川治 崇泰

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.

OBJECTIVES: Subcutaneous emphysema (SE) in pneumoperitoneum surgery is a complication not observed in open abdominal surgery, but data are scarce and epidemiology is inadequate. Although SE is considered less problematic because it is caused by carbon dioxide gas, past reports have shown that severe complications can occur, such as airway obstruction and cardiopulmonary collapse. We conducted an exploratory single-center retrospective study of patients admitted to the ICU after robotic or conventional laparoscopic abdominal surgery, focusing on epidemiological factors promoting severe SE. METHODS: This retrospective study examined cases of severe SE following robotic or conventional laparoscopic abdominal surgery that necessitated ICU admission. Patients older than 18 years with unscheduled ICU admission for grade 5 head SE between 1 January 2010 and 31 December 2021 were included. All robotic surgeries used the da Vinci Surgical System. RESULTS: We reviewed data from all 8 of 3,532 robotic surgeries and 5 of 10,305 conventional laparoscopic surgeries resulting in severe SE. By approach, the incidence of severe SE was 0.23% for robotic surgery and 0.05% for laparoscopic surgery (p=0.006). By organ, gastric surgery was the leading cause, with 6 cases from 2,224 gastric surgeries and 7 from a total of 11,613 other abdominal surgeries, giving incidences of 0.27% and 0.06%, respectively (p=0.011). The incidence in women was 0.15% (10/6,496), compared with only 0.04% (3/7,341) in men (p=0.048). CONCLUSIONS: Our findings confirmed that higher risk of severe SE-although still small-is associated with robotic and gastric surgeries and female sex.

Currently, sodium-glucose co-transporter 2 inhibitors (SGLT2is) are used frequently in a range of patients, including those with type 1 diabetes mellitus, raising concerns regarding the potential increased risk of SGLT2i-associated euglycemic diabetic ketoacidosis (EDKA). We report the case of a patient with type 1 diabetes who developed SGLT2i-associated EDKA during the perioperative period of concurrent pancreas and kidney transplantation procedure. A 41-year-old woman taking an SGLT2i underwent concurrent pancreas and kidney transplantation from a brain-dead donor. Acidosis was noted during surgery, which improved temporarily after the pancreas was transplanted. The pancreatic allograft was resected because of twisting of the anastomotic vessels, and acidosis recurred. The patient's blood glucose levels were consistently within the normal range. Blood ketone monitoring was initiated, and the patient was diagnosed with EDKA. Patients with type 1 diabetes taking SGLT2is who undergo emergency surgery are at risk of EDKA and should continually monitor their ketone levels.

A simple and robust method for veno-venous extracorporeal membrane oxygenation (V-V ECMO) involves a drainage cannula into the inferior vena cava via the femoral vein (FV) and a reinfusion cannula into the right atrium (RA) via the internal jugular vein (IJV) (F-J configuration). However, with this method, the arterial oxygen (PaO2) is said to remain below 100 mmHg.Since recently, in our ICU, to prevent drainage failure, we apply a modification from the commonly practiced F-J configuration by advancing the tip of the drainage cannula inserted via the FV into the superior vena cava (SVC) and crossing the reinfusion cannula inserted via the IJV in the RA (F(SVC)-J(RA) configuration). We experienced that this modification can be associated with unexpectedly high PaO2 values, which here we investigated in detail.Veno-arteriovenous ECMO was induced in a 65-year-old male patient who suffered from repeated cardiac arrest due to acute respiratory distress syndrome. His chest X-ray images showed white-out after lung rest setting, consistent with near-absence of self-lung ventilation. Cardiac function recovered and the system was converted to F(SVC)-J(RA) configuration, after which both PaO2 and partial pressure of pulmonary arterial oxygen values remained high above 200 mmHg. Transesophageal echocardiography could not detect right-to-left shunt, and more efficient drainage of the native venous return flow compared to common F-J configuration may explain the increased PaO2.Although the F(SVC)-J(RA) configuration is a small modification of the F-J configuration, it seems to provide a revolutionary improvement in the ECMO field by combining robustness/simplicity with high PaO2 values.