Yoshihiko Kishi

The morbidity, time course and predictive factors for persistent post-thoracotomy pain.

After thoracotomy, patients often suffer from a persistent pain syndrome called post‐thoracotomy pain. To elucidate morbidity, time course, and predictive factors for this syndrome, we analyzed follow‐up data for 85 post‐thoracotomy patients. We used a four‐point scale to assess pain: none, slight, moderate and severe. Of 85 patients, 50 reported pain (39 slight, 11 moderate) one day after surgery. A year after surgery, the patients were polled using a simple questionnaire received by the mail. Sixty patients reported persistent pain (34 slight, 14 moderate, 12 severe) a month after surgery, and 35 patients reported persistent pain (33 slight, two moderate) around the time of the poll (1 year after surgery). Although pain deterioration was observed in 40% (34/85) of patients during month 1 after surgery, pain alleviation was seen in 48% (41/85) of patients during months 2–12. Stepwise regression analysis revealed that female gender and pain at postoperative day 1 were predictive for persistent pain both 1 month and 1 year after thoracotomy. Among 35 patients with persistent pain 1 year after surgery, 24 cases reported paresthesia–dysesthesia, and 14 cases reported hypoesthesia. The present data thus suggests that persistent pain is common and often severe 1 month after surgery but is alleviated after 1 year. Clinical time course and symptoms indicate that nerve impairment rather than simple nociceptive impact may be involved in this syndrome.

Determination of the duration of Preoperative smoking cessation to improve wound healing after head and neck surgery

Background: Preoperative smoking cessation has been suggested to be effective in reducing various postoperative complications. However, the optimal duration of preoperative smoking cessation for reducing wound complications is unclear. Methods: One hundred eighty-eight consecutive patients who underwent reconstructive head and neck surgery at the authors’ institution were included in this retrospective study. Information on preoperative smoking habits was obtained from the patients’ medical records. Smokers were defined as having smoked within 7 days before surgery. Late, intermediate, and early quitters were defined as patients whose duration of abstinence from smoking was 8–21, 22–42, and 43 days or longer before the operation, respectively. Patients who required postoperative debridement, resuture, or reconstruction of their flap before hospital discharge were defined as having had impaired wound healing. Results: The incidences (95% confidence intervals) of impaired wound healing among the late, intermediate, and early quitters and nonsmokers were 67.6% (52–83%), 55.0% (33–77%), 59.1% (47–71%), and 47.5% (32–63%), respectively, and the incidence of impaired wound healing was significantly lower among the intermediate quitters, early quitters, and nonsmokers than among the smokers (85.7% [73–97%]). After controlling for sex, age, American Society of Anesthesiologists physical status, operation time, history of diabetes mellitus, chemotherapy, radiation therapy, and the type of flap, the odds ratios (95% confidence intervals) for development of impaired wound healing in the late, intermediate, early quitters, and nonsmokers were 0.31 (0.08–1.24), 0.17 (0.04–0.75), 0.17 (0.05–0.60), and 0.11 (0.03–0.51), respectively, compared with the smokers. Conclusions: Preoperative smoking abstinence of longer than 3 weeks reduces the incidence of impaired wound healing among patients who have undergone reconstructive head and neck surgery.

Fluid management and postoperative respiratory disturbances in patients with transthoracic esophagectomy for carcinoma

STUDY OBJECTIVE To investigate whether intraoperative fluid management contributes to postoperative respiratory disturbances in esophagectomy for carcinoma. DESIGN Retrospective study. SETTING Operating room and postanesthetic care unit of the cancer center. PATIENTS From 1997 to 2000, 112 ASA physical status I, II, and III patients with primary carcinoma of the esophagus undergoing transthoracic esophagectomy. INTERVENTIONS AND MEASUREMENTS As of 1998, we altered fluid management during esophagectomy to save intraoperative fluid administration. Then, we investigated postoperative respiratory disturbances after esophagectomy in the period from 1998 to 2000 (late period) compared with the period from 1997 to 1998 (early period). We also investigated the relationship between perioperative risk factors and postoperative respiratory disturbances. The need for frequent (>10) bronchoscopic suctioning of sputum during postoperative period, the need for tracheostomy, and failure in the removal of endotracheal tube (ETT) (extubation) on the first postoperative day (1 POD) were investigated for respiratory disturbances after surgery. MAIN RESULTS Intraoperative volume balance decreased more so in the late period compared with early period (p < 0.0,001). The need for tracheostomy, bronchoscopic suctioning, and extubation failure on 1 POD were more frequent in the early period than in the late period (p = 0.0083, p = 0.0319, and p = 0.0024, respectively). The hospital recovery period after surgery was shortened during the late period (p = 0.032). Intraoperative volume balance affected the need for tracheostomy and frequent bronchoscopy postoperatively. CONCLUSIONS Careful intraoperative fluid administration may decrease postoperative respiratory disturbances.

Intravenous anesthetic, propofol inhibits invasion of cancer cells.

Intravenous anesthetic, propofol (2,6-diisopropylphenol), is extensively used for general anesthesia without knowing the effects on cancer. We found here that clinically relevant concentrations of propofol (1-5 microg/ml) decreased the invasion ability of human cancer cells (HeLa, HT1080, HOS and RPMI-7951). In the HeLa cells treated with propofol, formation of actin stress fibers as well as focal adhesion were inhibited, and propofol had little effect on the invasion ability of the HeLa cells with active Rho A (Val(14)-Rho A). In addition, continuous infusion of propofol inhibited pulmonary metastasis of murine osteosarcoma (LM 8) cells in mice. These results suggest that propofol inhibits the invasion ability of cancer cells by modulating Rho A and this agent might be an ideal anesthetic for cancer surgery.

Infiltration anesthetic lidocaine inhibits cancer cell invasion by modulating ectodomain shedding of heparin-binding epidermal growth factor-like growth factor (HB-EGF)

Although the mechanism is unknown, infiltration anesthetics are believed to have membrane‐stabilizing action. We report here that such a most commonly used anesthetic, lidocaine, effectively inhibited the invasive ability of human cancer (HT1080, HOS, and RPMI‐7951) cells at concentrations used in surgical operations (5–20 mM). Ectodomain shedding of heparin‐binding epidermal growth factor‐like growth factor (HB‐EGF) from the cell surface plays an important role in invasion by HT1080 cells. Lidocaine reduced the invasion ability of these cells by partly inhibiting the shedding of HB‐EGF from the cell surface and modulation of intracellular Ca2+ concentration contributed to this action. The anesthetic action of lidocaine (sodium channel blocking ability) did not contribute to this anti‐invasive action. In addition, lidocaine (5–30 mM), infiltrated around the inoculation site, inhibited pulmonary metastases of murine osteosarcoma (LM 8) cells in vivo. These data point to previously unrecognized beneficial actions of lidocaine and suggest that lidocaine might be an ideal infiltration anesthetic for surgical cancer operations.

The Effects of Preanesthetic Oral Clonidine on Total Requirement of Propofol for General Anesthesia

STUDY OBJECTIVE To investigate the effects of preanesthetic oral clonidine on total propofol requirement for uniform minor surgery (breast conservative surgery: breast cancer removal with axillary lymph node dissection), and to compare the action of clonidine with that of preanesthetic oral diazepam, a commonly used benzodiazepine. DESIGN Randomized double-blinded study. SETTING Operating room ASA physical status I and II room and recovery room of the cancer center. PATIENTS 80 breast cancer patients scheduled for surgery. INTERVENTIONS Patients were randomized to one of four treatment groups (placebo, clonidine 75 micrograms, or 150 micrograms of clonidine, or 10 mg of diazepam were orally administered 60 min before induction of anesthesia); n = 20 per group. After evaluating the sedation and anxiety levels of patients using a visual analog scale, anesthesia was induced with propofol (1.5 mg/kg), and maintained with oxygen (O2): nitrous oxide (N2O) (30:70) with a continuous infusion of propofol. The propofol infusion was started at 10 mg/kg/h for 10 minutes, then decreased to 8 mg/kg/h, and 6 mg/kg/h thereafter, and the rate of infusion was adjusted to obtain adequate anesthesia (maintaining hemodynamic parameters within 20% of that prior to premedication). Fentanyl 0.2 mg (each 0.1 mg was given for intubation and axillary lymph node dissection, respectively) was administered. MEASUREMENTS AND MAIN RESULTS Preanesthetic oral clonidine (150 micrograms) and diazepam (10 mg) induced anxiolysis without sedation. The total requirement (the mean infusion rates) of propofol in placebo, clonidine 75 micrograms, clonidine 150 micrograms, and 10 mg of diazepam groups were 841 +/- 70 (9.0 +/- 0.3), 720 +/- 63 (7.1 +/- 0.4), 491 +/- 39 (5.6 +/- 0.2), and 829 +/- 77 mg (7.9 +/- 0.4 mg/kg/h), respectively. The cost of propofol in these groups was

Dopamine D2 receptor Taq IA polymorphism is associated with postoperative nausea and vomiting

51.0 +/- 3.8,

Epinephrine inhibits invasion of oral squamous carcinoma cells by modulating intracellular cAMP.

45.5 +/- 3.2,

Continuous epidural, not intravenous, droperidol inhibits pruritus, nausea, and vomiting during epidural morphine analgesia

33.5 +/- 2.3, and

Midazolam premedication reduces propofol requirements for sedation during regional anesthesia

50.5 +/- 4.4, respectively. CONCLUSIONS Preanesthetic oral clonidine (150 micrograms) but not diazepam (10 mg) reduced the total requirement of propofol while stabilizing hemodynamic parameters. In addition, 150 micrograms of oral clonidine attenuates the hemodynamic responses associated with tracheal intubation.