Seokha Yoo

Helical CT of postoperative patients with gastric carcinoma: value in evaluating surgical complications and tumor recurrence.

Background: We assessed computed tomographic (CT) features of postoperative complications and recurrent tumors in gastric cancer patients who underwent radical surgery.Methods: We performed a retrospective study of 397 patients who had undergone radical surgery for the treatment of gastric carcinoma and underwent postoperative CT in our institution over a 2-year period. Patients were assigned to one of two groups: group A consisted of 47 patients who underwent CT for complications in the early postoperative period, and group B consisted of 355 patients who underwent CT for evidence of tumor recurrence during the follow-up period. We classified recurrent tumors into four categories: local recurrence, lymph node metastasis, peritoneal seeding, and remote metastasis.Results: In group A, localized fluid collections or abscesses in the surgical bed were found in 38 patients (81%) and usually involved the left subphrenic area (74%) or the superior recess of the lesser sac (47%). In group B, recurrent tumors were found in 196 patients (55%). Among these, lymph node metastasis was the most common pattern (52%), followed by peritoneal seeding (44%), local recurrence (40%), and remote metastasis (37%).Conclusion: CT after radical surgery for the treatment of gastric carcinoma frequently shows postoperative complications or tumor recurrence. Familiarity with the common postoperative complications and patterns of the tumor recurrence is a prerequisite to accurate interpretation of CT findings in these patients.

Association Between Perioperative Hyperglycemia or Glucose Variability and Postoperative Acute Kidney Injury After Liver Transplantation: A Retrospective Observational Study.

BACKGROUND: Glucose control can be difficult in the intraoperative and immediate postoperative period of liver transplantation. Hyperglycemia and glucose variability have been associated with acute kidney injury (AKI) in critically ill patients. We performed a retrospective study to test the hypothesis that perioperative glucose levels represented by time-weighted average glucose levels and glucose variability are independently associated with the incidence of postoperative AKI in patients undergoing liver transplantation. METHODS: On the basis of blood glucose levels during liver transplantation and the initial 48 hours postoperatively, adult liver transplant recipients were classified into 4 groups according to their time-weighted average glucose: normoglycemia (80–200 mg/dL), mild hyperglycemia (200–250 mg/dL), moderate hyperglycemia (250–300 mg/dL), and severe hyperglycemia (>300 mg/dL) group. Patients were also classified into quartiles depending on their glucose variability, defined as the standard deviation of glucose measurements. The primary outcome was postoperative AKI. RESULTS: AKI after liver transplantation was more common in the patients with greater perioperative glucose variability (first versus third quartile; OR, 2.47 [95%CI, 1.22–5.00], P = .012; first versus fourth quartile; OR, 2.16 [95% CI, 1.05–4.42], P = .035). CONCLUSIONS: Our study suggests that increased perioperative glucose variability, but not hyperglycemia, is independently associated with increased risk of postoperative AKI in liver transplantation recipients.

Real-time compound ultrasonography: pictorial review of technology and the preliminary experience in clinical application of the abdomen

The purposes of this essay are to illustrate the technology overview and theoretical benefits of real-time compound ultrasonography (US) and to present our preliminary clinical experience in the evaluation of normal and diseased abdomens. The application of compounding principles to real-time US and its recent reintroduction into mainstream commercial systems have offered new opportunities for its clinical application to the routine examination of the abdomen. In our early preliminary experience, this technique effectively suppressed many of the US artifacts, better depicted the margin or boundary of the lesion, and increased contrast resolution or lesion conspicuity. Therefore, we believe that real-time compound US is a promising technique that may enhance the diagnostic confidence of the examination in the evaluation of normal and diseased abdomens.

Pharmacological interventions for protecting renal function after cardiac surgery: a Bayesian network meta-analysis of comparative effectiveness.

Many drugs have been investigated as potentially protective of renal function after cardiac surgery. However, their comparative effectiveness has not been established. We performed an arm‐based hierarchical Bayesian network meta‐analysis including 95 randomised controlled trials with 28,833 participants, which allowed us to compare some agents not previously compared directly. Renal outcomes, including: the incidence of postoperative renal dysfunction and haemodialysis; serum creatinine level at 24 hours postoperatively; all‐cause mortality; and length of hospital and ICU stay, were compared. Exploratory meta‐regression was conducted for potential effect modifiers. A random effects model was selected according to the evaluation of model fit by deviance information criteria. Atrial natriuretic peptide (odds ratio (95%CrI) 0.28 (0.17–0.48); moderate‐quality evidence), B‐type natriuretic peptide, dexmedetomidine, levosimendan and N‐acetyl cysteine significantly decreased the rate of postoperative renal dysfunction compared with placebo. Atrial natriuretic peptide (OR (95%CrI) 0.24 (0.10–0.58); low‐quality evidence), B‐type natriuretic peptide, and dexamethasone significantly decreased the need for haemodialysis. Levosimendan significantly decreased mortality, OR (95%CrI) 0.49 (0.27–0.91); low‐quality evidence). The benefit of atrial natriuretic peptide was still apparent when baseline renal function was normal. None of the potential effect modifiers were significantly correlated with our renal outcomes. Atrial natriuretic peptide was ranked best regarding renal dysfunction, haemodialysis and length of hospital stay. Levosimendan was ranked best regarding mortality and ICU stay. However, our results should be interpreted cautiously given the assumptions made about transitivity and consistency.

Anesthetic management of an 8-month-old infant with osteogenesis imperfecta undergoing liver transplantation: a case report.

Anesthetic management of pediatric liver transplantation in a patient with osteogenesis imperfecta (OI) requires tough decisions and comprehensive considerations of the cascade of effects that may arise and the required monitoring. Total intravenous anesthesia (TIVA) with propofol and remifentanil was chosen as the main anesthetic strategy. Malignant hyperthermia (MH), skeletal fragility, anhepatic phase during liver transplantation, uncertainties of TIVA in children, and propofol infusion syndrome were considered and monitored. There were no adverse events during the operation. Despite meticulous precautions with regard to the risk of MH, there was an episode of high fever (40℃) in the ICU a few hours after the operation, which was initially feared as MH. Fortunately, MH was ruled out as the fever subsided soon after hydration and antipyretics were given. Although the delivery of supportive care and the administration of dantrolene are the core principles in the management of MH, perioperative fever does not always mean a MH in patients at risk for MH, and other common causes of fever should also be considered.

Association of nefopam use with postoperative nausea and vomiting in gynecological patients receiving prophylactic ramosetron: A retrospective study

Background Postoperative nausea and vomiting (PONV) is a common adverse effect of opioid-based intravenous patient-controlled analgesia (IV PCA). Nefopam has been considered as a good candidate for inclusion in multimodal analgesia because of its opioid sparing effect, but it can be emetic. This study aims to examine whether the use of nefopam combined with fentanyl in IV PCA was associated with the higher incidence of PONV in patients receiving prophylactic ramosetron after gynecological surgery. Methods Data from 296 patients who underwent gynecological surgery were retrospectively reviewed. The patients received IV PCA containing either fentanyl 1500 μg and ketorolac 90 mg (Group K) or fentanyl 1500 μg and nefopam 80 mg (Group N). All patients in both groups received 0.3 mg of ramosetron at the end of surgery. The primary outcome measure was the incidence of PONV during the 3-day postoperative period. Results No difference was observed in the incidence of PONV during the 3-day postoperative period between the two groups. However, the incidence of nausea on postoperative day 2 was significantly higher in Group N (10.3%) than in Group K (2.8%) (P = 0.016). Multivariable logistic regression analysis showed that the use of nefopam was not associated with a higher incidence of PONV (adjusted odds ratio, 1.616; 95% confidence interval, 0.952–2.743, P = 0.076). There were no differences in postoperative pain scores between the two groups. Conclusion The combined use of nefopam with fentanyl in IV PCA was not associated with the higher incidence of PONV compared with the use of ketorolac and fentanyl combination in patients who received ramosetron as PONV prophylactic agent. However, prospective trials are required for a confirmative conclusion.

Association between remifentanil and acute kidney injury

We would like to discuss the methodological issues of the interesting study by Sakai et al. [1]. To prove an association and causal relationship between a potential predictor and an outcome variable, Hill’s criteria should be met [2, 3]. The criteria include strength, consistency, specificity, temporality, biological gradient (dose–response relationship), biological plausibility, coherence, experiment, and analogy. For example, as the remifentanil could result in vasodilation and increase in renal perfusion via suppression of vasopressin, there is a physiologic plausibility for remifentanil to decrease the risk of acute kidney injury (AKI). However, a significant association was not found, possibly due to small sample size. Regarding the dose–response relationship, the author’s analysis seems to be insufficient. The remifentanil administration was evaluated only as a binomial variable in the multivariate analysis. The distribution of three different dose categories was shown in Fig. 2. The dose–response relationship could be analyzed by adding these three dose categories to the multivariate analysis, Or, if the data on the remifentanil dose were available as a continuous variable, the dose of remifentanil as a continuous variable could be added to the multivariate analysis in their study or in a further prospective trial.

Comparison between general, spinal, epidural, and combined spinal-epidural anesthesia for caesarean delivery: a network meta-analysis

BACKGROUND This study is a network meta-analysis to compare maternal and fetal outcomes associated with four different anesthetic techniques for cesarean delivery. METHODS An arm-based, random-effects frequentist network meta-analysis was performed. A random effect model was selected considering deviance information criteria. Randomized trials reporting the following outcomes were included: Apgar score at 1- or 5-min; umbilical arterial and venous pH; umbilical arterial pH <7.2; and neonatal score at 2-4 hours. Loop-specific heterogeneity was evaluated by risk of odds ratio and τ2. Quality of evidence was assessed using the GRADE approach. RESULTS Data from 46 randomized trials including 3689 women contributed to the study. There were significant differences in Apgar score ≤6 at 1 min between spinal versus general anesthesia (odds ratio 0.27, 95% confidence interval [CI] 0.13 to 0.55: moderate quality evidence) and Apgar scores at 1- and 5-min, favoring spinal anesthesia. Umbilical venous pH associated with epidural anesthesia was significantly higher than that with general anesthesia (mean difference 0.010, 95% CI 0.001 to 0.020: moderate quality evidence) or spinal anesthesia. Spinal anesthesia was ranked best for Apgar score ≤6 at 1-min (SUCRA=89.8), Apgar score at 1-min (SUCRA=80.4) and 5-min (SUCRA=90.5). Epidural anesthesia was ranked highest for umbilical venous pH (SUCRA=87.4) and neonatal score (SUCRA=79.3). CONCLUSIONS Spinal and epidural anesthesia were ranked high regarding Apgar scores and epidural anesthesia was ranked high regarding umbilical venous pH, but the results were based on small heterogeneous studies with high or unclear risks of bias.

Postoperative pulmonary edema in a patient with POEMS syndrome

POEMS syndrome is a rare multisystemic disorder. It is characterized by polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes [1]. Because it is also associated with pulmonary dysfunction, a patient with POEMS syndrome may have postoperative respiratory difficulty. In this report, we describe a patient with this syndrome who underwent surgery under general anesthesia and failed ventilator weaning due to pulmonary edema. A 58-year-old male (height 163 cm; weight 48.5 kg) with POEMS syndrome was diagnosed with rectal cancer and planned to undergo low anterior resection. He displayed weakness and paresthesia of the right arm and both legs, skin lesions such as hypertrichosis, scleroderma, and thickened extremities, and orthopnea, which had developed 2 weeks previously. Chest radiography showed bilateral mild pleural effusion. A pulmonary function test (PFT) revealed a mild restrictive pattern. Arterial blood gas analysis (ABGA) in room air was pH 7.398, partial carbon dioxide pressure (PaCO2) was 27.8 mmHg, partial oxygen pressure (PaO2) was 91.4 mmHg, and bicarbonate (HCO3-) concentration was 16.8 mEq/L. On echocardiogram, the estimated pulmonary artery systolic pressure (PASP) was 40 mmHg, and the other values were normal. Other laboratory data and vital signs were within normal limits. Anesthesia was induced with propofol 120 mg, fentanyl 100 µg, and rocuronium 50 mg. A size 7.5, cuffed tube was used for intubation. A radial arterial line and a central venous catheter were placed in the right internal jugular vein. Anesthesia was maintained with sevoflurane in air/O2. Thirty minutes into the surgery, systolic blood pressure (BP) decreased to 70-80 mmHg. Continuous infusion of dopamine and norepinephrine was initiated. An additional 5 mg of rocuronium were injected four times. The last ABGA intraoperatively was pH 7.263, PaCO2 40.3 mmHg, PaO2 96.0 mmHg, HCO3- 17.8 mEq/L under FiO2 0.5. The surgery duration was 190 min and the anesthesia time was 270 min. The total amount of administered fluid was 1500 ml of crystalloid and 300 ml of colloid solution. One and a half units of packed RBCs were transfused. Estimated blood loss was 400 ml, and urine output was 150 ml. Postoperatively, the patient was transferred to the intensive care unit (ICU). On arrival at the ICU, his vital signs were BP, 132/58 mmHg; heart rate, 70 beats/min; and oxygen saturation, 100%. Continuous infusion of dopamine 5 µg/kg/min and norepinephrine 0.01 µg/kg/min was maintained. No additional neuromuscular blocking agents were injected. On the second postoperative day (POD), desaturation was not detected after self-respiration with O2 6 L for 3 h, and the patient was extubated. Six hours after extubation, oxygen saturation decreased and the dyspnea appeared. The patient was reintubated and mechanical ventilation was initiated. Thoracic radiography revealed diffuse haziness and parahilar consolidation in both lung fields (Fig. 1). On the seventh POD, the patient was extubated again but was reintubated due to desaturation and dyspnea. On the 10th POD, the haziness and consolidation on simple X-ray decreased, but the third extubation attempt on the 19th POD also failed. Finally on the 27th POD, he was weaned from the ventilator successfully. Four days after extubation, he was transferred to the ward. Fig. 1 Chest radiography on the second postoperative day. Various respiratory manifestations are seen in patients with POEMS syndrome. Relatively common manifestations are pleural effusion, pulmonary hypertension, restrictive lung disease, and a reduced diffusion capacity of carbon dioxide. Pulmonary tumors and phrenic neuropathy are less common [2,3]. Weakness of respiratory muscles also contributes to the pulmonary symptoms. The patient in this report had several pulmonary manifestations-muscle weakness, pleural effusion, marginally high PASP, and restrictive pattern on PFT. Hence, in case he required postoperative respiratory support, we prepared the ICU before starting the surgery. Ifuku et al. [4] reported that POEMS syndrome patients had a higher sensitivity to vecuronium and that the effects of vecuronium persisted longer. Therefore, during the anesthesia of POEMS syndrome patients, neuromuscular blocking agents should be carefully used with neuromuscular monitoring, or should be avoided when possible. In this case, we used rocuronium, 50 mg during induction and four doses of 5 mg each during surgery. We attempted to use the lowest possible dose of muscle relaxants, but because self-respiration was detected and the surgeon reported abdominal muscle tension, we used a small amount of additional rocuronium. During induction of anesthesia, we checked the train of four (TOF) using nerve stimulators (Ministim® MS-IV, Life-Tech, Williston, Vermont, USA and E-NMT-OO, GE Healthcare Finland Oy, Helsinki, Finland) but the twitching was not detected. It is thought that severe subcutaneous edema and skin thickening blocked transmission of electric stimulation, which prevented observation of proper muscle contraction. Tschida et al. [5] reported that in patients with edematous and dry skin, TOF responses were inappropriate and did not correlate with the clinical assessment. There were no significant findings on preoperative cardiac evaluations. However, after the surgery began, persistent hypotension was observed and inotropics were infused continuously. We infused 1500 ml of crystalloid and 300 ml of colloid to maintain blood pressure, and large amounts of fluid and blood were infused in the ICU. Such fluid infusion could aggravate pulmonary edema. After the second failed attempt at extubation, pulmonology and neurology specialists were contacted to determine the cause of failure. Nerve conduction studies and an electromyogram could not be performed due to severe pitting edema, but the neurologist suggested that the dyspnea was not due to a neurological problem since no focal neurologic deficits were observed. In addition, the 6 kg weight gain after ICU admission, severe pitting edema, and chest radiography suggested that pleural effusion and pulmonary edema were the main causes of the failure. In the ICU, diuretics were used to manage the pulmonary edema, but it was difficult to balance input and output because the blood pressure dropped easily with a small volume deficit. Ventilator weaning was finally accomplished on the 27th POD. In summary, because the POEMS syndrome may be accompanied by pulmonary dysfunction leading to postoperative respiratory distress, fluids should be managed judiciously and neuromuscular blocking agents should be used cautiously in anesthetic management.