Epidural versus patient-controlled intravenous analgesia on pain relief and recovery after laparoscopic gastrectomy for gastric cancer: randomized clinical trial.

BACKGROUND: Epidural analgesia (EDA) is a main modality for postoperative pain relief in major open abdominal surgery within the Enhanced Recovery After Surgery protocol. However, it remains unclear whether EDA is an imperative modality in laparoscopic gastrectomy (LG). This study examined non-inferiority of patient-controlled intravenous analgesia (PCIA) to EDA in terms of postoperative pain and recovery in patients who underwent LG. METHODS: In this open-label, non-inferiority, parallel, individually randomized clinical trial, patients who underwent elective LG for gastric cancer were randomized 1:1 to receive either EDA or PCIA after surgery. The primary endpoint was pain score using the Numerical Rating Scale at rest 24 h after surgery, analysed both according to the intention-to-treat (ITT) principle and per protocol. The non-inferiority margin for pain score was set at 1. Secondary outcomes were postoperative parameters related to recovery and adverse events related to analgesia. RESULTS: Between 3 July 2017 and 29 September 2020, 132 patients were randomized to receive either EDA (n = 66) or PCIA (n = 66). After exclusions, 64 patients were included in the EDA group and 65 patients in the PCIA group for the ITT analysis. Pain score at rest 24 h after surgery was 1.94 (s.d. 2.07) in the EDA group and 2.63 (s.d. 1.76) in the PCIA group (P = 0.043). PCIA was not non-inferior to EDA for the primary endpoint (difference 0.69, one side 95% c.i. 1.25, P = 0.184) in ITT analysis. Postoperative parameters related to recovery were similar between groups. More EDA patients (21 (32.8%) versus 1 (1.5%), P < 0.001) developed postoperative hypotension as an adverse event. CONCLUSIONS: PCIA was not non-inferior to EDA in terms of early-phase pain relief after LG.Registration number: UMIN000027643 (https://www.umin.ac.jp/ctr/index-j.htm).

Intraoperative Hypothermia Is Not Associated with Surgical Site Infections after Total Hip or Knee Arthroplasty.

Maintaining perioperative normothermia decreases the post-surgery surgical site infection (SSI) rate. We investigated whether SSI is associated with intraoperative hypothermia in total hip (THA) and total knee (TKA) arthroplasties by retrospectively analyzing 297 THA and TKA cases. The patients' intraoperative core body temperature (BT) was measured by bladder catheter or forehead sensor. We evaluated the associations between SSI and intraoperative BT and other variables and patient characteristics. Fifty-six patients (18.8%) had hypothermia (BT <36°C); 43 developed SSI (14.5%); only five had hypothermia (11.6%). Intraoperative hypothermia and SSI were not significantly associated. The SSI group had more men (34.9% vs. 18.1%) and THA patients (77.4%), a longer mean surgical duration (174.3 vs. 143.5 mins), and a higher average BT (36.4°C vs. 36.2°C) than the no-SSI group. The SSI patients had a higher intraoperative BT. A multivariable analysis revealed that SSI was associated with male sex (OR 2.3, 95%CI: 1.031-4.921, p=0.042), longer surgery (OR, 1.01, 95%CI: 1.003-1.017, p=0.004), THA (OR 3.6, 95%CI: 1.258-10.085, p=0.017), and intraoperative BT >36.0°C (OR 3.6, 95%CI: 1.367-9.475, p=0.009). Intraoperative hypothermia was not associated with SSI in adults who underwent THA or TKA. These results suggest that hypothermia might not be the problem for SSI.

Association between the Remifentanil Dose during Anesthesia and Postoperative pain.

Remifentanil is an ultra-short-acting opioid that sometimes causes opioid-induced hyperalgesia, which has led to controversy regarding the association between intraoperative remifentanil administration and postoperative pain. This study aimed to assess the effects of the intraoperative remifentanil dose on postoperative pain. Patients undergoing esophageal, gastric/hepatobiliary, or intestinal/colon surgery and using postoperative patient-controlled epidural analgesia were analyzed. The patients were divided into two groups based on the average intraoperative remifentanil dose (high-dose remifentanil [HR] group: ≥0.1 µg/kg/min; low-dose remifentanil [LR] group: <0.1 µg/kg/min). In all, 406 patients met the inclusion criteria. A significant difference in the average dose of remifentanil was seen between the groups during the anesthesia period (0.14±0.05 vs. 0.07±0.02 µg/kg/min). However, no significant difference was seen in pre- or intraoperative patient characteristics. Numerical rating scale (NRS) scores on postoperative day 1 were similar between the groups (HR: 1.7±2.0; LR: 1.7±2.0; p=0.74). The incidence of poor pain control (NRS > 3/10) was also similar between the groups (HR: 14%; LR: 16%; p=0.57). Older age (> 60 years) and type of surgery (esophageal surgery) were associated with worse postoperative NRS scores. No significant association was seen between the intraoperative remifentanil dose and postoperative NRS scores following thoracoabdominal surgery with postoperative epidural pain management.

Transversus Abdominis Plane Block Reduced Early Postoperative Pain after Robot-assisted Prostatectomy: a Randomized Controlled Trial.

Analgesic effect of transversus abdominis plane block (TAP block) in lower major abdominal laparoscopic surgery with about 5 cm of maximum surgical scar has been controversial. We hypothesized that TAP block has benefits, so the analgesic effect of TAP block after robot-assisted laparoscopic prostatectomy (RALP) was evaluated. One hundred patients were enrolled in this prospective, double-blinded, randomized study. Standardized general anesthesia with wound infiltration on camera port and fentanyl dose limit of 3 µg/kg was provided. Ultrasound-guided, single-shot subcostal TAP block with either 0.375% ropivacaine (Ropivacaine group, 48 patients) or normal saline (Control group, 52 patients) was performed by anesthesiologist in charge (34 anesthesiologists) after surgical procedure. Pain score using numerical rating scale (NRS) and postoperative intravenous fentanyl were evaluated for the first 24 postoperative hours. Median values (interquartile range) of NRS scores when the patients were transferred to post-anesthesia care unit (PACU) were 5 (2-7) in Ropivacaine group and 6 (4-8) in Control group at rest (P = 0.03), 5 (2-8) in Ropivacaine group and 7 (5-8) in Control group during movement (P < 0.01). These significant differences disappeared at the time of discharging PACU. Fentanyl doses for the first 24 postoperative hours were 210 µg (120-360) in Ropivacaine group and 200 µg (120-370) in Control group (P = 0.79). These results indicated that subcostal TAP block by anesthesiologists of varied level of training reduced postoperative pain immediate after RALP. TAP block had fundamental analgesic effect, but this benefit was too small to reduce postoperative 24-hour fentanyl consumption.

Pediatric Living Donor Liver Transplantation for Congenital Absence of the Portal Vein With Pulmonary Hypertension: A Case Report.

Few reports of liver transplantation exist in patients with congenital absence of the portal vein and pulmonary hypertension. Living donor liver transplantation is usually performed before exacerbation of pulmonary hypertension. A 7-year-old girl (height: 131.5 cm; weight: 27.4 kg) with congenital absence of the portal vein was diagnosed with pulmonary hypertension (mean pulmonary artery pressure 35 mm Hg), and liver transplantation was planned before exacerbation of pulmonary hypertension. We successfully managed her hemodynamic parameters using low-dose dopamine and noradrenaline under monitoring of arterial blood pressure, central venous pressure, cardiac output, and stroke volume variation. Anesthesia was maintained using air-oxygen-sevoflurane and remifentanil 0.1 to 0.6 µg∙kg-1∙min-1. It is necessary to understand the potential perioperative complications in such cases and to adopt a multidisciplinary team approach in terms of the timing of transplantation and readiness to deal with exacerbation of pulmonary hypertension.

Postoperative Course of Serum Albumin Levels and Organ Dysfunction After Liver Transplantation.

BACKGROUND AND AIMS: Postoperative hypoalbuminemia, especially following liver transplantation, can lead to adverse multisystem effects and even death. We investigated the relationship between postoperative albumin levels and organ failure (assessed using Sequential Organ Failure Assessment [SOFA] scores). METHODS: Sixty liver transplant recipients admitted to the intensive care unit (ICU) from 2012 to 2015 were retrospectively divided into 2 groups: lower albumin (LA) (n=28) and higher albumin (HA) (n=32), using whether serum albumin level fell below 3.0 g/dL during the first postoperative week as the stratifying factor. The SOFA scores (primary endpoint) and associated complications (ascites amount, rejection, re-intubation, abdominal re-operation, thrombosis), additional treatment (dialysis, pleural effusion drainage), and duration of ICU stay (secondary endpoints) of the 2 groups were compared. RESULTS: Average serum albumin levels were significantly different between HA and LA groups (3.6 [3.4-3.8] vs 3.1 [2.9-3.3], respectively, P<.05), although the amounts of albumin infused in the 2 groups during the first postoperative week were not different (HA vs LA: 42 [30-71] vs 40 [30-58], respectively, P=.37). Mean daily SOFA scores were not significantly different between the HA and LA groups (8.3 [6.6-9.0] vs 7.2 [6.3-8.6], P=.73), although the HA group had lower mean cardiovascular SOFA sub-scores than the LA group (0.1 [0-0.4] vs 0.4 [0-1.3], P=.032). There were no significant differences between the groups with regard to complication rates and duration of ICU and hospital stays. CONCLUSIONS: Serum albumin level might not influence cumulative organ function, but it decreases the amount of hemodynamic support required in liver transplant recipients.

Radio contrast imaging for continuous epidural infusion in humans: a report of three cases.

There are no reports of human research on continuous epidural contrast injection, and there are no definite methods to investigate the spread of drugs injected continuously into the epidural space. We investigated the feasibility of continuous epidural contrast injection in patients undergoing computed tomography (CT)-guided therapy. In this study, a combination of a contrast agent mixed with 0.75% ropivacaine was used as the test drug. The main outcome evaluated was the feasibility of continuous epidural contrast imaging by CT scan following epidural injection of a contrast agent with 0.75% ropivacaine. We studied three patients who underwent CT-guided procedures and found that continuous epidural contrast injection was possible without any deleterious effects, such as an allergic reaction. The spread of the contrast agent was not consistent with the level of the clinical analgesic effect. Continuous epidural contrast injection is a feasible procedure. The results of our study might contribute to future research on continuous epidural contrast administration, as well as provide patients with superior analgesia.

Effect of an enhanced recovery after surgery protocol in patients undergoing pancreaticoduodenectomy: A randomized controlled trial.

BACKGROUND & AIMS: Evidence of the advantages of enhanced recovery after surgery (ERAS) protocols following pancreaticoduodenectomy (PD) is limited. The aim of this study was to examine the efficiency of ERAS protocols in patients following PD. METHODS: Between June 2014 and October 2016, patients undergoing PD were randomly assigned to receive ERAS protocols or standard care. The primary endpoint was the postoperative length of stay. Secondary endpoints included postoperative complications, postoperative quality-of-life (QoR-40J), readmission, and medical cost. RESULTS: Of 80 eligible patients, 74 were analyzed in intention-to-treat principles: 37 in the control group and 37 in the ERAS group. The mean length of stay in the ERAS group was significantly shorter than that in the control group (20.1 ± 5.4 vs 26.9 ± 13.5 days, P < 0.001). The ERAS group had a significantly lower percentage of postoperative complications (32.4% vs 56.8%, P = 0.034) and readmissions (0% vs 8.1%, P = 0.038). Quality-of-life was also significantly better in the ERAS group (184 ± 12.4 vs 177 ± 14.5, P = 0.022). The total medical cost was lower in the ERAS group, but not significantly ($25,445 ± 5065 vs $28,384 ± 9999, P = 0.085). CONCLUSIONS: The optimization of ERAS protocols in patients undergoing PD is safe and accelerates perioperative recovery and quality-of-life, thereby reducing the length of stay. Morbidity was significantly decreased in the ERAS group without compromising surgical outcome. REGISTRATION NUMBER: UMIN000014068.

Comparison of the Effects of Epidural Analgesia and Patient-controlled Intravenous Analgesia on Postoperative Pain Relief and Recovery After Laparoscopic Gastrectomy for Gastric Cancer.

PURPOSE: Epidural analgesia (EDA) is an imperative modality for postoperative pain relief after major open abdominal surgery. However, whether EDA has benefits in laparoscopic surgery has not been clear. In this study, the effects of EDA and patient-controlled intravenous analgesia (PCIA) after laparoscopic distal gastrectomy (LDG) were compared. METHODS: This was a retrospective study that included 82 patients undergoing LDG for gastric cancer. Patients received either EDA (n=67) or PCIA (n=15) for postoperative pain relief. Postoperative outcomes and analgesia-related adverse events were compared between the two modalities. RESULTS: EDA and PCIA patients showed no differences in the incidence of complications [9 (13%) vs. 2 (13%); P=0.99] and the length of postoperative hospital stay (9.6±4.5 d vs. 9.7±4.0 d; P=0.90), although the PCIA included poorer preoperative physical status (PS) patients. The number of additional doses of analgesics was higher in the EDA than in the PCIA (1.8±2.4 vs. 0.9±1.0; P=0.01), although postoperative pain scores were similar in the 2 groups. Though the time to first passage of flatus was shorter in the EDA (P<0.05), more EDA patients developed postoperative hypotension as an adverse event (P<0.01). The full mobilization day and the day of oral intake tolerance were not significantly different between the 2 groups after surgery. CONCLUSIONS: After LDG, EDA may not be indispensable, while PCIA may be the optimal modality for providing safe and effective postoperative analgesia and recovery.

The Incidence of Desaturation during Anesthesia in Adult and Pediatric Patients: A Retrospective Study.

We investigated the incidence of desaturation during general anesthesia in preoperatively hypoxic (< 92%), and nonhypoxic (≥ 92%) pediatric (n=1,090) and adult (n=5,138) patients. We plotted the patients' SpO2 value time-courses and assessed desaturation in 6,228 patients. The crude overall incidence (95%CI) for desaturation was 11.1% (9.4-13.1) in the pediatric patients and 0.9% (0.6-1.2) in the adults. The crude incidence of desaturation in the hypoxic pediatric patients was 2.5 times the risk in the nonhypoxic patients: risk ratio (RR) 2.5 (1.8-3.5), p<0.001. The risk of desaturation in the hypoxic adult patients was 20.1 times the risk in the nonhypoxic adult patients: RR 20.1 (10.3-39.2), p<0.001. When the patients were separately stratified by American Society of Anesthesiologists Physical Status (ASA-PS) and by age, the directly adjusted risk-ratio (RRS) showed that the hypoxic pediatric patients had 1.8 and 1.6 times the risk in the nonhypoxic pediatric patients: ASA-PS adjusted RRS 1.6 (1.8-2.2), p<0.001; age-adjusted RRS 1.8 (1.3-2.5), p<0.001, and the hypoxic adult patients had 13.8 times the risk in the nonhypoxic adult patients: RRS 13.8 (6.9-27.6), p<0.001. A pulse-oximeter check before the start of general anesthesia could ensure timely preparation to avoid intraoperative desaturation.

A subclinical high tricuspid regurgitation pressure gradient independent of the mean pulmonary artery pressure is a risk factor for the survival after living donor liver transplantation.

BACKGROUND: Portopulmonary hypertension (POPH) is characterized by pulmonary vasoconstriction, while hepatopulmonary syndrome (HPS) is characterized by vasodilation. Definite POPH is a risk factor for the survival after orthotopic liver transplantation (OLT), as the congestive pressure affects the grafted liver, while subclinical pulmonary hypertension (PH) has been acknowledged as a non-risk factor for deceased donor OLT. Given that PH measurement requires cardiac catheterization, the tricuspid regurgitation pressure gradient (TRPG) measured by echocardiography is used to screen for PH and congestive pressure to the liver. We investigated the impact of a subclinical high TRPG on the survival of small grafted living donor liver transplantation (LDLT). METHODS: We retrospectively analyzed 84 LDLT candidates. Patients exhibiting a TRPG ≥25 mmHg on echocardiography were categorized as potentially having liver congestion (subclinical high TRPG; n = 34). The mean pulmonary artery pressure (mPAP) measured after general anesthesia with FIO20.6 (mPAP-FIO20.6) was also assessed. Patients exhibiting pO2 < 80 mmHg and an alveolar-arterial oxygen gradient (AaDO2) ≥ 15 mmHg were categorized as potentially having HPS (subclinical HPS; n = 29). The clinical course after LDLT was investigated according to subclinical high TRPG. RESULTS: A subclinical high TRPG (p = 0.012) and older donor age (p = 0.008) were correlated with a poor 40-month survival. Although a higher mPAP-FIO20.6 was expected to correlate with a worse survival, a high mPAP-FIO20.6 with a low TRPG was associated with high frequency complicating subclinical HPS and a good survival, suggesting a reduction in the PH pressure via pulmonary shunt. CONCLUSION: In cirrhosis patients, mPAP-FIO20.6 may not accurately reflect the congestive pressure to the liver, as the pressure might escape via pulmonary shunt. A subclinical high TRPG is an important marker for predicting a worse survival after LDLT, possibly reflecting congestive pressure to the grafted small liver.

Randomized Controlled Trial of Epidural versus Patient-controlled Intravenous Analgesia for Postoperative Pain Control after Laparoscopic Gastrectomy.

Although epidural analgesia (EDA) is considered standard postoperative analgesia for open gastrectomy, it has been unclear whether EDA has benefits in laparoscopic gastrectomy (LG) because postoperative pain after a laparoscopic procedure is significantly reduced. We are conducting a two-arm, single-center, prospective randomized non-inferiority trial to evaluate the postoperative pain relief of patient-controlled intravenous analgesia (PCIA) compared to EDA. A total of 132 patients undergoing LG will be randomized to EDA and PCIA groups (n=64 each) for postoperative pain control. The primary endpoint is postoperative pain at 24 h after surgery. This study will clarify the optimal pain management after LG.

Observational Study to Assess and Predict Serious Adverse Events after Major Surgery.

Many patients suffer from postoperative serious adverse events (SAEs). Here we sought to determine the incidence of SAEs, assess the accuracy of currently used scoring systems in predicting postoperative SAEs, and determine whether a combination of scoring systems would better predict postoperative SAEs. We prospectively evaluated patients who underwent major surgery. We calculated 4 scores: American Society of Anesthesiologists physical status (ASA-PS) score, the Charlson Score, the POSSUM (Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity) score, and the Surgical Apgar Score (SAS). We assessed the occurrence of SAEs. We assessed the association between each score and SAEs. We combined these scoring systems to find the best combination to predict the occurrence of SAEs. Among 284 patients, 43 suffered SAEs. All scoring systems could predict SAEs. However, their predictive power was not high (the area under the receiver operating characteristic curves [AUROC] 0.6-0.7). A combination of the ASA-PS score and the SAS was the most predictive of postoperative SAEs (AUROC 0.714). The incidence of postoperative SAEs was 15.1 . The combination of the ASA-PS score and the SAS may be a useful tool for predicting postoperative serious adverse events after major surgery.

Induction of hepatic Bach1 mRNA expression by carbon tetrachloride-induced acute liver injury in rats.

Hepatic oxidative stress is a major contributor to the pathogenesis of several acute liver diseases. Diagnostic markers of hepatic oxidative stress may facilitate early detection and intervention. Bach1 is an oxidative stress-responsive transcription factor that represses heme oxygenase 1 (HO-1), the rate-limiting enzyme in the catabolism of heme, a potent pro-oxidant. We previously demonstrated that carbon tetrachloride (CCl4) causes oxidative hepatic injury in rats, exacerbated by free heme, suggesting that CCl4 may affect Bach1 gene expression. In the present study, we used northern blot analysis to measure Bach1, HO-1 and δ-aminolevulinate synthase (ALAS1; a heme biosynthesis enzyme) mRNA expression levels during acute hepatic injury induced by CCl4 (at doses of 0.1, 1.0 and 2.0 ml/kg body weight). Oxidative injury was assessed by measuring serum alanine aminotransferase (ALT), hepatic malondialdehyde (MDA) and glutathione (GSH) content. Treatment with CCl4 induced a significant dose-dependent increase in Bach1 mRNA 1-3 h after administration. Bach1 mRNA peaked at 6 h after CCl4 treatment (1 ml/kg), followed by a rapid decrease and gradual return to baseline by 12 h after treatment. The timecourse of transient Bach1 mRNA induction roughly mirrored that of HO-1 mRNA, while ALAS1 mRNA was inversely downregulated. Serum ALT levels and hepatic MDA concentration were significantly increased at 24 h after CCl4 treatment, while the hepatic GSH content was significantly reduced within 3 h of treatment. Serum ALT levels were positively correlated with Bach1 mRNA levels. These findings indicate that Bach1 mRNA is transiently induced in rat liver by CCl4, possibly as a regulatory mechanism to restore HO-1 to baseline following free heme catabolism. Our findings also suggest that Bach1 mRNA expression may be a novel indicator of the extent of oxidative hepatic injury caused by free heme.

Complications related to invasive hemodynamic monitors during adult liver transplantation.

The rate of complications directly related to invasive monitors during liver transplantation (LT) was reviewed in 1206 consecutive adult LTs performed over 8.6 yr (1/1/2004-7/31/2012). The designated anesthesiologists placed intra-operative monitors, including two arterial catheters (via the radial and the right femoral arteries), central venous catheters (a 9 Fr. catheter and an 18 Fr. veno-venous bypass [VVB] return cannula in an internal jugular vein), a pulmonary artery catheter, and a transesophageal echocardiography (TEE) probe. A 17 Fr. VVB drainage cannula was placed via the left femoral vein. No Clavien-Dindo Grade V (death) or Grade IV (organ dysfunction) complication was identified. Nine Grade III complications (requiring surgical intervention) and 15 Grade II complications (conservative treatment) were noted. Seven (0.58% in 1206 cases) were related to a femoral arterial line with Grade III of four; seven (0.58%) were due to VVB return cannula in the femoral vein with Grade III of one; four (0.33%) were related to central venous catheters with Grade III of two; four (0.33%) were due to a TEE probe with Grade III of two; and two minor complications (0.17%) that were related to a radial arterial line. No complication was observed with a pulmonary arterial catheter. Current invasive monitors placed during LT have an acceptable risk.

Cardiac arrest during adult liver transplantation: a single institution's experience with 1238 deceased donor transplants.

Liver transplantation (LT) is one of the highest risk noncardiac surgeries. We reviewed the incidence, etiologies, and outcomes of intraoperative cardiac arrest (ICA) during LT. Adult cadaveric LT recipients from January 1, 2001 through December 31, 2009 were reviewed. ICA was defined as an event requiring either closed chest compression or open cardiac massage. Cardiac arrest patients who recovered with only pharmacological interventions were excluded. Data included etiologies and outcomes of ICA, intraoperative deaths (IDs) and hospital deaths (HDs), and potential ICA risk factors. ICA occurred in 68 of 1238 LT recipients (5.5%). It occurred most frequently during the neohepatic phase (60 cases or 90%), and 39 of these cases (65.0%) experienced ICA within 5 minutes after graft reperfusion. The causes of ICA included postreperfusion syndrome (PRS; 26 cases or 38.2%) and pulmonary thromboembolism (PTE; 24 cases or 35.3%). A higher Model for End-Stage Liver Disease (MELD) score was found to be the most significant risk factor for ICA. The ID rate after ICA was 29.4% (20 cases), and the HD rate was 50.0% (34 cases). The 30-day patient survival rate after ICA was 55.9%, and the 1-year survival rate was 45.6%: these rates were significantly lower (P < 0.001) than those for non-ICA patients (97.4% and 85.1%, respectively). In conclusion, the incidence of ICA in adult cadaveric LT was 5.5% with an intraoperative mortality rate of 29.4%. ICA most frequently occurred within 5 minutes after reperfusion and resulted mainly from PRS and PTE. A higher MELD score was identified as a risk factor.

The role of ultrasonography in determining central venous patency in patients undergoing bowel transplantation.

Ultrasonography (US) is an attractive alternative for invasive studies to evaluate venous patency. However, little data exist concerning the usefulness of US in patients undergoing bowel transplantation. Twenty-five adult patients with bowel transplantation were retrospectively identified with both US and contrast venography (VG) performed preoperatively. The median age was 43 yr, and the median duration of total parenteral nutrition was 36 months. The vessels were evaluated as positive with ≥ 50% stenosis. Among the internal jugular veins and the subclavian veins examined with US (96% of the all sites) and with VG (69%), 66 venous sites were available for comparison. VG confirmed positive in 42% (28/66), while US found positive in 27% (18/66); US had three false positives and 13 false negatives, giving the sensitivity of 54% (95% confidence interval [CI], 34-72) and the specificity of 92% (CI, 77-98). The positive and the negative likelihood ratios weighted by prevalence (42%) were 5 (CI, 1.7-14.3) and 0.37 (CI, 0.23-0.60), respectively. In addition, VG confirmed stenosis in 32% of the right and 50% of the left brachiocephalic veins and 41% of the superior vena cava. US is not a reliable method for assessing the upper body venous system of patients undergoing bowel transplantation.

Heme breakdown and ischemia/reperfusion injury in grafted liver during living donor liver transplantation.

Living donor liver transplantation (LDLT) requires ischemia/reperfusion (I/R), which can cause early graft injury. However, the detailed mechanism of I/R injury remains unknown. Heme oxygenase-1 (HO-1) is a rate-limiting enzyme in heme catabolism and results in the production of iron, carbon monoxide (CO), and biliverdin IXα. Furthermore, in animals, HO-1 has a protective effect against oxidative stress associated with I/R injury. However, in humans, the molecular mechanism and clinical significance of HO-1 remain unclear. We previously demonstrated that exhaled CO levels increase during LDLT, and postulated that this may indicate I/R injury. In this study, we elucidate the origin of increased exhaled CO levels and the role of HO-1 in I/R injury during LDLT. We studied 29 LDLT donors and recipients each. For investigation of HO-1 gene expression by polymerase chain reaction and HO-1 localization by immunohistological staining, liver biopsies from the grafted liver were conducted twice, once before and once after I/R. Exhaled CO levels and HO-1 gene expression levels significantly increased after I/R. In addition, HO-1 levels significantly increased after I/R in Kupffer cells. Furthermore, we found a significant positive correlation between exhaled CO levels and HO-1 gene expression levels. These results indicated that increased heme breakdown in the grafted liver is the source of increased exhaled CO levels. We also found a significant relationship between HO-1 gene expression levels and alanine aminotransferase (ALT) levels; i.e., the higher the HO-1 gene expression levels, the higher the ALT levels. These results suggest that HO-1-mediated heme breakdown is caused by I/R during LDLT, since it is associated with increased exhaled CO levels and liver damage.

The role of Certified Registered Nurse Anesthetists in the United States.

Certified Registered Nurse Anesthetists (CRNAs) have been providing anesthesia care in the United States (US) for nearly 150 years. Historically, anesthesia care for surgical patients was mainly provided by trained nurses under the supervision of surgeons until the establishment of anesthesiology as a medical specialty in the US. Currently, all 50 US states utilize CRNAs to perform various kinds of anesthesia care, either under the medical supervision of anesthesiologists in most states, or independently without medical supervision in 16 states; the latter has become an on-going source of conflict between anesthesiologists and CRNAs. Understanding the history and current conditions of anesthesia practice in the US is crucial for countries in which the shortage of anesthesia care providers has become a national issue.