Epidural anesthesia attenuates surgical stress responses, such as the immune reaction and the pituitary hormone response. In the present study, we investigated the leukocyte response to initial surgical stimulation during upper abdominal surgery. Twenty adult patients (American Society of Anesthesiologists physical status I∼II) undergoing elective upper abdominal surgery were randomly assigned to an epidural anesthesia group or a general anesthesia group. An epidural catheter for postoperative pain relief was inserted into all patients before induction. In the epidural anesthesia group, patients obtained preemptive analgesia from Th4 to Th12 with 2% mepivacaine, whereas general anesthesia was maintained with 2 L of oxygen, 4 L of nitrous oxide, and 1% to 3% isoflurane. Changes in the leukocyte count and leukocyte subset distribution were determined before induction (baseline), immediately after induction, 5 minutes after induction, 5 minutes after skin incision, and 5 minutes after peritoneal incision. The changes were significantly different between the groups throughout the observation period (p<0.0001). The general anesthesia group demonstrated an increase in the leukocyte count compared with the baseline data 5 minutes after skin incision and 5 minutes after peritoneal incision (p<0.01). Moreover, these counts were significantly higher in the general anesthesia group than in the epidural anesthesia group (p<0.05). The subset distributions were also significantly different between the groups throughout the observation period (p<0.0001). In the general anesthesia group, neutrophils decreased and lymphocytes increased significantly compared with baseline (p<0.05). Moreover, lymphocyte distribution was significantly higher in the general anesthesia group than in the epidural anesthesia group 5 minutes after peritoneal incision. Thus, anesthesia modifies the early response of leukocytes to surgical stress. The link between the early leukocyte response to surgery and postoperative outcome is the next subject of investigation.

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To determine the factors associated with 20 minute Tc-99m pertechnetate thyroid uptake, we examined all patients in whom thyrotoxicosis was diagnosed at Chiba-Hokusoh Hospital, Nippon Medical School from 2001 April through 2003 March. Patients with thyrotoxicosis diagnosed during this period were 57 with Graves' disease (76%), 11 with transient hyperthyroxinemia (TH)(14.7%), and 7 with subacute thyroiditis (SAT)(9.3%). The uptake of Tc-99m ranged from 0.97% to 40.1% in Graves' disease and from 0.15% to 0.8% in TH. Although TH may include spontaneous resolution of Graves' disease as well as painless thyroiditis, no treatment was necessary for these patients. Uptake in all patients with SAT was less than 0.5%. There were significant correlations between the level of Tc-99m uptake and the levels of free triiodothyronine (fT3), free thyroxine (fT4), thyroid-stimulating hormone (TSH)-binding inhibitory immunoglobulin (TBII), and thyroid stimulating antibody (TSAb) in patients with Graves' disease. Older patients with Graves' disease showed lower uptake than did younger patients. Both Tc-99m pertechnetate uptake and TBII levels, but not fT3, fT4 or TSAb levels, at the beginning of antithyroid drug treatment correlated significantly with the duration of treatment until the daily dose of methimazole reached 5 mg. These data suggest that Tc-99m pertechnetate uptake reflects the severity of Graves' disease and its response to the medical treatment and that antithyroid drug therapy is not necessary when the uptake is less than 0.9%.

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Wound healing is far more rapid in the gastrointestinal tract than in the skin. Once dehiscence of a surgical anastomosis in the gastrointestinal tract occurs, the high collagenase activity in the gastrointestinal tract may delay wound healing and promote the formation of a nonhealing fistula. Because factor XIII promotes cross-linking of fibrin during the early phase of wound healing, we investigated the effect of factor XIII concentrate on 16 anastomotic leaks and a nonhealing fistula. A 240-U dose of factor XIII concentrate (Fibrogammin P) was administrated intravenously for 5 days. Factor XIII activity and plasma levels of epidermal growth factor (EGF), transforming growth factor (TGF)-β, and interleukin-6 were measured before treatment and 1 day and 7 days after the end of treatment. Clinical outcomes were evaluated on the basis of the findings of contrast radiography, computed tomography, and drainage volume. Improvement relevant to the therapy was observed in 15 cases (88.2%). Factor XIII activity increased to more than 70% of the normal value in 11 cases (64.7%) but remained at 40% to 70% of the normal value in 6 cases (35.3%). Plasma EGF and TGF-βlevels increased in patients with improvement but were unchanged in patients without improvement. Our findings suggest that factor XIII significantly accelerates wound healing of anastomotic leaks and nonhealing fistulas by increasing circulating growth factors after systemic administration.

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Introduction: Characteristics of prostatic fluid (PF), which can be obtained in large amounts during screening transrectal ultrasound just before prostate biopsy to detect prostate cancer, were investigated. These characteristics include the amount of PF obtained and the number of leukocytes in PF, which would be useful for planning cell-biological or immunological studies of leukocytes in PF and for increasing the understanding of prostatitis in elderly men. Patients and Methods: The volume of PF and the number of leukocytes in PF were measured in 50 patients suspected of having prostate cancer because of elevated levels of serum prostate-specific antigen (PSA). Correlations of the volume of PF, the number of leukocytes per milliliter, the total leukocyte number with age and prostate volume and correlation of PSA levels with the number of leukocytes per milliliter and total leukocyte number were also investigated. Results: The average patient age was 67.2 years, and PF specimens were obtained from 43 of the 50 patients (86%). The mean ± SD of PF volume, number of leukocytes in PF, and total leukocyte number were 347.65 ± 305.76 μl, 4.84 ± 6.07 × 10⁶ /ml, and 1.47 ± 2.10 × 10⁶, respectively. A correlation was observed only between the total leukocyte number and the volume of the transitional zone (P=0.039). Conclusions: These data provide information for investigators to plan cell-biological or immunological studies of leukocytes in PF and for understanding prostatitis in elderly men.

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Spontaneous pneumothorax is a relatively common disease in the clinical practice setting and is generally recognized to occurs most often in slender young men. However, spontaneous pneumothorax that occurs bilaterally and simultaneously and progresses to tension pneumothorax has rarely been documented. Although spontaneous pneumothorax can be diagnosed based on the patient's medical history or information from ambulance personnel, it should be remembered that there are some rare cases of bilateral tension pneumothorax. Prompt and appropriate diagnosis and treatment are necessary for patients with such conditions, which may can be life-threatening.

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Floating right heart thrombi (FRHTs) are rare in patients with acute pulmonary thromboembolism (PTE). FRHTs are an extreme therapeutic emergency, and any delay in treatment could be lethal. Heparin, thrombolysis, and catheter therapy are used most frequently to treat acute PTE. Here we present three cases involving operative treatment of FRHTs associated with PTE. Diagnose were made with echocardiography before proceeding to emergency surgery. Thromboembolectomy was performed on cardiopulmonary bypass. One patient became brain dead 10 days postoperatively owing to cardiopulmonary arrest before surgery. The two survivors were subsequently discharged home after uneventful recoveries.

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