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Oral surgery and hemodialysis
Int. J. Oral Surg. 1984: 13: 31-34 (Key words: hemodialysis; adenoma,monomorphic; tumor, salivarygland;.",rgery,ora£)
Oral surgery and hemodialysis BARUO SHIBATA, KUNIG IKEMURA AND MASATERU MIYAKE Department of Oral Surgery, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
A case of a hemodialysis patient with a palatal tumor is presented. The problems requiring surgical management were as follows: anemia, hyperkalemia, bleeding tendency, delayed wound healing and usage of drugs, especially antibiotics. The palatal tumor was diagnosed histologically as monomorphic adenoma. ABSTRACT -
(Received for publication 17 December 1982, accepted 25 March 1983)
Hemodialysis patients with chronic renal failure are gradually increasing in number and they were estimated to be more than 40,000 in Japan in 1981. Many of these patients present surgical problems. Because of abnormalities of the systemic conditions, careful preoperative, intraoperative and postoperative management are required 2 •3 ,4 ,9 . However, there are few reports with regard to oral surgery of hemodialysis patients", This report presents our experience in the treatment of a hemodialysis patient with a palatal tumor.
Case report A 50-year-old man was referred to our department on March 16, 1981, for removal of a palatal tumor. The patient had first noticed the tumor in 1976. In January 1980, the tumor was biopsied at another hospital and diagnosed histologically as monomorphic adenoma. Preoperative examination revealed renal failure and thereafter hemodialysis therapy was carried out on the patient. Therefore, no treatment of the tumor had
been performed, except the biopsy, until visiting our department. Clinical examination showed the tumor mass to be located in the posterior region of the hard palate with the mixed form of a round and nodular mass (Fig. 1). The tumor was approximately 3 x 3 em in size, covered with intact mucosa, elastic hard, freely movable, and not tender when palpated. Radiographic examination of the palate showed no abnormality. The osteodystrophy of the cranium that is occasionally found in longterm hemodialysis patients!' was not clearly shown. The results of examination on admission are shown in Table 1. Anemia, proteinuria, and increases of BUN, creatinine and serum potassium were noted. Bleeding tendency was not shown in the laboratory data, but there was occasional nasal bleeding in his history. BBs antigen was highly positive. The hospital treatment and course are summarized in Fig. 2. Preoperative hemodialysis (4 h/time, 4 times) and blood transfusion (200 ml of packed red cells, twice) were performed for improvement of uremic and anemic states. Consequently, the following laboratory data were obtained: RBC count (264 x 104jmm3) , hemoglobin
32
SHIBATA. IKEMURA AND MIYAKE
Fig. 1. The palatal tumor showing a mixed form of round and nodular mass.
(8.0 g/dl), hematocrit (23.8%), BUN (44 mg/dl), creatinine (l2.1 mg/dl), and serum potassium (5.3 mEqfl). These treatments were carried out in the Renal Center of The University Hospital of Occupational and Environmental Health. Administration of antibiotics (cephalosporine; half dose of usual usage) was started one day before operation and continued for 10 days after the operation. The operation was performed under general anesthesia (OOF) and the tumor was extirpated with en bloc (Fig. 3). The bone under the tumor was intact. The wound was covered with oxidized cellulose gauze by using the tie-over technique. A
plastic plate was applied on the palate for wound protection. Oozing from the wound occurred on the night of the operation, which necessitated a supplementary blood transfusion of packed red cells (200 ml), There were no other abnormal postoperative courses. Hemodialysis was commenced on the 3rd postoperative day and the sutures were removed on the 8th day. The resected specimen microscopically consisted of uniform and monotonous epithelial cells which had round nuclei (Fig. 4). The tumor cells were arranged in nest-like or canalicular types. The stroma was rich in connective tissue. A diagnosis of monomorphic adenoma was made. There was no evidence of recurrence during one-year follow-up examinations.
Discussion Problems related to surgery in hemodialysis patients are anemia, hyperkalemia, bleeding tendency, retarded immune response and delayed wound healing 2 •3 .4 .9 . Preoperative hemodialysis and blood transfusion were possible, improving these states to some extent. The operation was performed in the usual manner with careful hemostatic treatment. However, the postoperative bleeding occurred in spite of no apparent bleeding tendency on laboratory examination. It is
Table I. Examination data on admission
Blood RBC count WBC count hemoglobin hematocrit platelet total protein BUN creatinine uric acid Na+ K+
CI-
232 x 104 / m m 3 6700/mm 3 7.0 g/dl 20.9% 32.5 x 10 4/mm 3
7.6 g/dl 71 rng/dl 19.6 rng/dl 7.5 mg/dl 138 mEq/1 5.5 mEqfl 97 mEqjl
bleeding time prothrombin time (control) activated partial thromboplastin lime (control)
Urine protein glucose Others HBs antigen: positive (4096 titers) blood pressure: 126/80 mml-Ig ECG: slightly peaked T (hyperkalemia suspected) chest X-ray: normal
3 min 10.8 s 10.9 s 21.8 s 29.9 s
+2 +1
33
ORAL SURGERY AND HEMODIALYSIS Day 1
*
14
7
21
...J..'...J..'-L-1.-1.-L-+....L...J......L....L-L.-L-L-I-....L....L-L.....L~ ~ [ I I I I I I
1-1
Admission
Hemodialysis (4 hrs/day)
'V
'V
Transfusion of packed red cells (200 ml/time)
Removing the sutures
Operation
'V
'V 'V
'V
'V
'"
'V
Discharge
'V
" ""
Antibiotics
[
III
L.-JCET~,-----:CE=-·""IX:---....
Fig. 2. Hospital treatment and course. (CET: cephalotin, 2 g/day, CEX: cephalexin, I g/day.)
suggested that the bleeding tendency in hemodialysis patients is due to platelet dysfunction". The meticulous hemostasis during operation, the physical protection of the wound and the use of local or systemic hemostatic agents are necessary, especially in surgery of hemodialysis patients. In postoperative management, it is most important to monitor hyperkalemia, which happens in sudden cardiac arrest'':". To reduce increasing serum potassium, we used the deionization method by intestinal infusion of ion-exchanger before the resumption of hemodialysis. The hemodialysis was restarted on the postoperative third day and no wound bleeding was seen. The regional
.,' Inn
"'1
l~rJ
140
Fig. 3. The extirpated tumor, approximately 3 x 3 em in size.
heparinization was not used in the Renal Center because of difficulty in accurate control; however, minimal heparinization was used. Usage of antibiotics for hemodialysis patients is selected in order to maintain optimum therapeutic effect without producing a toxic reaction. Cephalexin and cephalotin were chosen according to the descriptions of BENNETT et al,' or OTA 9 . No wound infection or side effect were noticed. Development of monomorphic adenoma in the palate is rare S • 7 •S • The upper lip is the
Fig. 4. Monomorphic adenoma with a mixed appearance of nest-like and canalicular types. (Hematoxylin and Eosin staining, x 125.)
34
SHIBATA, lKEMURA AND MIYAKE
most common site for monomorphic adenoma arising from the minor salivary glands 7 • Uniform cellularity and lack of myxoid or chondroid component are features which separate this tumor from pleomorphic adenoma. It was suggested that the mixed appearance of nest-like and canalicular types be placed into the "other types" of the WHO classification'P.
glands: a reappraisal and report of 9 new cases. J. Oral Surg, 1981: 39: 101-107. 6. LITTLE, J. W. & FALACE, D. A.: Dental man-
agement of the medically compromised patient. 7.
8.
Acknowledgement - The authors wish to thank the staff in the Renal Center of The University Hospital of Occupational and Environmental Health for their collaboration.
9.
ro.
References 1. BENNETT, W. M., SINGER, 1. & COGGINS, C. H.: Guide to drug usage in adult patients with impaired renal function: a supplement. J. Am. Med. Assoc. 1973: 223: 991-997. 2. HAlMov, M., GLABMAN, S., SCHUPAK, E., NEFF, M. & BURROWS, L.: General surgery in patients on maintenance hemodialysis. Ann. Surg. 1974: 179: 863-867. 3. HAMPERS, C. L., BAILEY, G. L., HAGER, E. B., VANDAM, L. D. & MERRILL, J. P.: Major surgery in patients on maintenance hemodialysis. Am. J. Surg. 1968: 115: 747754. 4. HATA, M., REMMERS, A. R., JR., LINDLEY, J. D., SARLES, H. E. & FISH, J. C.: Surgical management of the dialysis patient. Ann. Surg. 1973: 178: 134-137. 5. LEVINE, J., KRUTCHKOFF, D. J. & EISENBERG, E.: Monomorphic adenoma of minor salivary
11.
The C. V. Mosby Co., St. Louis 1980, pp. 110-116. MADER, C. L. & NELSON, J. F.: Monomorphic adenoma of the minor salivary glands. J. Am. Dent. Assoc. 1981: 102: 657-659. MINTS, G. A., ABRAMS, A. M. & MELROSE, R. J.: Monomorphic adenomas of the major and minor salivary glands: report of 21 cases and review of the literature. Oral Surg. 1982: 53: 375-386. OTA, K.: Operative surgery in dialysis patients. Jap. J. Clin. Med. 1980: 38: 2392-2397. THACKRAY, A. C. & SOBIN, L. H.: Histological typing ofsalivary gland tumours. International histological classification of tumours, no. 7. World Health Organization, Geneva 1972, pp.21-22. YAMAGUCHI, A., YAMAGATA, Y., KUSUNOKJ, N. & NARITA, S.: Osteodystrophy in dialysis patients. lap. J. Clin. Med. 1972: 30: 25012506.
Address:
Haruo Shibata Department of Oral Surgery School of Medicine University of Occupational and Environmental Health 1-1, Iseigaoka Yahatanishi-ku Kitakyushu City 807 Japan
Oral surgery and hemodialysis BARUO SHIBATA, KUNIG IKEMURA AND MASATERU MIYAKE Department of Oral Surgery, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
A case of a hemodialysis patient with a palatal tumor is presented. The problems requiring surgical management were as follows: anemia, hyperkalemia, bleeding tendency, delayed wound healing and usage of drugs, especially antibiotics. The palatal tumor was diagnosed histologically as monomorphic adenoma. ABSTRACT -
(Received for publication 17 December 1982, accepted 25 March 1983)
Hemodialysis patients with chronic renal failure are gradually increasing in number and they were estimated to be more than 40,000 in Japan in 1981. Many of these patients present surgical problems. Because of abnormalities of the systemic conditions, careful preoperative, intraoperative and postoperative management are required 2 •3 ,4 ,9 . However, there are few reports with regard to oral surgery of hemodialysis patients", This report presents our experience in the treatment of a hemodialysis patient with a palatal tumor.
Case report A 50-year-old man was referred to our department on March 16, 1981, for removal of a palatal tumor. The patient had first noticed the tumor in 1976. In January 1980, the tumor was biopsied at another hospital and diagnosed histologically as monomorphic adenoma. Preoperative examination revealed renal failure and thereafter hemodialysis therapy was carried out on the patient. Therefore, no treatment of the tumor had
been performed, except the biopsy, until visiting our department. Clinical examination showed the tumor mass to be located in the posterior region of the hard palate with the mixed form of a round and nodular mass (Fig. 1). The tumor was approximately 3 x 3 em in size, covered with intact mucosa, elastic hard, freely movable, and not tender when palpated. Radiographic examination of the palate showed no abnormality. The osteodystrophy of the cranium that is occasionally found in longterm hemodialysis patients!' was not clearly shown. The results of examination on admission are shown in Table 1. Anemia, proteinuria, and increases of BUN, creatinine and serum potassium were noted. Bleeding tendency was not shown in the laboratory data, but there was occasional nasal bleeding in his history. BBs antigen was highly positive. The hospital treatment and course are summarized in Fig. 2. Preoperative hemodialysis (4 h/time, 4 times) and blood transfusion (200 ml of packed red cells, twice) were performed for improvement of uremic and anemic states. Consequently, the following laboratory data were obtained: RBC count (264 x 104jmm3) , hemoglobin
32
SHIBATA. IKEMURA AND MIYAKE
Fig. 1. The palatal tumor showing a mixed form of round and nodular mass.
(8.0 g/dl), hematocrit (23.8%), BUN (44 mg/dl), creatinine (l2.1 mg/dl), and serum potassium (5.3 mEqfl). These treatments were carried out in the Renal Center of The University Hospital of Occupational and Environmental Health. Administration of antibiotics (cephalosporine; half dose of usual usage) was started one day before operation and continued for 10 days after the operation. The operation was performed under general anesthesia (OOF) and the tumor was extirpated with en bloc (Fig. 3). The bone under the tumor was intact. The wound was covered with oxidized cellulose gauze by using the tie-over technique. A
plastic plate was applied on the palate for wound protection. Oozing from the wound occurred on the night of the operation, which necessitated a supplementary blood transfusion of packed red cells (200 ml), There were no other abnormal postoperative courses. Hemodialysis was commenced on the 3rd postoperative day and the sutures were removed on the 8th day. The resected specimen microscopically consisted of uniform and monotonous epithelial cells which had round nuclei (Fig. 4). The tumor cells were arranged in nest-like or canalicular types. The stroma was rich in connective tissue. A diagnosis of monomorphic adenoma was made. There was no evidence of recurrence during one-year follow-up examinations.
Discussion Problems related to surgery in hemodialysis patients are anemia, hyperkalemia, bleeding tendency, retarded immune response and delayed wound healing 2 •3 .4 .9 . Preoperative hemodialysis and blood transfusion were possible, improving these states to some extent. The operation was performed in the usual manner with careful hemostatic treatment. However, the postoperative bleeding occurred in spite of no apparent bleeding tendency on laboratory examination. It is
Table I. Examination data on admission
Blood RBC count WBC count hemoglobin hematocrit platelet total protein BUN creatinine uric acid Na+ K+
CI-
232 x 104 / m m 3 6700/mm 3 7.0 g/dl 20.9% 32.5 x 10 4/mm 3
7.6 g/dl 71 rng/dl 19.6 rng/dl 7.5 mg/dl 138 mEq/1 5.5 mEqfl 97 mEqjl
bleeding time prothrombin time (control) activated partial thromboplastin lime (control)
Urine protein glucose Others HBs antigen: positive (4096 titers) blood pressure: 126/80 mml-Ig ECG: slightly peaked T (hyperkalemia suspected) chest X-ray: normal
3 min 10.8 s 10.9 s 21.8 s 29.9 s
+2 +1
33
ORAL SURGERY AND HEMODIALYSIS Day 1
*
14
7
21
...J..'...J..'-L-1.-1.-L-+....L...J......L....L-L.-L-L-I-....L....L-L.....L~ ~ [ I I I I I I
1-1
Admission
Hemodialysis (4 hrs/day)
'V
'V
Transfusion of packed red cells (200 ml/time)
Removing the sutures
Operation
'V
'V 'V
'V
'V
'"
'V
Discharge
'V
" ""
Antibiotics
[
III
L.-JCET~,-----:CE=-·""IX:---....
Fig. 2. Hospital treatment and course. (CET: cephalotin, 2 g/day, CEX: cephalexin, I g/day.)
suggested that the bleeding tendency in hemodialysis patients is due to platelet dysfunction". The meticulous hemostasis during operation, the physical protection of the wound and the use of local or systemic hemostatic agents are necessary, especially in surgery of hemodialysis patients. In postoperative management, it is most important to monitor hyperkalemia, which happens in sudden cardiac arrest'':". To reduce increasing serum potassium, we used the deionization method by intestinal infusion of ion-exchanger before the resumption of hemodialysis. The hemodialysis was restarted on the postoperative third day and no wound bleeding was seen. The regional
.,' Inn
"'1
l~rJ
140
Fig. 3. The extirpated tumor, approximately 3 x 3 em in size.
heparinization was not used in the Renal Center because of difficulty in accurate control; however, minimal heparinization was used. Usage of antibiotics for hemodialysis patients is selected in order to maintain optimum therapeutic effect without producing a toxic reaction. Cephalexin and cephalotin were chosen according to the descriptions of BENNETT et al,' or OTA 9 . No wound infection or side effect were noticed. Development of monomorphic adenoma in the palate is rare S • 7 •S • The upper lip is the
Fig. 4. Monomorphic adenoma with a mixed appearance of nest-like and canalicular types. (Hematoxylin and Eosin staining, x 125.)
34
SHIBATA, lKEMURA AND MIYAKE
most common site for monomorphic adenoma arising from the minor salivary glands 7 • Uniform cellularity and lack of myxoid or chondroid component are features which separate this tumor from pleomorphic adenoma. It was suggested that the mixed appearance of nest-like and canalicular types be placed into the "other types" of the WHO classification'P.
glands: a reappraisal and report of 9 new cases. J. Oral Surg, 1981: 39: 101-107. 6. LITTLE, J. W. & FALACE, D. A.: Dental man-
agement of the medically compromised patient. 7.
8.
Acknowledgement - The authors wish to thank the staff in the Renal Center of The University Hospital of Occupational and Environmental Health for their collaboration.
9.
ro.
References 1. BENNETT, W. M., SINGER, 1. & COGGINS, C. H.: Guide to drug usage in adult patients with impaired renal function: a supplement. J. Am. Med. Assoc. 1973: 223: 991-997. 2. HAlMov, M., GLABMAN, S., SCHUPAK, E., NEFF, M. & BURROWS, L.: General surgery in patients on maintenance hemodialysis. Ann. Surg. 1974: 179: 863-867. 3. HAMPERS, C. L., BAILEY, G. L., HAGER, E. B., VANDAM, L. D. & MERRILL, J. P.: Major surgery in patients on maintenance hemodialysis. Am. J. Surg. 1968: 115: 747754. 4. HATA, M., REMMERS, A. R., JR., LINDLEY, J. D., SARLES, H. E. & FISH, J. C.: Surgical management of the dialysis patient. Ann. Surg. 1973: 178: 134-137. 5. LEVINE, J., KRUTCHKOFF, D. J. & EISENBERG, E.: Monomorphic adenoma of minor salivary
11.
The C. V. Mosby Co., St. Louis 1980, pp. 110-116. MADER, C. L. & NELSON, J. F.: Monomorphic adenoma of the minor salivary glands. J. Am. Dent. Assoc. 1981: 102: 657-659. MINTS, G. A., ABRAMS, A. M. & MELROSE, R. J.: Monomorphic adenomas of the major and minor salivary glands: report of 21 cases and review of the literature. Oral Surg. 1982: 53: 375-386. OTA, K.: Operative surgery in dialysis patients. Jap. J. Clin. Med. 1980: 38: 2392-2397. THACKRAY, A. C. & SOBIN, L. H.: Histological typing ofsalivary gland tumours. International histological classification of tumours, no. 7. World Health Organization, Geneva 1972, pp.21-22. YAMAGUCHI, A., YAMAGATA, Y., KUSUNOKJ, N. & NARITA, S.: Osteodystrophy in dialysis patients. lap. J. Clin. Med. 1972: 30: 25012506.
Address:
Haruo Shibata Department of Oral Surgery School of Medicine University of Occupational and Environmental Health 1-1, Iseigaoka Yahatanishi-ku Kitakyushu City 807 Japan