Successful resection of sigmoid colon cancer in a patient with factor XI deficiency

A 42-year-old-women with sigmoid colon adenocarcinoma was found to have isolated prolonged activated partial thromboplastin time (aPTT 102.5 s, normal range 24-36 s) preoperatively. Her medical history included an episode of prolonged postdelivery uterine bleeding 16 years previously. A mixed aPTT test showed immediate correction of the prolonged aPTT, indicating a coagulation factor deficiency in the intrinsic pathway. Factor assays showed factor XI was below 1% of average normal value whereas factor VIII, IX and XII activities were normal. Family screening revealed one sister among the three siblings also had isolated prolonged aPTT. The patient was transfused with four units (5mL/kg) of fresh frozen plasma the day before surgery, then with two units during surgery. The operation was uneventful with no bleeding problems. The patient recovered smoothly and is currently undergoing adjuvant chemotherapy. This is the first formal report of a patient with factor XI deficiency undergoing major surgery in Taiwan. Careful monitoring of aPTT, with fresh frozen plasma transfusion, when needed, may safely overcome bleeding problems during surgery.

Power spectral analysis of arterial blood pressure after spinal anesthesia

BACKGROUND

The continuous, on-line and real-time analysis of the power spectrum (CORAPS) of systemic arterial pressure (SAP) and heart rate (HR) signals is one of the current progresses in the development of non-invasive indexes for autonomic nervous system. It might be a useful clinical tool to monitor the progress of preganglionic block of sympathetic nervous system and the homeostatsis of cardiac neuroregulation after spinal anesthesia. The purpose of this study is to examine the relationship between the hypotensive response and the changes of components in CORAPS throughout the course of spinal anesthesia.

METHODS

In 10 ASA class I-II patients (aged from 17 to 75 years) scheduled for elective surgery, we analyzed the changes of spectrum of systemic arterial blood pressure signals during spinal anesthesia. Spinal anesthesia was performed with 0.5% bupivacaine (dosage at 13-15 mg). For CORAPS, SAP signals were simultaneously relayed to an analog-digital converter connected to a computer. Power spectral density of the data was computed using a fast Fourier transform. The areas of the spectral peaks within each measurement were calculated as the follows: very low (BVLF, 0.01-0.08 Hz), low (BLF, 0.09-0.15 Hz), and high (BHF, 0.16-0.25 Hz).

RESULTS

During the time interval (S2 period) when spinal anesthesia was initiated and 15 min thereafter the power density of low frequency (BLF), (1.2 vs. 2.3), and very low frequency (BVLF) components decreased, (3.4 vs. 7.8), in comparison with that at the baseline level (S1 period). We also found the shift of dominance between low frequency (BLF) and high frequency (BHF) in S2 period. The effects of intrathoracic pressure on the venous return may contribute to the increase of power density of BHF components (1.7 vs. 1.1). We also found that even in patients with stable hemodynamic variability, the decrease of BLF and BVLF components, and the shift of dominance were the same as in patients with unstable hemodynamic variability.

CONCLUSIONS

It might prove that the cephalic spread of spinal block abolished the sympathetic tone of the autonomic nervous system. These results validated previous speculations of a sympathetic block during spinal anesthesia. More importantly, patients with stable hemodynamic variability still have profoundly sympathetic block with decreased power density of BLF and BVLF. The CORAPS is a good clinical monitoring tool to evaluate the homeostatsis of cardiac neuroregulation after spinal anesthesia.

Right ventricular dysfunction after tetralogy repair in a pediatric patient with successful ECMO support--a case report

Right ventricular dysfunction after surgical repair of tetralogy is a serious life threatening complication. Although pulmonary vasodilators and inotropes can be used for cardiac support in tetralogy repair, these drugs may be ineffective in some patients. To date extracorporeal membrane oxygenation (ECMO) support may be used effectively in these patients when medical therapy fails. We report a case with successful ECMO support in right ventricular dysfunction and pulmonary hypertension after total surgical correction of Fallot's tetralogy. ECMO circuit was instituted in the operating room due to difficulty in weaning from cardiopulmonary bypass in spite of aggressive medical therapy. We reviewed and discussed the indications, contraindications of application of ECMO and patient survival with treatment of ECMO. At the same time we wish to share our limited experience we gained in our first attempt of ECMO support.

Effect of BL-10 (tianzhu), BL-11 (dazhu) and GB-34 (yanglinquan) acuplaster for prevention of vomiting after strabismus surgery in children

BACKGROUND

Stimulation of P6 (Neiguan) acupoint can prevent nausea and vomiting in adults. However, there is no antiemetic effect in children undergoing strabismus surgery. The effect of P6 may act only on hollow organs; in contrast, BL-10 (Tianzhu), BL-11 (Dazhu) and GB-34 (Yanglinquan) are more related to the meridians of the eye. Therefore these three more relevant acupoints, BL-10, BL-11 and GB-34 were stimulated to evaluate the antiemetic effect in children undergoing strabismus surgery.

METHODS

Sixty-five children, ASA physical status I, between 3 and 14 years of age, were randomly divided into two groups as follows: placebo group (n = 31) and acuplaster group (n = 34). Bilateral acupressure using the Vital Point Needleless Acuplaster (Koa, Japan) was applied to BL-10, BL-11 and GB-34 points the night before surgery. Anesthesia was induced and maintained with halothane and nitrous oxide in oxygen. Postoperative emesis was assessed at early (at PACU) and late (at ward) phases, and was recorded by an investigator blind to the treatment characteristics.

RESULTS

In the early emesis phase, the incidence of vomiting was 35.5% for placebo group, compared with 14.7% for acuplaster group. In the late emesis phase, acuplaster patients had a significantly lower incidence of vomiting (23.5% vs. 58.1% in placebo patients, p < 0.05). The overall postoperative vomiting incidence in the acuplaster patients in a 24 h period which was significantly decreased was 29.4% as opposed 64.5% in the placebo group (p < 0.05).

CONCLUSIONS

The results demonstrated that prophylactic use of bilateral noninvasive acuplaster on the BL-10, BL-11, and GB-34 acupoints significantly reduces vomiting after strabismus correction. The mechanism may be dispersal of these three acupoints, thus diminishing the parasympathetic stimulation resulting from surgical traction of eye muscles.

Surgical treatment of thoracic arachnoiditis with multiple subarachnoid cysts caused by epidural anesthesia

We report on a 36 year-old woman who had sensorimotor and sphincter dysfunction 0.5 day after having an epidural anesthesia to deliver her baby. The patients' neurological deficits recovered gradually and she could walk without support 1.5 months after the operation. However, her neurological function deteriorated 4 months after anesthesia and a magnetic resonance imaging (MRI) study revealed spinal arachnoiditis with multiple subarachnoid cysts at the T5-7 levels. Surgical treatment consisted of lysis of adhesions and wide opening of the subarachnoid cysts. Her motor function improved after operation and she could walk without support after a 1 year follow-up. However, her sphincter and sensory abnormalities persisted for the most part. The literature on the surgical treatment of arachnoiditis with myelopathy is reviewed and the surgical indications are discussed.

Non-surgical treatment of hepatocellular carcinoma

A decade ago, surgery was the only satisfactory treatment modality for hepatocellular carcinoma (HCC), but it was limited only to selected cases. For the majority of cases of HCC, systemic chemotherapy was one of the few treatment alternatives, but provided only marginal benefit. In the past 20 years, diagnostic methods have improved to an extent that small HCC less than 1 cm can be detected. Moreover, non-surgical treatment is available, of which regional therapy has been shown to prolong patients' survival, and may even replace surgical resection in some cases. Regional therapy is indicated for the treatment of HCC when there is no extrahepatic metastasis and the patient has adequate liver function reserve, thus permitting repeated therapy. Transcatheter hepatic arterial embolization (TAE) using various embolizers has been well documented to include controlled studies. However, it is not indicated for patients with thrombosed main portal veins. Its therapeutic effect is also doubtful when the tumour is infiltrative in nature or is hypovascular, too large or too small. Additional chemotherapeutic agents mixed into the embolizer with lipiodol and degraded starch microspheres or styrene-maleic acid-neocarzinostatin in which chemotherapeutic agents are embedded, are used with a better response, but the survival rate has not shown significant improvement. Ultrasound-guided local injection therapy is another new method of treatment of HCC. Of these techniques, percutaneous ethanol injection therapy (PEIT) is widely used with excellent results for small, encapsulated tumours in livers with less than three HCC. Percutaneous ethanol injection therapy can also be used in cases with portal vein thrombosis, but it is not suitable for patients having coagulopathy or ascites. Using acetic acid, OK-432, interferon or anti-cancer drugs in the injection therapy shows no further benefit over ethanol alone. Transcatheter echoguided thermotherapy or cryotherapy has been reported in small series of patients, as has target therapy with immune or radiotherapy and conformal radiotherapy. Preliminary studies show encouraging results. Systemic therapy with either single drug or multidrugs is ineffective, with a response rate of less than 20%. Immunotherapy, such as with interferon or other cytokines, is not beneficial. Hormone therapy has not been promising, except for treatment with tamoxifen, which has been reported to show some beneficial effect. Gene therapy is still in its infancy. In summary, recent progress in non-surgical treatment of HCC has resulted in a breakthrough of regional therapy looking quite promising. Moreover, a combination of different types of regional therapies may yield better outcomes in selected individuals.

Induction of antitumor immunity by intracerebrally implanted rat C6 glioma cells genetically engineered to secrete cytokines

To test whether cytokine gene therapy can be applied to an immunologically privileged site, such as the brain, we investigated antitumor immunity in the brain induced by cytokine-secreting glioma cells. Three cytokine genes, interleukin-2 (IL-2), interleukin-4 (IL-4), and granulocyte-macrophage colony-stimulating factor (GM-CSF) were transduced into a rat C6 glioma cell line via a retroviral vector, S2. Rats intracerebrally (IC) implanted with the C6 cells genetically engineered to secrete the cytokines, especially GM-CSF, manifested significantly higher survival rates than those with C6 cells or with C6 cells bearing the control vector (p < 0.002). In vivo, C6 tumors bearing the cytokine genes grew more slowly than wild-type tumors at any time point, and eventually diminished within 6 weeks after tumor cell implantation. Histopathological and immunohistochemical studies revealed that different cytokines induced diverse immune reactions. In the IL-2 group, CD4+ and CD8+ T cells dominated from day 3 to week 4, but disappeared at week 6. Some granulocytes were noted between weeks 2 and 4. In the IL-4 group, eosinophils were noted from day 3 to week 4, and CD4+ and CD8+ T cells, as well as macrophages at week 2. At week 6, only residual levels of macrophages and CD8+ T cells remained. In the GM-CSF group, granulocytes appeared as early as day 1 post-IC tumor implantation, and macrophages at day 2. CD4+ and CD8+ T cells were found from day 3 to week 4. At week 6, only residual CD4+ T cells and macrophages remained. Long-lasting antitumor immunity was confirmed in all groups by rechallenging surviving rats with wild-type C6 cells in the brain 100 days after implanting cytokine gene-bearing C6 cells. In vivo depletion of GM-CSF by anti-GM-CSF antibody further confirmed that the immune reaction induced by GM-CSF-secreting tumor cells were mainly from the action of GM-CSF, rather than the immunogenicity of C6 cells.

Response of patients with dual hepatitis B virus and C virus infection to interferon therapy

Patients with dual infection with hepatitis B virus (HBV) and delta virus (HDV) responded poorly to interferon (IFN) therapy. Little is known about the effect of IFN therapy in patients with HBV and hepatitis C virus (HCV) dual infection. The patients in two randomized controlled trials with chronic HBV infection were retrospectively assayed for HCV markers. The HBV responses to IFN therapy in patients with and without HCV markers were compared. An open trial was conducted in 4 patients who had lost their serum HBV surface antigen (HBsAg) but had continuing HCV viremia and hepatitis. Of the 15 patients seropositive for HCV marker(s), only 1 (6.7%) responded with seroclearance of HBV DNA and HBV e antigen, as compared with 46 (28%) of 164 HCV-negative patients (p = 0.058). Icteric hepatitis developed in 1 patient on emergence of serum HCV RNA in association with seroclearance of HBV DNA. In contrast, good response was demonstrated in 3 of the 4 patients who had lost serum HBsAg before therapy. The results suggest that IFN therapy is not only of limited value in patients with dual infection with HBV and HCV but also has a potential risk of severe hepatitis if the clearance of one virus removes its suppressive effect on and facilitates the emergence of the other. However, patients with continuing HCV hepatitis after termination of the chronic HBsAg carrier state responded well to IFN therapy.

Disseminated miliary cerebral candidiasis

We present a case of disseminated intracranial infection by Candida albicans in a 5-year-old girl who had fever and a change of consciousness after surgery for complex congenital heart malformation. MR imaging revealed multiple small ring-enhancing hemorrhagic abscesses. One year after antifungal treatment, the abscesses and ventriculomegaly were almost completely resolved. The patient was discharged in a stable but vegetative condition.

Priming technique accelerates the onset time of mivacurium in children during halothane anesthesia

BACKGROUND

Mivacurium is considered a relaxant suitable for tracheal intubation in children due to its rapid onset. We compared the neuromuscular effects of mivacurium, with and without priming, in children undergoing elective surgery during halothane anesthesia.

METHODS

Forty pediatric patients (2-10 yr, ASA class I) were randomly into 2 groups and studied under halothane anesthesia. The non-priming group (n = 20) received mivacurium 0.25 mg/kg, and the priming group (n = 20) received a priming dose of mivacurium 0.025 mg/kg, followed by an intubating dose of 0.225 mg/kg 3 min later. Thenar Electromyogram responsive to supramaximal train-of-four stimulation of the ulnar nerve at 12 s intervals was used as neuromuscular monitoring.

RESULTS

The onset time in the priming group was significantly faster than in the non-priming group (1.04 min vs. 1.7 min). The mean time from injection of intubating dose to spontaneous recovery to 25%, 50% and 75% twitch were not influenced by priming technique. Side effects, such as cutaneous flushing and hypotension, were unremarkable at this dose in children.

CONCLUSIONS

Priming technique can significantly accelerates the onset of mivacurium in the pediatric patients under halothane anesthesia.

Primary hemangiopericytoma in the axis bone: case report and review of literature

OBJECTIVE AND IMPORTANCE

To the best of our knowledge, this is the first reported case of primary hemangiopericytoma in the axis bone. With this report, we attempt to better characterize this uncommon lesion in the vertebral column.

CLINICAL PRESENTATION

This report describes a case of primary heman-giopericytoma in the axis bone of a 16-year-old female patient who presented with acute torticollis. Her neurological status was unimpaired. A lateral radiograph of the cervical spine demonstrated an odontoid neck fracture and a C1-C2 rotatory deformity. The magnetic resonance imaging study showed a hypodense lesion with moderate enhancement on T1- and T2-weighted images on the dens and body of the axis with an odontoid neck fracture. Reviewing the literature, primary hemangiopericytoma in the spine is rare; 9 cases of hemangiopericytoma with vertebral bone involvement and 44 cases of this tumor with intraspinal meningeal involvement have been reported.

INTERVENTION

The patient was treated with odontoidectomy via the transoral approach, along with posterior fixation using the Halifax clamp. She was followed up 17 months after surgery, and no evidence of tumor recurrence was found.

CONCLUSION

The treatment for osseous hemangiopericytoma is still controversial. At present, adequate surgical removal with postoperative radio-therapy is recommended. In addition, although hemangiopericytoma is rare in the spine, it should be kept in mind in the differential diagnosis of spinal tumors.

Measurement of motor conduction in the thoracolumbar cord. A possible predictor of surgical outcome in cervical spondylotic myelopathy

STUDY DESIGN

A prospective motor-evoked potential study with measurement of spinal cord motor conduction velocity in the thoracolumbar cord was performed before and after decompression surgery in 30 patients with cervical spondylotic myelopathy.

OBJECTIVES

To evaluate the neurofunctional integrity of the spinal motor pathways in cervical spondylotic myelopathy in patients compared with age-matched control subjects; to assess any changes after posterior surgical decompression; and to correlate such changes with functional outcomes so that the predictability of preoperative motor-evoked potentials could be determined.

SUMMARY OF BACKGROUND DATA

Previous studies evaluating neurologic function and predictability of surgical results in cervical spondylotic myelopathy patients always depended on the morphologic changes of the cord and spinal structures. The recently developed motor-evoked potential study and noninvasive measurement of spinal cord motor conduction velocity may provided an objective method to evaluate physiologic motor function in cervical spondylotic myelopathy patients.

METHODS

Spinal cord motor conduction velocity in the thoracolumbar cord was measured using percutaneous magnetic stimulation over the motor cortices and F-wave studies in median and peroneal nerves. Motor function of cervical spondylotic myelopathy patients was graded according to evaluation of signs of cord involvement, ambulation, and degree of dependence in activities of daily living. Evaluation was performed at 6 months, 1 year, and 2 years after decompression surgery.

RESULTS

Motor functional improvement accompanied by increased spinal cord motor conduction velocity occurred in Grade I patients with a mild neurologic dysfunction but not in Grade II or III patients with a moderate-to serve neurologic deficit. Neurologic improvement does not appear to occur until 6 months after surgery.

CONCLUSIONS

Measurement of spinal cord motor conduction velocity may provide an objective and quantitative approach to assessing the motor functional integrity of the spinal cord and serving as a predictor in evaluating surgical outcome in patients with cervical spondylotic myelopathy.

Severe clinical rebound upon withdrawal of corticosteroid before interferon therapy: incidence and risk factors

To analyse the incidence and risk factors of clinical rebound and hepatic decompensation during or upon withdrawal of prednisolone pretreatment before interferon (IFN) therapy, two series of Taiwanese patients with chronic viral hepatitis from two independent randomized controlled trails were compared. Group 1 included 41 patients with chronic hepatitis B who were pretreated with daily prednisolone (30 mg) for 3 weeks, 15 mg for 1 week and no prednisolone for 2 weeks prior to lymphoblastoid IFN therapy. Group 2 consisted of 59 patients with chronic hepatitis B who were pretreated with daily prednisolone (40 mg) for 2 weeks, 30 mg prednisolone for 2 weeks, 20 mg prednisolone for 2 weeks and no prednisolone for 2 weeks prior to INF alpha-2a therapy. Clinical rebound developed more frequently in group 2 (67.8%) than in group 1 patients (41.5%; P < 0.01). The peak serum transaminase levels of group 1 and 2 patients during clinical rebound were similar. Icteric and symptomatic clinical rebound occurred in four (one cirrhotic) group 2 patients. The incidence of hepatic decompensation was 3.4% in group 2 patients, or 5.0% in group 2 patients with clinical rebound. Patients pretreated with a higher dose (40 mg) of prednisolone (odds ratio 3.0; 95% CI 1.3-6.6; P < 0.01) and non-cirrhotic patients (odds ratio 6.2; 95% CI 1.2-32.1; P < 0.02) tended to suffer from clinical rebound more frequently. However, once clinical rebound develops in cirrhotic patients, the relative risk of decompensation is 16 times that of non-cirrhotic patients. These results suggest that clinicians should be cautious in prescribing a short course of corticosteroids for patients with chronic viral hepatitis, because hepatic decompensation might occur in Oriental people with or without cirrhosis.

Initiator elements and regulated expression of the herpes simplex virus thymidine kinase gene

Regulated expression of thymidine kinase mRNA in herpes simplex virus mutants harboring thymidine kinase promoters that lacked functional TATA boxes was largely unaffected by additional sequence alterations around the transcriptional start site. A strong initiator element increased the regulated expression of a TATA-containing promoter by 50% but did not affect that of the TATA-less promoter. Thus, initiator elements exert only small effects in this promoter context.

The effect of intrathecal bupivacaine with combined fentanyl in cesarean section

BACKGROUND

The use of neuraxial opioids has gained popularity over the last few years; they may augment the analgesia produced by the local anesthetic through direct binding with the specific spinal receptors. Morphine, a lipophobic opioid, may not be optimal as an intrathecal drug for intraoperative analgesia because of its slow onset. The lipophilic opioid, fentanyl for instance, if administered intrathecally, its onset is fast and many of its merits by virtue of its lipophilic property may be seen intraoperatively.

METHODS

Seventy five healthy pregnant women who sustained cesarean section under spinal anesthesia were assessed in a randomized fashion. The spinal anesthetic used was 0.5% hyperbaric bupivacaine. Patients were divided into 5 groups, 15 in each group. Fentanyl 0 (Group I), 7.5 (Group II), 10 (Group III), 12.5 (Group IV) and 15 (Group V) micrograms was respectively added to normal saline to make a total volume of 0.3 ml, which was then added to bupivacaine and administered to patients in a randomized fashion. The effect of analgesia, vital signs and side effects were observed every 5 min during operation and every 30 min after operation.

RESULTS

It was disclosed that all patients in group V and IV had excellent analgesia intraoperatively, while only 33.3% patients in the control group had an analgesia which was qualified as excellent. Complete analgesia (time from injection to first report of pain) also lasted longer in group IV (201.3 +/- 16.4 min, mean +/- SEM) and group V (210.3 +/- 18.6 min) compared with group I (118.9 +/- 10.4 min). The duration of effective analgesia (time from injection to first parental opioid) was increased with the dose of intrathecal fentanyl above 12.5 micrograms (293 +/- 22.4 min). Both complete analgesia and effective analgesia were not significantly different between group IV and group V. Pruritus was the most common side effect. The incidence of shivering decreased significantly in group IV & V as compared with control group.

CONCLUSIONS

The combination of bupivacaine with a dose of fentanyl as low as 7.5 micrograms did not produce actual clinical effects. As the dose of fentanyl was increased to 12.5 micrograms or 15 micrograms the quality of surgical analgesia was better and the postoperative analgesia lasted longer. It seemed that the clinical effect might reach its ceiling at the dose of 12.5 micrograms. Pruritus was the most common side effect, but it was mild.

Power spectral analysis of systemic arterial pressure signals during open heart surgery

BACKGROUND

The close relationship between the balance of sympathetic and parasympathetic tones and the results of power spectral analysis (PSA) of systemic arterial pressure (SAP) has been suggested recently. The purpose of this study was to further describe the changes of balance between the two autonomic nervous components during open heart surgery for coronary arterial disease (CAD) or valvular heart disease (VHD) with the PSA technique of SAP.

METHODS

By relaying the SAP signals to a personal computer utilizing a power spectral analysis algorithm, radial arterial pressure signals of 27 patients (11 with CAD for coronary artrial bypass graft, as CAD groups; 16 with VHD, as VHD group, including 8 for aortic valve replacement and 8 for mitral valve replacement) during open heart surgery were monitored in a continuous, on-line and real-time manner. On-line power spectral analysis was performed according to the five different stages of the operation.

RESULTS

Power density tended to increase in the high frequency (HF) band during the ventilator-supported stages of the open heart procedures, i.e., the pre-cardiopulmonary bypass (CPB) and the off-CPB periods. The power density in other frequency bands during the whole course of general anesthesia otherwise decreased significantly, with the lowest values occurring during CPB. The power density in very low frequency (VLF) band was much higher than in other bands during CPB, and became the major component of total power density in this period.

CONCLUSIONS

The balance between sympathetic and parasympathetic components of autonomic nervous system changes rapidly during open heart surgery and needs careful monitoring. By utilizing PSA of SAP, mathematical error might be an obstacle of using LF:HF ratio as an index of autonomic balance during the CPB period when the HF density approaches zero.

Continuous, on-line, real-time spectral analysis of SAP signals during cardiopulmonary bypass

We communicated the application of continuous, on-line, real-time power spectral analysis of systemic arterial pressure (SAP) signals during cardiopulmonary bypass when the heart was functionally but reversibly disconnected from the blood vessels. Based on observations from 15 cases of successfully completed coronary artery bypass grafting procedures, we found that the very low (0.00-0.08 Hz), low (0.08-0.15 Hz)-, high (0.15-0.25 Hz)-, and very high (0.80-1.60 Hz) frequency components of SAP signals exhibited differential changes before, during, and after cardiopulmonary bypass. In particular, the very low-frequency component, which purportedly represents the contribution of vasomotor activity to SAP, presented only a mild decrease in power during hypothermic cardioplegia. Interestingly, the total peripheral resistance also manifested only a slight reduction during the same period. On the other hand, the low-, high-, and very high frequency components were essentially eliminated. These results unveiled an active role for the blood vessels in the maintenance of SAP during cardiopulmonary bypass, possibly as a result of a maintained vasomotor tone as reflected by the sustained very low frequency component of the SAP signals.

Cerebellar medulloblastomas: a comparison between adults and children

A retrospective analysis of 19 medulloblastomas in patients aged 2 to 24 years was conducted employing 14 children (<15 years old) and 5 adults. All patients received gross total excision of the tumour with postoperative craniospinal irradiation. The patients were then followed up for more than 5 years. To determine which factors influenced the prognosis of these two age groups, we analysed the differences of the proliferating cell nuclear antigen (PCNA), the degree of tumour invasion and the outcome between adult and childhood medulloblastomas. In summary, medulloblastomas in adults and children had similar cell proliferative activity and long term survival rates but the tumours with brain stem invasion, which commonly occurred in children, had an early recurrence rate and a poor prognosis. The prognosis of medulloblastoma may depend upon the degree of tumour invasion of the brain stem.

Lack of effect of flumazenil on the reversal of propofol anaesthesia

Propofol, like the benzodiazepines, activates the GABAA receptor-chloride ionophore complex; they potentiate one another. Since neither pharmacodynamic nor pharmacokinetic data concerning drug interaction between flumazenil and propofol is available, and especially considering the relationship of binding sites, flumazenil, the antagonist of benzodiazepines, was investigated to determine its effect upon recovery from propofol anaesthesia. Forty women receiving dilatation and curettage procedures were included in this double-blind test. After 50 micrograms fentanyl, propofol 2 mg.kg-1 was injected for induction and followed by infusion at the rate of 15 mg.kg-1.hr-1. After the operation, patients were given normal saline (Group A) or flumazenil 10 micrograms.kg-1 (Group B) randomly. Recovery time in Group A was 15.2 +/- 5.1 min and Group B 15.8 +/- 4.8 min. Propofol concentrations at the end of infusion were 4.17 +/- 1.33 micrograms.ml-1 (Group A) and 4.03 +/- 1.45 micrograms.ml-1 (Group B); these then declined to 1.22 +/- 0.17 micrograms.ml-1 (Group A) and 1.18 +/- 0.15 micrograms.ml-1 (Group B) when patients were able to open their eyes on command. No significant differences were found between the groups based on propofol concentrations and recovery time, nor did haemodynamic changes differ between them after administration of reversal agents. It was concluded that flumazenil 10 micrograms.kg-1 does not influence recovery from propofol anaesthesia.

Intraoperative monitoring of motor function by magnetic motor evoked potentials

Under etomidate anesthesia, motor evoked potentials produced by magnetic stimulation were successfully recorded from 10 thenar muscles and 10 anterior tibial muscles of eight patients who had undergone surgery on the medulla oblongata and the cervical and thoracic spinal cords. Recordings taken before placing the neural tissue at risk were assessed for variability in amplitude and latency. The lower limit in amplitude was approximately one-third (25-43%) of the baseline. The latencies were more difficult to monitor than were the amplitudes. The latency variations were 2.56 +/- 0.50 milliseconds for the hand and 6.84 +/- 1.37 milliseconds for the leg. During surgery, the unilateral recordings of two patients were transiently lost but partially recovered after a pause in the operation. No obvious postoperative weaknesses in the corresponding limbs occurred. One patient, who showed a permanent loss of unilateral recording, had transient monoplegia with a complete recovery. None of the remaining five patients who had amplitudes larger than one-third of the baseline at the end of the operation had additional motor deficits. Our conclusions are that under etomidate anesthesia, the magnetic motor evoked potentials can be convenient and reliable monitors of motor function, that changes in the amplitude may be superior to those in the latency for intraoperative warning, that the criterion for potential neural damage under magnetic motor evoked potential monitoring might be an amplitude reduction of two-thirds of the control value, and that the magnetic stimulation seems to be more sensitive than the electrical stimulation in the monitoring of motor function and also allows more time and opportunities for the motor function to recover.

Intraoperative transcranial electrical motor evoked potential monitoring during spinal surgery under intravenous ketamine or etomidate anaesthesia

Motor evoked potentials (MEPs), monitoring the motor function directly, are superior to somatosensory evoked potentials (SSEPs) in monitoring the motor system during spinal surgery. Reliable MEPs are difficult to elicit under normal anaesthesia. Using intravenous anaesthesia with either ketamine or etomidate infusion, we performed intraoperative MEP monitoring in 12 spinal operations for 11 cases from February 1992 to May 1992. For anaesthesia, ketamine was used in 5, etomidate in 7, fentanyl was supplemented in all, muscle relaxation at 30% to 50% of pre-anaesthetic muscle power was maintained with atracurium or vencuronium infusion. Transcranial bipolar electrical stimulation was used to induce MEPs. Concomitant SSEP monitoring was performed in 3. No significant anaesthesia related side effects were noted except one episode of unpleasant dream occurred in the ketamine anaesthesia group. Successful monitoring was achieved in 10 sessions. In 5 of which warning to the surgeons was made due to sudden MEP deterioration, which recovered followed by definite management in four and persisted in one. In the other 5 sessions, no warning was made due to stationary or gradual change in MEPs. Bilateral two-channel recordings were used in 3 sessions. In 2 of which unilateral transient change was noted. Loss of SSEPs was noted in one despite unchanged MEPs, in whom only new sensory deficits occurred postoperatively. Compared to the baseline MEPs in terms of latency and amplitude, the final MEPs improved in 5 sessions, did not change significantly in 4 sessions, deteriorated in one session, and were correlated well with the immediate postoperative motor status.(ABSTRACT TRUNCATED AT 250 WORDS)

Percutaneous lumbar discectomy: indications and surgical results in 35 consecutive cases

Thirty-five patients (27 men and eight women) who met our criteria of case selection for percutaneous lumbar discectomy (PLD) were treated by this method during the period May 1992 to June 1993. Thirty-six spaces, including one man with double disc disease, were decompressed. Patients ranged in age from 14 to 64 years. All patients but one were followed up for a minimum of six months. The operative results, evaluated by a more objective functional grading system, revealed a short-term (two months) success rate of 83% and a mid-term (six months) success rate of 76%. This discrepancy resulted from two recurrences of sciatic symptoms. It indicates that the medical conditions of those who have received PLD are by no means static, but instead may fluctuate. The operative result was similar to that of open discectomy, averaging 81.1% in reported series. Our "functional grading system" reflects these fluctuations quantitatively. With respect to the operative success rate, there was a statistical difference between the very good, good and fair-poor indication groups of patients, as were categorized by our major criteria of indications that included three clinical manifestation criteria and the other three radiographic findings. This result emphasizes the critical role of case selection in the operative success rate. Complications consisted of one disc infection which cleared without sequelae. This study provides an objective means of selecting cases and evaluating surgical results which, in turn, makes the use of this procedure convincing and predictable.

Cholangiography of icteric type hepatoma

OBJECTIVES

Icteric type hepatoma caused by floating tumor debris in the major bile duct was rare. Such cases were often incorrectly identified as biliary carcinoma or choledocholithiasis until pathological proof. The goal of this study was to analyze the cholangiograms of icteric type hepatomas, and to identify the characteristic cholangiographic features of this rare disease.

METHODS

A retrospective analysis of 20 cholangiographies of icteric type hepatomas during a 10-yr period was carried out.

RESULTS

There were 15 males and five females in this series. Seventeen (85%) patients were hepatitis B virus carriers, and liver cirrhosis was detected in 16 (80%) patients. Serum alpha-fetoprotein levels in 13 (65%) of the patients were over 400 ng/ml. The cholangiographic findings included: 1) intraductal filling defects resulting in partial or complete obstruction and ductal dilation in 14 cases (70%), 2) abrupt complete obstruction of the common hepatic duct with an irregular cut surface in three cases (15%), and 3) tumor encasement and stricture of the biliary system in three cases (15%). Management of these patients included hepatic resection, choledochotomies with T tube stenting, or PTCD. Most of them died within one-half year after diagnosis, but one patient in our series, who received hepatic resection, survived more than 70 months.

CONCLUSIONS

It is important to recognize this group of patients. Because with proper management, good palliation or cure is possible. The cholangiographic appearances, when taken alone, are not diagnostic of icteric type hepatomas. Once these cholangiograms are seen in patients with associated risks of developing a hepatoma, such as liver cirrhosis, chronic viral hepatitis, and elevated serum alpha-fetoprotein, however, an icteric type hepatoma should be suspected.

The role of laparoscopy in the evaluation of ascites of unknown origin

The role of laparoscopy in the diagnostic evaluation of ascites of unknown origin was studied in 129 patients. Laparoscopic results were as follows: (1) Carcinomatosis peritonei in 78 (60.5%). Peritoneal biopsies in 76 of these cases revealed malignancy in 67 (adenocarcinoma 62, lymphoma 4, mesothelioma 1) and tuberculosis in 5; specimens were inadequate for diagnosis in 4. (2) Tuberculous peritonitis in 26 (20.2%). Peritoneal biopsies in 24 of these cases revealed tuberculosis in 22 and non-specific chronic peritonitis in 2. (3) Cirrhosis in 7 (5.4%). (4) No gross abnormality in 18 (14.0%). Of the latter, causes of ascites had already been identified in 13 (72.2%), including chronic renal failure in 7, systemic lupus erythematosus in 2, constrictive pericarditis in 2, chronic pancreatitis with chylous ascites in 1, and retroperitoneal lymph node metastasis with chylous ascites in 1. Thus, laparoscopic observation in combination with biopsy established the cause of ascites of unknown origin in 111 (86.0%) of 129 patients. Most of the 18 patients without gross laparoscopic abnormality had underlying disease identified as a cause of ascites; laparoscopy was indicated in these cases to exclude other processes that may also cause ascites.