Increased age and the volume of intraoperative fluid administered predict urinary retention after elective inguinal herniorrhaphy.

BACKGROUND: Inguinal hernia repair (IHR) is a common surgical procedure worldwide. Although IHR can be performed by the minimally invasive method, which accelerates recovery, postoperative urinary retention (POUR) remains a common complication that significantly impacts patients. Thus, it is essential to identify the risk factors associated with POUR to diminish its negative impact. METHODS: We conducted a single-center retrospective review of elective IHR from 2018 to 2021. POUR was defined as the postoperative use of straight catheter or placement of an indwelling catheter to relieve the symptoms. Adjusted multivariate regression analysis was performed to address the associations of clinicodemographic, surgical, and intraoperative factors with POUR. RESULTS: A total of 946 subjects were included in the analysis after excluding cases of emergent surgery, recurrent hernia, or concomitant operations. The median age was 68.4 years, and 92.0% of the patients were male. Twenty-three (2.4%) patients developed POUR. In univariate analysis, POUR in comparison with non-POUR was significantly associated with increased age (72.2 versus 68.3 years, P = 0.012), a greater volume of intraoperative fluid administered (500 versus 400 ml, P = 0.040), and the diagnosis with benign prostate hypertrophy (34.8% versus 16.9%, P = 0.025). In the multivariate model, both increased age (odds ratio [OR] 1.04, 95% CI 1.01-1.08; P = 0.049) and a greater volume of intraoperative fluid administered (OR 1.12 per 100-mL increase, 95% CI 1.01-1.27; P = 0.047) were significantly associated with the occurrence of POUR. CONCLUSIONS: We found that increased age and a greater volume of intraoperative fluid administered were significantly associated with the occurrence of POUR. Limiting the administration of intraoperative fluid may prevent POUR. From the perspective of practical implications, specific guidelines or clinical pathways should be implemented for fluid management and patient assessment.

Recovery of cardiac electrophysiological alterations by heart rate complexity based on multiscale entropy following liver transplantation.

Autonomic nervous dysfunction is a known cardiac sequalae in patients with end-stage liver disease and is associated with a poor prognosis. Heart rate analysis using nonlinear models such as multiscale entropy (MSE) or complexity may identify marked changes in these patients where conventional heart rate variability (HRV) measurements do not. To investigate the application of heart rate complexity (HRC) based on MSE in liver transplantation settings. Thirty adult recipients of elective living donor liver transplantation were enrolled. HRV parameters using conventional HRV analysis and HRC analysis were obtained at the following time points: (1) 1 day before surgery, (2) postoperative day (POD) 7, (3) POD 14, (4) POD 90, and (5) POD 180. Preoperatively, patients with MELD score ≥ 25 had significantly lower HRC compared to patients with lower MELD scores. This difference in HRC disappeared by POD 7 following liver transplantation and subsequent analyses at POD 90 and 180 continued to show no significant difference. Our results indicated a significant negative correlation between HRC based on MSE analysis and liver disease severity preoperatively, which may be more sensitive than conventional linear HRV analysis. HRC in patients with MELD score ≧ 25 improved over time and became comparable to those with MELD < 25 as early as in 7 days.

Immunocyte profiling changes in patients received epidural versus intravenous analgesia after pancreatectomy: A randomized controlled trial.

BACKGROUND: Perioperative immunosuppressants, such as surgical stress and opioid use may downregulate anti-cancer immunocytes for patients undergoing pancreatectomy. Thoracic epidural analgesia (TEA) may attenuate these negative effects and provide better anti-cancer immunocyte profile change than intravenous analgesia using opioid. METHODS: We randomly assigned 108 adult patients undergoing pancreatectomy to receive one of two 72-h postoperative analgesia protocols: one was TEA, and the other was intravenous patient-controlled analgesia (IV-PCA). The perioperative proportional changes of immunocytes relevant to anticancer immunity-namely natural killer (NK) cells, cytotoxic T cells, helper T cells, mature dendritic cells, and regulatory T (Treg) cells were determined at 1 day before surgery, at the end of surgery and on postoperative day 1,4 and 7 using flow cytometry. In addition, the progression-free survival and overall survival between the two groups were compared. RESULTS: After surgery, the proportions of NK cells and cytotoxic T cells were significantly decreased; the proportion of B cells and mature dendritic cells and Treg cells were significantly increased. However, the proportions of helper T cells exhibited no significant change. These results were comparable between the two groups. Furthermore, there were no significant differences in progression-free survival (52.75 [39.96] and 57.48 [43.66] months for patients in the TEA and IV-PCA groups, respectively; p = 0.5600) and overall survival (62.71 [35.48] and 75.11 [33.10] months for patients in the TEA and IV-PCA groups, respectively; p = 0.0644). CONCLUSIONS: TEA was neither associated with favorable anticancer immunity nor favorable oncological outcomes for patients undergoing pancreatectomy.

Comparisons in analgesic effects between ultrasound-guided erector spinae plane block and surgical intercostal nerve block after video-assisted thoracoscopic surgery: A randomized controlled trial.

STUDY OBJECTIVE: This study aimed to compare the analgesic effects of anesthesiologist-administrated erector spinae plane block (ESPB) and surgeon-administrated intercostal nerve block (ICNB) following video-assisted thoracoscopic surgery (VATS). DESIGN: Randomized, controlled, double-blinded study. SETTING: Operating room, postoperative recovery room and ward in two centers. PATIENTS: One hundred patients, ASA I-III and scheduled for elective VATS. INTERVENTIONS: The anesthesiologist-administrated ESPB under ultrasound guidance or surgeon-administrated ICNB under video-assisted thoracoscopy was randomly provided during VATS. Regular oral non-opioid analgesic combined with intravenous rescue morphine were prescribed for multimodal analgesia after surgery. MEASUREMENTS: The primary outcomes were the pain score and morphine consumption during 48 h after surgery. Postoperative pain intensity were assessed using the 10-cm visual analogue scale at 1 h, 24 h, and 48 h after surgery. Morphine consumption at these time points was compared between the two study groups. Furthermore, oral weak opioid rescue analgesic was also provided at 24 h after surgery. Postoperative quality of recovery at 24 h was also assessed using the QoR-15 questionnaire, along with duration of chest tube drainage and hospital stay were compared as secondary outcomes. MAIN RESULTS: Patients in the two study groups had comparable baseline characteristics, and surgical types were also similar. Postoperative VAS changes at 1 h, 24 h, and 48 h after surgery were also comparable between the two study groups. Both groups had low median scores (<4.0) at all time points (all p > 0.05). Patients in the ESPB group required statistically non-significant higher 48-h morphine consumption [3 (0-6) vs. 0 (0-6) mg in the ESPB group and ICNB group respectively; p = 0.135] and lower numbers of oral rescue analgesic (0.4 ± 1.2 vs. 1.0 ± 1.8 in the ESPB group and ICNB group respectively; p = 0.059). Additionally, patients in the two study groups had similar QoR15 scores and lengths of hospital stay. CONCLUSIONS: Both anesthesiologist-administered ultrasound-guided ESPB and surgeon-administered VATS ICNB were effective analgesic techniques for patients undergoing VATS for tumor resection.

Efficacy of intraoperative thoracoscopic intercostal nerve blocks in nonintubated and intubated video-assisted thoracic surgery: A randomized study.

BACKGROUND: The efficacy of thoracoscopic intercostal nerve blocks (TINBs) for noxious stimulation from video-assisted thoracic surgery (VATS) remains unclear. The efficacy of TINBs may also be different between nonintubated VATS (NIVATS) and intubated VATS (IVATS). We aim to compare the efficacy of TINBs on analgesia and sedation for NIVATS and IVATs intraoperatively. METHODS: Sixty patients randomized to the NIVATS or IVATS group (30 each) received target-controlled propofol and remifentanil infusions, with bispectral index (BIS) maintained at 40-60, and multilevel (T3-T8) TINBs before surgical manipulations. Intraoperative monitoring data, including pulse oximetry, mean arterial pressure (MAP), heart rate, BIS, density spectral arrays (DSAs), and propofol and remifentanil effect-site concentration (Ce) at different time points. A two way ANOVA with post hoc analysis was applied to analyze the differences and interactions of groups and time points. RESULTS: In both groups, DSA monitoring revealed burst suppression and α dropout immediately after the TINBs. The Ce of the propofol infusion had to be reduced within 5 min post-TINBs in both NIVATS (p < 0.001) and IVATS (p = 0.252) groups. The Ce of remifentanil infusion was significantly reduced after TINBs in both groups (p < 0.001), and was significantly lower in NIVATS (p < 0.001) without group interactions. CONCLUSION: The surgeon-performed intraoperative multilevel TINBs allow reduced anesthetic and analgesic requirement for VATS. With lower requirement of remifentanil infusion, NIVATS presents a significantly higher risk of hypotension after TINBs. DSA is beneficial for providing real-time data that facilitate the preemptive management, especially for NIVATS.

Effects of Goal-Directed Hemodynamic Therapy Using a Noninvasive Finger-Cuff Monitoring Device on Intraoperative Cerebral Oxygenation and Early Delayed Neurocognitive Recovery in Patients Undergoing Beach Chair Position Shoulder Surgery: A Randomized Controlled Trial.

BACKGROUND: Perioperative cerebral desaturation events (CDEs) and delayed neurocognitive recovery are common among patients undergoing beach chair position (BCP) shoulder surgery and may be caused by cerebral hypoperfusion. This study tested the hypothesis that the application of goal-directed hemodynamic therapy (GDHT) would attenuate these conditions. METHODS: We randomly assigned 70 adult patients undergoing BCP shoulder surgery to GDHT group or control at a 1:1 ratio. Cerebral oxygenation was monitored using near-infrared spectroscopy, and GDHT was administered using the ClearSight pulse wave analysis system. The primary outcome was CDE duration, whereas the secondary outcomes were CDE occurrence, delayed neurocognitive recovery occurrence, and Taiwanese version of the Quick Mild Cognitive Impairment (Qmci-TW) test score on the first postoperative day (T 2 ) adjusted for the baseline score (on the day before surgery; T 1 ). RESULTS: CDE duration was significantly shorter in the GDHT group (0 [0-0] vs 15 [0-75] min; median difference [95% confidence interval], -8 [-15 to 0] min; P = .007). Compared with the control group, fewer patients in the GDHT group experienced CDEs (23% vs 51%; relative risk [95% confidence interval], 0.44 [0.22-0.89]; P = .025) and mild delayed neurocognitive recovery (17% vs 40%; relative risk [95% confidence interval], 0.60 [0.39-0.93]; P = .034). The Qmci-TW scores at T 2 adjusted for the baseline scores at T 1 were significantly higher in the GDHT group (difference in means: 4 [0-8]; P = .033). CONCLUSIONS: Implementing GDHT using a noninvasive finger-cuff monitoring device stabilizes intraoperative cerebral oxygenation and is associated with improved early postoperative cognitive scores in patients undergoing BCP shoulder surgery.

Changes in the quick mild cognitive impairment test over time: A normative study in an adult sample in Taiwan.

BACKGROUND: The Quick Mild Cognitive Impairment (Qmci) test has been suggested to be an easy-to-use and precise screening tool for detecting postoperative cognitive dysfunction (POCD). To provide essential information for future POCD studies in Taiwan, the present study provided data regarding the Taiwan version of the Qmci (Qmci-TW) test conducted in the normative Taiwanese population and changes in them over time. METHODS: The present study recruited adult native Taiwanese volunteers without known neurologic or psychiatric diseases. All enrolled participants received protocolized serial Qmci-TW test at baseline, 2-day follow-up, and 6-month follow-up. RESULTS: In total, 30 participants, 15 men and 15 women, were enrolled in this study. The baseline Qmci-TW score ranged from 55 to 80, with a mean of 68.9 and a standard deviation (SD) of 7. At 2-day follow-up, the mean Qmci-TW test score was significantly higher (by 5.3; SD = 7.3) than that at baseline (P = 0.001). At 6-month follow-up, the mean Qmci-TW score was 71.3 (SD = 6.1), with no significant difference compared with that at baseline. The decline in Qmci-TW scores by > 9 points on postoperative day 1 and by > 11 points at 6-month follow-up was the criterion for POCD. CONCLUSION: The present study provided data regarding the Qmci-TW test conducted in the normative Taiwanese population and its time trajectory during the 6-month follow-up.

Influence of scalp block on oncological outcomes of high-grade glioma in adult patients with and without isocitrate dehydrogenase-1 mutation.

High-grade gliomas are notorious for a high recurrence rate even after curative resection surgery. Studies regarding the influence of scalp block on high-grade gliomas have been inconclusive, possibly because the condition's most important genetic mutation profile, namely the isocitrate dehydrogenase 1 (IDH1) mutation, had not been analyzed. Therefore, we conducted a single-center study including patients with high-grade glioma who underwent tumor resection between January 2014 and December 2019. Kaplan-Meier survival analysis revealed that scalp block was associated with longer progression-free survival (PFS; 15.17 vs. 10.77 months, p = 0.0018), as was the IDH1 mutation (37.37 vs. 10.90 months, p = 0.0149). Multivariate Cox regression analysis revealed that scalp block (hazard ratio: 0.436, 95% confidence interval: 0.236-0.807, p = 0.0082), gross total resection (hazard ratio: 0.405, 95% confidence interval: 0.227-0.721, p = 0.0021), and IDH1 mutation (hazard ratio: 0.304, 95% confidence interval: 0.118-0.784, p = 0.0138) were associated with better PFS. Our results demonstrate that application of scalp block, regardless of IDH1 profile, is an independent factor associated with longer PFS for patients with high-grade glioma.

Accuracy of dynamic preload variables for predicting fluid responsiveness in patients with pediatric liver cirrhosis: A prospective study.

BACKGROUND: We have previously reported that dynamic preload variables predicted fluid responsiveness in adult patients with liver cirrhosis. However, pediatric patients with cirrhosis may present with unique hemodynamic characteristics, and therefore, the predictive accuracy of these variables in such patients must be clarified. AIMS: To investigate the accuracy of dynamic preload variables for predicting fluid responsiveness in pediatric patients with cirrhosis. METHODS: A total of 27 pediatric patients with cirrhosis undergoing orthotopic liver transplantation were enrolled in this study. Patients' pulse pressure variation, stroke volume variation, stroke volume index, and central venous pressure were measured using the calibrated pulse contour cardiac output system. The plethysmographic variability index was measured using a Masimo Radical 7 co-oximeter. During the hepatic dissection phase of the surgery, repeated intraoperative fluid challenges with 10 mL kg-1 of crystalloid within 15 minutes were administered. Fluid responsiveness was defined as an increase in stroke volume index of ≥15% after fluid challenge. RESULTS: A total of 61 fluid challenges were administered resulting in 15 fluid responders and 46 fluid nonresponders. Fluid challenge induced significant decreases in all three dynamic preload variables but not in the fluid nonresponders. However, the area under the receiver operating characteristic curves for pulse pressure variation, stroke volume variation, plethysmographic variability index, and central venous pressure for predicting fluid responsiveness were 0.67 (95% confidence interval: 0.52-0.82; P = .0255), 0.68 (95% confidence interval: 0.54-0.83; P = .0140), 0.56 (95% confidence interval: 0.40-0.71; P = .4724), and 0.57 (95% confidence interval: 0.40-0.74; P = .4192), respectively. CONCLUSIONS: Dynamic preload variables do not predict fluid responsiveness in pediatric patients with liver cirrhosis.

Non-intubated thoracoscopic surgery for lung cancer in patients with impaired pulmonary function.

BACKGROUND: Patients with impaired lung function or chronic obstructive pulmonary disease (COPD) are considered high-risk for intubated general anesthesia, which may preclude them from surgical treatment of their lung cancers. We evaluated the feasibility of non-intubated video-assisted thoracoscopic surgery (VATS) for the surgical management of lung cancer in patients with impaired pulmonary function. METHODS: From August 2009 to June 2015, 28 patients with impaired lung function (preoperative forced expiratory volume in 1 second <70% of the predicted value) underwent non-intubated VATS using a combination of thoracic epidural anesthesia or intercostal nerve block, and intra-thoracic vagal block with target-controlled sedation. RESULTS: Eighteen patients had primary lung cancers, 4 had metastatic lung cancers, and 6 had non-malignant lung tumors. In the patients with primary lung cancer, lobectomy was performed in 4, segmentectomy in 3 and wedge resection in 11, with lymph node sampling adequate for staging. One patient required conversion to intubated one-lung ventilation because of persistent wheezing and labored breathing. Five patients developed air leaks more than 5 days postoperatively while subcutaneous emphysema occurred in 6 patients. Two patients developed acute exacerbations of pre-existing COPD, and new-onset atrial fibrillation after surgery occurred in 1 patient. The median duration of postoperative chest tube drainage was 3 days while the median hospital stay was 6 days. CONCLUSIONS: Non-intubated VATS resection for pulmonary tumors is technically feasible. It may be applied as an alternative to intubated general anesthesia in managing lung cancer in selected patients with impaired pulmonary function.

Nonintubated laryngomicrosurgery with Transnasal Humidified Rapid-Insufflation Ventilatory Exchange: A case series.

BACKGROUND: Nonintubation anaesthesia for laryngomicrosurgery (LMS) provides both excellent visualization of the surgical field and complete examination on vocal cord. However, adequate oxygenation remains challenging during nonintubated LMS. Recently, transnasal humidified rapid-insufflation ventilator exchange (THRIVE) has been reported effectively maintaining apneic oxygenation in patient with difficult airways. The feasibility and safety of nonintubated LMS with THRIVE was evaluated in this case series. METHODS: From September 2016 to February 2017, a total of 23 patients receiving nonintubated LMS were included. Anaesthesia was induced and maintained through target-controlled propofol infusion and muscle relaxation with THRIVE oxygen support. Perioperative data were collected from medical records and analysed. RESULTS: The mean (±SD) duration of the operation was 12.4 (±4.4) min. The mean (±SD) total anaesthesia time (from induction to emergence) was 24.1 (±6.4) min. 22 patients received nonintubated LMS with surgical satisfaction without intraoperative desaturation. One patient who underwent laryngeal tumour biopsy experienced a single episode of desaturation. A 5.5-mm tracheal tube was needed for short-term mechanical ventilation to regain SpO2 to 100%. No significant complication was noted in all patients. All patients discharged as per schedule on the next day after surgery as intubated LMS patients in our hospital. CONCLUSION: Nonintubated LMS with THRIVE is a feasible and safe alternative to intubated LMS with a small size tracheal tube to provide a better surgical field. However, for patients with easy-bleeding tumor, intubated LMS remains suggestive for better airway protection.

Intraoperative multiple intercostal nerve blocks exert anesthetic-sparing effect: A retrospective study on the effect-site concentration of propofol infusion in nonintubated thoracoscopic surgery.

OBJECTIVE(S): Less general anesthetic is required in patients with regional blocks than in those without, as assessed through commonly used anesthesia monitoring parameters such as blood pressure, heart rate, and bispectral index (BIS). Although intraoperative regional anesthesia has become more widely adopted, few studies have confirmed or monitored its anesthetic-sparing effects. Using recent reports of nonintubated video-assisted thoracoscopic surgery (VATS) by BIS-targeted propofol infusion and intraoperative multilevel thoracoscopic intercostal nerve blocks (TINBs), this retrospective study investigated whether the anesthetic-sparing effect can be realized by reducing the effect-site concentration (Ce) to the targeted BIS level or by reducing the blood pressure at the onset of regional blocks. METHODS: A retrospective study of a prospectively collected case series of non-intubated VATS. RESULTS: Data on 56 adult patients who underwent nonintubated VATS were collected and analyzed. The mean operative time was 121 ± 32 minutes. BIS levels before and after one-lung ventilation/TINBs and surgery were 48% ± 11% and 47% ± 12%, respectively. The Ce of propofol infusion decreased significantly from 3.4 ± 0.8 µg/mL to 3.0 ± 0.7 µg/mL (p < 0.01) after surgery with TINBs. Blood pressure did not change significantly, whereas the heart rate increased moderately but significantly (77 ± 14 beats/minute to 82 ± 15 beats/minute, p < 0.01). CONCLUSION: With comparable BIS and blood pressure in the subsequent surgical procedure, the adequacy of anesthesia and the anesthetic component provided by intraoperative TINBs and vagal nerve could be monitored adequately. The anesthetic-sparing effect of intraoperative nerve blocks can be realized when the Ce of propofol infusion was reduced to the target BIS level.

Evaluation of cardiac output by bioreactance technique in patients undergoing liver transplantation.

BACKGROUND: This study compared the cardiac output (CO) obtained from PiCCO with that obtained from the noninvasive NICOM method. METHODS: Twenty-one cirrhotic patients receiving liver transplantation were enrolled. During the operation, their CO was measured by the PiCCO system via the thermodilution method as the standard and by the NICOM method. Two parameters including cardiac index (CI) and stroke volume index (SVI) were collected simultaneously at three phases during the surgery including the dissection phase (T1), the anhepatic phase (T2), and the reperfusion phase (T3). Correlation, Bland and Altman methods, and linear mixed model were used to evaluate the monitoring ability of both systems. RESULTS: Poor correlation was noted between the data measured by NICOM and PiCCO; the correlation coefficients for CI and SVI measured between the two systems were 0.32 and 0.39, respectively. Bland and Altman analysis showed the percentage error of CI as 63.7%, and that of SVI as 66.6% for NICOM compared to PiCCO. Using the linear mixed model, the CI and SVI measured using NICOM were significantly higher than those using PiCCO (estimated regression coefficient 0.92 and 10.77, both p < 0.001). Mixed model analysis showed no differences between the trends of CI and SVI measured by the two methods. CONCLUSIONS: NICOM provided a comparable CI and SVI trend when compared to the gold standard PiCCO, but it raises concerns as an effective CO monitor because of its tendency to overestimate CI and SVI especially during the state of high cardiac output.

Nonintubated thoracoscopic lobectomy for lung cancer using epidural anesthesia and intercostal blockade: a retrospective cohort study of 238 cases.

Intubated general anesthesia with single-lung ventilation has been considered mandatory for thoracoscopic lobectomy for nonsmall cell lung cancer. Few reports of thoracoscopic lobectomy without tracheal intubation are published, using either thoracic epidural anesthesia (TEA) or intercostal blockade. The comparisons of perioperative outcomes of nonintubated thoracoscopic lobectomy using epidural anesthesia and intercostal blockade are not reported previously. From September 2009 to August 2014, a total of 238 patients with lung cancer who underwent nonintubated thoracoscopic lobectomy were recruited from our prospectively maintained database of all patients undergoing nonintubated thoracoscopic surgery using TEA or intercostal blockade. A multiple regression analysis, adjusting for preoperative variables, was performed to compare the perioperative outcomes of the 2 anesthesia methods. Overall, 130 patients underwent nonintubated thoracoscopic lobectomy using epidural anesthesia whereas 108 had intercostal blockade. The 2 groups were similar in demographic data, except for sex, preoperative lung function, physical status classification, and history of smoking. After adjustment for the preoperative variables, nonintubated thoracoscopic lobectomy using intercostal blockade was associated with shorter durations of anesthetic induction and surgery (P < 0.001). Furthermore, hemodynamics were more stable with less use of vasoactive drugs (odds ratio: 0.53; 95% confidence interval [CI], 0.27 to 1.04; P = 0.064) and less blood loss (mean difference: -55.2 mL; 95% CI, -93 to -17.3; P = 0.004). Postoperatively, the 2 groups had comparable incidences of complications. Patients in the intercostal blockade group had a shorter average duration of chest tube drainage (P = 0.064) but a similar average length of hospital stay (P = 0.569). Conversion to tracheal intubation was required in 13 patients (5.5%), and no in-hospital mortality occurred in either group. Nonintubated thoracoscopic lobectomy using either epidural anesthesia or intercostal blockade is feasible and safe. Intercostal blockade is a simpler alternative to epidural anesthesia for nonintubated thoracoscopic lobectomy in selected patients with lung cancer.

Nonintubated uniportal thoracoscopic surgery for peripheral lung nodules.

BACKGROUND: Uniportal video-assisted thoracoscopic surgery (VATS) has recently been introduced for various thoracic diseases. However, management of peripheral lung nodules by uniportal VATS without tracheal intubation has rarely been attempted. We evaluated the feasibility and safety of nonintubated uniportal VATS for peripheral lung nodules. METHODS: From January to March 2014, 32 patients with indeterminate peripheral lung nodules underwent uniportal VATS without tracheal intubation using a combination of intercostal nerve block, intrathoracic vagal block, and target-controlled sedation. Computed tomography-guided dye localization was sometimes used to identify small or ground-glass opacity lesions. RESULTS: A definite diagnosis was obtained in all 32 patients. A wedge resection was performed in 31 patients and a lobectomy in 1. Conversion to nonintubated multiport VATS was required in 4 patients (13%), in 3 because of primary lung cancer requiring further resection for adequacy of margins and in 1 because of difficulty in identifying a small nodule. Conversion to intubated 1-lung ventilation was required in 1 patient (3%) because of vigorous mediastinal movement. Operative complications developed in 2 patients who had air leaks for more than 3 days postoperatively. The median durations of postoperative chest tube drainage and hospital stay were 1 and 3 days, respectively. Postoperative neuralgia that required occasional use of analgesics occurred in only 1 patient (3%), and 97% of patients were very satisfied or satisfied with the resulting scars at 1 month. CONCLUSIONS: Nonintubated uniportal VATS is technically feasible and safe for selected patients and is a less invasive alternative in managing indeterminate peripheral lung nodules.

New 6% hydroxyethyl starch 130/0.4 does not increase blood loss during major abdominal surgery - a randomized, controlled trial.

BACKGROUND/PURPOSE: Ideal fluid management during surgery still poses a clinical dilemma gauging the benefits and adverse effects. This randomized controlled trial compared the tissue perfusion and coagulation profiles under clinically equivalent hydroxyethyl starch (HES 130/0.4) and lactated Ringer's solution (LR). METHODS: Eighty-four patients undergoing major abdominal surgery were randomized to receive either HES or LR. Tissue perfusion parameters using heart rate, arterial blood pressure, central venous pressure, cardiac index, stroke volume index, and central venous oxygen saturation were measured at T0 (baseline), T1 (start of surgery), T2 (1 hour after start of surgery), and T3 (end of surgery). Coagulation parameters using thrombelastography (TEG) were measured at T0 (baseline), T4 (after 15 mL/kg fluid transfused), and T5 (24 hours after baseline). RESULTS: The total amount of fluid administrated was 1547.9 ± 424.0 mL in HES group and 2303.1 ± 1033.7 mL in LR group (p < 0.001). The parameters of tissue perfusion and TEG did not differ significantly between groups at any time point except for a transient decrease in clot kinetic and clot strength at T4 for HES group. There was no significant difference in blood loss and consumption of blood products between the two fluids. CONCLUSION: HES 130/0.4 is a more efficient intravascular volume expander to maintain tissue perfusion than conventional crystalloid. Transient hypocoagulability induced by HES 130/0.4 does not warrant excessive blood loss and blood transfusion.

Non-intubated thoracoscopic surgery using internal intercostal nerve block, vagal block and targeted sedation.

OBJECTIVES: Thoracoscopic surgery using internal intercostal nerve block, vagal block and targeted sedation without endotracheal intubation is a promising technique for selected patients, but little is known about its feasibility and safety. METHODS: We evaluated 109 patients with lung (105), mediastinal (3) or pleural (1) tumours treated using non-intubated thoracoscopic surgery. Internal, intercostal nerve block was performed at the T3-T8 intercostal level and vagal block was performed adjacent to the vagus nerve at the level of the lower trachea for right-sided operations and at the level of the aortopulmonary window for left-sided operations. Sedation was performed with propofol infusion to achieve a bispectral index value between 40 and 60. RESULTS: Thoracoscopic lobectomy was performed in 43 patients, wedge resection in 50, segmentectomy in 12 and mediastinal or pleural tumour excision in 4. Three patients (2.8%) required conversion to intubated one-lung ventilation because of vigorous mediastinal movement and dense diaphragmatic adhesions. Anaesthetic induction and operation had a median duration of 10.0 and 127.0 min, respectively. Operative complications developed in 13 patients with air leaks for more than 3 days and 1 patient required transfusion of blood products. The median postoperative chest drainage and hospital stay were 2.0 and 4.0 days, respectively. CONCLUSIONS: Non-intubated thoracoscopic surgery using internal intercostal nerve block, vagal block and targeted sedation is technically feasible and safe in surgical treatment of lung, mediastinal and pleural tumours in selected patients.

Nonintubated thoracoscopic anatomical segmentectomy for lung tumors.

BACKGROUND: Intubated general anesthesia with one-lung ventilation is considered mandatory for anatomical pulmonary resections. Nonintubated thoracoscopic segmentectomy for management of lung tumors, which is technically challenging, has not been reported previously. The goal of this study was to evaluate the feasibility and safety of thoracoscopic anatomical segmentectomy without endotracheal intubation. METHODS: From August 2009 to December 2012, 21 patients with lung tumors were treated using thoracoscopic anatomical segmentectomy without endotracheal intubation using a combination of thoracic epidural anesthesia, intrathoracic vagal blockade, and target-controlled sedation. RESULTS: There were 16 patients with primary or metastatic lung cancers and 5 patients with nonmalignant tumors. Left upper lobe apical trisegmentectomy was most commonly performed (n = 6), followed by superior segmentectomy of the right lower lobe (n = 4) and left lower lobe (n = 4). One patient required conversion to intubated single-lung ventilation because of vigorous mediastinal and diaphragmatic movement. No patient required conversion to a thoracotomy or lobectomy. Operative complications developed in 1 patient who had an air leak for more than 3 days postoperatively. The mean duration of postoperative chest tube drainage and mean hospital stay were 2.5 days and 6.0 days, respectively. Anesthetic induction and the operation required a mean 26.5 minutes and 148.0 minutes, respectively. CONCLUSIONS: Nonintubated thoracoscopic segmentectomy is technically feasible and safe. It can be an alternative to intubated single-lung ventilation for management of lung tumors in selected patients.