The use of transesophageal echocardiography (TEE) after esophagectomy remains controversial. Herein, we describe a case in which TEE use was safe and effective during cardiac surgery after esophagectomy with retrosternal gastric tube reconstruction. A 71-year-old man, who had undergone esophagectomy with retrosternal gastric tube reconstruction, was scheduled for removal of a left atrial myxoma via right anterior thoracotomy under cardiopulmonary bypass. A multiplane TEE probe was smoothly inserted into the gastric tube, providing echocardiographic images similar to those acquired by transthoracic echocardiography via the parasternal and subcostal windows. TEE monitoring helped confirm the positions of the devices placed in the great vessels, tumor location, absence of residual air or leakage, and normal heart function. No complications related to the TEE were observed. Intraoperative TEE monitoring is a feasible option even in patients who have undergone esophagectomy with retrosternal gastric tube reconstruction.

Cardiac herniation is a rare but potentially fatal complication that may occur after surgery involving pericardial incision or resection. Most cases develop intraoperatively or in the early postoperative period, and delayed-onset cases after minimally invasive thoracic surgery have not been reported. A 48-year-old woman developed left shoulder pain and nausea six years after thoracoscopic thymectomy for myasthenia gravis. Electrocardiography indicated ST-segment elevation myocardial infarction. Computed tomography of the chest showed cardiac herniation into the left thoracic cavity and coronary angiography revealed stenosis corresponding to the hernial defect. The patient was diagnosed with coronary artery compression due to cardiac herniation and underwent hernia reduction and coronary artery bypass grafting. The postoperative course was uneventful. Cardiac herniation may occur even long after minimally invasive thoracic surgery and should be considered in patients presenting with chest symptoms or hemodynamic instability.

Lumbar disc herniation often causes disabling radicular pain and impaired quality of life (QOL). Disc-FX and L'DISQ are minimally invasive percutaneous disc decompression devices, but their comparative efficacy remains uncertain. We retrospectively reviewed adults with single-level lumbar disc herniation treated with Disc-FX or L'DISQ at a single centre (October 2018-August 2023). Eligibility required radicular pain consistent with magnetic resonance imaging and either positive provocative discography or pain relief after intradiscal injection. Pain intensity (Numerical Rating Scale [NRS]) and QOL (EuroQOL 5-Dimension 5-Levels [EQ-5D-5L]) were assessed at baseline and up to 6 months. The primary outcome was the between-group difference in change in NRS from baseline to 6 months. Secondary outcomes included 6-month change in EQ-5D-5L and minimal clinically important difference (MCID) attainment (NRS ≥ 2-point reduction; EQ-5D-5L ≥ 0.08 increase). Forty-two patients were included (Disc-FX n = 16; L'DISQ n = 26). Both procedures reduced NRS pain scores over 6 months, and the primary outcome showed no statistically significant between-group difference (mean difference 1.32 points; 95% CI - 0.36 to 3.01). Among patients with baseline EQ-5D-5L data (n = 38), Disc-FX showed greater 6-month EQ-5D-5L improvement (mean difference 0.134; 95% CI 0.013 to 0.255) and higher EQ-5D-5L MCID attainment (83.3% vs. 50.0%), but these are secondary results from a small retrospective cohort. In this pilot study, Disc-FX and L'DISQ had comparable short-term pain outcomes. Any apparent QOL advantage with Disc-FX should be interpreted cautiously as exploratory and potentially confounded, and requires confirmation in adequately powered prospective comparative studies.

BackgroundThis study aimed to evaluate the effect of combined administration of remimazolam and propofol on extubation time during anesthesia maintenance.MethodsThis retrospective study was conducted at Hamamatsu University Hospital, enrolling adult patients who underwent non-cardiac surgery between September 2020 and October 2024. Eligible patients underwent invasive arterial pressure monitoring and anesthesia maintenance with remimazolam alone (RB group), propofol alone (PROP group), or a combination of both (RB + PROP group). Extubation time was defined as the interval between the cessation of sedative administration and tracheal extubation. Propensity score matching was performed after adjusting for age, sex, body mass index, American Society of Anesthesiologists Physical Status, preoperative comorbidities, type of surgery, combined with epidural anesthesia, scheduled or emergency surgery, operation time, and blood loss. The primary endpoint was the extubation time, while the secondary endpoints included the severity of hypotension, assessed by the time-weighted average area under the threshold, and the incidence of postoperative nausea and vomiting.ResultsThe study included 165, 403, and 178 patients in the RB, PROP, and RB + PROP groups, respectively. After propensity score matching, 75 matched cohorts were analyzed. Among the three groups, significant differences were found in terms of extubation time and hypotension (p < 0.001 and p = 0.04, respectively), whereas the incidence of postoperative nausea and vomiting did not significantly differ (p = 0.23). In multiple comparisons, the RB group (9.0 min) and the RB + PROP group (9.0 min) had significantly shorter extubation times than the PROP group (13.0 min) (each p < 0.001). Time-weighted average area under the threshold was significantly lower in the RB group (0.74 mmHg) than in the PROP group (2.03 mmHg) (p = 0.03).ConclusionExtubation time with combined remimazolam and propofol was comparable to that with remimazolam alone, and both were shorter than that with propofol alone.Supplementary InformationThe online version contains supplementary material available at 10.1186/s40981-025-00836-2.

BackgroundCT myelography is a definitive diagnostic tool for cerebrospinal fluid leakage. We report a case in which the site of a cerebrospinal fluid leak that had been difficult to identify on CT myelography was fortuitously localized owing to incidental injection of a contrast agent into the subdural space.Case presentationA 37-year-old man developed headache and neck pain following a massage. He was diagnosed with intracranial hypotension, but the exact site of cerebrospinal fluid leakage could not be identified by CT myelography. An epidural blood patch was performed at the Th11/12 level, during which a contrast agent was inadvertently injected into the subdural space, revealing cerebrospinal fluid leakage from the Th2/3 level into the epidural space.ConclusionsAn unintentional subdural injection of contrast agent resulted in extensive distribution, facilitating the precise identification of the cerebrospinal fluid leakage site.

BackgroundOperational loss, defined as unanticipated financial deficits in intensive care unit (ICU) management, is challenging to predict yet critical for hospital sustainability. This study aimed to evaluate whether machine-learning models can predict financial loss events in postoperative ICU patients.MethodsWe conducted a retrospective analysis of postoperative patients admitted to the ICU at Tohoku University Hospital between April 2017 and March 2021. A total of 22 clinical and administrative variables collected within 24 h of ICU admission were used to develop machine-learning models. The outcome was defined as financial loss events, determined by a negative contribution margin below the break-even threshold of − 909 USD. The dataset was randomly split into training (70%) and test (30%) sets. Predictive performance was assessed using the area under the receiver operating characteristic curve (AUC) and accuracy.ResultsAmong 6743 postoperative ICU patients, 425 (6.3%) experienced financial loss events. The random forest classifier demonstrated high predictive performance, with an AUC of 0.859 and accuracy of 0.785.ConclusionsMachine-learning models may accurately predict financial loss events in postoperative ICU patients, potentially supporting efficient resource allocation and hospital financial planning.Supplementary InformationThe online version contains supplementary material available at 10.1186/s40981-025-00819-3.

BackgroundPulmonary artery catheter (PAC) entrapment is a rare but serious complication caused by inadvertent suturing to cardiac or vascular structures.Case presentationA 42-year-old man underwent minimally invasive mitral valve repair via right mini-thoracotomy. Thirty minutes after weaning from cardiopulmonary bypass (CPB), pulmonary artery pressure suddenly dropped, and the waveform became identical to that of central venous pressure. Two centimeters of PAC mobility, aspiration of blood from the balloon port, and blood accumulation in the monitor connector were noted. On postoperative day 1, resistance was encountered during catheter withdrawal at 7 cm, and chest radiography revealed abnormal catheter curvature. Reoperation under CPB confirmed PAC entrapment at the left atriotomy suture line, and the catheter was successfully removed.ConclusionsIn minimally invasive mitral valve repair, a left atriotomy approach might be associated with a risk of PAC entrapment, and the option of not inserting a PAC should always be considered.

BackgroundGuidelines recommend prophylactic chest tube placement in patients with traumatic pneumothorax who require positive pressure ventilation to prevent tension pneumothorax. However, chest tube insertion is not without complications, and avoiding it when safely possible is desirable.Case presentationA man in his 50 s with a left clavicle fracture and mild left-sided occult pneumothorax on computed tomography was scheduled for surgery under general anesthesia. Conservative management was chosen given the absence of respiratory symptoms and stable imaging. To minimize the risk of pneumothorax progression during positive pressure ventilation, one-lung ventilation was employed to avoid ventilating the affected lung. Surgery proceeded uneventfully, with transient hypoxemia that was managed by increasing FiO2 to 100%. Postoperative imaging confirmed re-expansion of the left lung and no pneumothorax progression. The patient was discharged in good condition.ConclusionsGeneral anesthesia was safely managed without prophylactic chest tube placement by employing one-lung ventilation in a patient with occult traumatic pneumothorax.

BackgroundHamman’s syndrome is a clinical entity characterized by the spontaneous leakage of air into the mediastinum. We report a patient with Hamman’s syndrome associated with diabetes ketoacidosis (DKA).Case presentationA 20-year-old foreign technical intern visited to a hospital because of nausea and shortness of breath. He had been diagnosed with diabetes in his home country and had initiated insulin therapy; however, since arriving in Japan, he had not accessed any medical services. Computed tomography revealed pneumomediastinum, while laboratory tests showed marked hyperglycemia, metabolic acidosis, and a significantly elevated blood ketone level (15,044 µmol/L). The patient was diagnosed with Hamman’s syndrome associated with DKA. Upper gastrointestinal endoscopy showed no evidence of gastrointestinal perforation. Conservative intensive care, including insulin therapy and fluid resuscitation, resulted in clinical improvement.ConclusionThis case highlights the importance of recognizing Hamman’s syndrome in DKA and the need for culturally competent care in international residents.