Novel technique of abdominal wall nerve block for laparoscopic colostomy: Rectus sheath block with transperitoneal approach

A 62-year-old man who had acute rectal obstruction due to a large rectal cancer is presented. He underwent emergency laparoscopic colostomy. We used the laparoscopic puncture needle to inject analgesia with the novel transperitoneal approach. In this procedure, both ultrasound and laparoscopic images assisted with the accurate injection of analgesic to the correct layer. The combination of laparoscopic visualization and ultrasound imaging ensured infiltration of analgesic into the correct layer without causing damage to the bowel. Twentyfour hours postoperatively, the patient's pain intensity as assessed by the numeric rating scale was 0-1 during coughing, and a continuous intravenous analgesic was not needed. Colostomy is often necessary in colon obstruction. Epidural anesthesia for postoperative pain cannot be used in patients with a coagulation disorder. We report the use of a novel laparoscopic rectus sheath block for colostomy. There has been no literature described about the nerve block with transperitoneal approach. The laparoscopic rectus sheath block was performed safely and had enough analgesic efficacy for postoperative pain. This technique could be considered as an optional anesthetic regimen in acute situations.

A New Protocol for Determining Intervention with Trans-Catheter Arterial Embolization or Surgical Hemostasis for Obstetric Hemorrhage

Objectives: The aim of this study is to introduce protocols for choosing trans-arterial embolization (TAE) or surgical hemostasis as an initial therapy for obstetric hemorrhage. Materials and Methods: From 2002 to 2011 at our hospital, the medical records of the patients who underwent TAE or surgical hemostasis for obstetric hemorrhage were reviewed to assess the following data: The causes of obstetric hemorrhage, Shock Index (SI) and obstetrical disseminated intra-vascular coagulation (DIC) score, amount of bleeding, transfusion, and operation time. Results: Twenty-five patients underwent TAE and six underwent surgical hemostasis. SI and obstetrical DIC score of the TAE group were 1.0 (0.4 - 2.2) and 6.0 (1 - 32), respectively. They were significantly lower than those of the surgical hemostasis group (SI: 1.6, obstetrical DIC score: 12.5, p < 0.05). Though the hemorrhage could be controlled sufficiently in 23 cases of the TAE group, 5 cases went into shock during TAE. The SI and obstetrical DIC score of shock group were 1.2 (1 - 2) and 10 (2 - 32), respectively. Conclusion: Though TAE is a useful therapy to control obstetric inevitable hemorrhage, special attention should be paid to the vital signs during TAE, especially in cases where SI and/or obstetrical DIC score are higher than 1.2 and 10, respectively.

Severe Pelvic Organ Prolapse with Large Vaginal Mucosal Defect Underwent Laparoscopic Shull’s Uterosacral Ligament Colpo-Suspension and TVM Operation by Two Stage Surgery

A 75-year-old woman complained of anuria and a sense of discomfort with severe pelvic organ prolapse (POP). We planned tension-free vaginal mesh (TVM) surgery after curing mucosal defects and completing treatment for diabetes mellitus. Anuria and pyelonephritis relapsed repeatedly due to the failure of ring pessary therapy. Surgical treatment was required emergently. We performed a total laparoscopic hysterectomy and uterosacral ligament colpo-suspension (Shull’s method). Although the vaginal apex was supported to a good position, cystocele occurred six months after the initial surgery. A TVM procedure for recurrent cystocele was performed after curing the mucosal defects, and after the improvement of glycemic control. Transvaginal native tissue repair has the advantages of low risk of ureter injury, firm colpo-suspension, and no need for mesh usage. On the other hand, it is not good at treating cystocele. Transvaginal native tissue repair should prove to be a useful surgical option for apical support without mesh.

Plasma levels of catecholamine metabolites and serum levels of brain-derived neurotorophic factor in smokers with schizophrenia treated with varenicline: A pilot study

Objective: The present study sought to determine changes in plasma levels of catecholamine metabolites and serum levels of brain-derived neurotorophic factor (BDNF) among smokers with schizophrenia who were treated with varenicline. Methods: We compared plasma homovanillic acid (HVA) and 3-methoxy-4-hydroxyphenylglycol (MHPG) levels and serum BDNF levels across 4 groups, divided as follows: smokers with schizophrenia (S-Sc), nonsmokers with schizophrenia (NS-Sc), smokers who were otherwise healthy (S-HC) and nonsmokers who were otherwise healthy (NS-HC). In addition, we also examined plasma HVA and MHPG levels and serum BDNF levels prior to study initiation (T0) and 8 weeks after varenicline treatment (T8) in the S-Sc and S-HC groups. Results: Plasma HVA levels in the S-Sc group at T0 were significantly higher than in the NS-Sc, S-HC and NS-HC groups at the same time point (S-Sc at T0;7.6 ± 1.6 ng/mL, NS-Sc;4.8 ± 1.0 ng/mL, S-HC;4.3 ± 0.9 ng/mL, NS-HC;3.4 ± 1.4 ng/mL, p < 0.0001). Plasma MHPG levels in the S-Sc group at T0 were significantly higher than in the NS-Sc and S-HC groups;in addition, plasma MHPG levels in the NS-HC group were significantly higher than in the S-HC group (S-Sc at T0;5.2 ± 0.7 ng/mL, NS-Sc;2.8 ± 1.2 ng/mL, S-HC;1.9 ± 0.8 ng/mL, NS-HC;3.6 ± 1.3 ng/mL, p < 0.0002). Serum BDNF levels did not differ between the S-Sc and NS-Sc groups. In contrast, no difference in plasma HVA levels, plasma MHPG levels or serum BDNF levels was observed between T0 and T8. Conclusions: In conclusion, plasma levels of HVA and MHPG in the S-Sc group were significantly higher than in the NS-Sc group. Serum BDNF levels did not differ between the S-Sc and NS-Sc groups. Plasma HVA and MHPG levels and serum BDNF levels did not change after treatment with varenicline.