[Effect of indomethacin as an adjunct to postoperative pain relief by continuous epidural infusion of bupivacaine and buprenorphine]

We examined the analgesic effects of indomethacin as an adjunct to postoperative epidural analgesia in 40 patients who underwent upper abdominal surgery. Twenty patients in control group were epidurally given 0.1 mg of buprenorphine in 8 ml of 0.25% bupivacaine immediately after surgery and subsequently infused 15 micrograms buprenorphine in 1 ml of 0.25% bupivacaine at a rate of 1 ml.h-1 for 48 h. The remaining 20 patients were rectally given 50 mg of indomethacin in addition to the same epidural method described above. The patients who did not need additional narcotics in the control and indomethacin groups were 45% and 80%, respectively (P < 0.05). In upper abdominal surgery, postoperative pain relief by epidural buprenorphine and bupivacaine plus rectal indomethacin was more effective than that by epidural buprenorphine and bupivacaine.

[Usefulness of continuous intra-arterial blood gas monitoring in a patient undergoing tracheal transection and reconstruction]

Usefulness of a new continuous intra-arterial blood gas monitoring system (PB3300, Puritan-Bennett, Carlsbad, California) was evaluated in a patient with tracheal cancer who was undergoing tracheal transection and reconstruction. The PB3300 detected continuous changes in pH, PaCO2, and PaO2 during the surgical intervention and provided reliable information to take appropriate therapeutic measures. PB3300 was superior to pulse oximetry because the latter can not detect changes in PaO2 more than 100 mmHg accompanying pulmonary dysfunction caused by surgical procedures. We conclude that the PB3300 is a useful monitor when used during anesthetic management of the patient who needs frequent arterial blood gas analyses.

[Effects of repeated sevoflurane anesthesia on hepatic and renal function in a pediatric patient]

A 10-yr-old boy with an injured lower extremity received sevoflurane anesthesia 5 times within 40 days. Laboratory tests for hepatic and renal function i.e., serum transaminase (glutamic oxaloacetic transaminase, glutamic pyruvic transaminase, gamma-glutamyl transpeptidase), serum cholinesterase, plasma protein, serum cholinesterase, serum bilirubine, serum lactic dehydrogenase, serum prothrombin time, blood urea nitrogen, serum creatinine, beta 2-microglobulin, N-acetyl-D-glucosamidase and 24 hr-creatinine clearance remained within normal ranges throughout his perioperative period. Repeated sevoflurane anesthesia did not exert any adverse effect on hepatic and renal function in this patient.

[The effects of continuous interpleural vs. epidural infusion for postoperative pain relief following thoracotomy]

We studied whether continuous interpleural infusion of bupivacaine would be effective in alleviating pain after thoracotomy compared with effect of continuous epidural infusion of bupivacaine and buprenorphine. Twenty patients who had received thoracotomy and lobectomy were randomly divided into two groups to receive continuous interpleural infusion (IP group) of 0.5% bupivacaine at the rate of 5 ml.h-1 or continuous epidural infusion (E group) of 0.25% bupivacaine and 0.025 buprenorphine at the rate of 1 ml.h-1. The patients assessed their level of pain using a 100 mm visual analog scale (VAS) at rest and on coughing or changing the posture, verbal descriptor pain scale (VDPS), and times of supplemental analgesic. Assessment was performed at 7 points (mornings and evenings) for 3 postoperative days. In the evening of the day of surgery, VAS at rest in IP group was significantly higher than one in E group, but VASs at rest were similar in both groups from the first postoperative day to the third postoperative day. VAS on coughing or changing the posture in IP group was significantly higher than in E group in the evening of the day of surgery, and VASs on coughing or changing the posture in IP group were higher than in E group for 3 postoperative days. Supplemental analgesics were administered significantly more often than in E group in the evening of the first postoperative day. We conclude that continuous interpleural infusion does not give better analgesia than continuous epidural infusion after thoracotomy.

[Changes in plasma concentrations of human hepatocyte growth factor before and after major intra-abdominal surgery under nitrous oxide-sevoflurane anesthesia]

The measurements of human hepatocyte growth factor (hHGF) in plasma and liver function tests were performed in 23 patients before and after major intra-abdominal surgery under nitrous oxide-sevoflurane anesthesia. Plasma concentrations of hHGF in 12 patients with normal liver function (Group 1) and in 11 patients with liver dysfunction (Group 2) were 0.34 +/- 0.07 and 0.44 +/- 0.12 ng.ml-1 (mean +/- SD) before the surgery, respectively. After the surgery, plasma concentration of hHGF remained unchanged in Group 1, but significantly increased to 0.61 +/- 0.32 ng.ml-1 in Group 2. Other routine laboratory data reflecting hepatic functions remained unchanged in both groups. These results suggest that liver damage during surgery and anesthesia occurs more likely in patients with liver dysfunction than in patients with normal liver function, and hHGF can be a more sensitive indicator of hepatic damage than conventional liver function tests.

[Psychological evaluation of patients by state-trait anxiety inventory in pain clinic]

In 84 outpatients who visited our pain clinic, we evaluated their anxiety before the first examination, using State-Trait Anxiety Inventory. State anxiety scores were high in all the patients regardless of their underlying disease. Trait anxiety scores in patients with chronic pain such as postherpetic neuralgia or cervic-shoulder-hand syndrome were higher than in patients with facial nerve palsy, sudden hearing loss or herpetic pain. This study indicates that psychosomatic management is mandatory for patients with chronic pain.

[An unusual supine hypotensive syndrome during cesarean section: the importance of trying right tilt if there is a poor response to left tilt]

A case of severe supine hypotensive syndrome in a parturient associated with breech presentation was presented. It is suggested that failure of left tilt to prevent the hypotension was associated with anatomical displacement of the uterus to the right. The importance of trying right tilt, if response to left tilt is poor, is emphasized.

Changes in blood lactate and heart rate in thoroughbred horses during swimming and running according to their stage of training

The purpose of this study was to investigate whether the change in the performance capacity of horses trained by running could be evaluated with a standardised swimming exercise test as well as by a standardised running exercise test. Seven two-year-old thoroughbred horses were trained by running for four months and were subjected to a standardised swimming exercise tolerance test before the training began and after two and four months of training in addition to the standardised running tolerance test after two and four months of training. The running training brought about a significant change in the correlation between the swimming speed of the horses and their blood lactate concentration, and the correlation between the blood lactate concentration and maximum heart rate and running speed also changed significantly after two months of training.

[Comparison of intraoperative complications between laparoscopic cholecystectomy by intraperitoneal insufflation and abdominal wall lifting]

We compared intraoperative circulatory and respiratory complications and changes in body temperature during laparoscopic cholecystectomy by intraperitoneal insufflation of carbon dioxide gas (24 cases) with those by abdominal wall lifting (16 cases). The abdominal wall lifting method tended to produce fewer complications than the intraperitoneal insufflation method, but not significantly. In conclusion, the former was thought to be safer than the latter.

Erythropoietin induces tyrosine phosphorylation and activation of phospholipase C-gamma 1 in a human erythropoietin-dependent cell line

Erythropoietin (Epo) is the major regulator of the proliferation and differentiation of erythroid precursors through interaction with its receptor (Epo-R). Although Epo-R lacks a tyrosine kinase consensus sequence within its intracellular domain, the addition of its ligand to Epo-responsive cells, UT-7/Epo, induces the rapid and transient tyrosine phosphorylation of 145-, 130-, 80-, and 40-kDa cellular proteins. Tyrosine phosphorylation of these proteins occurred dose- and time-dependently. We showed that the tyrosine phosphorylated 145- kDa protein is identical to phospholipase C-gamma 1 (PLC-gamma 1). Tyrosine phosphorylation of this protein is detectable within 30 s and almost reaches the maximum at 1 min. This can last up to 10 min and declines thereafter. Additionally, in Epo-stimulated cells, PLC-gamma 1 become physically associated with 80- and 40-kDa proteins which have been tyrosine-phosphorylated in response to Epo. The activity of PLC-gamma 1 was also investigated using inositol 1,4,5-trisphosphate (Ins-P3) as an indicator. We found that stimulation of UT-7/Epo cells with Epo induces a significant accumulation of Ins-P3. This effect is dose-dependent and occurs very rapidly. The production of Ins-P3 can explain the Epo-induced mobilization of calcium from intracellular stores in these cells. These results demonstrate that Epo induces tyrosine phosphorylation and activation of PLC-gamma 1 to produce Ins-P3 and then it mobilizes calcium from intracellular stores. This signal transduction pathway may play a role in regulating the proliferation of erythroid cells.

[Continuous epidural buprenorphine for postoperative pain relief in upper abdominal surgery]

To evaluate postoperative analgesia and side effects of epidural buprenorphine, 100 patients who underwent upper abdominal surgery were divided into 5 groups. All patients were given initially 0.1 mg of buprenorphine in 8 ml of 0.25% bupivacaine in bolus. Following an epidural bolus, 20 patients in each group were given 0.25% bupivacaine alone (group A), 5 micrograms buprenorphine in 1 ml of 0.25% bupivacaine (group B), 8 micrograms buprenorphine in 1 ml of 0.25% bupivacaine (group C), 12 micrograms buprenorphine in 1 ml of 0.25% bupivacaine (group D), or 15 micrograms buprenorphine in 1 ml of 0.25% bupivacaine (group E) with a portable disposable device at a rate of 1 ml.h-1 for 48 h. The analgesic efficacy in group E was superior to that in groups A, B, C and D. No significant difference was found in the incidence of side-effect among 5 groups. Therefore, epidural buprenorphine 15 micrograms in 1 ml of 0.25% bupivacaine given to patients at a rate of 1 ml.h-1 was thought to be optimal for postoperative pain relief in upper abdominal surgery in terms of its efficacy and side effects. However, 35% of these patients required supplementary systemic analgesics in the early postoperative period.

[Meralgia paresthetica after spinal anesthesia]

A 27-year-old man underwent appendectomy under spinal anesthesia with 0.3% dibucaine 2.7 ml. The perioperative course was uneventful. The surgical procedure, however, lasted for 1.5 hours in the supine position. On the second postoperative day, a postspinal headache occurred and lasted for 18 days. On the seventh postoperative day the patient complained of numbness along the anterolateral aspect of the left thigh innervated by the lateral cutaneous nerve. There was no reflex or motor deficit indicative of the involvement of other nerves. The disorder was diagnosed as meralgia paresthetica caused by the surgical procedures. The numbness disappeared after the oral administration of mecobalamin in several days. In the treatment of a case like this, it is important to exclude neurological complications caused by spinal anesthesia.

[Failures of lumbar epidural analgesia caused by transforaminal passage of an epidural catheter in two cases]

In one case, analgesia level obtained with a 20 ml of 1.5% mepivacaine was unilateral and inadequate. In the other case, an epidural catheter was inserted after a 20 ml of 2% mepivacaine was injected through a Tuohy needle. Toxicity by local anesthetic was induced by an overdose of local anesthetic through the catheter. In both cases, transforaminal passage of a catheter was confirmed by epidurogram with iohexol. If an epidural catheter is advanced beyond 5 cm into the epidural space, it may migrate outwards through the intervertebral foramen. Therefore, the insertion of an epidural catheter should be limited to 3-4 cm.

[Intravenous lidocaine in the treatment of post treatment neuropathy]

A 46-yr-old man with a 3-month history of post treatment neuropathy following insulin treatment for diabetes mellitus was suffering from severe pain and dysesthesia in his bilateral feet and legs. The patient described his pain as constant burning sensation which was severest in the soles and extended circumferentially over the legs. Previous trials of tricyclic antidepressants and nonsteroidal antiinflammatory drugs were uneffective. The patient received a trial dose of intravenous lidocaine (200mg), which markedly decreased his pain. Subsequently, mexiletine was administered orally in a dose of 300 mg a day and the dose was increased up to 450 mg a day, by which a severity of pain was halved and anxiety was relieved one month later. In conclusion, intravenous lidocaine and oral mexiletine may be useful drugs for post treatment neuropathy.

Reconstruction of the hepatic vein to the prosthetic inferior vena cava in right extended hemihepatectomy with ex situ procedure

BACKGROUND

Ex situ procedure permits complete resection of a tumor involving the confluence of the three main hepatic veins, which is difficult when conventional technique is used.

METHODS

We report treatment of a patient with intrahepatic cholangiocellular carcinoma involving this confluence of the three main hepatic veins and the retrohepatic inferior vena cava (IVC) by using right extended hemihepatectomy and resection of the retrohepatic IVC with ex situ procedure. Reconstruction of the left hepatic vein required anastomosis of the left hepatic vein and a polytetrafluoroethylene (PTFE) replacement for the IVC. To our knowledge this is the first report of reconstruction of the hepatic vein by use of a PTFE prosthesis.

RESULTS

Anastomosis of the left hepatic vein to the PTFE graft was successfully performed during extracorporeal liver operation. The patient has had no recurrence during 8 months since the operation. Neither torsion nor obstruction of the hepatic vein and the graft has been observed.

CONCLUSIONS

Reconstruction of main hepatic veins and the PTFE graft as the replacement of the IVC under extracorporeal liver operation may be useful in improving the cure rate and resection rate for liver cancer that is unresectable by the conventional technique.

[Spinal anesthesia for open reduction of tibial fracture in a patient with late cerebellar cortical atrophy]

We could successfully perform spinal anesthesia with bupivacaine for open reduction of tibial fracture in a patient with late cerebellar cortical atrophy (LCCA). LCCA is a very rare neurologic degenerative disorder localized chiefly in the cerebellum, and it may be followed by various complications. His postoperative course was uneventful, followed by no neurological complication. Regional anesthesia including spinal anesthesia seems to be safe for operations in patients with LCCA.

The validity of swimming training for two-year-old thoroughbreds

To investigate the validity of swimming training, the following matters were considered: 1) changes in the performance capacity, 2) changes in the constitution and 3) frequency of locomotor diseases. These were evaluated during a training program including both conventional exercise on a track and swimming. In this study, 24 two-year-old thoroughbred horses were studied, and divided into the following three groups: Group A, trained by only running; Group B, trained by running plus a gradual increase in swimming; Group C, trained by running plus constant swimming. As a result of standardized exercise tests, only the intercepts of the 3 regression curves between the speed and the blood lactate concentration in Group B increased significantly as the training progressed. While the growth in height in Groups B and C were greater than in Group A, the increase in girth and weight in Groups B and C were smaller than in Group A. The percentages with locomotor diseases during this experiment in Groups A, B, and C were 62.5%, 12.5% and 25.0%, respectively, and there was a significant difference (p < 0.05) between Group A and Group B. As mentioned, it was suggested that a training program including swimming training is seen as being useful for improvement in performance capacity, since it can reduce locomotor diseases in young horses and allow for smooth progress in future training.

[Responses of arterial pressure and heart rate to epidural anesthesia in controlled hypertensive patients]

We have compared the responses to thoracic epidural anesthesia in 14 controlled hypertensive patients with those in 36 normotensive patients. Arterial pressure and heart rate were measured on the day before surgery, before and after the establishment of the epidural anesthesia, during light general anesthesia combined with epidural anesthesia, and after extubation. No significant difference in systolic, diastolic and mean arterial pressures were found between hypertensive and normotensive patients on the day before surgery. Changes in systolic and mean arterial pressures were greater in hypertensive patients than in normotensive ones, but absolute values of systolic, diastolic and mean arterial pressures after the establishment of the epidural anesthesia were similar between hypertensive patients and normotensive ones. Although no significant difference was found between the groups with respect to the highest and lowest systolic arterial pressure during operation, systolic arterial pressure after extubation was significantly higher in hypertensive patients than in normotensive ones. These suggest that the combination of epidural and general anesthesia is a safe technique for patients with medically controlled hypertension.

[Cardiac arrests probably induced by hypermagnesemia during anesthesia for caesarean section]

A 24-year-old pregnant woman was scheduled for Caesarean section during the 31st week of pregnancy. The patient had been treated with MgSO4 for premature labor and toxemia. During anesthesia, cardiac arrest occurred twice. The first cardiac arrest occurred immediately after induction of anesthesia and seemed to be due to combined effects of hypermagnesemia, thiopental and supine hypotensive syndrome. Three babies were delivered during cardiac massage. The second one occurred immediately after administration of methyl-ergometrine malate and seemed to be due to combined effects of hypermagnesemia and methyl-ergometrine malate. The patient and three babies did not develop any complication. In giving anesthesia for patients with hypermagnesemia, anesthetists should take account of interactions between magnesium, anesthetics and other drugs.

[A method of tracheal intubation tried in a patient with multicentric reticulohistiocytosis]

A 48-year-old woman had suffered from multiple destructive arthritis, skin nodules and skin ulcer of bilateral legs caused by multicentric reticulohistiocytosis for 16 years. Skin transplantation and total hip joint replacement were scheduled. Tracheal intubation was anticipated to be difficult because of destructive arthritis of the temporomandibular joint. We tried a new method to intubate the trachea through a laryngeal mask. After topical application of 8% lidocaine to the oropharynx, a size 4 laryngeal mask was inserted and its cuff was inflated by 20 ml of air. Anesthesia was induced with 4% sevoflurane in 50% nitrous oxide via laryngeal mask. A fiberscope through a tracheal tube was inserted through the laryngeal mask into the trachea. A tracheal tube with the internal diameter of 6.5 mm, was successfully intubated. This method gave little discomfort to the patient.

[Atropine has little significance as a premedication for spinal anesthesia]

Intramuscular atropine 0.5 mg as an anticholinergic premedicant for spinal anesthesia was studied in 14 patients. Twelve patients of a control group did not receive atropine. No significant difference was found between the groups with regard to changes in blood pressure during spinal anesthesia whose analgesic level reached T4. A significant difference was found between the groups with regard to changes in heart rate during spinal anesthesia, but the incidence of bradycardia below 60 beats.min-1 was similar between the groups. Intramuscular atropine 0.5 mg as a premedicant offered little vagal blockade of the heart during spinal anesthesia.