JA Clinical Reports最新文献

Mesenteric traction syndrome (MTS) is a transient circulatory disturbance characterized by sudden hypotension, tachycardia, and facial flushing following mesenteric manipulation during abdominal surgery. Early recognition is essential; however, conventional monitoring often detects these events only after hemodynamic deterioration. We report a 68-year-old man who underwent distal pancreatectomy and splenectomy under combined general and thoracic epidural anesthesia. Sixteen minutes after the start of surgery, the hypotension prediction index (HPI)-an artificial intelligence-based monitoring system-abruptly increased to > 85 despite stable vital signs. The systemic vascular resistance index decreased, suggesting early vasodilatory change. Prompt intravenous phenylephrine boluses were administered, and rapid colloid infusions were initiated to minimize hypotension. Recognition of facial flushing subsequently confirmed the diagnosis of MTS, and intravenous flurbiprofen stabilized the circulation. This case suggests that HPI monitoring may assist in the early identification of vasodilatory changes associated with MTS and support timely intervention before severe hypotension develops.

Background: CT myelography is a definitive diagnostic tool for cerebrospinal fluid leakage. We report a case in which the site of a cerebrospinal fluid leak that had been difficult to identify on CT myelography was fortuitously localized owing to incidental injection of a contrast agent into the subdural space.

Case presentation: A 37-year-old man developed headache and neck pain following a massage. He was diagnosed with intracranial hypotension, but the exact site of cerebrospinal fluid leakage could not be identified by CT myelography. An epidural blood patch was performed at the Th11/12 level, during which a contrast agent was inadvertently injected into the subdural space, revealing cerebrospinal fluid leakage from the Th2/3 level into the epidural space.

Conclusions: An unintentional subdural injection of contrast agent resulted in extensive distribution, facilitating the precise identification of the cerebrospinal fluid leakage site.

Background: Myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) is a demyelinating disorder that may relapse during pregnancy. The safety of neuraxial anesthesia in such patients remains unclear.

Case presentation: We describe a 32-year-old multiparous woman with MOGAD who developed intractable hiccups due to new medullary lesions at 35 weeks of gestation. Despite steroid pulse therapy, symptoms persisted. At 36 weeks and 2 days, premature rupture of membranes occurred, and hiccups worsened with labor pain. After informed consent, labor epidural analgesia was initiated using low-concentration levobupivacaine with minimal fentanyl. Pain relief coincided with the reduction of hiccups. Vaginal delivery of a male infant was uneventful. Her hiccups resolved by postpartum day 4, and magnetic resonance imaging showed improvement in the lesion. She was discharged on postpartum day 7 without neurological worsening.

Conclusions: Labor epidural analgesia provided effective pain control and was associated with symptom relief in a parturient with active MOGAD.

Background: Transesophageal echocardiography (TEE) is widely used in cardiac and non-cardiac surgeries with major hemodynamic fluctuations. In patients with vascular anomalies near the esophagus, such as an aberrant left subclavian artery (ALSA), TEE may pose a risk of vascular compression. However, no guidelines exist.

Case presentation: A 19-year-old woman with biliary atresia underwent living donor liver transplantation. Preoperative imaging showed a right-sided aortic arch with ALSA coursing posterior to the esophagus, and ALSA compression was considered a risk during TEE. Therefore, bilateral radial arterial pressures and regional cerebral oxygen saturation (rSO₂) were monitored. The TEE probe was inserted under videolaryngoscopic guidance without resistance or hemodynamic disturbance, and no arterial waveform attenuation or rSO₂ changes occurred. Transplantation was uneventful, and the patient showed no postoperative neurological or upper-limb deficits.

Conclusion: This case highlights that appropriate imaging and monitoring strategies can support safe TEE use in non-cardiac surgery, even with vascular anomalies.

Background: Esophagectomy for esophageal cancer is complex and frequently complicated by pulmonary issues, cardiac problems, and anastomotic leakage. While numerous factors contribute to these complications, the specific effects of intraoperative hypotension (IOH) on postoperative outcomes remain poorly understood. This study examined the relationship between IOH severity during esophagectomy and subsequent complications.

Methods: This retrospective observational study analyzed patients undergoing elective open transthoracic or thoraco-laparoscopic esophagectomy for esophageal cancer between May 2007 and February 2020. Multiple logistic regression assessed IOH's association with primary outcomes (composite of major complications including 30-day mortality, reoperation, anastomotic leakage, pneumonia, reintubation, and prolonged ventilation > 48 h) and secondary outcomes of anastomotic leakage. Additionally, Cox regression analyzed IOH's impact on long-term prognosis.

Results: The final cohort comprised 884 patients. The most prevalent postoperative complications were anastomotic leakage (25.2%) and pneumonia (23.4%). The 30-day mortality rate was 0.8%. No significant association existed between IOH and major composite outcomes across mean blood pressure (MBP) and systolic blood pressure thresholds. However, IOH was significantly associated with anastomotic leakage when MBP fell below 65 mmHg for extended periods (adjusted odds ratio: 1.02 per 10-min interval, 95% confidence interval: 1.01-1.04, P = 0.01). IOH did not significantly affect long-term survival.

Conclusions: This study did not identify a significant association between intraoperative hypotension and composite major postoperative complications or long-term survival outcomes. However, intraoperative hypotension, specifically prolonged episodes with mean blood pressure below 65 mmHg, was significantly associated with the short-term complication of anastomotic leakage.

Trial registration: UMIN Clinical Trials Registry, UMIN000040455. Registered 28 May 2020, https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000046165 .

Several cases of tracheal stenosis due to thoracic aortic aneurysm have been reported. However, cases of aortic aneurysm discovered following ventilation difficulties immediately after the induction of general anesthesia are rare. The patient, a 90-year-old woman with a history of ascending aortic replacement for a thoracic aortic aneurysm, was scheduled for sternum infection debridement. During induction, adequate ventilation could not be achieved despite the use of positive pressure, even after tracheal intubation. Bronchoscopy showed tracheal compression, which was not apparent in preoperative evaluations. CT imaging on the day demonstrated that the compression was caused by a thoracic aortic aneurysm. A thoracic endovascular aneurysm repair was performed successfully, and the tracheal compression improved afterwards. Compression from outside the trachea should be considered as a potential cause of sudden ventilation difficulties. Particularly in patients with a history of aortic surgery, additional preoperative assessments should be considered.

Background: Long QT syndrome (LQTS) refractory to standard treatments, including β-blockers and implantable cardioverter-defibrillators (ICDs), has been indicated for left cardiac sympathetic denervation (LCSD) in Europe and the United States. However, the clinical implementation of LCSD remains rarely performed in Japan as it is not covered by national health insurance.

Case presentation: A 49-year-old woman with LQTS experienced frequent ICD activations, and β-blocker up-titration was limited due to severe heart failure. As a stellate ganglion block transiently shortened QT interval, LCSD was considered to prevent life-threatening arrhythmic events. Total intravenous anesthesia combined with a left thoracic paravertebral block was used to attenuate sympathetic nervous activation. Thoracoscopic LCSD was performed without arrhythmia or hemodynamic instability. The patient remained stable postoperatively, with no further ICD activations.

Conclusion: This case demonstrates the safe perioperative management of LCSD for drug-refractory LQTS by incorporating strategies to minimize QT prolongation and suppress malignant arrhythmias.

Background: Venous air embolism (VAE) is a rare but potentially fatal complication in neurosurgery typically caused by injury to dura mater, especially venous sinuses, during craniotomy. We report two cases of VAE that occurred before dural incision.

Case presentation: Both patients underwent craniotomy under general anesthesia in a head-up position. Hemodynamic and respiratory deterioration occurred during or immediately after burr hole drilling with abnormal vital signs and transesophageal echocardiography findings, raising suspicion for VAE. Immediate management, including surgical field protection and cardiopulmonary support, stabilized the patients' conditions. The procedure was subsequently discontinued in case 1 and modified to limited resection in case 2. Postoperative computed tomography revealed intracranial venous air within the internal jugular vein, cavernous sinus, and diploic veins.

Conclusion: These cases highlight that VAE can occur even before dural incision. Vigilant intraoperative monitoring and prompt intervention are essential for preventing potentially fatal outcomes.