The key to success in blocking lateral cutaneous branches with re-modified thoracoabdominal nerves block through perichondrial approach: a newly discovered space between the endothoracic fascia, diaphragm, and costodiaphragmatic recess.

PURPOSE: This study aimed to determine whether the administration of a modified thoracoabdominal nerves block through perichondrial approach (M-TAPA) could result in the blockade of the lateral cutaneous branches. This study focused on a newly discovered anatomical space/plane adjacent to the M-TAPA plane, which we termed "space between the endothoracic fascia, diaphragm, and costodiaphragmatic recess: SEDIC." METHODS: Thirteen sides of nine formalin-embalmed cadavers were macroscopically dissected to investigate the anatomical spaces related to the effects of M-TAPA. Furthermore, ten adult volunteers were administered 20 mL of 0.2% ropivacaine into the abdominal plane (corresponding to the M-TAPA plane) and the SEDIC, and a pinprick test was performed 1 h after the injection. RESULTS: Cadaver macrodissection revealed the presence of the SEDIC adjacent to the M-TAPA plane. The SEDIC was completely spatially isolated from the M-TAPA plane by the presence of costal cartilage and/or tendinous structures. In the volunteer study, the administration of local anesthetics into the SEDIC effectively blocked the lateral cutaneous branches of T8-T12, in addition to the anterior branches. CONCLUSION: Our study revealed the presence of the SEDIC adjacent to the M-TAPA plane. Administration of local anesthetics into the SEDIC, named re-modified TAPA, may have the potential to enhance the analgesic effect in the abdominal region.

Persistent pneumothorax after laparoscopic appendectomy in a patient who had undergone radical esophagectomy 5 years before: possible relationship with vulnerability of the hiatus after esophagectomy: a case report.

Postoperative pneumothorax is a well-known but relatively rare complication after laparoscopic surgery. Herein, we report a case of persistent pneumothorax after laparoscopic appendectomy. A 57-year-old male, with a history of minimally invasive esophagectomy and intrathoracic gastric tube reconstruction 5 years before, underwent a laparoscopic appendectomy. A chest X-ray taken on postoperative Day 1 revealed the development of the right pneumothorax, which took more than 3 days to resolve spontaneously. Although the mechanism of postoperative pneumothorax was unclear, it seemed likely that the air that had replaced carbon dioxide in the peritoneal cavity migrated into the thoracic cavity through the esophageal hiatus, which was not covered by the peritoneum or pleura after surgical resection. The present case, together with our previous similar case, suggests that a history of esophageal cancer surgery per se increases the risk of pneumothorax after laparoscopic surgery, probably regardless of when this was performed.

Association between smoking and central sensitization pain: a web-based cross-sectional study.

PURPOSE: This study aimed to investigate whether smoking is an independent risk factor for central sensitization syndrome (CSS) in individuals with pain as measured by the Central Sensitization Inventory (CSI). METHODS: In 2020, we conducted an Internet survey targeting 2000 ordinary residents of Japan (aged 20-69 years) who had pain symptoms from October to November 2020. A multiple regression analysis was performed on the association between smoking status (nonsmokers and current smokers; Brinkman index) and CSI values. Moreover, compared to nonsmokers, the relative risk (RR) of the CSI cut-off score of 40 points or higher among current smokers was calculated using a modified Poisson regression model. Covariates included age, sex, body mass index, marital status, equivalized income, exercise habits, history of hypertension, history of hyperlipidemia, history of diabetes, pain chronicity, and Pain Catastrophizing Scale score. RESULTS: This study analyzed 1,822 individuals (1,041 men and 781 women). Among those experiencing pain, current smoking was associated with the increase in CSI values (ß = 0.07). The Brinkman index was also significantly associated with the increase in CSI values (ß = 0.06). Current smoking also increased the risk of being over the CSI cut-off score, with a relative risk (RR) of 1.29 (95% confidence intervals, 1.04-1.60). Younger age, being women, experiencing chronic pain, and higher pain catastrophizing thinking were also significantly associated with increased CSS severity, independent of smoking status. CONCLUSION: Smoking is an independent risk factor for CSS. This indicates that smoking may be an important factor in the management of central pain disorders.

Successful one-lung ventilation in a patient after laryngectomy by inserting a long spiral single-lumen tube into the left main bronchus: a case report.

Background: Patients who have had laryngectomy require a thorough preoperative assessment for potential stomal stenosis, and an action plan for possible inadvertent displacement of the voice prosthesis (VP) must be considered. We report the anesthetic management of a post-laryngectomy patient undergoing lung resection surgery. The patient had both a laryngectomy and a VP in situ. Case Description: A 66-year-old man with Parkinson's disease, who had previously undergone total laryngectomy for supraglottic laryngeal cancer, had a cuffed tracheostomy tube and a VP inserted into the tracheoesophageal fistula below it. He was scheduled for segmentectomy combined with lymph node dissection under combined epidural-general anesthesia due to lung cancer in the apical segment of the right lung. Following induction of general anesthesia, instead of using a double-lumen endotracheal tube, we inserted a long spiral single-lumen tube (SLT) (6 mm inner diameter, 8.7 mm outer diameter) through the tracheostoma under the guidance of a 4 mm bronchoscope because of concerns about airway injury due to the narrowed diameter of the stoma and potential dislodgement of the VP. The tube was carefully advanced and smoothly placed into the left main bronchus, and the surgery was completed using one-lung ventilation (OLV). Conclusions: For post-total laryngectomy patients, it is important to assess the size and condition of the tracheostoma and the usage of a VP, and choose an appropriate endotracheal tube. A long spiral SLT might be an option for OLV in patients after laryngectomy with a tracheoesophageal VP.

Videolaryngoscopy use before and after the initial phases of the COVID-19 pandemic: The report of the VL-iCUE survey with responses from 96 countries.

BACKGROUND: The potential benefit of videolaryngoscopy use in facilitating tracheal intubation has already been established, however its use was actively encouraged during the COVID-19 pandemic as it was likely to improve intubation success and increase the patient-operator distance. OBJECTIVES: We sought to establish videolaryngoscopy use before and after the early phases of the pandemic, whether institutions had acquired new devices during the COVID-19 pandemic, and whether there had been teaching on the devices acquired. DESIGN: We designed a survey with 27 questions made available via the Joint Information Scientific Committee JISC online survey platform in English, French, Spanish, Chinese, Japanese and Portuguese. This was distributed through 18 anaesthetic and airway management societies. SETTING: The survey was open for 54 to 90 days in various countries. The first responses were logged on the databases on 28 October 2021, with all databases closed on 26 January 2022. Reminders to participate were sent at the discretion of the administering organisations. PARTICIPANTS: All anaesthetists and airway managers who received the study were eligible to participate. MAIN OUTCOME MEASURES: Videolaryngoscopy use before the COVID-19 pandemic and at the time of the survey. RESULTS: We received 4392 responses from 96 countries: 944/4336 (21.7%) were from trainees. Of the 3394 consultants, 70.8% (2402/3394) indicated no change in videolaryngoscopy use, 19.9% (675/3394) increased use and 9.3% (315/3393) reduced use. Among trainees 65.5% (618/943) reported no change in videolaryngoscopy use, 27.7% (261/943) increased use and 6.8% (64/943) reduced use. Overall, videolaryngoscope use increased by 10 absolute percentage points following the pandemic. CONCLUSIONS: Videolaryngoscopy use increased following the early phase of the COVID-19 pandemic but this was less than might have been expected.

Prognosis for major abdominal surgeries based on intraoperative low-dose nutrition: A metabolic perspective.

BACKGROUND & AIMS: The optimal nutrition intake during surgery is unknown. This study aimed to investigate the prognosis of low-dose nutrition during laparoscopic colorectal cancer surgery. METHODS: In the glucose and amino acids (GA) group, 20 patients were infused with glucose (75 g/L) and amino acids (30 g/L) at 60 mL/h and bicarbonate Ringer's solution. However, 20 patients in the control (C) group were infused with bicarbonate Ringer's solution without GA. The length of hospital stay was determined, and measurements were taken before (TI) and after (T2) the surgery under general anesthesia. RESULTS: The lengths of hospital stay were comparable between the GA (13 days) and C (16 days) groups. Ketone body levels were 294 (C group) and 33 (GA group) µmol/L at T2. Nitrogen balance was 0.32 g (GA group) and -1.60 g (C group) at T2. CONCLUSIONS: Although the lengths of hospital stay were comparable, ketone body levels, and nitrogen balance were significantly different (P < 0.01) between the two groups after surgery.

Risk factors for failure of conversion from epidural labor analgesia to cesarean section anesthesia and general anesthesia incidence: an updated meta-analysis.

OBJECTIVES: Ongoing controversies persist regarding risk factors associated with the failure of transition from epidural labor analgesia to cesarean section anesthesia, including the duration of labor analgesia, gestational age, and body mass index (BMI). This study aims to provide an updated analysis of the incidence of conversion from epidural analgesia to general anesthesia, while evaluating and analyzing potential risk factors contributing to the failure of this transition to cesarean section anesthesia. METHODS: We conducted an extensive literature search utilizing databases such as PubMed, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure (CNKI), WANGFANG, and the Chinese Biomedical Literature Database (CBM) up to September 30, 2022. The meta-analysis was performed using STATA 15.1 software. The quality of the included studies was assessed using the 11-item quality assessment scale recommended by the Agency for Healthcare Research and Quality (AHRQ). RESULTS: A total of 9,926 studies were initially retrieved, and after rigorous selection, 19 studies were included in the meta-analysis. The overall incidence of conversion from epidural analgesia to general anesthesia was found to be 6% (95% confidence interval [CI]: 5-8%). Our findings indicate that, when compared to patients in the successful conversion group, those in the failure group tended to be younger (weighted mean difference [WMD] = -1.571, 95% CI: -1.116 to -0.975) and taller (WMD = 0.893, 95% CI: 0.018-1.767). Additionally, the failure group exhibited a higher incidence of incomplete block in epidural anesthesia, received a higher dosage of additional epidural administration, experienced a greater rate of emergency cesarean sections, and received anesthesia more frequently from non-obstetric anesthesiologists. However, no statistically significant differences were observed in gestational age, depth of the catheter insertion into the skin, epidural catheter specifics, duration of epidural analgesia, infusion rate of epidural analgesia, primiparity status, cervical dilatation during epidural placement, BMI, or weight. CONCLUSION: Our study found that the incidence of conversion from epidural analgesia to cesarean section under general anesthesia was 6%. Notably, the failure group exhibited a higher rate of incomplete block in epidural anesthesia, a greater incidence of emergency cesarean sections, a more frequent provision of anesthesia by non-obstetric anesthesiologists, a higher dosage of epidural administration, and greater height when compared to the success group. Conversely, women in the failure group were younger in age compared to their counterparts in the success group.

Unusual severe hypoxemia due to unilateral pulmonary edema after conventional cardiopulmonary bypass salvaged by veno-venous extracorporeal membrane oxygenation: a case report.

BACKGROUND: We report a case in which veno-venous extracorporeal membrane oxygenation (V-V ECMO) saved the life of a patient who developed severe hypoxemia due to unusual unilateral pulmonary edema (UPE) after cardiopulmonary bypass (CPB). CASE PRESENTATION: A 69-year-old man underwent aortic valve replacement and coronary artery bypass grafting. Following uneventful weaning off CPB, he developed severe hypoxemia. The ratio of arterial oxygen tension to inspired oxygen fraction (PaO2/FiO2) decreased from 301 mmHg 5 min after CPB to 42 mmHg 90 min after CPB. A chest X-ray revealed right-sided UPE. Immediately established V-V ECMO increased PaO2/FiO2 to 170 mmHg. Re-expansion pulmonary edema (REPE) was likely, as the right lung remained collapsed during CPB following the accidental opening of the right chest cavity during graft harvesting. CONCLUSIONS: V-V ECMO was effective in improving oxygenation and saving the life of a patient who had fallen into unilateral REPE unusually developing after conventional CPB.

External oblique muscle plane blocks in combination with modified thoracoabdominal nerves block through perichondrial approach for analgesia in abdominal surgery: A case report.

The costal and lateral external oblique muscle plane (EXOP) blocks anesthetize the lateral cutaneous branches, whereas the modified thoracoabdominal nerves block through perichondrial approach (M-TAPA) anesthetizes the anterior branches of the thoracoabdominal nerves. Herein, we report two cases of successful perioperative pain management with the combination of these blocks: case 1 was a 67-year-old man who underwent open cholecystectomy and case 2 was a 38-year-old woman who underwent emergency laparoscopic surgery for strangulation ileus. Both patients were administered the costal and/or lateral EXOP blocks along with bilateral M-TAPA for perioperative analgesia. A pin-prick test performed 1 h after surgery revealed that the cutaneous sensory block covered all areas of the abdominal surgical field. Combined use of these blocks can be a new local analgesic strategy for abdominal surgery.

Anesthesia outcomes of pregnant women with spinal diseases: a single-center case-series study.

BACKGROUND: Neuraxial anesthesia is widely used as the most effective and standard method in obstetric anesthesia. However, there is a concern that neuraxial anesthesia may be technically difficult or ineffective in pregnant women with spinal disease. Therefore, this study aimed to investigate the implementation rate of neuraxial anesthesia among pregnant women with spinal diseases and their success rate at our institution. METHODS: The subjects of this study were pregnant patients who delivered at Juntendo University Nerima Hospital between April 2017 and December 2020. After obtaining ethics committee approval, data were collected from patients' medical records. RESULTS: Of the 2682 pregnant women who delivered, 1550 underwent preanesthetic evaluation. There were 42 deliveries in 39 pregnant women with spinal diseases (1.7% of all pregnant women and 2.7% of those who underwent preanesthetic evaluation). The diagnoses included adolescent idiopathic scoliosis (51.3%), lumbar disc herniation (23.1%), and others. The mode of delivery was the elective cesarean section in 5 cases, emergent cesarean section in 8 cases, and vaginal delivery in 29 cases. Only one case required general anesthesia. Of the 38 cases of labor analgesia, the neuraxial block was inadequate in 3 cases (7.9%) and technically difficult in 3 cases (7.9%). However, the patients complained of no lower extremity neuropathy, infection, or inadvertent dural puncture. DISCUSSION: Neuraxial anesthesia was an option in most cases, even in pregnant women complicated with spinal disease, if an anesthesiologist's plan before delivery after careful preanesthetic evaluation.

Persistent bilateral pneumothorax after robotic-assisted inguinal hernia repair: possible relevance to recent esophageal cancer surgery - a case report.

BACKGROUND: Postoperative pneumothorax is a well-known but relatively rare complication after laparoscopic surgery. There has been no report describing pneumothorax that persisted for a week or more after laparoscopic surgery. Herein, we report a case of bilateral pneumothorax after laparoscopic surgery, which appears to have occurred by a different mechanism than previously described. CASE PRESENTATION: A 65-year-old male, with a past history of esophagectomy and retrosternal gastric tube reconstruction 4 months earlier, underwent a robotic-assisted inguinal hernia repair. Postoperative chest x-rays revealed the development of bilateral pneumothorax, which became worse on postoperative day (POD) 1 and took more than 9 days to resolve spontaneously. We assumed that intra-abdominal gas replaced by the air after pneumoperitoneum might have migrated into thoracic cavities through an opened esophageal hiatus or along the retrosternal route. CONCLUSIONS: Laparoscopic surgery after radical esophagectomy may be associated with an increased risk of postoperative pneumothorax.

Therapeutic Potential of Orally Administered Rubiscolin-6.

Rubiscolins are naturally occurring opioid peptides derived from the enzymatic digestion of the ribulose bisphosphate carboxylase/oxygenase protein in spinach leaves. They are classified into two subtypes based on amino acid sequence, namely rubiscolin-5 and rubiscolin-6. In vitro studies have determined rubiscolins as G protein-biased delta-opioid receptor agonists, and in vivo studies have demonstrated that they exert several beneficial effects via the central nervous system. The most unique and attractive advantage of rubiscolin-6 over other oligopeptides is its oral availability. Therefore, it can be considered a promising candidate for the development of a novel and safe drug. In this review, we show the therapeutic potential of rubiscolin-6, mainly focusing on its effects when orally administered based on available evidence. Additionally, we present a hypothesis for the pharmacokinetics of rubiscolin-6, focusing on its absorption in the intestinal tract and ability to cross the blood-brain barrier.

Distinct Profiles of Desensitization of µ-Opioid Receptors Caused by Remifentanil or Fentanyl: In Vitro Assay with Cells and Three-Dimensional Structural Analyses.

Remifentanil (REM) and fentanyl (FEN) are commonly used analgesics that act by activating a µ-opioid receptor (MOR). Although optimal concentrations of REM can be easily maintained during surgery, it is sometimes switched to FEN for optimal pain regulation. However, standards for this switching protocol remain unclear. Opioid anesthetic efficacy is decided in part by MOR desensitization; thus, in this study, we investigated the desensitization profiles of REM and FEN to MOR. The efficacy and potency during the 1st administration of REM or FEN in activating the MOR were almost equal. Similarly, in ß arrestin recruitment, which determines desensitization processes, they showed no significant differences. In contrast, the 2nd administration of FEN resulted in a stronger MOR desensitization potency than that of REM, whereas REM showed a higher internalization potency than FEN. These results suggest that different ß arrestin-mediated signaling caused by FEN or REM led to their distinct desensitization and internalization processes. Our three-dimensional analysis, with in silico binding of REM and FEN to MOR models, highlighted that REM and FEN bound to similar but distinct sites of MOR and led to distinct ß arrestin-mediated profiles, suggesting that distinct binding profiles to MOR may alter ß arrestin activity, which accounts for MOR desensitization and internalization.

Postoperative analgesia following robot-assisted thoracic surgery for mediastinal disease: retrospective comparative study of general anesthesia alone, combined with epidural analgesia, and with ultrasound-guided thoracic paraspinal block.

Background: Recently, robot-assisted thoracic surgery has been increasingly performed for mediastinal disease. However, appropriate postoperative analgesic methods have not been evaluated. Methods: We retrospectively studied patients who underwent robot-assisted thoracic surgery for mediastinal disease at a single university hospital between January 2019 and December 2021. Patients were performed either general anesthesia alone, general anesthesia combined with thoracic epidural anesthesia, or general anesthesia combined with ultrasound-guided thoracic block. Patients were divided into three groups [non-block (NB), thoracic epidural analgesia (TEA), and thoracic paraspinal block (TB)] according to postoperative analgesic methods, and they compared with terms of postoperative pain scores by using numerical rating scale (NRS) at 0, 3, 6, 12, 18, 24, and 48 h. Additionally, rescue supplemental analgesic within 24 h, side effects of anesthesia such as respiratory depression, hypotension, postoperative nausea and vomiting, pruritus and urinary retention, time to ambulation after surgery, and hospital stay after surgery were also compared among the three groups. Results: Data from 169 patients (Group NB: 25, Group TEA: 102, and Group TB: 42) were progressed to the analysis. Postoperative pain scale at 6 and 12 h was significantly lower in Group TEA than NB (1.2±1.6 vs. 2.4±1.8, P<0.01; and 1.2±1.5 vs. 2.2±1.7, P=0.018, respectively). There were no differences in pain scores between Groups TB and TEA at any point. The incidence of patients using rescue analgesics within 24 h was significantly different between groups [Group NB: 15/25 (60%), Group TEA: 30/102 (29.4%), Group TB: 25/42 (59.5%), P=0.01]. For postoperative side effects, only the number of patients complaining of postoperative nausea and vomiting for 24 h after surgery differed significantly between groups [Group NB: 7/25 (28%), Group TEA: 19/102 (18.6%), Group TB: 1/42 (2.4%), P=0.01]. Conclusions: TEA provided better analgesia after robot-assisted thoracic surgery for mediastinal disease than NB as indicated by lower pain scores and fewer rescue analgesic requirements. However, the frequency of postoperative nausea and vomiting was lowest in Group TB of all the groups. Thus, TBs might also provide adequate postoperative analgesia following robot-assisted thoracic surgery for mediastinal disease.

Migration rate of proximal adductor canal block catheters placed parallel versus perpendicular to the nerve after total knee arthroplasty: a randomized controlled study.

BACKGROUND: Perineural catheters placed parallel to the nerve course are reported to have lower migration rates than those placed perpendicular to it. However, catheter migration rates for a continuous adductor canal block (ACB) remain unknown. This study compared postoperative migration rates of proximal ACB catheters placed parallel and perpendicular to the saphenous nerve. METHODS: Seventy participants scheduled for unilateral primary total knee arthroplasty were randomly assigned for parallel or perpendicular placement of the ACB catheter. The primary outcome was the migration rate of the ACB catheter on postoperative day (POD) 2. Catheter migration was defined as being unable to confirm saline administration via the catheter around the saphenous nerve at the mid-thigh level under ultrasound guidance. Secondary outcomes included active and passive range of motion (ROM) of the knee on postoperative rehabilitation. RESULTS: Sixty-seven participants were included in the final analyses. The catheter migrated significantly less often in the parallel group (5 of 34 (14.7%)) than in the perpendicular group (24 of 33 (72.7%)) (p<0.001). The mean (SD) active and passive knee flexion ROM (degrees) improved significantly in the parallel than in the perpendicular group (POD 1: active, 88.4 (13.2) vs 80.0 (12.4), p=0.011; passive, 95.6 (12.8) vs 85.7 (13.6), p=0.004; POD 2: active, 88.7 (13.4) vs 82.2 (11.5), p=0.036; passive, 97.2 (12.8) vs 91.0 (12.0), p=0.045). CONCLUSION: Parallel placement of the ACB catheter provided a lower postoperative catheter migration rate than perpendicular placement of the ACB catheter along with corresponding improvements in ROM and secondary analgesic outcomes. TRIAL REGISTRATION NUMBER: UMIN000045374.

The balance between lung regulatory T cells and Th17 cells is a risk indicator for the acute exacerbation of interstitial lung disease after surgery: a case-control study.

BACKGROUND: Acute exacerbation (AE) of interstitial lung disease (ILD) (AE-ILD) is a life-threatening condition and the leading cause of 30-day mortality among patients who underwent pulmonary resection for lung cancer in Japan. This study was conducted to clarify the characteristics of the immune environment of lung tissues before the onset of AE-ILD. METHODS: This retrospective matched case-control study compared the immune phenotypes of helper T cells in lung tissues from patients with and without AE-ILD after surgery. In total, 135 patients who underwent surgical resection for lung cancer and were pathologically diagnosed with idiopathic interstitial pneumonia (IIP) at our institute between 2009 and 2018 were enrolled. Thirteen patients with AE-IIP and 122 patients without AE (non-AE) were matched using a propensity score analysis, and 12 cases in each group were compared. We evaluated the percentages of T helper (Th)1, Th2, Th17, regulatory T (Treg), and CD8 cells in CD3+ T cells and the Th1:Th2, Th17:Treg, and CD8:Treg ratios in patients with AE by immunostaining of lung tissues in the non-tumor area. RESULTS: We found a significant difference in the lung Th17:Treg ratio between the AE and non-AE groups (1.47 and 0.79, p = 0.041). However, we detected no significant differences in the percentages of lung Th1 (21.3% and 29.0%), Th2 (34.2% and 42.7%), Th17 (22.3% and 21.6%), Treg (19.6% and 29.1%), and CD8+ T cells (47.2% and 42.2%) of CD3+ T cells between the AE and non-AE groups. CONCLUSION: The ratio of Th17:Treg cells in lung tissues was higher in participants in the AE group than in those in the non-AE group. CLINICAL TRIAL REGISTRATION: This study was approved by the ethics committee of our institute (2,016,095).