Effects of lung protective ventilation on postoperative respiratory parameters in patients undergoing robot-assisted radical prostatectomy

To investigate the effects of lung protective ventilation (LPV) compared to conventional ventilation (CV) on postoperative respiratory parameters in patien     

Synbiotics reduce postoperative infectious complications: a randomized controlled trial in biliary cancer patients undergoing hepatectomy

Background and aims The clinical value of synbiotics in surgical patients remains unclear. The aim of this study was to investigate the effect of synbiotics on intestinal integrity and microflora, as well as on surgical outcome, in patients undergoing high-risk hepatectomy.Methods Fifty-four patients with biliary cancer were randomly allocated to two groups before hepatectomy. One group received postoperative enteral feeding that included synbiotics; the other received enteral feeding only. Lactulose/mannitol (L/M) ratio, serum diamine oxidase (DAO) activity, and fecal microflora and organic acid concentrations were determined. Postoperative infectious complications were recorded.Results Of the 54 patients, 44 completed the trial (21 receiving synbiotics and 23 others as controls). Postoperative changes in L/M ratios and serum DAO activities were identical between the two groups. Numbers of beneficial bacteria increased in the synbiotics group after surgery but decreased in controls. Numbers of harmful microorganisms decreased in the synbiotics group but increased in controls. Total organic acid concentrations increased in the synbiotics group but decreased in controls. Incidence of infectious complications was 19% (4/21) in the synbiotics group and 52% (12/23) in controls (P<0.05). All study patients tolerated surgery (mortality 0%).Conclusions Synbiotics, combined with early enteral nutrition, can reduce postoperative infections. This beneficial effect presumably involves correction of an intestinal microbial imbalance induced by surgical stress.     

肺保护性通气策略对腹腔镜胃癌根治手术老年患者肺氧合功能及术后肺部并发症的影响

目的探讨肺保护性通气策略(lung protective ventilation strategy,LPVS)对腹腔镜胃癌根治手术老年患者肺氧合功能及术后肺部并发症(postoperative pulmonary complications,PPCs)的影响。方法选择接受腹腔镜胃癌根治手术的老年患者115例,男69例,女46例,年龄≥65岁,ASAⅠ—Ⅲ级,随机分为两组:常规容量控制通气组(CV组,n=57)和肺保护性通气组(PV组,n=58)。记录插管后10 min(T_1)、气腹后10 min(T_2)、气腹后60 min(T_3)、气腹结束10 min(T_4)时的气道峰压(Ppeak),计算肺顺应性(Cdyn),并在T_1—T_4时抽取动脉血进行血气分析,计算氧合指数(OI)、肺泡动脉血氧分压差(A-aDO_2);记录术后第2天改良肺部感染评分(mCPIS);记录术后7 d内PPCs发生情况。结果与T_1时比较,T_2时两组Cdyn均明显降低(P0.05);T_3—T_4时PV组Cdyn明显高于CV组(P0.05);T_3—T_4时PV组OI明显高于CV组、A-aDO_2明显低于CV组(P0.05)。术后第2天PV组mCPIS明显低于CV组(P0.05)。术后7 d内PV组PPCs发生率明显低于CV组(P0.05)。结论肺保护性通气策略能明显改善老年腹腔镜胃癌根治手术老年患者的肺氧合功能,降低术后肺部并发症,具有一定的肺保护作用。     

Dose ranging effects of pregabalin on pain in patients undergoing laparoscopic hysterectomy: A randomized,double blinded,placebo controlled,clinical trial

ObjectiveThe study aimed to investigate the preemptive analgesia efficacy of different concentrations (75, 150 and 300 mg) of preemptive pregabalin for the postoperative pain management after laparoscopic hysterectomy.DesignProspective, randomized, placebo-controlled, double-blind study.SettingThe Gynecology and Obstetrics Center of Arash Hospital, Tehran, Iran, from October 2013 to November 2014.PatientsA total of 96 women with American Association of Anesthesiologist (ASA) physical status I and II underwent elective laparoscopic hysterectomy surgery. Patients were then randomly assigned to four groups, of which groups 1–3 (treatment groups; n = 20) received orally pregabalin concentrations of 75 mg, 150 mg, and 300 mg, respectively, for a night before surgery, 30 min before surgery and 6 h after surgery, whereas group 4 (control group; n = 22) received a matching dosage of placebo at the same scheme.MeasurementsVisual Analog Scale (VAS) scores for postoperative pain at rest and on movement at first 24 h after surgery were evaluated as primary outcome. Drug-related side effects were also evaluated as a secondary outcome. Somnolence was evaluated using Ramsay Sedation Scale, while nausea and vomiting were assessed using numeric scores. The data were analyzed using SPSS.Main resultsPreemptive pregabalin in different concentrations provided better pain relief as compared with placebo. Post-hoc test indicated that there was a significant difference among four groups, indicating where the concentration was increased, the pain score decreased as an independent variable of time. The highest concentration of pregabalin (300 mg) revealed higher sedation scores as compared with other groups.ConclusionOur data demonstrated preemptive administration of 75, 150, and 300 mg pregabalin play an important role in reducing postoperative pain after laparoscopic hysterectomy. Comparison of different concentrations and side effects indicates oral administration of 150 mg pregabalin is an effective and safe method for postoperative pain management after laparoscopic hysterectomy.     

中性粒细胞/淋巴细胞比值在肌层浸润性膀胱癌预后评估中的价值

目的探讨术前外周血中性粒细胞与淋巴细胞比值(NLR)是否可以作为肌层浸润性膀胱癌(MIBC)患者术后的预后评价指标。方法回顾性分析2008年1月至2011年12月行膀胱癌根治术的214例MIBC患者的临床资料,根据患者术前外周血NLR大小分为低NLR组(NLR<3,92例)和高NLR组(NLR≥3,122例),比较两组患者的5年生存率并进行预后危险因素分析。结果低NLR组和高NLR组MIBC患者5年生存率分别为70.9%和55.8%(P<0.01)。单因素分析显示,术前NLR、吸烟史、病理T分期、肿瘤分级、围手术期输血、淋巴结转移、淋巴结密度及切缘阳性与MIBC患者预后有关(P<0.05);Cox回归分析证实,NLR是影响MIBC患者预后的独立危险因素(HR=2.142,95%CI:1.212~3.786,P<0.01)。结论术前NLR是影响MIBC患者术后生存时间的独立危险因素,可作为MIBC患者的预后指标。     

液体加温护理在老年患者机器人辅助腹腔镜根治性膀胱切除术中的研究

目的 探讨液体加温护理在老年患者机器人辅助腹腔镜根治性膀胱切除术中的研究。方法 108例拟行达芬奇辅助腹腔镜根治性膀胱切除术的膀胱癌患者,随机分入对照组（n=55）,术中接受变暖毯加温（41℃）,和加温组（n=53）,术中接受液体加温（41℃）。比较两组的手术数据、身体温度、凝血功能指标和术后并发症。结果 与对照组相比,加温组显著减少了术中输血（P=0.028）和更短的住院天数（P<0.05）。在围术期期间（从1至6 h）,加温组体温显著高于对照组。两组患者术前纤维蛋白原（FIB）,白细胞（WBC）、总胆红素（total bilirubin）、术中血糖、术后凝血酶原时间（TT）、血小板（PLT）对比具有显著差异（P均<0.05）。多元回归分析证实,TT是唯一的显著因素,这表明加温组具有更低的TT水平。结论 液体加温护理可以有效减少术中输血和患者住院天数,并维持术中常温,促进术后凝血功能。     

液体加温护理在老年患者机器人辅助腹腔镜根治性膀胱切除术中的研究

目的 探讨液体加温护理在老年患者机器人辅助腹腔镜根治性膀胱切除术中的研究。方法 108例拟行达芬奇辅助腹腔镜根治性膀胱切除术的膀胱癌患者,随机分入对照组（n=55）,术中接受变暖毯加温（41℃）,和加温组（n=53）,术中接受液体加温（41℃）。比较两组的手术数据、身体温度、凝血功能指标和术后并发症。结果 与对照组相比,加温组显著减少了术中输血（P=0.028）和更短的住院天数（P<0.05）。在围术期期间（从1至6 h）,加温组体温显著高于对照组。两组患者术前纤维蛋白原（FIB）,白细胞（WBC）、总胆红素（total bilirubin）、术中血糖、术后凝血酶原时间（TT）、血小板（PLT）对比具有显著差异（P均<0.05）。多元回归分析证实,TT是唯一的显著因素,这表明加温组具有更低的TT水平。结论 液体加温护理可以有效减少术中输血和患者住院天数,并维持术中常温,促进术后凝血功能。     

最佳呼吸末正压肺保护通气策略对腹腔镜下结直肠癌根治术患者氧合功能的影响

目的探讨最佳呼吸末正压(PEEP)肺保护通气策略对腹腔镜下结直肠癌根治术患者围术期氧合功能的影响。方法择期行腹腔镜下结直肠癌根治术患者54例,男36例,女18例,年龄65～85岁,ASAⅡ或Ⅲ级。随机分为两组:传统组(T组)和保护组(P组),每组27例。T组设置V_T 9 ml/kg且无PEEP和肺复张(RMs);P组通过肺动态顺应性(Cdyn)PEEP滴定确定患者最佳PEEP值,设置低V_T 7 ml/kg联合最佳PEEP,每30分钟RMs一次。于麻醉诱导后10 min(T_1)、每次RMs后30 min(T_2、T_3、T_4)记录Cdyn及气道平台压(Pplat)、并在T_1—T_4、拔管后30 min(T_5)及术后第3天(T_6)采集动脉血样本,计算氧合指数(OI),记录术前和T_6时的改良临床肺部感染评分(mCPIS)。结果与T组比较,T_3、T_4时P组Cdyn明显升高(P0.05),T_4—T_6时P组OI明显升高(P0.05),T_6时P组mCPIS明显降低(P0.05)。结论最佳PEEP联合低V_T和RMs的肺保护通气策略可改善腹腔镜结直肠癌根治术患者围术期氧合,降低mCPIS。     

A phase II trial of neoadjuvant erlotinib in patients with muscle‐invasive bladder cancer undergoing radical cystectomy: clinical and pathological results

Study Type – Therapy (cohort)
Level of Evidence 2b

OBJECTIVE

To evaluate the clinicopathological efficacy of neoadjuvant erlotinib (an epidermal growth factor receptor, EGFR, inhibitor) for invasive bladder cancer in patients undergoing radical cystectomy (RC) as despite definitive surgical therapy, only half of patients undergoing RC will have long‐term disease‐free survival, and effective adjunctive therapies, especially using agents with lower toxicity, would be a significant advance in the treatment of invasive bladder cancer.

PATIENTS AND METHODS

The primary endpoint of this phase II trial is to determine the effect of neoadjuvant erlotinib (150 mg once daily for 4 weeks) before RC on the pathological complete response rate (pT0 rate) in RC specimens. In addition, the safety of therapy with erlotinib was also evaluated. Patients selected for study included those with histologically confirmed muscle‐invasive bladder cancer who had undergone initial transurethral resection.

RESULTS

In all, 20 patients with clinical stage T2 disease had neoadjuvant erlotinib therapy followed by RC. On surgical pathology, five patients (25%) were pT0; in addition, seven (35%) were clinically down‐staged (≤pT1) and 15 (75%) had organ‐confined disease at surgical pathology. At a mean follow‐up of 24.8 months, 10 patients remain alive and with no evidence of disease, four with organ‐confined disease had progression and nine died, including six from disease and three from other causes. Erlotinib was tolerated in all patients, with drug rash being the most common side‐effect, in 15 patients (75%). Interestingly, all pT0 and pTis/T1 patients had a rash.

CONCLUSIONS

The EGFR inhibitor erlotinib, when administered in the neoadjuvant setting, can have beneficial effects in terms of surgical pathology and short‐term clinical outcomes in patients undergoing RC for invasive bladder cancer. Analyses are underway to examine the molecular correlates of the apparent clinical effect of neoadjuvant therapy in these patients.     

Multi-institutional study of symptomatic deep venous thrombosis and pulmonary embolism in prostate cancer patients undergoing laparoscopic or robot-assisted laparoscopic radical prostatectomy

OBJECTIVES: The true incidence of symptomatic deep venous thrombosis (DVT) and pulmonary embolism (PE) in patients undergoing laparoscopic radical prostatectomy is unknown. Our aim was to determine the incidence of symptomatic DVT and PE and the risk factors for these complications. METHODS: Fourteen surgeons from 13 referral institutions from both Europe and the United States provided retrospective data for all 5951 patients treated with laparoscopic radical prostatectomy (LRP), with or without robotic assistance, since the start of their institution's experience. Symptomatic DVT and PE within 90 d of surgery were regarded as venous thromboembolism (VTE). DVT was diagnosed mostly by Doppler ultrasound or contrast venography and PE by lung ventilation/perfusion scan or chest computed tomography or both. Statistical analysis included evaluation of incidence of symptomatic DVT and PE and risk factors as determined by exact methods and logistic regression. RESULTS: Of 5951 patients in the study, 31 developed symptomatic VTE (0.5%; 95% confidence interval [CI], 0.4%, 0.7%). Among patients with an event, 22 (71%) had DVT only, 4 had PE without identified DVT, and 5 had both. Two patients died of PE. Prior DVT (odds ratio [OR]=13.5; 95%CI, 1.4, 61.3), current tobacco smoking (OR=2.8; 95%CI, 1.0, 7.3), larger prostate volume (OR=1.18; 95%CI, 1.09, 1.28), patient re-exploration (OR=20.6; 95%CI, 6.6, 54.0), longer operative time (OR=1.05; 95%CI, 1.02, 1.09), and longer hospital stay (OR=1.05; 95%CI, 1.01, 1.09) were associated with VTE in univariate analysis. Neoadjuvant therapy, body mass index, surgical experience, surgical approach, pathologic stage, perioperative transfusion, and heparin administration were not significant predictors. CONCLUSIONS: The incidence of symptomatic VTE after LRP is low. These data do not support the administration of prophylactic heparin to all patients undergoing LRP, especially those without risk factors for VTE.     

Fibrinogen prophylaxis for reducing perioperative bleeding in patients undergoing radical cystectomy: A double-blind placebo-controlled randomized trial

ObjectiveExcessive bleeding is an important complication of radical cystectomy. We aimed to assess whether preoperative administration of fibrinogen decreases perioperative bleeding and improves the outcome of radical cystectomy.DesignDouble-blinded randomized trial with two parallel arms.SettingThe study was conducted in the department of surgery at a teaching hospital affiliated with a University of Medical Sciences.PatientsIn total, 70 men undergoing radical cystectomy were randomized to fibrinogen (n = 35) and placebo-control groups. Mean (SD) age was 64.7 (7.4) years.InterventionsThe intervention group received 2 g fibrinogen concentrate diluted in 100 ml distilled water, and the control group received 100 ml normal saline; both intravenously 15 ̶ 30 min before the start of the surgery.Outcome measuresThe primary outcome was the amount of perioperative blood loss. The secondary outcomes were hemodynamic features and vital signs.Main resultsFibrinogen significantly decreased the volume of blood loss (p < 0.001) and the total number of transfused packed-cell units per group (38 vs. 115 units); and compensated the decrease of HCO3 (p = 0.030), the mean arterial pressure (p < 0.001), hemoglobin O2 saturation (p = 0.001), heart rate (p < 0.001), and temperature (p < 0.001) throughout the surgery compared with the placebo. Patients in the fibrinogen group had shorter Intensive Care Unit (p = 0.001) and hospital (p < 0.001) stay. We did not find any adverse reaction in our patients receiving fibrinogen concentrate.ConclusionFibrinogen concentrate reduces perioperative bleeding and the need for blood transfusion in radical cystectomy. It improves the outcomes of the surgery and decreases patients' length of stay in the healthcare system following radical cystectomy.RegistrationIranian Registry of Clinical Trials (IRCT) http://www.irct.ir/, reference number: IRCT20191013045091N1.Ethics codeShahid Beheshti University of Medical Sciences, reference number: IR.SBMU.RETECH.REC.1398.033.     

肺保护性通气策略对胸腔镜下肺癌根治术患者免疫功能的影响

目的观察肺保护性通气策略对胸腔镜下肺癌根治术患者免疫功能的影响。方法择期于全麻下行胸腔镜下肺癌根治术患者60例,男47例,女13例,年龄35～64岁,BMI 18～29kg/m2,ASAⅠ或Ⅱ级,随机分为两组:保护性机械通气组(P组)和传统机械通气组(C组),每组30例。两组均采用容量控制通气模式,保护性机械通气参数:双肺通气时VT8ml/kg,RR 12～14次/分;单肺通气时VT6ml/kg,RR14～16次/分,单肺通气期间设定PEEP 5cmH2O。分别于麻醉诱导前(T0)、术毕(T1)、术后24h(T2)、术后72h(T3)采集外周静脉血样,采用流式细胞仪检测外周血T淋巴细胞亚群(CD3+、CD4~+、CD8~+)、NK细胞数量,计算CD4~+/CD8~+比值。结果与T0时比较,T1和T2时两组CD3+、CD4~+和NK细胞明显减少,CD4~+/CD8~+明显降低(P0.05)。与P组比较,T1和T2时C组CD3+、CD4~+和NK细胞明显减少,CD4~+/CD8~+明显降低(P0.05)。与T0时比较,T3时C组CD3+、CD4~+和NK细胞明显减少,CD4~+/CD8~+明显降低(P0.05),P组CD3+、CD4~+、CD4~+/CD8~+和NK细胞差异无统计学意义。结论与传统机械通气相比,肺保护性通气策略可减轻胸腔镜下肺癌根治术患者围术期T淋巴细胞亚群和NK细胞水平下降的程度,减轻术后细胞免疫功能的抑制,细胞免疫功能恢复更快。