Impact of Body Mass Index and Sarcopenia on Short- and Long-Term Outcomes After Esophageal Cancer Surgery: An Observational Study.

BACKGROUND: The effects of specific body mass index (BMI) category and sarcopenia within each BMI category on outcomes in patients undergoing esophageal surgery with esophageal squamous cell carcinoma have not been thoroughly examined. METHODS: This study included 1141 patients. Sarcopenia was determined with a total psoas muscle cross-sectional area at the level of the third lumbar vertebra in computed tomography. The outcomes were long-term survival, including overall survival (OS) and recurrence-free survival (RFS), and postoperative complications. RESULTS: The overweight and no sarcopenia group was considered as the reference. After adjusting covariates, the underweight and the normal weight and sarcopenia groups both showed worse OS (underweight group: hazard ratio [HR] 2.04, 95% confidence interval [CI] 1.33-3.13, p = 0.001; normal weight and sarcopenia group: HR 1.93, 95% CI 1.39-2.69, p < 0.001) and worse RFS (underweight group: HR 1.78, 95% CI 1.19-2.67, p = 0.005; normal weight and sarcopenia group: HR 1.70, 95% CI 1.25-2.30, p = 0.001). In addition, the underweight group (odds ratio [OR] 4.74, 95% CI 2.05-10.96, p < 0.001), the normal weight and sarcopenia group (OR 3.26, 95% CI 1.60-6.62, p = 0.001), the overweight and sarcopenia group (OR 2.54, 95% CI 1.14-5.68, p = 0.023), and the obese and no sarcopenia group (OR 2.44, 95% CI 1.14-5.22, p = 0.021) were at significantly higher risk of postoperative 30-day composite complications. CONCLUSIONS: Compared with the overweight and no sarcopenia group, the underweight and the normal weight and sarcopenia groups were associated with worse short- and long-term outcomes.

Conditions for laryngeal mask airway placement in terms of oropharyngeal leak pressure: a comparison between blind insertion and laryngoscope-guided insertion.

BACKGROUND: Insertion under laryngoscopic guidance has been used to achieve ideal positioning of the laryngeal mask airway (LMA). However, to date, the efficacy of this technique has been evaluated only using fiberoptic evaluation, and the results have been conflicting. Other reliable tests to evaluate the efficacy of this technique have not been established. Recently, it has been suggested that the accuracy of LMA placement can be determined by clinical signs such as oropharyngeal leak pressure (OPLP). The aim of this study was to assess the efficacy of LMA insertion under laryngoscopic guidance using OPLP as an indicator. METHODS: After approved by the institutional ethics committee, a prospective comparison of 100 patients divided into 2 groups (50 with blind technique and 50 with the laryngoscope technique) were evaluated. An LMA (LarySeal™, Flexicare medical Ltd., UK) was inserted using the blind approach in the blind insertion group and using laryngoscopy in the laryngoscope-guided insertion group. The OPLP, fiberoptic position score, whether the first attempt at LMA insertion was successful, time taken for insertion, ease of LMA insertion, and adverse airway events were recorded. RESULTS: Data were presented as mean ± standard deviation. The OPLP was higher in the laryngoscope-guided insertion group than in the blind insertion group (21.4 ± 8.6 cmH2O vs. 18.1 ± 6.1 cmH2O, p = 0.031). The fiberoptic position score, rate of success in the first attempt, ease of insertion, and pharyngolaryngeal adverse events were similar between both groups. The time taken for insertion of the LMA was significantly longer in the laryngoscope-guided insertion group, compared to blind insertion group (35.9 ± 9.5 s vs. 28.7 ± 9.5 s, p < 0.0001). CONCLUSION: Laryngoscope-guided insertion of LMA improves the airway seal pressure compared to blind insertion. Our result suggests that it may be a useful technique for LMA insertion. TRIAL REGISTRATION: cris.nih.go.kr , identifier: KCT0001945 (2016-06-17).

Effect of operative time on the outcome of patients undergoing off-pump coronary artery bypass surgery.

BACKGROUND: Several studies have been reporting circadian variation in postoperative morbidity and mortality. We investigated whether the outcomes after off-pump coronary artery bypass (OPCAB) surgery are influenced by the operation start time. METHODS: We retrospectively evaluated 1690 patients who received elective OPCAB surgery from January 2006 to December 2016. The patients were divided into two groups according to the operation start time (morning or afternoon). The primary outcome was the occurrence of a major adverse cardiac event (MACE) within 30 days after surgery and death within 1 year after surgery. Propensity matching analysis and multivariable analyses were performed to evaluate the relationship between the operation start time and postoperative outcomes. RESULTS: There were no significant differences in the overall 1-year mortality rate (2.2% vs 2.9%; P = .568 in the entire cohort and 1.5% vs 2.7%; P = .259 in the propensity-matched cohort) and 30-day MACE rate (8.9% vs 10.4%; P = .378 in the entire cohort and 9.4% vs 10.0%; P = .827 in the propensity-matched cohort) between the morning and afternoon surgery group. Multivariable regression analyses also did not show any significant relationship between the operation start time and postoperative outcomes. CONCLUSIONS: In elective OPCAB surgery, the operative time was not associated with an increased risk of postoperative mortality and complications.

Effect-site concentration of remifentanil for preventing cough during emergence in elderly patients undergoing nasal surgery: a comparison with adult patients.

PURPOSE: Prevention of cough during emergence after nasal surgery is important for avoiding surgical site bleeding. We investigated the remifentanil effect-site concentration in 50% (EC50) of the elderly patients undergoing nasal surgery for smooth emergence without cough and compared it with that of adult patients. METHODS: Twenty-two elderly (aged 65-80 years) and 25 adult patients (aged 20-60 years) with an American Society of Anesthesiologists physical status I/II undergoing nasal surgery were enrolled. Anesthesia was maintained with sevoflurane and remifentanil. Remifentanil EC50 and EC95 for preventing cough were determined using the modified Dixon's up-and-down method and isotonic regression with bootstrapping approach. Recovery profiles were also recorded. RESULTS: With Dixon's up-and-down method, the EC50 of remifentanil in elderly patients (2.40±0.25 ng/mL) was not significantly different from that of adults (2.33±0.30 ng/mL) (P=0.687). With isotonic regression, the EC95 of remifentanil in elderly patients (3.32 [95% confidence interval: 3.06-3.38] ng/mL) was not significantly different from that of adults (3.30 [95% confidence interval: 2.96-3.37] ng/mL). However, eye opening time (14.1±3.8 vs 12.0±2.9 seconds), extubation time (17.2±4.1 vs 14.0±3.0 seconds), and postanesthesia care unit duration (44.5±7.6 vs 38.7±3.4 minutes) in elderly patients were significantly longer than those in adults (P<0.05). CONCLUSION: Remifentanil EC50 for preventing cough after nasal surgery with sevoflurane anesthesia did not differ between elderly and adult patients. However, delayed awakening and respiratory adverse events may warrant attention in elderly patients.

Predicted EC50 and EC95 of Remifentanil for Smooth Removal of a Laryngeal Mask Airway Under Propofol Anesthesia.

PURPOSE: The purpose of this study was to determine the effect-site concentration (Ce) of remifentanil in 50% of patients (EC50) and 95% of patients (EC95) for smooth laryngeal mask airway (LMA) removal in adults under propofol and remifentanil anesthesia. MATERIALS AND METHODS: Twenty-five patients of ASA physical status I-II and ages 18-60 years who were to undergo minor gynecological or orthopedic surgery were assessed in this study. Anesthesia was induced and maintained with propofol and remifentanil target-controlled infusion (TCI). Remifentanil was maintained at a predetermined Ce during the emergence period. The modified Dixon's up-and-down method was used to determine the remifentanil concentration, starting from 1.0 ng/mL (step size of 0.2 ng/mL). Successful removal of the LMA was regarded as absence of coughing/gagging, clenched teeth, gross purposeful movements, breath holding, laryngospasm, or desaturation to SpO2<90%. RESULTS: The mean±SD Ce of remifentanil for smooth LMA removal after propofol anesthesia was 0.83±0.16 ng/mL. Using isotonic regression with a bootstrapping approach, the estimated EC50 and EC95 of remifentanil Ce were 0.91 ng/mL [95% confidence interval (CI), 0.77-1.07 ng/mL] and 1.35 ng/mL (95% CI, 1.16-1.38 ng/mL), respectively. CONCLUSION: Our results showed that remifentanil TCI at an established Ce is a reliable technique for achieving safe and smooth emergence without coughing, laryngospasm, or other airway reflexes.