl, and muscle relaxation was obtained with intravenous vecuronium. A quadruplet pacing lead with an interelectrode distance of 10 mm and an electrode diameter of 3 mm (TOEC-P; MEDICO, Rubano, Italy) was inserted orally into the esophagus and positioned at a distance of 15 cm from the inferior alveolar ridge. The pacing lead was connected to a pulse generator (TECS II, MEDICO). Bipolar pacing was initiated at a rate of 100 beats/min, and the 4 electrodes were used alternately as cathodes or anodes. Ventricular pacing was easily established with a threshold current of 20 mA at a pulse duration of 20 milliseconds using the distal electrode as the cathode and the second electrode as the anode. HR increased from 52 to 100 beats/min, and arterial blood pressure increased slightly from 96/54 mmHg to 100/62 (Fig 1). Transesophageal ventricular pacing was continued until the permanent pacemaker was implanted. Case 2 A 5-day-old neonate boy (weight 2,410 g) was scheduled for urgent implantation of a permanent pacemaker. Because of his mother’s extremely low level of amniotic fluid, the patient was delivered by cesarean section at 36 weeks and 4 days gestation. Immediately after delivery, the patient was intubated and mechanically ventilated. An ECG showed complete atrioventricular block and an HR of about 45 beats/min. Echocardiography revealed pulmonary hypertension and an LV ejection fraction of 27%. Intravenous dopamine, 3 g/kg/min, and isoproterenol, 0.1 g/kg/min, were continuously administered, and his HR increased to about 65 beats/min. When the patient arrived in the operating room, his HR was about 55 beats/min. Anesthesia was induced with sevoflurane, air, and oxygen (FIO2 0.5) and maintained with sevoflurane and intravenous fentanyl. Muscle relaxation was obtained with intravenous vecuronium. A quadruplet pacing lead (TOEC-P) was inserted orally into the esophagus and positioned at a distance of 13 cm from the inferior alveolar ridge. The pacing lead was connected to a pulse generator (TECS II) and was adjusted to achieve ventricular capture as confirmed by ECG and central venous pressure waveforms. Ventricular pacing at 100 beats/min was established with a threshold current of 32 mA at a pulse duration of 20 milliseconds; the distal electrode served as the cathode and the second electrode as the anode. HR increased from 73 to 100 beats/min, and arterial blood pressure decreased from 107/64 to 101/66 mmHg. Transesophageal ventricular pacing was maintained until the permanent pacemaker was implanted. Case 3 A 6-year-old girl (height 117 cm, weight 20 kg) with sick sinus syndrome was scheduled for permanent pacemaker implantation and ventricular septal defect (VSD) closure. A fetal heart murmur was identified, and she was diagnosed with tetralogy of Fallot after birth. When she was 2 years and 3 months old, she underwent VSD closure and repair of the right ventricular outflow tract; however, a residual shunt was revealed by postoperative echocardiography. At the age of 4 years, she was diagnosed with atrial fibrillation (AF), and Stokes Adams syndrome occurred. Medication was started, but the conditions could not be controlled. Even after 3 catheter ablations, the patient experienced several episodes of bradycardia or AF so she was scheduled for pacemaker implantation and further VSD repair. The ECG showed an incomplete right bundle-branch block and sinoatrial block. Preoperative medication included propranolol, 15 mg/d, and digoxin, 0.1 mg/d; when she had an episode of AF, a bolus of verapamil, 3 mg, was administered intravenously. The patient was premedicated with atropine, 0.2 mg, and midazolam, 2 mg, intramuscularly, 30 minutes before induction of anesthesia. Anesthesia was induced with sevoflurane, nitrous oxide, and oxygen (FIO2 0.33). Muscle relaxation was obtained with intravenous vecuronium. A quadrapolar pacing lead (TOEC-P) was fixed anteriorly to the pediatric biplane TEE probe (21366A; Philips Medical Systems, Andover, MA) with silk thread (Fig 2). The distal electrode was placed 20 mm from the TEE probe tip, and a pacing lead was connected to a pulse generator (TECS II). The biplane TEE probe was inserted atraumatically into the esophagus. After the start of surgery, HR decreased gradually to about 60 beats/min. The TEE probe was positioned to obtain a long-axis 3-chamber view. At first, the authors planned ventricular pacing and started pacing with a 20-millisecond pulse duration at a rate of 120 beats/min. Atrial pacing was unexpectedly established with a threshold current of 11 mA. HR increased from 69 to 118 beats/min, arterial blood pressure increased from 80/44 to 85/55 mmHg (Fig 3), and central venous pressure was unchanged. Transesophageal atrial pacing was maintained for 2 hours until the initiation of cardiopulmonary bypass.