[Purpose] We conducted a clinical investigation comparing surgical cases of pheochromocytoma with other cases of adrenal tumor. [Subjects and Methods] We examined retrospectively 57 patients with adrenal tumor who underwent surgery in our department from April 2010 to August 2015. Cases were classified into 17 cases of pheochromocytoma and 40 cases of other adrenal tumors. The two groups were compared in terms of factors such as sex, surgical methods, and tumor size. Patients who underwent laparoscopic surgery were classified as pheochromocytoma cases and other adrenal tumor cases, and were compared regarding factors such as operating time, blood loss, and length of hospital stay. All cases of pheochromocytoma were classified into cases requiring use of a vasopressor immediately after surgery and cases not requiring a vasopressor, and these groups were compared regarding preoperative levels of catecholamines. [Results] The mean age of patients with pheochromocytoma was 53.4 years, and thise group comprised 9 men and 8 women. Mean tumor size of the pheochromocytoma was 4.03 cm, significantly larger than that of other adrenal tumors (P < 0.0001). Regarding surgical methods,13 laparoscopic and 4 open procedures were performed. Mean operating time of laparoscopic surgery was 182.2 min, significantly longer than that of the other adrenal tumor group (P = 0.0061). The group requiring postoperative use of a vasopressor had a significantly higher preoperative urinary noradrenaline level (P = 0.0018) than the group not requiring vasopressor. [Discussion and Conclusion] The longer operating time in laparoscopic surgery for pheochromocytoma was attributed to changes in blood pressure and large tumor size. Patients requiring postoperative use of a vasopressor had higher preoperative levels of blood and urinary noradrenaline, and urinary vanillymandelic acid. These higher levels were considered predictive of need to use a vasopressor postoperatively.
Propofol is widely used for general anesthesia administered by manually controlled infusion (MCI) or target-controlled infusion (TCI). Multi-compartment pharmacokinetic models, such as The Marsh or Schnider model are used by TCI systems to calculate the infusion rates required to achieve the target concentration (plasma or effect-site concentration). However, several reports indicated a difference between predicted blood propofol concentration (Cp) and measured blood propofol concentration (Cm). We investigated whether genetic polymorphisms of cytochrome P450 2B6 (CYP2B6) and UDP-glucuronosyltransferase 1A9 (UGT1A9) can influence the difference between Cp and Cm using prediction error (PE) of propofol anesthesia. Between June 2009 and May 2011, 89 patients (48 males,41 females) who underwent respiratory surgery with total intravenous anesthesia were examined. Arterial blood samples were collected at 0, 5, 10, 20, 30, and 60 min after the termination of propofol infusion for the determination of Cm and genetic polymorphisms of CYP2B6 and UGT1A9. We calculated Cp with the TIVA trainer® using the Marsh and Schnider models at 0, 5, 10, 20, 30, and 60 min after the termination of propofol infusion. There was a significant difference in PE in the Marsh model, immediately after propofol infusion for CYP2B6 (p=0.042), but there was no significant difference in PE in the Schnider model. Our results suggested that the polymorphism of CYP2B9 may affect the difference in TCI in the Marsh model, but not in the Schnider model. However, the results also suggest that there is no clinical usefulness of this statistical difference in anesthetic management.
The patient was a 54-year-old man referred to us for a gastric tumor revealed by abdominal computed tomography during an examination for ureteral calculi. Upper gastrointestinal gastroscopy suggested that something was pressing on the outside the stomach wall on the greater curvature of the stomach. Ultrasound revealed an 8-cm hypoechoic mass. The gastric lesion was suspected to be cancerous because the contrast effect continued to the 4th layer. We confirmed a vasogenic malignant tumor by MRI. PET/CT did not show any clear uptake of FDG. We therefore diagnosed a gastric submucosal tumor and frequent occurrence of liver hemangiomas. Because we could not confirm malignancy of the gastric lesion, we decided to perform a laparoscopic partial gastric resection. When we observed the abdominal cavity, no gastric submucosa tumor was seen, but we found numerous hepatic hemangiomas and a fibrous tumor on the outside of the liver, which we thought was the lesion revealed by CT. We thus performed a partial hepatic resection laparoscopically. The patient was discharged from the hospital on postoperative day 7. Histopathology revealed a nonmalignant hepatic hemangioma. We report a case of complete laparoscopic resection of peculiarly shaped hepatic hemangioma that was difficult to discriminate from a gastric submucosal tumor.
Case report: The patient was an 84-year-old woman with paroxysmal atrial fibrillation receiving warfarin potassium. She was admitted to our hospital with a distal radius fracture caused by a fall on the right hand. Heparin was intravenously administered as perioperative anticoagulation therapy. Six days after surgery, she complained of pain in her right leg, and her skin color turned purple. Since electrocardiography indicated atrial fibrillation, and echocardiography depicted left atrial thrombus, the patient was suspected as having cardiogenic thromboembolism in the right lower limb artery, triggered by paroxysmal atrial fibrillation. However, cardiogenic thromboembolism could not explain thrombus in the bilateral pulmonary artery we found using contrast computed tomography. This discovery suggested that the patient might have been suffering from systemic thrombosis. Furthermore, platelet count significantly decreased after heparin administration; thus, the patient was suspected as having heparin-induced thrombocytopenia (HIT). Argatroban was immediately administered. The blood examination resulted in HIT antibody positive and supported our diagnosis. Conclusion: We encountered a patient with systemic thrombosis caused by HIT. The results of this case suggested that HIT should be ruled out in the early stages of diagnosis of systemic thrombosis to prevent thrombotic complication induced by the use of heparin.
We report a case of communicating hydrocele in a 58- year-old man with end-stage renal disease due to diabetic nephropathy. Peritoneal dialysis was initiated without difficulty. On the following day, the patient complained of hydrocele. Computed tomographic peritoneography demonstrated communication from the inguinal canal to the peritoneum. We stopped peritoneal dialysis, and the hydrocele resolved by the following day. We again proceeded with peritoneal dialysis 7 days later, however, the patient had a recurrence of the hydrocele within one day. The communication was surgically closed in such a manner similar to the surgical repair of inguinal hernia. The scrotal edema resolved, and peritoneal dialysis was re-started 7 days after the operation. Little is known regarding the approach to the treatment and postoperative management of communicating hydrocele in patients on peritoneal dialysis. We report our experience in successfully treating a communicating hydrocele, and we review case reports on the treatment and postoperative management of communicating hydroceles in patients on peritoneal dialysis.