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BACKGROUND: Radiation enteritis following radiotherapy targeting the abdomen occasionally causes ulcers or ileus, which can be difficult to treat and usually progressive and refractory, significantly degrading the patient's quality of life. CASE PRESENTATION: A 58-year-old woman had undergone surgery for cervical cancer approximately 21 years ago. During treatment, she had also received radiotherapy targeting the pelvis and stomach. She presented with complaints of vomiting and lower abdominal pain and was subsequently diagnosed with multiple gastric ulcers, enterocolitis, and paralytic ileus due to late radiation-induced sequelae. We reasoned that visceral sympathetic block would improve the abdominal symptoms; therefore, we performed a splanchnic nerve block and an inferior mesenteric artery plexus block. As predicted, these block procedures improved the symptoms. CONCLUSIONS: Radiation enteritis is an iatrogenic disease, and there is no established treatment for intractable cases. However, visceral sympathetic nerve block may show efficacy as a potential therapy for radiation enteritis-associated abdominal pain and ileus.

DOI： 10.1186/s40981-019-0239-9

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Opioid-related postoperative nausea and vomiting should not occur following remifentanil administration because of its relatively short time to elimination. However, studies have indicated that the incidence of postoperative nausea and vomiting associated with remifentanil is similar to that with other opioids. Hence, we aimed to determine whether intraoperative remifentanil itself is associated with postoperative nausea and vomiting when postoperative pain is managed without opioid use. In this prospective pilot study, 150 patients who underwent unilateral upper limb surgery under general anesthesia with brachial plexus block were included. Patients in the remifentanil and control groups received 0.5 µg/kg/min remifentanil and saline, respectively. Postoperative pain was managed using a brachial plexus block, non-steroidal anti-inflammatory drugs, and acetaminophen. The presence of postoperative nausea and vomiting within the first 24 h after anesthesia was assessed by an evaluator blinded to patient allocation. Eight patients were excluded from the final analysis, resulting in 72 and 70 patients in the remifentanil and control groups, respectively. Postoperative nausea and vomiting within 24 h after surgery occurred in 11 and 9 patients in the remifentanil and control groups, respectively. These data suggest that remifentanil use only minimally affects the incidence of postoperative nausea and vomiting under sevoflurane anesthesia. UMIN Clinical Trials Registry identification number: UMIN000016110.

DOI： 10.1007/s00540-018-2550-4

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：WILEY  

AIM
The kinetics of propofol are influenced by cardiac output. The aim of this study was to examine changes in blood propofol concentrations during phaeochromocytoma surgery using target-controlled infusion (TCI) anaesthesia with propofol.
METHODS
This is a prospective observational study. Ten patients with phaeochromocytoma who underwent unilateral adrenalectomy were included. Cardiac output was measured using an arterial pressure-based cardiac output analysis method. The target blood propofol concentrations were adjusted to maintain an approximate bispectral index (BIS) value of 40 before initiating surgery. The settings remained constant during surgery. Blood samples for propofol concentrations were collected from the radial artery at seven time points: two before tumour manipulation (T1, 2), two during tumour manipulation (T3, 4), and three after tumour vein ligation (T4-7). BIS values, the arterial pressure cardiac index (APCI) and haemodynamic parameters were measured at the same time points as the blood samples. The prop-ratio was calculated by dividing blood propofol concentrations by target concentrations of TCI.
RESULTS
APCI increased during tumour manipulation and after tumour vein ligation. The prop-ratio was reduced significantly by approximately 40% and showed a significant negative correlation with APCI. BIS values increased significantly and showed a significant negative correlation with the prop-ratio.
CONCLUSION
The increased APCI during tumour manipulation and after tumour vein ligation was associated with markedly reduced blood propofol concentrations. These results reveal that significant decreases in the anaesthetic effect may be observed in patients undergoing phaeochromocytoma surgery even if TCI anaesthesia is used with propofol.

DOI： 10.1111/bcp.13334

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：LIPPINCOTT WILLIAMS & WILKINS  

BACKGROUND: Nasogastric tube (NGT) insertion is an easy procedure that can be routinely performed under general anesthesia. However, for difficult cases, there are limited insertion techniques available in routine clinical practice, considering the flexibility of NGTs. The SUZY curved forceps are designed for the removal of pharyngolaryngeal foreign bodies under guidance of the McGRATH MAC (McG) videolaryngoscope. Because McG enables clear visualization of the esophageal inlet, we hypothesized that the SUZY forceps can facilitate easier NGT insertion compared with the conventional Magill forceps under McG guidance and designed a randomized, crossover manikin study to test this hypothesis. MATERIALS AND METHODS: Ten anesthesiologists participated in this study. Each participant was instructed to insert an NGT using either the SUZY or the Magill forceps under McG guidance. Both types of forceps were used by each participant in a computer-generated random order. The primary outcome measure was the number of "strokes" (1 stroke was defined by a specific sequence of participant actions) required to advance the NGT 30 cm from the starting point. Data are expressed as medians (interquartile ranges [ranges]). RESULTS: The number of strokes required for NGT insertion was fewer in the SUZY group than in the Magill group {7 [7.0-12.5 (5-14)] vs 16.5 [13.5-20.3 (7-22)]; P <.05}. The time required for NGT insertion was also lesser in the SUZY group than in the Magill group {15.4 [13.7-20.0 (7.0-38.3)] seconds vs 30.3 [22.0-42.3 (12.8-47.5) seconds]; P <.05}. CONCLUSIONS: The SUZY curved forceps facilitated NGT insertion more effectively than the Magill straight forceps under McG guidance. Our results suggest that NGT insertion using the SUZY forceps under McG guidance is a secure and easy procedure.

DOI： 10.1097/MD.0000000000007983

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Language：English   Publisher：LIPPINCOTT WILLIAMS & WILKINS  

DOI： 10.1097/EJA.0000000000000572

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Background: Postoperative pain management after upper limb surgery is important for preventing adverse events that can prolong hospital stay and cause readmission. This study aimed to identify the risk factors associated with rescue analgesic use on the first postoperative day after upper limb surgery performed under single-injection brachial plexus block (BPB). Findings: We retrospectively analyzed records from 930 patients who underwent upper limb surgery under a single-injection BPB. Postoperatively, patients were administered oral loxoprofen regularly and rescue analgesics when analgesia was insufficient. We assessed the association between patient, surgical information, and rescue analgesic use on the first day after surgery (from 7:00 PM on the day of surgery to 7:00 AM on the first postoperative day), using a logistic regression model. Multivariate analysis revealed a significant association between rescue analgesic use and bone surgery, in particular, osteotomy, ligament repair and reconstruction, osteosynthesis, treatment for an amputated digit, and surgical duration. Conclusion: Bone surgery (osteotomy, ligament repair and reconstruction, osteosynthesis, treatment for an amputated digit) and a longer operative time were risk factors for rescue analgesic use for treating postoperative pain after upper limb surgery performed under single-injection BPB.

DOI： 10.1186/s40981-017-0110-9

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Language：English   Publisher：ELSEVIER SCIENCE INC  

We describe a very rare case of an indwelling central venous catheter (CVC) through the left internal jugular vein that perforated the superior vena cava (SVC) wall postoperatively, although the CVC was placed in the appropriate position preoperatively. Three days after CVC insertion, a chest radiograph showed that the CVC tip had moved from the lower SVC to the upper SVC. Five days after the insertion, computed tomography showed SVC perforation and the resulting hydrothorax. In cases of CVC insertion through the left side, the CVC tip should not be placed in the upper SVC (zone B). Considering individual clinical factors and the indwelling period for the CVC, the left innominate vein (zone C) may be a suitable site for the left-sided CVC tip to reduce the risk of SVC perforation. (C) 2016 Elsevier Inc. All rights reserved.

DOI： 10.1016/j.jclinane.2016.02.002

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：SPRINGER JAPAN KK  

We describe a case in which an anatomic diagnosis was useful for diagnosing and estimating the cause of femoral nerve palsy following gynecologic surgery. A 49-year-old female received general and epidural anesthesia for radical ovarian cancer surgery. Although injection pain was noted in the left medial shin with 1 % mepivacaine administered as a test dose, the catheter was left indwelling because it improved her symptoms. The surgery, which lasted 195 min, was performed in the lithotomy position, and a self-retained retractor was used to gain a good surgical field. Postoperatively, the patient complained of difficulty in stretching her knee joint and left lower limb paresthesia that did not improve after stopping continuous epidural administration. A spinal cord injury related to epidural anesthesia was suspected because the sites of sensory impairment and epidural injection pain were the same; however, the patient had greater weakness of the quadriceps muscle than the iliopsoas, and no other muscle weakness was observed. These findings and previous reports suggest that her femoral nerve palsy was caused by compression of the inguinal ligament from the self-retaining retractor and lithotomy position. Twenty months after surgery, her muscle strength had fully recovered.

DOI： 10.1007/s00540-015-2113-x

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Language：Japanese   Publishing type：Research paper (scientific journal)   Publisher：Kokuseido Publishing Co. Ltd  

A patient with medication resistant schizophrenia underwent modified electroconvulsive therapy (12 sessions). Propofol was chosen as a hypnotic agent and the adjustment of its dose and stimulus intensity was attempted. However, despite using propofol of a dose minimally required for hypnosis, adequate seizures could not be induced even with the maximum stimulation. Assuming that propofol was preventing the induction of seizures, it was decided to reduce its dose and at the same time to combine it with remifentanil 100 μg starting from the fifth session. This allowed to reach the seizure adequacy during the next and the four subsequent sessions. Although from the tenth session on, adequate seizures could no longer be induced (possibly due to the development of resistance to propofol), the patient's symptoms showed improvement after completion of all 12 sessions.

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DOI： 10.1007/s12630-015-0400-5

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：NATURE PUBLISHING GROUP  

Transient ischemia produces postischemic tingling sensation. Ischemia also produces nerve conduction block that may modulate spinal neural circuits. In the present study, reduced mechanical thresholds for hindpaw-withdrawal reflex were found in mice after transient hindpaw ischemia, which was produced by a high pressure applied around the hindpaw for 30 min. The reduction in the threshold was blocked by spinal application of LY354740, a specific agonist of group II metabotropic glutamate receptors. Neural activities in the spinal cord and the primary somatosensory cortex (S-1) were investigated using activity-dependent changes in endogenous fluorescence derived from mitochondrial flavoproteins. Ischemic treatment induced potentiation of the ipsilateral spinal and contralateral S-1 responses to hindpaw stimulation. Both types of potentiation were blocked by spinal application of LY354740. The contralateral S-1 responses, abolished by lesioning the ipsilateral dorsal column, reappeared after ischemic treatment, indicating that postischemic tingling sensation reflects a sensory modality shift from tactile sensation to nociception in the spinal cord. Changes in neural responses were investigated during ischemic treatment in the contralateral spinal cord and the ipsilateral S1. Potentiation already appeared during ischemic treatment for 30 min. The present findings suggest that the postischemic potentiation shares spinal mechanisms, at least in part, with neuropathic pain.

DOI： 10.1038/srep11191

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DOI： 10.1007/s12630-015-0331-1

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Language：English   Publisher：SPRINGER JAPAN KK  

DOI： 10.1007/s00540-013-1707-4

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Language：English   Publisher：LIPPINCOTT WILLIAMS & WILKINS  

DOI： 10.1213/ANE.0000000000000025

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Language：Japanese   Publishing type：Research paper (scientific journal)   Publisher：Kokuseido Publishing Co. Ltd  

Background : There is an increasing number of patients scheduled for abdominal aortic aneurysm resection in whom epidural anesthesia cannot be performed because of concomitant antiplatelet/anticoagulant therapy. Instead of epidural anesthesia for postoperative analgesia in such patients it is possible to use repeated bilateral subcostal transversus abdominis plane (TAP) blocks. Methods : Four patients receiving antiplatelet/anticoagulant therapy for abdominal aortic aneurysm resection under general anesthesia were studied. After the completion of surgery and before emergence from anesthesia 18-gauge intravenous catheters were inserted bilaterally into subcostal TAP and 100 ml (50 ml on each side) of 0.2% lidocaine with 1/500,000 epinephrine were injected via the catheters twice daily until the second postoperative day. Pain intensity was assessed using a 0-10 numerical rating scale at rest and during movement before and after each block. Results : Numerical pain ratings at rest and during movement decreased after each block, and good analgesia was obtained. No complications such as nausea, vomiting or infection were observed in the postoperative period. Conclusions : These findings suggest that repeated bilateral subcostal TAP blocks with 0.2% lidocaine performed via 18-gauge intravenous catheters provide good postoperative analgesia after abdominal aortic aneurysm resection.

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Language：Japanese   Publishing type：Research paper (scientific journal)  

Background : We performed a retrospective study of the efficacy and safety of spinal anesthesia with 0.1 mg morphine in the postoperative course of elderly patients with femoral neck fracture. Methods : Sixty patients with ages averaging 84 years participated in this study. Surgery was performed under spinal anesthesia. Patients were assigned to either a group receiving of 0.1 mg morphine added to isobaric bupivacaine (Group M) or a group receiving of isobaric bupivacaine alone (Group B). The frequency of analgesic use and the occurrence of adverse side effects during the first 48 hours after surgery were compared between the two groups. Results : In the first 24 hours, the patients in Group M needed significantly less analgesics compared to Group B. The incidence of adverse side effects did not differ significantly between the groups, although nausea had a tendency to increase in Group M. One patient in Group M showed a mild decrease in oxygen saturation. Conclusions : The spinal administration of 0.1 mg morphine had beneficial effects and was safe in the postoperative period of elderly patients with femoral neck fracture provided that sufficient observation was given.

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：SPRINGER INTERNATIONAL PUBLISHING AG  

We report the anesthetic management of a patient scheduled for tumor resection with a giant ovarian tumor containing 83 l of fluid. A 59-year-old woman [height 154 cm; weight 146 kg (ideal: 52 kg)] with a giant ovarian tumor was scheduled for tumor resection. Her preoperative abdominal circumference was 194 cm, which made supine positioning difficult. The thoracoabdominal computed tomography revealed a right giant cystic ovarian tumor with an estimated mass of 100 kg. Evidence of malignant tumor was not observed. In the operation room, she was intubated using a video laryngoscope (Airway Scope (R), Hoya, Tokyo, Japan) in a semirecumbent position under conscious sedation. Following general anesthesia, the tumor fluid was gradually aspirated at a rate of 500 ml/min, and during this procedure, spontaneous respiration was preserved with pressure support ventilation. After the fluid was drained, the tumor was resected in a supine position. There were no major perioperative complications in hemodynamic and respiratory status, such as supine hypotensive syndrome or re-expansion pulmonary edema. Her weight decreased to 50 kg postoperatively. Maintenance of spontaneous respiration and slow aspiration of the tumor fluid prevented respiratory and hemodynamic failure and resulted in safe anesthesia management during giant ovarian tumor resection.

DOI： 10.1186/2193-1801-2-487

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：SPRINGER  

In this report we describe an alternative approach to catheter placement for continuous selective median nerve blockade. It spared the finger movements and therefore allowed early postoperative rehabilitation in a patient who underwent surgical repair of the index finger flexor tendon.
A patient with a complicated history of traumatic index finger flexor tendon rupture, surgical repair, failed rehabilitation due to poor postoperative pain control, adhesion formation, and subsequent rerupture due to tenolysis was admitted for reconstructive surgery. This time, a continuous regional block was used. Although the insertion of a catheter at the wrist level would have spared the anterior interosseous branch of the median nerve and preserved finger movements, a more distant site had to be chosen to avoid proximity to the surgical wound. Therefore, under combined ultrasonography and neurostimulation guidance, the catheter was inserted in the proximal one-third of the patient's forearm distal to the branching-off point of the anterior interosseous nerve. Continuous ropivacaine infusion was initiated and maintained until being stopped on the afternoon of the third postoperative day, providing good analgesia without interfering with postoperative physiotherapy, which was successfully completed during this hospitalization.
Placement of a catheter for continuous median nerve blockade in the proximal one-third of the forearm for effective postoperative pain-free rehabilitation after hand surgery should be considered in cases in which the surgical incision extends toward the patient's wrist. The block site can be readily identified by a combined use of ultrasonography and neurostimulation guidance.

DOI： 10.1007/s12630-011-9613-4

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Language：Japanese   Publishing type：Research paper (scientific journal)  

A 61-year-old man receiving anticoagulant therapy after the aortic valve replacement underwent emergency surgery for acute appendicitis. Although the patient was intubated with difficulty, no immediate complications were evident after extubation. On the evening of the first postoperative day he complained of a sore throat, difficulty in swallowing and dysphonia. The swelling of the tongue with right-side predominance and the swelling of the right neck were observed. The right-sided sublingual hematoma was confirmed by CT. The symptoms improved with steroid administration. The possibility of airway obstruction due to hematoma of the tongue should be considered in patients on anticoagulant therapy.

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Language：English   Publisher：ELSEVIER SCIENCE INC  

DOI： 10.1016/j.jclinane.2009.09.002

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