Therapeutic effects of flurbiprofen axetil on mesenteric traction syndrome: randomized clinical trial.

BACKGROUND: This study aimed to reveal the appropriate timing for the intravenous administration of flurbiprofen axetil for preventing mesenteric traction syndrome (MTS), caused by prostacyclin release. METHODS: In this prospective, randomized, clinical study, forty-five patients who were undergoing elective surgery for colorectal cancer via laparotomy were enrolled. Patients were randomly divided into 3 groups: a preoperative group (n = 16) receiving flurbiprofen axetil directly before surgery; a post-MTS group (n = 14) receiving following MTS onset; and a control group (n = 15) who were not administered flurbiprofen axetil. 6-keto-PGF1α, a stable metabolite of prostacyclin, levels were measured and mean blood pressures were recorded. RESULTS: In the preoperative group, 6-keto-PGF1α levels did not increase, blood pressure levels did not decrease, and no facial flushing was observed. In both the post-MTS and control groups, 6-keto-PGF1α levels increased markedly after mesenteric traction and blood pressure decreased significantly. The post-MTS group exhibited a faster decreasing trend in 6-keto-PGF1α levels and quick restore of the mean blood pressure, and the use of vasopressors and phenylephrine were lower than that in the control group. CONCLUSIONS: Even therapeutic administration of flurbiprofen axetil after the onset of MTS has also effects on MTS by suppressing prostacyclin production. TRIAL REGISTRATION: Clinical trial number: UMIN000009111 . (Registered 14 October 2012).

Modified enhanced recovery after surgery (ERAS) protocols for patients with obstructive colorectal cancer.

BACKGROUND: Enhanced recovery after surgery (ERAS) protocols are now well-known to be useful for elective colorectal surgery, as they result in shorter hospital stays without adversely affecting morbidity. However, the efficacy and safety of ERAS protocols for patients with obstructive colorectal cancer have yet to be clarified. METHODS: We evaluated 122 consecutive resections for obstructive colorectal cancer performed between July 2008 and November 2012 at Tokyo Metropolitan Bokutoh Hospital. Patients with rupture or impending rupture and those who received simple colostomy were excluded. The first set of 42 patients was treated based on traditional protocols, and the latter 80 according to modified ERAS protocols. The main endpoints were length of postoperative hospital stay, postoperative short-term morbidity, rate of readmission within 30 days, and mortality. Differences in modified ERAS protocols relative to traditional care include intensive preoperative counseling (by both surgeons and anesthesiologists), perioperative fluid management (avoidance of sodium/fluid overload), shortening of postoperative fasting period and early provision of oral nutrition, intraoperative warm air body heating, enforced postoperative mobilization, stimulation of gut motility, early removal of urinary catheter, and a multidisciplinary team approach to care. RESULTS: Median (interquartile range) postoperative hospital stay was 10 (10-14.25) days in the traditional group, and seven (7-8.75) days in the ERAS group, showing a 3-day reduction in hospital stay (p < 0.01). According to the Clavien-Dindo classification, overall incidences of grade 2 or higher postoperative complications for the traditional and ERAS groups were 15 and 10% (p = 0.48), and 30-day readmission rates were 0 and 1.3% (p = 1.00), respectively. As for mortality, one patient in the traditional group died and none in the ERAS group (p = 0.34). CONCLUSION: Modified ERAS protocols for obstructive colorectal cancer reduced hospital stay without adversely affecting morbidity, indicating that ERAS protocols are feasible for patients with obstructive colorectal cancer.

Hemodynamics of mesenteric traction syndrome measured by FloTrac sensor.

BACKGROUND: Mesenteric traction syndrome (MTS) develops in the early phase of laparotomy, which is triggered by pulling of the mesentery. We attempted to analyze the circulatory dynamics of MTS by using the FloTrac sensor. METHODS: Prospective randomized control study, the MTS trial, was conducted with or without prophylactic administration of flurbiprofen axetil in order to control MTS development in 57 elective open colorectal surgeries. None of the Flurbipurofen group patients (n = 23) develop MTS and were allocated to the non-MTS group. Among the non-flurbiprofen group, 28 patients (82%) developed MTS and were categorized into the MTS group. For these patients, in addition to blood pressure, stroke volume variation (SVV) and systemic vascular resistance index (SVRI) were measured by FloTrac sensor. RESULTS: The lowest blood pressure was noted within 30 minutes from the beginning of the intra-abdominal examination; in the non-MTS group, the mean blood pressure decreased by 16.7%, and in the MTS group, it decreased by 34.2% (P < .01). SVV of the 28 MTS patients was as follows: <9% in 10 patients (35.7%), >9% and <13% in 8 patients (28.6%), and >13% in 10 patients (35.7%). SVRI rose in the non-MTS group by 5.1%, whereas it fell in the MTS group by 15.1% (P < .01), indicating the close relationship between MTS and SVRI. CONCLUSIONS: The SVV results indicate that fluid loading is not that optimal treatment against hypotension of MTS and that it is also important to consider the use of a vasoconstrictor. FloTrac is therefore useful for making an appropriate decision on the treatment strategy for MTS.

The postoperative patient-reported quality of recovery in colorectal cancer patients under enhanced recovery after surgery using QoR-40.

BACKGROUND: Enhanced recovery after surgery (ERAS) protocols may reduce postoperative complications and the length of hospital stay. Studies of the effectiveness of ERAS should include not only doctor-reported outcomes, but also patient-reported outcomes, in order to better estimate their impact on recovery. However, patient-reported outcomes are not commonly reported. Thus, it needs to be assessed whether early discharge from the hospital is compatible with a better outcome from the viewpoint of the patients themselves. METHODS: The 40-item quality of recovery score (QoR-40) is a recovery-specific, and patient-rated questionnaire, which provides a good measurement of early postoperative recovery. Ninety-four colorectal cancer patients undergoing surgery under ERAS protocol management were asked to answer QoR-40 questionnaires preoperatively and on post-operative day (POD) 1, 3, 6 and one month after surgery. RESULTS: The median (25th, 75th percentiles) preoperative global QoR-40 scores as an indicator of the baseline health status, was 189 (176.75, 197). On POD1 and POD3, the scores had decreased significantly to 154 (132.5, 164.25) and 177 (161.75, 190), respectively. On POD 6, the score dramatically recovered up to 183.5 (167.9, 191), which was not significantly different from the baseline level (p = 0.06). The scores at 1 month after surgery were 190 (176, 197). Younger patients, compared to older patients, and rectal cancer patients, compared to colon cancer patients, had significantly lower scores on POD1. CONCLUSION: This study clearly demonstrated that the quality of recovery based on patient-reported outcomes is in agreement with discharge around POD6 for colorectal cancer patients under ERAS.

Enhanced recovery after surgery (ERAS) protocols for colorectal cancer in Japan.

BACKGROUND: Japan has one of the highest five-year relative survival rates for colorectal cancer in the world, with its own traditions of perioperative care and a unique insurance system. The benefits of enhanced recovery after surgery (ERAS) protocols in the Japanese population have yet to be clarified. METHODS: We evaluated 352 consecutive cases of colorectal cancer resection at Tokyo Metropolitan Bokutoh Hospital between July 2009 and November 2012. Of these, 95 cases were performed according to traditional protocols (traditional group), and 257 according to ERAS protocols (ERAS group), which were introduced to the hospital in July 2010. Primary endpoints included length of postoperative hospital stay, postoperative short-term morbidity, and rate of readmission within 30 days. Intensive pre-admission counselling, no pre- and postoperative fasting (provision of oral nutrition), avoidance of sodium/fluid overload, intraoperative warm-air body heating, enforced postoperative mobilization, and multimodal team care were among the main changes brought about by the introduction of ERAS protocols. RESULTS: The median (interquartile range) length of postoperative hospital stay was 10 (10-12.75) days in the traditional group and seven (6-8) days in the ERAS group, i.e., a three-day reduction (p < 0.05) in the ERAS group. Moreover, the proportion of patients discharged within one week dramatically increased from 1 % to 77 % in the ERAS group. The overall incidence of grade 2 and 3 postoperative complications according to the Clavien-Dindo classification was 9.5 % in the traditional group and 9.3 % in the ERAS group, and 30-day readmission rates were 8.3 % and 6.6 % in the traditional and ERAS groups, respectively. There were no significant differences between the two groups. Although operative time and blood loss did not differ significantly between the two groups, the volume of intraoperative infusion was significantly decreased in the ERAS group (p < 0.05), possibly due to ERAS recommendations to avoid dehydration (i.e., avoidance of sodium/fluid overload, no preoperative fasting). CONCLUSION: ERAS protocols for colorectal surgery helped reduce the length of postoperative hospital stay without adversely affecting morbidity, indicating that ERAS protocols are feasible and effective in Japanese settings as well.

[The preventive effect of flurbiprofen on preventing mesenteric traction syndrome].

BACKGROUND: Mesenteric traction syndrome (MTS) is associated with facial flushing, hypotension and tachycardia. The ways to treat MTS are fluid replacement, administration of vasopressors and nonsteroidal anti-inflammatory drugs (NSAIDs) such as flurbiprofen. In order to stabilize the hemodynamics during operation, preventing MTS is more reasonable. Thus, we investigated the preventive effect of flurbiprofen on MTS, the only injectable formulation which can be used in Japan. METHODS: In a prospective randomized study, 24 patients undergoing elective colorectal surgery were assigned to two groups. In one group (n = 11 group F), flurbiprofen (1 mg x kg(-1), 50 mg max) was administered before surgery. In the second group (n = 13; group C), flurbiprofen was not administered. After laparotomy, presence of facial flushing and blood pressure reduction were compared. MTS is defined as facial flushing with concomitant blood pressure reduction. RESULTS: MTS occurred in no patients in group F, but in 11 patients in group C (84.6%, P < 0.05). In cases of the patients in which MTS appeared, facial flushing was observed at 5.9 +/- 5.2 min after starting mesenteric manipulation, and the mean reduction in blood pressure was 40.3% at 9.9 +/- 4.4 min after starting mesenteric manipulation. CONCLUSIONS: Our results indicate that pretreatment with flurbiprofen might prevent MTS.

[Perioperative quality of life in patients who received "Bokutoh enhanced recovery after surgery" protocol management].

BACKGROUND: After introducing "BOKUTOH enhanced recvery after surgery (ERAS)" protocol for colorectal surgery in our hospital, the hospital stay after surgery was reduced from 10 days to 7. However, the patients' quality of life (QOL) throughout the perioperative period was not quantified. We assessed the QOL of these patients by using QoR-40J and SF-36v2J (Japanese versions of QoR-40 and SF-36v2) questionnaires. METHODS: Twenty-seven colorectal cancer patients undergoing surgery and "BOKUTOH ERAS" protocol management were asked to answer both QoR-40 J and SF-36v2J questionnaires pre- and post-operatively. The scores were evaluated by using Mann-Whitney U-test. RESULTS: From preoperative score (183.5), the scores of QoR-40 J differed significantly on post-operating day (POD) 1 and POD3 (150.9 [15.7] and 168.1 [17.5] points, respectively). Before leaving the hospital (POD6) and after one month from surgery, both QoR40 J and SF-36v2J scores were similar to preoperative ones. CONCLUSIONS: Under "BOKUTOH ERAS" protocol management, patients who had had colorectal surgery were able to recover their QOL within 6 days. Thus, leaving hospital by 7 days after surgery was appropriate to our patients.

[Combined use of the Airway Scope and gum elastic bougie for tracheal intubation in a patient with an epiglottic cyst].

A 71-year-old man with sigmoid colon cancer was scheduled for the sigmoidectomy under general anesthesia. In preoperative examination, an epiglottic cyst was found accidentally. He had no subjective symptom. Rapid induction with remifentanil, propofol, rocuronium and ephedrine was performed, and the mask ventilation was easy. The Airway Scope (AWS) was inserted at first, but it was difficult to intubate because of the epiglottic cyst. Then a gum elastic bougie (GEB) was inserted under observation by AWS monitor. GEB was passed into the trachea, and the tube was passed over the GEB into the trachea. Combined use of AWS and GEB is useful for endotracheal intubation in a patient with a epiglottic cyst.

[Introduction of enhanced recovery after surgery (ERAS) protocols: reducing 3.4 days of postoperative hospital stay].

BACKGROUND: Enhanced recovery after surgery (ERAS) protocols aim to improve patient care, reducing complication rates, and shortening hospital stay following colorectal surgery in Europe. In cooperation with colorectal surgeons, ERAS protocols were initially introduced in our hospital to the patients undergoing open colorectal resection in July 2010. METHODS: Length of postoperative hospital stay was compared of 139 consecutive patients undergoing open colorectal resection before (n = 96) and immediately after implementing ERAS (n = 43). RESULTS: In the ERAS group, length of postoperative hospital stay was significantly reduced from 12.7 +/- 7.7 to 9.3 +/- 6.2 days (P < 0.0001). Oral intake, one of important ERAS elements, both before and after surgery had dramatically changed, implying tolerance of ERAS protocol in Japan. CONCLUSIONS: We, anesthesiologists as perioperative physicians, can improve key elements of perioperative care such as patients' counseling, perioperative analgesia and early mobilization by collaboration with surgeons and nurses, to facilitate postoperative recovery.

[Change of surgeons' opinion against anesthesiologists after introduction of enhanced recovery after surgery (ERAS) protocols: questionnaire survey among surgeons who participated ERAS care].

BACKGROUND: Enhanced recovery after surgery (ERAS) protocols aim to improve patient care, reducing complication rates, and shortening hospital stay following colorectal surgery in Europe. In cooperation of colorectal surgeons and anesthesiologists, ERAS protocols were initially introduced in our hospital to the patients who underwent open colorectal resection in July 2010. METHODS: Using a questionnaire, we surveyed the change of surgeons' opinion against anesthesiologists after introduction of ERAS among 15 surgeons at Metropolitan Bokutoh hospital. RESULTS: Surgeons realized that introduction of ERAS made strong communication between surgeons and anesthesiologists. And they also thought it is not surgeons themselves nor anesthesiologists themselves but 'team care' which could produce positive outcome of ERAS. CONCLUSIONS: Introduction of ERAS as collaboration of surgeons and anesthesiologists resulted in facilitating communication of surgeons and anesthesiologists.

[Rosai-Dorfman disease accompanying hypertrophic cranial pachymeningitis with an early symptom of right peripheral facial palsy].

We experienced a rare case of sinus histiocytosis with massive lymphoadenopathy (Rosai-Dorfman disease) accompanying hypertrophic cranial pachymeningitis. The patient is a 64-year-old woman with an early symptom of rt. peripheral facial palsy. She had a 4-month history of headache with a 5-week history of numbness in the rt. supraorbital nerve area, and lost her weight by 10 kg in 2 months. She developed rt. trochlea nerve palsy and numbness in the lt. mandibular nerve area. Laboratory findings showed that ALP, LDH and CRP were higher than normal. Of CT, MRI and MRA, the images of her head were normal. However, the Gd-enhanced MRI only showed a diffuse pachymeningeal enhancement. After about 3 months from the onset of rt. peripheral facial palsy, she died of DIC of unknown etiology. As a result of examinations in anatomical pathology, she was diagnosed as having sinus histiocytosis with massive lymphoadenopathy (Rosai-Dorfman disease). There were a large number of histiocytes on the pachymeninx. These findings suggest that hypertrophic cranial pachymeningitis caused multiple cranial neuropathy. We emphasize that use of Gd-enhanced MRI in the early stage is important for diagnosis.