Search

The patient was a 81-year-old female with a history of treatment for the right breast cancer 29 years earlier. She presented with a chief complaint of dyspnea. CT showed pleural effusion and a mediastinal tumor. A biopsy was performed on the mediastinal tumor, and not only pathological but also immunohistological examination findings were similar to those of the surgical specimens 29 years ago. In view of the patient's age, we initiated treatment by anastrozole. The treatment was effective, and other forms of endocrine therapy were administered. She continued to be treated with the endocrine therapy over 4.5 years. The late recurrence of breast cancer in the form of carcinomatous pleurisy 29 years postoperatively is rare.

Case 1: A 68-year-old woman was diagnosed with advanced HER2-positive breast cancer(T2N2aM0, cStage ⅢA). She was treated with 4 courses of preoperative chemotherapy with pertuzumab, trastuzumab, and docetaxel. She was diagnosed to have achieved partial remission(PR), and subsequently underwent a mastectomy and axillary dissection. Pathological examination revealed smaller than 1 mm(Grade 2b). Case 2: A 59-year-old woman was diagnosed with advanced HER2-positive breast cancer(T4bN1M0, cStage ⅢB). She was treated with 4 courses of preoperative chemotherapy with pertuzumab, trastuzumab, and docetaxel. She was diagnosed to have achieved PR(primary lesion: complete remission), and subsequently underwent a mastectomy and axillary dissection. Pathological examination revealed complete pathological response(Grade 3). Combination therapy with pertuzumab, trastuzumab, and docetaxel appears to be a useful preoperative chemotherapy regimen for locally advanced HER2-positive breast cancer.

A 65-year-old woman with a right breast tumor and right arm pain was seen in our hospital. She was diagnosed with scirrhous carcinoma (Stage IV, hormone receptor-positive, and HER2-negative) with pleural effusion and metastasis to the lung, liver, bone, and multiple lymph nodes. Systemic chemotherapy with biweekly bevacizumab and weekly paclitaxel was administered, and an opioid (oxycodone 40 mg/day) was administered for pain control. At the end of the first course, the patient's pain was improved, and the opioid dose was reduced (oxycodone 20 mg/day). The patient had a partial response (PR) over 24 treatment courses (1 year 10 months), and good pain control was obtained. Bevacizumab and paclitaxel therapy successfully brought about a rapid and good response and improved the patient's quality of life as palliative chemo- therapy.

A 59-year-old woman with an exudative, reddish bilateral breast tumor and dyspnea visited our hospital. She was diagnosed as having scirrhous carcinoma with metastasis to the liver and pleural effusion, designated as Stage IV, hormone receptor positive, and human epidermal growth factor receptor-2 (HER2) negative. Systemic chemotherapy (3 regimens) and endocrine therapy (5 regimens) were administered for a total of 5 years 7 months. Eribulin was administered as fourth line systemic chemotherapy. The pleural effusion reduced and dyspnea improved. Her status was maintained for 1 year 3 months. This case suggests that eribulin may provide long-term survival and maintenance of quality of life (QOL) in metastatic breast cancer patients.

Background: Femoral nerve block and sciatic nerve block are used to provide intraoperative and postoperative analgesia for total knee arthroplasty. Sciatic nerve block is contraindicated in our hospital, because orthopedists want to assess peroneal nerve function after the surgery. We retrospectively assessed postoperative analgesic effect and complications of the continuous femoral nerve block for total knee arthroplasty., Methods: We included 19 cases in 17 patients scheduled to undergo total knee arthroplasty under femoral nerve block combined with general anesthesia. Ultrasound-guided femoral nerve block was performed before the surgery. The ultrasound linear probe was used to visualize the femoral nerve. A 22 gauge needle attached to a nerve stimulator, was inserted with in-plane method. Five percent glucose solution was injected through the needle to encircle the femoral nerve. Then, the 22 gauge needle was withdrawn and an 18 gauge needle was inserted with out-of-plane method. Five percent glucose solution was injected through the needle to confirm the needle tip and perineural catheter was inserted through the needle. To achieve femoral nerve block, 0.375% ropivacaine 20 ml was injected through the needle. Perineural infusion with 0.15% ropivacaine at 4 ml x hr(-1) was initiated at the end of the surgery. Intravenous patient-controlled analgesia (IV-PCA) was also conducted postoperatively. We assessed pain at rest with a verbal numeric pain rating score (0-10) including pain on moving, and nausea as well as vomiting., Results: Patients with numeric pain scores at 3 or less were 14 out of 19. Two patients complained of severe pain. There were 4 cases suffering pain on moving., Conclusions: Femoral nerve separation with 5% glucose solution using in-palne method and catheter placement with out-of-plane method could be useful for perineural catheter placement. Perineural infusion of 0.15% ropivacaine at 4 ml x hr(-1) combined with IV-PCA provided a good postoperative analgesia in patients receiving total knee arthroplasty.

There are several causes of hypotension during anesthesia. We report a case of severe hypotension caused by external cardiac compression. A 72-year-old man was scheduled for resection of mediastinal tumor under general anesthesia. He had undergone mediastinal tumor resection four times uneventfully. Anesthesia was induced and maintained with target controlled infusion of propofol and continuous infusion of remifentanil. Tracheal intubation was facilitated with rocuronium. Massive bleeding and severe hypotension developed during the operation. Blood transfusion, cryoprecipitate, fresh frozen plasma, and percutaneous cardiopulmonary support were commenced. However, hemorrhage was not the only cause of hypotension. The transesophageal echocardiography revealed external cardiac compression by tumor and doctor's hand. Transesophageal echocardiography was useful for verifying the causes of hypotension. It is necessary to evaluate the causes of hypotension during the operation, because a certain number of problems may exist.

A 30-year-old pregnant woman (151 cm, 49 kg) with twin gestation who had got pregnant with frozen-thawed embryo transfer was scheduled to undergo cesarean section at 37 weeks of gestation. Combined spinal and epidural anesthesia was performed separately at the T12-L1 (epidural) and at the L3-4 interspace (spinal). The sensory anesthesia was extended to T2 and the operation was started. The cesarean delivery was uneventful and healthy 2,370 g and 2,334 g neonates were delivered. Five minutes after the delivery, placenta was removed manually from the uterus. Despite using oxytocin, methylergometrine and prostaglandin F2alpha, uterine contraction was severely impaired and massive bleeding occurred. General anesthesia was not commenced and packed red blood cells, fresh frozen plasma and cryoprecipitate were given. Uterus gradually contracted and the patient was transferred to the ward. However, massive bleeding continued postoperatively, and magnetic resonance imaging indicated retained placenta. Total hysterectomy was performed on the second postoperative day. Atonic bleeding and placental invasion should be the main causes of massive bleeding. Frozen-thawed embryo transfer might be one of the important factors for placental invasion. We have to prepare for massive bleeding during and after the cesarean section in patients receiving frozen-thawed embryo transfer.

The patient was a 48-year-old male with a right subclavicular tumor. The pathological diagnosis showed primitive neuroectodermal tumor(PNET)because of the rosette formation and the positive neurogenic marker.Radiation was administered at a total dose of 50 Gy, because surgical resection would induce the loss of right arm function. CT examination demonstrated a reduction of the primary tumor and new multiple lung metastases. The patient received intravenous AI regimen(ADM and IFM). After the 7th course, both the primary tumor and multiple lung metastases decreased. AI regimen might be effective for PNET.

We experienced a case of dilution coagulopathy successfully treated with cryoprecipitate. A seven-month-old male infant with tetralogy of Fallot and right femoral arteriovenous fistula had undergone a modified Blalock-Taussig shunt at 63 days of age. He was scheduled to undergo complete repair of TOF and closure of femoral arteriovenous fistula. The patient was transferred to the operating room with tracheal intubation. Anesthesia was induced with midazolam and fentanyl and maintained with sevoflurane and fentanyl. Before cardiopulmonary bypass (CPB), femoral arteriovenous fistula was corrected. Then complete repair of TOF was performed under CPB. Massive bleeding was observed and laboratory results showed low plasma fibrinogen level (45 mg x dl(-1)). Cryoprecipitate 2 units were given and fibrinogen level was restored (171 mg x dl(-1)). Bleeding quickly slowed down sufficiently for weaning from CPB. The patient was separated easily from CPB on dopamine and dobutamine infusion. Post-CPB bleeding was minimal and the patient was transferred to intensive care unit. The patient was discharged from the hospital on postoperative day 50. In the present case, dilution coagulopathy occurred as a result of the combination of excessive fluid infusion due to massive bleeding and blood dilution due to CPB. Fresh frozen plasma could have been contraindicated to supplement fibrinogen because the patient's body weight was low. Cryoprecipitate, a highly concentrated source of fibrinogen, was effective for correcting fibrinogen deficit.

An 83-year-old man (158 cm, 42 kg) was scheduled for cholecystectomy. He had a history of hypertension and atrial fibrillation. The patient received no premedication. An epidural catheter was inserted via the T9-10 interspace and 2% mepivacaine 7 ml was injected, producing a sensory block from T4 to T12. Anesthesia was induced with propofol and remifentanil, and was maintained with propofol, remifentanil, and nitrous oxide in oxygen. Rocuronium was given to provide neuromuscular block. Just before the completion of surgery, a bolus epidural injection of 2% mepivacaine 2 ml with fentanyl 50 microg was performed. Then epidural solution of ropivacaine 0.1% with fentanyl 6.25 microg x ml(-1), and droperidol 25 microg x ml(-1) was infused at 4 ml x hr(-1). Soon after the surgery, the patient developed atrial fibrillation that was treated with external electrocardioversion with 100 watt x sec. After the restoration of sinus rhythm, anesthetics were discontinued. The patient did not emerge from anesthesia though he breathed spontaneously Doxapram was slightly effective, but he did not respond to the verbal command. Epidural infusion was stopped and the patient was transferred to the ward. The patient fully recovered from anesthesia after 2 hours. Epidural infusion was restarted 17 hours later, and the patient fell asleep. He woke up after stopping epidural infusion. Epidurally administered fentanyl must have been the cause of delayed recovery from anesthesia. He could have been highly sensitive to fentanyl. Patient controlled epidural anesthesia may have been useful for this patient.

We present a case of diltiazem intoxication resulting in repeated asystole after the induction of anesthesia. A 39-year-old man was diagnosed as subarachnoid hemorrhage, and cerebral aneurysm clipping was scheduled on the next day. Electrocardiogram revealed normal sinus rhythm with complete right bundle branch block. Continuous intravenous administration of diltiazem, nicardipine and midazolam were started for intractable hypertension and tachycardia. In the operating room, electrocardiogram showed atrioventricular nodal rhythm. Nicardipine and midazolam were stopped and anesthesia was induced with thiamylal, fentanyl and vecuronium, and was maintained with sevoflurane. After tracheal intubation, the patient developed asystole, and cardiopulmonary resuscitation was provided immediately. Diltiazem was stopped. Cardiac rhythm was restored 8 min afterwards; however, asystole recurred six times. Temporary cardiac pacing was effective, and percutaneous cardiopulmonary support (PCPS), intraaortic balloon pumping (IABP), and continuous hemodiafiltration (CHDF) were initiated. The operation was canceled. On the next day, normal sinus rhythm was restored and the temporary pacing, PCPS, IABP, and CHDF were discontinued. Cerebral aneurysm was treated by endovascular coiling and the patient was discharged from the hospital without sequelae. This case illustrates asystole associated with diltiazem intoxication. It is necessary to consider this potential complication when diltiazem is used.

A 69-year-old woman (156 cm, 53 kg) underwent a Miles' operation, total hysterectomy, resection of vagina, and thigh flap to vulva for rectal cancer. Before general anesthesia, an epidural catheter was inserted at T11-12 interspace, and 1.5% mepivacaine 7ml was administered. Sensory block level spread from T4 to L1. Anesthesia was induced with propofol and maintained with sevoflurane in air oxygen mixture. Operation was performed uneventfully. After the operation, postoperative analgesia was achieved with patient-controlled epidural analgesia (PCEA). The epidural solution of 0.06% ropivacaine with 4 microg x ml(-1) fentanyl and 20 microg x ml(-1) was connected to a PCA pump (i-Fuser, JMS, Japan) that was programmed as an 8 ml initial bolus, 4 ml x hr(-1) basal infusion, 2 ml bolus dose, and 10-min lockout interval. Although abdominal pain was well controlled by PCEA, intractable pain in the pelvic nerve region existed. Patient-controlled intravenous analgesia (IV-PCA) with fentanyl, ketamine, and lidocaine was added to PCEA. Then excellent pain relief was obtained without any side effects such as nausea, vomiting, drowsiness, and respiratory depression. It could be useful to use IV-PCA together with PCEA when wide spread postoperative analgesia is necessary.

We present a case of Mobitz type II atrioventricular block during one-lung ventilation in a 74-year-old man with lung cancer under anesthesia. Premedication with atropine 0.5 mg and midazolam 2 mg intramuscularly were given 30 min before entering the operating room. Before anesthesia, his heart rate was 72 beats x min(-1) with normal sinus rhythm and blood pressure was 120/70 mmHg. An epidural catheter was placed at T4-5 interspace and 1.5% mepivacaine was infused (7 ml bolus and 5 ml x hr(-1) thereafter). After placing external pacemaker paddle, general anesthesia was induced with propofol 3 microg x ml(-1) and fentanyl 0.1 mg, and tracheal intubation was facilitated with vecuronium 6 mg. Anesthesia was maintained with propofol and fentanyl. After initiating one-lung ventilation, the patient developed Mobitz type II block with a heart rate of 30 beats x min(-1). External pacing was started (rate: 80 beats x min(-1), output: 150 mA). However, body movement associated with external pacing interrupted operative procedure, and blood pressure was not restored effectively. Therefore, external pacing was stopped and atropine and dopamine were administered. Mobitz type II block continued, but blood pressure and heart rate were maintained during the operation. Cardiac rhythm was restored the next morning without any treatment. Propofol, fentanyl, and thoracic epidural anesthesia could caused Mobitz type II block. External pacing should not be used for thoracic surgeries.

A 69-year-old man (150 cm, 57 kg)who had been diagnosed as having COPD, was admitted to our hospital because of abdominal pain and drowsiness. He was diagnosed as CO2 narcosis and perforation of appendix. When he recovered from CO2 narcosis, he was scheduled for elective ilectomy. Because his pulmonary function was impaired, combined spinal and epidural anesthesia was selected. With the patient in the right lateral position, an epidural catheter was inserted at T12-L1 interspace, and spinal anesthesia was performed at L3-4 interspace with 0.5% isobaric bupivacaine 4 ml. When the patient was positioned laterally, SpO2 decreased from 82% to 77%. After completion of injection, the patient was returned to the supine position, and SpO2 immediately recovered. Spinal block level was not satisfactory, and fentanyl 0.1 mg and 2% mepivacaine 4 ml were administered through epidural catheter to achieve a T4 level of block. Because severe intraperitoneal inflammation was observed, ilectomy was changed to drainage of intra-abdominal abscess. The patient did not complain of dyspnea, pain, or nausea, intraoperatively. SpO2 was 85-93% with O2 inhalation at 1l x min(-1) during the operation. Post-operative course was uneventful. Although lateral position is popular in performing epidural and spinal anesthesia, sitting position could be suitable for this patient. Decrease in SpO2 may have occurred due to ventilation-perfusion mismatch. Since combined spinal and epidural anesthesia can preserve spontaneous respiration and it is possible to titrate anesthetic level, it would be preferable for abdominal surgery in patients with COPD.

We described our management of a patient with moyamoya disease who presented for emergency cesarean section. A 29-year-old primigravida (162 cm, 61 kg) who had been diagnosed as having moyamoya disease at age 24, underwent urgent cesarean section at 35 weeks of gestation. Because she was medicated with aspirin, general anesthesia was selected. Anesthesia was induced with thiamylal and was maintained with sevoflurane in air oxygen mixture and fentanyl before delivery. After delivery, anesthesia was maintained with midazolam and fentanyl. Ventilation and depth of anesthesia were adjusted according to the end-tidal carbon dioxide tension and bispectral index, respectively. Hypertension caused by tracheal intubation was successfully prevented by nicardipine, which was ineffective for intraoperative hypertension. On the other hand, landiolol was effective for treating intraoperative hypertension and tachycardia. The cesarean delivery was uneventful and a healthy 2104 g neonate was delivered with Apgar score of 7 and 9 at 1 and 5 min, respectively. Landiolol was effective for treating intraoperative hypertension and tachycardia. Monitoring of depth of anesthesia, blood pressure, and ventilation would be essential for cesarean section under general anesthesia in patients with moyamoya disease.

We report a case of grand mal convulsion due to inadvertent intravascular injection of ropivacaine. An 83-year-old woman was scheduled for upper limb surgery. The interscalene block was performed with neurostimulator and 0.5% ropivacaine 30 ml was injected after careful negative aspiration. Approximately 3 min after the injection, the patient lost consciousness and developed generalized convulsion, which was repeated 7 times. The seizures stopped after administration of diazepam 10 mg and thiamylal 250 mg i.v. Trachea was intubated and lungs were mechanically ventilated. During the seizure, arterial blood pressure increased from 180/110 mmHg to 190/120 mmHg and heart rate changed from 90 beats x min(-1) to 88 beats x min(-1). Ventricular premature beats were observed sporadically but stopped spontaneously. After the episode, the operation was performed under general anesthesia (nitrous oxide 50% and sevoflurane 1.5-2% in oxygen 50%). The patient recovered uneventfully after the operation. Although careful aspiration was done before the injection of ropivacaine, inadvertent intravenous injection could have occurred during the administration. Intermittent aspiration should be indispensable during the administration, because a large dose of local anesthetic is necessary for interscalene block. In this case, the only cardiovascular manifestation was ventricular premature beats indicating that ropivacaine has less cardiotoxicity.

Background: Postoperative shivering, nausea, and vomiting are common problems after general anesthesia. We compared the effects of clonidine and those of midazolam on postoperative shivering, nausea and vomiting in elderly patients., Methods: We studied 40 elderly patients (age > 60 yr) undergoing elective surgery under general anesthesia combined with epidural anesthesia. Patients were allocated randomly to receive oral clonidine 3-4 microg x kg(-1) (clonidine group) or intramuscular midazolam 0.04-0.05 mg x kg(-1) (midazolam group). Anesthesia was maintained with sevoflurane in a nitrous oxide and oxygen mixture, and fentanyl as needed, combined with epidural anesthesia with mepivacaine. Shivering, nausea, and vomiting were recorded at recovery from anesthesia, 3 h after the transference to the ward, and the next morning. Shivering was graded by using a three-point rating scale, whereas nausea and vomiting were assessed by means of a four-point rating., Results: The incidence of shivering was lower at recovery from anesthesia in the clonidine group (P < 0.05). Likewise, the incidence of nausea was lower at recovery from anesthesia in the clonidine group (P < 0.05). There were no differences in shivering and nausea at other recording points. One patient in each group had vomiting., Conclusions: Clonidine premedication is effective for preventing shivering and nausea after general anesthesia combined with epidural anesthesia.

There has been an increase in the use of psychophysiological techniques, especially event-related potentials (ERPs) to evaluate the effects of odor on the central nervous system. In the study of ERPs related to odor, there are two main methods of the odor presentation: (1) to investigate the olfactory ERP (OERP) or chemosensory ERP (CSERP), that is to calculate electrophysiological responses to odor stimulation as a trigger; (2) to compare ERP of mental functioning during the odor exposed condition with that of no odor exposure. The amplitude of contingent negative variation (CNV) varies with the odorant being present, when the odor is presented as a trigger and when it is administrated during a task. It is suggested that CNV changes depend on not only the odorant but the anticipation, expectation and emotion of the subject. The latency of the N1 component becomes shorter with increasing concentrations of odors. The N1 amplitude does not depend on the odor concentration while the amplitude of the auditory N1 strongly depends on the stimulus intensity. There is only one report that the olfactory mismatch negativity (MMN) is present in the CSERP. On the other hand, auditory MMN is not affected by odor administration. In relation to the P3 component, rare odors evoked a larger amplitude in contrast to frequent odors, as well as P3 evoked by other modalities. These ERP studies with odors are expected to be applied to such clinical settings as the differentiation between the anosmic patients and normosmic persons, the functional evaluation of patients with brain tumors, the earlier detection of dementia, and the objective evaluation of aromatherapy.

The patient was a 45-year-old woman who had ascending colon cancer with multiple paramesenteric and paraaortic lymph node metastases. Combined l-LV 400 mg/body (250 mg/m2) +5-FU 950 mg/body (600 mg/m2) therapy was carried out as neoadjuvant chemotherapy. After 2 cycles of this therapy, the lymph node metastases were not detectable on computed tomography. Thus, right hemicolectomy was performed (D3, CurB). It is suggested that l-LV+5-FU therapy may be useful for advanced colon cancer as neoadjuvant chemotherapy.

Propofol has been used to treat convulsions, while the drug is known to induce convulsions. We described a case of generalized convulsions during brain tumor resection under propofol anesthesia. A 24-year-old man was scheduled to undergo brain tumor resection. He had no history of epilepsy. Anesthesia was induced and maintained with propofol and fentanyl. During the craniotomy, the patient developed generalized convulsions. Diazepam, thiamylal, and phenytoin were given intravenously and the seizure activity resolved. Generalized convulsions recurred three times during the operation. Postoperative course was uneventful. On the 16 th postoperative day, the patient underwent ventriculoperitoneal shunt under general anesthesia using sevoflurane, nitrous oxide and oxygen. Convulsions were not noted intra- and postoperatively. Because convulsions did not occur during sevoflurane anesthesia and the patient had no history of epilepsy, propofol may have induced a generalized convulsions on the first operation.

Case 1: A 77-year-old woman with advanced gastric cancer and peritoneal dissemination was treated with TS-1/CDDP therapy. TS-1 (100 mg/day) was orally administered for 21 days and CDDP (70 mg/body) was administered intravenously on day 8. After 2 courses reduction in size of the primary carcinoma was observed (PR). The duration of the PR and the survival time were over 1 year and 6 months. Case 2: A 77-year-old woman with recurrent abdominal and liver metastasis from advanced gastric cancer was treated with TS-1/CDDP therapy. TS-1 (100 mg/day) was orally administered for 21 days and CDDP (80 mg/body) was administered intravenously on day 8. The reduction was judged to be CR for the liver metastasis and PR for the abdominal tumor (total judgment: PR). The duration of the PR and the survival time were over 1 year and 5 months. It is suggested that TS-1/CDDP chemotherapy is useful for advanced and recurrent gastric cancer.

A 75-year-old woman was scheduled to undergo resection of pheochromocytoma under general and epidural anesthesia. Continuous infusion of magnesium sulfate was initiated at the time of tracheal intubation and was terminated at the tumor resection. Intraoperative blood pressure and heart rate were stable, but blood pressure rose above 160 mmHg when the tumor was handled. Hypertension caused by the tumor manipulation was successfully treated with intravenous nicardipine. Following the tumor removal, reduced blood pressure was treated with dopamine and norepinephrine. After the operation, spontaneous respiration did not appear until 120 minutes following the last vecuronium injection. Although neuromuscular blockade was reversed with neostigmine and atropine, muscle tone was not restored and satisfactory spontaneous respiration was not obtained. One hour later the patient was extubated. Intraoperative use of magnesium sulfate provides adequate hemodynamic stability for resection of pheochromocytoma, but may cause prolonged neuromuscular blockade. Monitoring of neuromuscular function should be essential and reduction of ve curonium dose should be considered on using magnesium sulfate intraoperatively.

A 58-year-old female with incomplete atrioventricular septal defect was treated successfully with surgery. We repaired the defect by closure of atrioventricular septal defect, suture of cleft and tricuspid valve annuloplasty. We adopted method of minimally invasive cardiac surgery (MICS) expecting to preserve pulmonary function and to perform tracheostomy on early stage. After the operation she recovered with no major complications. It is suggested that MICS is effective method for patients with pulmonary dysfunction.

Congenital sensory neuropathy with anhydrosis is a rare disorder characterized by insensitivity to pain with normal tactile perception, self-mutilation, anhydrosis, recurrent unexplained fever, mental retardation and variable autonomic abnormality. We managed a 14-year-old boy with this syndrome who underwent repair of right femur fracture. Anesthesia was induced with propofol and ketamine. Adequate depth of anesthesia was carefully controlled by processed electroencephalogram, and core body temperature was maintained at 37.0 degrees C during the surgery. The patient was well sedated, and nausea and vomiting were not noted postoperatively. Use of droperidol and propofol may be beneficial for anesthetic management of this syndrome, because droperidol exerts residual hypnotic effect postoperatively, and both drugs have antiemetic property.

We report a case of traumatic diaphragmatic hernia (TDH) resulting from continuous thoracic drainage and was successfully treated by surgical procedures. A 45-year-old man was admitted to our department due to shock after a blunt trauma by a traffic accident. As he revealed left hemothorax on admission, continuous thoracic drainage was performed. Soon after the drainage, diaphragmatic hernia occurred as an incarceration of the spleen into the thoracic cavity. In the literature, 80 cases with TDH have been reported in Japan since 1986. The purpose of this study is to discuss the mechanism of TDH in the acute phase and to consider its appropriate diagnostic tools. The following two results were obtained. (1) TDH may be appeared during the clinical course, especially after a continuous thoracic drainage, in patients with damaged diaphragm by blunt traumas. (2) CT is the most effective tool for the diagnosis of TDH.

We experienced a rare case of endotracheal metastasis derived from squamous cell lung cancer. The patient was 56 year-old male whose primary lung cancer of the left upper lobe was completely resected. Pathological diagnosis indicated stage IIB and he underwent two cycles of chemotherapy with CDDP + VDS. He had been asymptomatic thereafter, however, two years postoperative chest CT revealed a nodular lesion of the anterior carinal wall. Bronchofiberoptic examination showed same as CT finding and its brushing cytology confirmed squamous cell carcinoma. WE successfully resected his endotracheal metastatic lesion and reconstructed by direct sutures assisted by PCPS (Percutaneous Cardiopulmonary Support System). His postoperative course was uneventful. Majority of the reported cases of endotracheal metastases were treated conservatively as radiation, laser and/or chemotherapy. We conclude that PCPS is useful device for surgical management for selected cases.

A 46-year-old male underwent resection of parathyroid tumor under general anesthesia. The preoperative chest radiography was normal. Arterial blood pressure, heart rate, and arterial oxygen saturation (SpO2) were stable during the operation. Because the tumor was in the mediastinum, incision was made behind the sternum and a drainage catheter was placed. At the completion of the surgery, spontaneous breathing began immediately. The neuromuscular blockade was reversed, and severe bucking was noted. Although the patient was not fully recovered from anesthesia, he was extubated because of his stable respiration and SpO2. Soon after the extubation, the patient developed cyanosis and the SpO2 declined to less than 50%. Chest radiography revealed bilateral pneumothorax, which was successfully treated by inserting bilateral chest tubes. Injury of parietal pleura, which might have been associated with the surgery and/or postoperative bucking, may be the main cause of the pneumothorax. Anesthetists should be aware of the occurrence of pneumothorax during neck surgery and have to avoid bucking postoperatively.

A 70-yr-old woman was scheduled for hepatectomy and colectomy. We gave general anesthesia with N2O-O2-Isoflurane and continuous epidural block. About 4.5 hours after the start of the operation, 8 units of irradiated RBC-MAP were transfused. Then elevated T waves were noted and serum potassium was increased to 5.4 mmol.l-1. The transfusion of RBC-MAP was stopped and calcium gluconate was administered immediately. Then serum potassium decreased to 4.3 mmol.l-1 and ECG returned to normal. During the operation, 10 units of irradiated RBC-MAP were transfused and 8 units of them had been stored more than 1 week after the irradiation. We suspect that hyperkalemia was induced by high concentration of potassium in RBC-MAP. Irradiation of blood products is an effective way to prevent post-transfusion graft versus host disease. However, the increase in potassium is greater in the irradiated than nonirradiated RBC-MAP. We must pay attention to the high concentration of potassium in th eplasma of RBC-MAP stored after irradiation.

Two patients had fatal fat pulmonary embolism during bipolar hip endoprosthesis. Two women, 71-year-old and 76-year-old, with femoral neck fracture underwent bipolar hip endoprosthesis under combined lumbar epidural/general anesthesia. Soon after the placement of bone cement and a femoral stem with a bipolar endoprosthesis in the femoral shaft, the patients developed circulatory collapse. Immediate cardiopulmonary resuscitation did not restore adequate circulation and the patients died 3.5 hours and 1 hour thereafter, respectively. Pathological examination revealed the presence of fat particles within the entire pulmonary arteries, arterioles and capillaries. Main cause of the present pulmonary fat embolism may be an increase in the intramedullary pressure during cement pressurization and femoral stem placement. Anesthetists have to be aware of occurrence of this serious syndrome during bipolar hip endoprosthesis. For earlier detection of this serious complication we recommend to monitor central venous pressure and pulmonary artery pressure in patients undergoing bipolar hip endoprosthesis.

A 73-year-old man presented with pain in lower limbs, lower abdomen, and anterior chest. His past medical history includes inferior myocardial infarction 3 years ago and hypertension. Electrocardiogram revealed ST elevation in II, III, and aVF indicating inferior myocardial reinfarction and angiography showed abdominal aortic embolism. Axillobifemoral bypass was performed urgently under general anesthesia. Because the patient developed acute renal failure and furosemide did not show diuretic effect, hemodialysis was used. The patient needed circulatory support with dopamine, dobutamine, epinephrine, and lidocaine intraoperatively. Approximately 90 minutes after the start of the operation, the patient developed ventricular fibrillation. The cardiac rhythm returned to normal after 2 minutes of cardiopulmonary resuscitation. The operation was performed successfully. An increase in serum potassium and metabolic acidosis were not noted postoperatively. However, weaning from the catecolamines was very difficult, and the patient died on 29th postoperative day. In this case, we employed general anesthesia without epidural anesthesia, because intraoperative hypotension might be the major cause for perioperative cardiac complications. Increase in serum potassium and myoglobin and metabolic acidosis were reported to occur after revascularization. Because the patient developed acute renal failure, intraoperative hemodialysis was valuable for preventing adverse effects due to reperfusion.

A 67-year old man noticed swelling of left maxillary in October 1992. Surgical biopsy of the left maxillary tumor revealed the plasmacytoma at the department of oral surgery. The Tumor disappeared after radiation therapy. He was admitted with dizziness and tarry stool in June 1994. We found left cervical and abdominal paraaortic lymph node swellings by the computer tomography. He died inspite of chemotherapy in December. Autopsy showed that plasma cells diffusely and nodularly invased in all alimentary tract with multiple ulcerations. Invasion was also observed in the liver, lungs, thyroid, heart, kidneys, and adrenals. The plasma cells in the liver showed IgG kappa type by tissue immunostain. Diffuse invasion of extramedullary plasmacytoma is very rare in alimentary tract and many other organs. This case may be value to delineate the nature of this disease.

We investigated the differences in the response to arterial CO2 tension and vasoconstrictors between the cerebral and spinal vasculatures using cranial and spinal window technique which provided the direct observation of pial vessels. Pentobarbital anesthetized dogs (n = 18) (CO2 tension; n = 6 and vasoconstrictor; n = 12) were instrumented for measurement of pial vessel diameters by intravital microscopy in the cranial and spinal window preparation simultaneously. We achieved hypocarbia (20-25 mmHg) followed by adjusting CO2 levels for normocarbia (35-40 mmHg) and for hypercarbia (55-60 mmHg) using CO2 gas addition. After obtaining the desired PaCO2, the measurements were made. In the next experiment, we administered 2 different concentrations of epinephrine or phenylephrine solutions (1:2 x 10(6), 1:2 x 10(5)) through the window, and the measurement was made sequentially. The response of cerebral and spinal vasculature to change in PaCO2 was almost similar. Topical application of both drugs produced a significant constriction of spinal pial arterioles compared with the cerebral ones, while epinephrine but not phenylephrine constricted cerebral pial venules compared with spinal ones. These results suggest that the responses to vasoconstrictor of cerebral and spinal pial vessels are not similar, and high sensitivity of spinal arterioles to vasoconstrictors may possibly contribute to a risk of ischemic damage of the spinal cord.

We studied the effects of continuous epidural administration of fentanyl and morphine with bupivacaine for management of postcesarean pain. Eighteen patients received either bolus epidural administration of fentanyl 100 micrograms or morphine 3 mg with 0.5% bupivacaine 4 ml, followed by continuous infusion of fentanyl 33 micrograms.ml-1 with 0.17% bupivacaine or morphine 0.21 mg.ml-1 with 0.17% bupivacaine for 48 hours, respectively. Pain score was assessed at 0 h, 12h, 24h and 48h after leaving the operating room. Pain score increased significantly and progressively in the fentanyl group. In all cases pruritus was noted. Severe pruritus was observed in the morphine group significantly more than in the fentanyl group. The current results indicate that morphine may be preferable to fentanyl for postcesarean pain control using the present opioid doses.

A 61-year-old, 54-kg man with gastric cancer was scheduled for total gastrectomy under general anesthesia combined with thoracic epidural anesthesia. Approximately 20 minutes after the start of the operation, the patient developed sudden hypotension and ventricular fibrillation. The cardiac rhythm returned to normal after 38 minutes of cardiopulmonary resuscitation. The operation was discontinued and the patient was transferred to an intensive care unit. A 12-lead electrocardiogram (ECG) revealed complete right bundle branch block and elevation of the ST-segment from leads II, III, aVF, V1, and V2 which indicated an inferior myocardial infarction. Laboratory data showed elevated levels of enzymes such as glutamic oxaloacetic transaminase (495 IU.l-1), lactic dehydrogenase (1781 IU.l-1), and creatine kinase-MB (112 IU.l-1). The mildly elevated levels of the enzymes decreased around 10 hours after the termination of the operation, but they increased markedly again without any change in ECG on the second postoperative day. Elevation in serum myoglobin and glutamic pyruvic transaminase and decline in arterial ketone body ratio were also detected. Furthermore, renal failure developed with increase in blood urea nitrogen and creatinine. Because of hepatic failure and renal failure which might have been caused by rhabdomyolysis, the patient needed inotropic support with dopamine, dobutamine, and epinephrine to maintain the circulation. The patient died of reinfarction of the 20th postoperative day despite intensive care such as intraaortic balloon pumping, hemodiafiltration, and continuous intravenous infusion of prostaglandin E1.

We investigated rearrangements of immunoglobulin heavy chain (Ig(H)) gene of the bone marrow mononuclear cells by Southern hybridization in 7 patients with Waldenström's macroglobulinemia. Three of 7 cases showed the rearrangement of Ig (H) gene. The cases with Ig (H) gene rearrangements showed high rates of CD19 and CD20 positive cells compared to the cases with no rearrangements. Two out of 3 cases included less than 3 g/dl IgM. On the other hand, 4 cases without rearrangements had lower percentage of B cells in the bone marrow and higher serum IgM (4/4; more than 3g/dl) than the cases with the rearrangements. Thus, the rearrangements of Ig (H) chain gene did not correlate with serum IgM level and related to the quantity of B cells in the bone marrow in WM.

A 77 year-old woman was admitted to the hospital because of nasal obstraction on March 1994. Tumorectomy of the nasopharyngeal tumor disclosed non-Hodgkin's lymphoma (LSG : diffuse, medium sized). The patient was treated with local radiotherapy to nasopharyngeal region and combined chemotherapy (2 courses of CHOP) to reduce residual tumor. On July, the pericardial effusion appeared and the large granular lymphocyte (LGL) like lymphoma cells were observed in the effusion. Flow cytometic analysis of these cells showed that they expressed CD 2, CD 7, CD 56 and HLA-DR, but did not express CD 3. T-cell receptor gene (TCR beta) rearrangement was not observed and natural killer activity was detected in these lymphoma cells. The patient was treated with ProMACE and the pericardial infusion of methotrexate, carboplatin and prednisolone, but the patient died of heart failure. Monoclonarity of lymphoma cells in the pericardial effusion was determined by southernblot analysis, using the terminal repeat of Epstein-Barr virus (EBV) for probe. It was suggested that EBV participated in tumorgenesis in this case.

Increased levels of soluble interleukin-2 receptor (sIL-2R) have been noted in the sera of patients with various diseases such as adult T cell leukemia, malignant lymphoma and autoimmune diseases. Using an enzyme-linked immunoabsorbent assay, we assessed sIL-2R levels in the sera of 16 patients with multiple myeloma (MM) and 27 normal subjects. There was a significant increase in the levels of sIL-2R in the patients with myeloma (963 +/- 523 U/ml) compared to normal subjects (213 +/- 80 U/ml). The levels of sIL-2R corresponded well with the clinical stage, M-protein, serum IL-6 and serum beta 2 microglobulin levels. Taking the evidence that the CD4/CD8 ratio decreased as the disease worsened into consideration, the increase in the serum sIL-2R levels of the patients with MM is considered to have some correlation with B and T cell activation through various cytokines including IL-6. Furthermore such evidence would support the role of sIL-2R as a disease monitor of MM.

To evaluate the effects of systemic bupivacaine on the baroreflex control of heart rate, we investigated the baroreflex sensitivity assessed with a pressor and a depressor test using phenylephrine and nitroglycerin in pentobarbital anesthetized dogs (n = 12). Intravenous injection of bupivacaine (mean plasma concentration of 2.4 +/- 0.9 micrograms.ml-1) caused a significant suppression of the baroreflex sensitivity, defined by the slopes of regression line (in msec of RR interval change per mmHg increase or decrease in systolic blood pressure). The sensitivity obtained with the pressor and the depressor tests decreased from 6.0 +/- 2.3 to 3.5 +/- 1.7, from 2.4 +/- 1.3 to 1.3 +/- 0.8 msec.mmHg-1, respectively (P < 0.01). Suppression of the baroreflex sensitivity during epidural anesthesia with bupivacaine could be due not only to cardiac sympathectomy but also to a direct effect of bupivacaine on the reflex arch including the receptors, the afferent nerve pathways, the CNS, the efferent pathway, and the effector organs. Therefore, the hemodynamic responses to reduction of blood pressure are likely to be inhibited by epidural bupivacaine.

A 49-year-old man was admitted to our hospital with anemia and hypergammaglobulinemia. Physical examination revealed superficial lymph node swelling and no hepatosplenomegaly. Laboratory findings showed WBC 5,300/microliters with normal hemogram, microcytic and hypochromic anemia. Total protein was 11.5 g/dl and immunoglobulinemia (IgG 10,100 mg/dl, IgA 295 mg/dl, IgM 160 mg/dl) was observed without M-component in serum and urine. The CD4/CD8 ratio of lymphocyte subsets was 0.58 and the tuberuculin skin test was negative. Urinary protein was positive and renal biopsy disclosed plasma cell infiltration. Lymph node biopsy revealed multiple lymphoid follicles and infiltration of plasma cells in the interfollicular areas. A diagnosis of multicentric Castleman's disease (MCD) was made baredon clinical findings and lymph node biopsy. After therapy with plasmapheresis and the CHOP regimen, he was given etoposide. Although discharged with clinical improvement and a decrease of serum IgG, he was readmitted because of pyrexia after 4 days and died of pneumonia with adult respiratory distress syndrome. The autopsy revealed lymphoid interstitial pneumonia. It seems important to notice that some of MCD have poor prognoses because of accompanying immunodeficiency.

A number of environmental cells in the bone marrow (BM) of multiple myeloma (MM) has been reported to be activated. Evidence is growing that many cytokines, namely IL-6, IL-1 beta, TNF and GM-CSF, are detected in the BM of MM. Tumor environment may support, not only MM cell proliferation, but also bone resorption. In addition, immuno-regulatory cells, both CD8+T cells and NK cells, are also activated. High serum IL-2 levels are indicated. Recently, we detected numerous CD5+NK cells, which may be activated, in the peripheral blood and the BM of MM.

A 66-year-old man was treated for IgD (lambda) multiple myeloma with 2mg/day melphalan and 20mg/day prednisolone. Subsequently, he developed pneumonia for which he received antibiotics, an antifungal agent and granulocyte colony-stimulating factor (G-CSF) twice. Myeloma cells appeared in the peripheral blood 10 days after the second G-CSF course. In addition, skin tumors developed on his extremities and chest 14 days after the second use of G-CSF. The skin tumors consisted of immunohistochemically IgD (lambda)-positive myeloma cells. The skin tumors may have been formed from the bone marrow by metastasis, a very rare occurrence in multiple myeloma. Before the development of the tumors we administered G-CSF, which may also have been related to the formation of the skin tumors.

Efficacy and safety of tretinoin (all-trans retinoic acid, ATRA, Ro01-5488) for refractory and relapsed acute promyelocytic leukemia were studied by multi-institutional study in Japan. 22 out of 27 (81.5%) patients with previously untreated who were intolerable to chemotherapy, relapsed and refractory were achieved CR. And 4 out of 11 (36.4%) in relapsed patients who received ATRA remission induction therapy previously responded. Side effects, such as dryness of the lip and skin, headache, increase of triglyceride, beta-lipoprotein and lactate dehydrogenase, were observed in 36 of 41 eligible patients (87.8%) but these were well tolerated. In addition to these, hyperleukocytosis in 4 cases and retinoic acid syndrome in 3 cases were observed. However, all patients were prescribed tretinoin again by adequate management.

Cases of pure red cell aplasia with thymoma and myasthenia gravis are rare. We described a patient who had concomitant pure red cell aplasia, thymoma, myasthenia gravis and a normal pressure hydrocephalus. A 63-year-old man with disturbances of gait, left blepharoptosis and anemia was presented to our hospital. Laboratory examination on admission revealed severe anemia. Bone marrow aspirates showed erythroid hypoplasia of marked degree. Chest x-ray and chest CT revealed a tumor to the right of cardiac wall. The tensilon chloride test and antiacetylcholine receptor antibody were positive. A hydrocephalus was demonstrated with brain CT. Cerebrospinal fluid pressure was in the normal range. He was diagnosed as having pure red cell aplasia with thymoma, myasthenia gravis and a normal pressure hydrocephalus. This appears to be a fairly rare case. It seems important to consider that a normal pressure hydrocephalus may have immunological disorders.

A 49-year-old female admitted because of anemia. had skin rashes since age 20. Generalized lymphadenopathy and fever appeared and the patient was diagnosed as multicentric Castleman's disease (MCD) at 40 years of age. Lymphadenopathy and fever improved with combined chemotherapy. In November, 1992, anemia increased with reticulocytosis (11.8%) and laboratory examination revealed a positive result for Coombs test and increased indirect bilirubin. A diagnosis of autoimmune hemolytic anemia (AIHA) was made. Steroid and plasmapheresis showed temporary effects, but anemia relapsed when steroids were decreased. Immunosuppressive drugs, vincristine and danazole were ineffective. Anemia improved on the second attempt at steroid therapy. The level of Hb rose to 11.2 g/dl after 3 months. The relationship between MCD and AIHA was discussed.

An elevation of creatine-kinase was noted postoperatively in a 50 year-old male who had cerebral aneurysm surgery under isoflurane, N2O and O2 anesthesia. Serum CK concentration reached as high as 5919 IU.l-1 immediately after surgery and elevation was associated with the temperature elevation of above 39.5 degrees C and port-wine urine. The postoperative course was uneventful and elevated serum creatine-kinase was corrected within next 6 days. Since elevated serum creatine-kinase is known to occur in acute stage of cerebrovascular accident, and since the influence of myocardial infarction, malignant hyperthermia and drugs could be neglected, we assumed that an abnormal elevation of CK values observed in the present patient resulted from stimulation of sympathetic nervous system due to cerebral bleeding and to hyperpermeability of sarcolemma of skeletal muscle.

Recently an increase of the elderly patients with hematological malignancies has been pointed out. We analyzed second malignancies in elderly patients with hematological malignancies (95 age 65 or more), and made a comparative study with non-elderly case for the past 5 years. Second malignancies were observed in 26 cases out of the total of 282 hematological malignancies (9.2%). The percentage of patients with second malignancies in the elderly group (19/95; 20%) was significantly higher than that of the non-elderly group (7/187; 3.7%). Among the all kinds of hematological malignancies, the second malignancies were mainly observed in cases with myelodysplastic syndrome and chronic myelo-proliferative disorder. Colon carcinoma, gastric carcinoma and lung carcinoma accounted for nearly half of all the second malignancies. On 11 of the 26 cases with second malignancies, the first malignancies had been treated with some anti-cancer drug such as alkylating agents. Development of a second cancer was greater in cases in which the first hematological malignancy was treated with alkylating agents more than in cases in which the first carcinoma was not treated with alkylating agents.