Atsushi Kotera

Magnet compression anastomosis for bile duct stenosis after duct‐to‐duct biliary reconstruction in living donor liver transplantation

A 44-year-old woman who had undergone living donor liver transplantation for fulminant hepatic failure presented obstructive jaundice 1 year after transplantation. A right lobe from her husband had been used for the original graft. Intraoperative cholangiography of the donor showed the bile duct of posterior inferior segment (B6) branching from the bile duct of anterior segment (Fig. 1). The bile duct of the donor was transected in the very short segment of the common trunk of the posterior and anterior branches of the right lobe. The orifice of the bile duct of the graft was single, but the shape of it was like the nose of a pig. This single orifice was anastomosed to the stump of the recipient’s common hepatic duct. A biliary stent tube (4-Frenchsized) was inserted into only the bile duct of the posterior segment. Coldand warm-ischemia time was 42 and 45 minutes, respectively. She initially recovered uneventfully in the early period after liver transplantation. The external stent tube was removed 3 months after the transplantation. Laboratory data at 11 months after the transplantation showed slight elevation of transaminases (aspartate aminotransferase: 80 IU/L, alanine aminotransferase: 100 IU/L) and total bilirubin (1.4 mg/dL). One month later, ultrasonography showed the dilated intrahepatic duct. Endoscopic retrograde cholangiography and percutaneous transhepatic cholangiography disclosed the complete obstruction of the anterior branch (Fig. 2). The dilated duct was drained by the percutaneous transhepatic cholangiography drainage tube. Balloon dilatation was attempted though the percutaneous transhepatic cholangiography drainage tube, but it was

Manganese deposits in patients with biliary atresia after hepatic porto-enterostomy

PURPOSE The aim of this study was to determine if there is latent manganese toxicity in patients with biliary atresia. METHODS Fifteen children with biliary atresia were examined postoperatively with regard to whole-blood manganese levels using brain magnetic resonance imaging (MRI) and I-123 iodoamphetamine (IMP) per rectal portal scintigraphy. RESULTS Nine (60%) of the 15 had high whole-blood manganese levels (mean, 4.1 microg/dL; range, 1.2 to 9.6; normal, 0.5 to 2.5), and these 9 had hyperintense globus pallidus on T1-weighted images, with no corresponding signal change in T2 sequences. I-123 IMP per rectal portal scintigraphy was done for 13 patients to evaluate portosystemic shunt flow. 12 (92%) of these patients had an increased flow. Mean shunt ratio was estimated to be 41% (range, 0.6 to 98; normal, <5%). Encephalopathy was evident in only 1 patient. CONCLUSIONS Some patients with biliary atresia in the postoperative period have manganese deposits in globus pallidus on T1-weighted images and high whole-blood manganese levels, possibly caused by increased portsystemic shunt, and a latent or subclinical encephalopathy is also present.

Comparison of the McGrath MAC video laryngoscope and the Pentax Airwayscope during chest compression: a manikin study

We tested the utility of the McGrath MAC® (McG) video laryngoscope during chest compression compared with the Pentax Airwayscope® (AWS). We recruited 59 participants into the simulation study. The difference in the time to intubation (TTI [sec]) between without and with chest compression was significant for the AWS attempts (median 13, range 6–28 vs. median 15, range 6–72, p = 0.0247) but not significant for the McG attempts (median 16, range 6–75 vs. median 16, range 6–71); however, the difference of the TTIs is not serious clinically. The utility of the two devices during chest compressions is almost similar although their characteristics are different.

A validation of presepsin levels in kidney dysfunction patients: four case reports

Here, we measured presepsins (PSPs) in four patients with acute kidney injury (AKI) or chronic kidney disease (CKD) and discuss the relationship between PSP and kidney dysfunction.Case 1: an 83-year-old man was admitted to the ICU to manage postoperative respiratory failure with AKI. He had undergone resection for rectal cancer and ileal conduit replacement. On day 1 in the ICU, Escherichia coli (E. coli) was isolated by urine culture. PSP level (pg/ml) on day 2 was 2,745 without elevation of other conventional biomarkers. On day 6, the patient was diagnosed with severe sepsis, and E. coli was isolated by blood culture. By then, PSP had risen to 3,977, along with elevation of other conventional biomarkers. His kidney function recovered gradually after continuous administration of hemodiafiltration; however, PSP continued to rise up to 6,051, along with high systemic inflammatory response syndrome (SIRS) and Acute Physiology and Chronic Health Evaluation (APACHE) II values. The patient expired on day 13 due to multiple organ failure. Case 2: a 78-year-old woman with CKD on hemodialysis (HD) was admitted to the ICU after cardiovascular surgery. Continuous HD was administered postoperatively, and PSP ranged from 1,473–1,870 without signs of sepsis. Temporary elevation of other conventional biomarkers was observed postoperatively. Case 3: a 74-year-old woman with CKD on HD was admitted to the ICU after neurosurgery. She underwent intermittent HD postoperatively, and PSP ranged from 1,240–1,935 without sepsis symptoms. Temporary elevation of other conventional biomarkers was observed postoperatively. Case 4: a 62-year-old man with CKD was admitted to the ICU to control gastrointestinal bleeding. PSP was 606 without signs of infection or elevation of other conventional biomarkers. In cases 2, 3, and 4, bacteria were not isolated in blood cultures. Patients’ clinical prognoses were good, with low or moderate SIRS and APACHE II scores.PSP in kidney dysfunction patients will be high despite non-infectious conditions. Therefore, evaluation of PSP in kidney dysfunction patients will be difficult. Further investigation is needed to clarify the relationship between PSP and kidney dysfunction.

A resuscitated case of cardiopulmonary arrest due to massive hemoptysis caused by a ruptured thoracic aortic aneurysm

Dear Editor, We report a resuscitated case of cardiopulmonary arrest (CPA) following massive hemoptysis due to a ruptured thoracic aortic aneurysm (TAA). A 73-year-old man was admitted with a sudden onset of hemoptysis. He presented with atrial fibrillation, and he had been taking warfarin (1 mg/day). He had not been previously diagnosed as having a TAA and had had no episode of hemoptysis. On admission, he was lucid with the following vital data: blood pressure, 143/107 mmHg; pulse rate, 90–110 b.p.m.; respiratory rate, 20/min. His breathing sound was reduced in his left lung field. Laboratory tests showed: hemoglobin, 14.7 g/dL; total leukocyte count, 10,800/mm; platelet count, 135,000/mm; PT (INR), 1.17; d-dimer, 29.4 μg/mL. A chest X-ray revealed a hazy shadow in the patient’s left lung field (Fig. 1A). A contrast-enhanced chest computed tomography scan showed a leakage of the contrast material from the TAA and consolidated lung tissue adjacent to the TAA (Fig. 1B). He was diagnosed as having a ruptured TAA into the tracheobronchial trees or the lung, and an emergent endovascular stent-grafting was scheduled. Just before the induction of general anesthesia, CPA following sudden massive hemoptysis occurred. He was intubated immediately, and we started cardiopulmonary resuscitation (CPR). An endovascular intervention was also started under the CPR. We inserted the stent-graft through the femoral artery with fluoroscopy guidance. After the dilation of the stent-graft with an endovascular balloon, the patient was resuscitated. The duration of the CPR was 67 min; however, we had to interrupt the chest compression several times during the fluoroscopy guidance. During the CPR, his electrocardiogram revealed pulseless electrical activity and mechanical ventilation was continued with 100% oxygen; however, the lowest PaO2 was 52 mmHg and the highest PaCO2 was 98 mmHg. The lowest value of

Infective Endocarditis Caused by Odontogenic Infection withDentinogenesis Imperfecta in Jeune Syndrome

Osteogenesis imperfecta is main symptom in an autosomal recessive Jeune syndrome. Odontogenic infection by dentinogenesis imperfecta and poor oral hygiene is not known and Infective Endocarditis (IE) as a life threatening complication is the first report in Jeune syndrome. Case: A 13-year-old female patient presented with fever, disturbed consciousness, and convulsion. She had Jeune syndrome with mitral regurgitation and mental retardation. Cerebral hemorrhage, vegetation of mitral valve and poor oral hygiene demonstrated clinical definite diagnosis of IE by Duke Criteria. Bacterial aneurysm would cause to be cerebral hemorrhage that was no worsening by Computed Tomography. Vancomycin or Linezolid was treated after MRSA was detected in blood culture. Decayed teeth were removed as source of IE. Consciousness level and inflammation response were improved and no sign of infection was confirmed by frequent echocardiogram and blood culture. Outcome: Patient was discharged the hospital after she had no symptoms with appropriate treatment. Conclusion: Observation of oral hygiene and consideration of IE as the differential diagnosis are beneficial in a severe infectious disease of unknown origin with osteogenesis imperfecta, Jeune syndrome. Antibiotics therapy, oral hygiene and teeth extraction are effective for IE caused by decayed teeth with dentinogenesis imperfecta.

Comparison of the conventional Macintosh laryngoscope, the Pentax Airwayscope, and the McGrath MAC video laryngoscope under restricted cervical motion: a manikin study

We compared the utility of the conventional Macintosh laryngoscope, the Pentax Airway Scope, and the McGrath MAC video laryngoscope under restricted cervical motion using a manikin.

Healthy baby delivered vaginally from a brain-dead mother: Healthy neonate from brain-dead mother

A pregnant (20 gestational weeks) 32‐year‐old woman was found in cardiac arrest. Spontaneous circulation returned after 15 min. She became brain dead on the 13th hospital day. The patient was in stable circulatory condition under nasal desmopressin and 20–30 mg/day of hydrocortisone. On the 92nd hospital day at gestational week 33 + 3 days, natural labor began and a healthy 2,130‐g girl (Apgar 6/8) was delivered vaginally with minimum assistance.

Comparison of the utility of the Pentax Airway Scope (AWS) with that of the conventional Macintosh laryngoscope during chest compression: is the AWS an easy‐to‐use device for a novice?

The Pentax Airway Scope occasionally contacts the arm of the chest compressor at insertion because of its large body. Here, we test the Airway Scopes ease of use compared to that of the conventional Macintosh laryngoscope during chest compression, when operated by a novice.

Electrocardiogram findings of patients with serum potassium levels of nearly 10.0 mmol/L: a report of two cases

In Case 1, a 63‐year‐old woman was admitted with muscular weakness. She had hypertension, diabetes mellitus, and chronic renal failure on hemodialysis. She was taking a beta‐blocker. Her pulse rate was 42 b.p.m. (irregular rhythm); serum potassium level was 9.8 mmol/L; electrocardiogram revealed widening of the QRS complex (0.256 s). In Case 2, a 59‐year‐old man was admitted with muscular weakness. He had hypertension and chronic renal failure, and was taking a renin–angiotensin–aldosterone system inhibitor. His pulse rate was 42 b.p.m. (irregular rhythm); serum potassium level was 10.1 mmol/L; electrocardiogram revealed widening of the QRS complex (0.180 s).