The choices for practical monitoring of free jejunal transfer have been quite limited because of its own characteristics, such as buried form, lack of skin surface, and the structure of a hollow viscous tract. Physiologically, it is known that tissue hypoxia caused by compromised perfusion leads to an increase of partial pressure of carbon dioxide (PCO2). Because of its physiological properties, the diffusion of carbon dioxide is always equilibrated between the mucosa of a hollow viscous organ and its lumen. The intramucosal PCO2 (PiCO2) of the gastrointestinal tract can therefore be determined indirectly from the intraluminal PCO2, which is measured with the aid of the tonometer catheter. To develop an optimal monitoring method for free jejunal transfer, the authors proposed the application of PiCO2 measurement by a modified use of a tonometer catheter. Since May of 1999, the authors performed postoperative PiCO2 monitoring on 20 cases of reconstructed pharyngoesophageal tracts in 18 patients who underwent radical tumor resection and one-stage reconstruction at the Shizuoka Red Cross Hospital. All 20 cases were safely monitored by PiCO2 measurement without any complications associated with the use of the tonometer catheter. In the 17 cases that succeeded uneventfully, the mean values of PiCO2 were kept lower than 40 mmHg throughout the monitoring period. On the other hand, the other three cases (15 percent) needed reexploration due to development of vascular complications, which was alerted by an abrupt increase of PiCO2 in each case (229, 130, and 99.6 mmHg). Two of the patients were fortunately successfully treated by immediate reexploration, leading to a 95 percent overall success rate. No false-negative or false-positive cases were observed. The authors' experience suggests that PiCO2 measurement using a tonometer catheter can provide the surgeon with reliable information for evaluating the perfusion and viability of a free jejunal transfer. Simplified manipulation and the objectivity of the numerical data allow stable measurement of PiCO2 and prompt judgment of the adequacy of the perfusion, which could minimize the burden and anxiety of the surgeon, particularly in the early postoperative period.

A 90-year-old man underwent emergency thrombectomy for acute occlusion of the right femoral and popliteal arteries. After an epidural catheter (used for intraoperative/postoperative management) was removed, a spinal epidural hematoma involving the Th12 to L3 areas developed. Emergency removal of the hematoma and decompression of the spinal cord were performed. Possibly, the hematoma had developed due to therapy with an antiplatelet agent, cilostazol, which had been started on the first postoperative day, and due to the removal of the catheter, on the third postoperative day, in addition to the patient's advanced age. This case may be the first report of spinal epidural hematoma associated with both cilostazol and epidural anesthesia. From the time course in this patient, important knowledge of drug actions and follow-up may be gained for determining the timing of catheter removal in a patient receiving antiplatelet therapy with cilostazol.

We performed anesthesia for a subtotal gastrectomy in a 70-year-old female patient with paramyotonia congenita (PC). She had been diagnosed with PC at the age of 47 years by electromyogram analysis. Several points to consider have been revealed regarding the management of anesthesia in patients with PC. In this patient, anesthesia was safely maintained using sevoflurane and nitrous oxide together with concomitant epidural anesthesia using mepivacaine. Efforts should be made to prevent perioperative attacks of muscle weakness when planning anesthesia for patients with this kind of disorder. Specifically, refraining from the use of muscle relaxants, care with regard to the composition of infusion fluids during operations, and the maintenance of body temperature are required for anesthesia. In addition, postoperative pain management using a continuous epidural block proved to be a useful method.

Lupus anticoagulant (LA), an antiphospholipid antibody, prolongs in vitro activated partial thromboplastin time (APTT) despite the presence of a hypercoagulable state in vivo. Irrespective of whether they receive antithrombotic therapy, meticulous anesthetic management is imperative in patients with LA positivity to prevent thrombotic complication. Additionally, emergency surgery in such patients can be challenging, as the time to devise perioperative strategies is limited. Here, we described the case of a patient with LA positivity and prolonged APTT who underwent emergency laparoscopic cholecystectomy with successful anesthetic management using epidural analgesia. An 83-year-old woman presented with acute cholecystitis and underwent emergency laparoscopic cholecystectomy. Preoperative blood test results revealed a prolonged APTT of 83 s, prothrombin time/international normalized ratio of 1.14, and normal platelet count. The patient had experienced a marked prolongation of APTT ten years previously, which was attributed to LA positivity, and she had previously undergone surgery for rectal cancer under general and epidural anesthesia. The patient did not receive antithrombotic therapy, and she demonstrated neither liver dysfunction nor a bleeding tendency. We prioritized optimal analgesia to enable early mobilization; therefore, an epidural catheter was placed in preparation for transition to open abdominal surgery. The operation was completed under laparoscopy, and good pain control was achieved postoperatively with continuous epidural analgesia, facilitating early ambulation. The epidural catheter was removed on the second postoperative day, and the patient did not develop any signs of thromboembolism or neurologic complications during her hospital stay. Anesthetic management for emergency laparoscopic cholecystectomy was successfully performed using epidural analgesia in a patient with LA positivity and prolonged APTT. Careful evaluation of laboratory data, treatment history, and clinical symptoms is of critical importance in such patients.