<原著>後方からの直腸粘膜切除と回腸貫通術式 : 新しい大腸全摘再建法

We reported a new method of restorative proctocolectomy using posterior approach and pull through reconstruction. This method obviated transanal manipulation, a major factor causing damage to the internal sphincter, thus preventing fecal incontinence due to sphincter dysfunction. Also, temporary ileostomy was not necessary becaasue the spout of an S-pouch was pulled down below the anal verge and its distal free end acted as a diverting stoma while the more proximal, healing zone (future anastomotic line) was kept from fecal contamination. This method was applied to a 32-year-old woman with familial polyposis coli and a 50 year old woman with ulcerative colitis. Their bowel movements steadily decreased to three times and five times a day, respectively. There was no fecal leakage or perianal excoriation. The advantages as well as disadvantages of this method compared with the conventional techniques were discussed.後方からの直腸到達法と貫通術式による新しい大腸全摘再建法を報告した. 本法は内肛門括約筋損傷の主因である経肛門操作を必要とせず, 括約筋障害による便失禁を予防できる. またS型貯留嚢の下方遊離断端が肛門外に引き出されて人工肛門の役割を果たし, 口側の回腸肛門癒合帯(将来の吻合線)の便汚染を防ぐために, 一時的回腸瘻造設も不必要である. 本法を32歳の家族性結腸腺腫症の女性と50歳の潰瘍性大腸炎の女性に施行した. 術後便回数は着実に減少し各々1日3回と5回となった. また肛門からの便漏れや皮膚びらんも認めなかった. 本法の利点や欠点を他の方法と比較検討した

Risk factors for insufficient ultrasound‐guided supraclavicular brachial plexus block

Abstract Purpose Ultrasound‐guided supraclavicular brachial plexus block (SCBPB) is performed by surgeons for upper limb anesthesia; however, certain patients need additional local anesthesia. This study aimed to identify risk factors for additional local anesthetic injection requirements. Methods In total, 269 patients receiving ultrasound‐guided SCBPB were enrolled. Patient age, sex, body mass index, anesthetic drug dose, surgeon expertise (hand surgeon or resident), tourniquet time, comorbidities (diabetes mellitus and mental disorders), and preoperative blood pressure representing anxiety were compared between the additional local anesthesia and no additional local anesthesia groups matched for background using propensity scores. Receiver operating characteristic analysis was performed to determine risk factor cut‐off values with the highest predictive potential. Results Of 269 patients, 41 (15.2%) required additional intraoperative local anesthesia. Among surgical sites, elbow surgery showed the highest prevalence of the need for additional local anesthesia (17/41, 41%). A high body mass index and high systolic blood pressure before surgery were identified as risk factors for additional intraoperative local anesthesia requirement. Furthermore, systolic blood pressure > 170 mmHg (area under the curve, 0.66) predicted the need for intraoperative local anesthesia with 36% sensitivity, 89% specificity, 37.5% positive predictive value, and 88.6% negative predictive value. The median systolic blood pressure was significantly greater in patients requiring additional local anesthesia than in those not requiring it [151 (139–171) mmHg vs. 145 (127–155) mmHg; P = 0.026]. Conclusion Elbow surgery, obesity, and high systolic blood pressure (> 170 mmHg) before surgery are predictive of additional intraoperative local anesthesia requirement. Level of Evidence Prognostic Level II

What should be known prior to performing EUS?

Direct referral of patients for EUS – instead of preprocedural consultation with the endosonographer – has become standard practice (like for other endoscopic procedures) as it is time- and cost-effective. To ensure appropriate indications and safe examinations, the endosonographer should carefully consider what information is needed before accepting the referral. This includes important clinical data regarding relevant comorbidities, the fitness of the patient to consent and undergo the procedure, and the anticoagulation status. In addition, relevant findings from other imaging methods to clarify the clinical question may be necessary. Appropriate knowledge and management of the patients' anticoagulation and antiplatelet therapy, antibiotic prophylaxis, and sedation issues can avoid unnecessary delays and unsafe procedures. Insisting on optimal preparation, appropriate indications, and clear clinical referral questions will increase the quality of the outcomes of EUS. In this paper, important practical issues regarding EUS preparations are raised and discussed from different points of view.publishedVersio

What should be known prior to performing EUS?

Direct referral of patients for EUS – instead of preprocedural consultation with the endosonographer – has become standard practice (like for other endoscopic procedures) as it is time- and cost-effective. To ensure appropriate indications and safe examinations, the endosonographer should carefully consider what information is needed before accepting the referral. This includes important clinical data regarding relevant comorbidities, the fitness of the patient to consent and undergo the procedure, and the anticoagulation status. In addition, relevant findings from other imaging methods to clarify the clinical question may be necessary. Appropriate knowledge and management of the patients' anticoagulation and antiplatelet therapy, antibiotic prophylaxis, and sedation issues can avoid unnecessary delays and unsafe procedures. Insisting on optimal preparation, appropriate indications, and clear clinical referral questions will increase the quality of the outcomes of EUS. In this paper, important practical issues regarding EUS preparations are raised and discussed from different points of view