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.

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.

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.

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.

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.

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.

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.

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).

Proteomic analysis of plasma exosomes in patients with non-small cell lung cancer.

Background: Currently, the prognosis of patients with non-small cell lung cancer (NSCLC) remains unsatisfactory. This current study evaluated the relationship between histology of NSCLC and protein expression of exosomes in the plasma from NSCLC patients, and furthermore investigate the impact of the exosome profile on the tumor, node, metastasis (TNM) classification. Methods: Plasma samples were collected from 26 NSCLC patients before surgery. The exosomes were extracted from the plasma and liquid chromatography-mass spectrometry (LC/MS) was used to evaluate the expression of the proteins in the exosomes. Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analyses were performed using the Cytoscape 3.8.2 software. Multivariate logistic regression and receiver operating characteristic (ROC) curves were used to identify proteins which could effectively distinguish between lung adenocarcinoma and lung squamous cell carcinoma. The relationship between protein expression and the TNM stage was calculated using Spearman rank correlation. Results: The expression levels of ZSWIM9, FYB1, SERPINF1, C1orf68, MASP2, and IGHV3-72 were higher in patients with lung adenocarcinoma compared to patients with lung squamous cell carcinoma. MFGE8 was associated with the occurrence of squamous cell carcinoma. CORO1A was positively correlated with the TNM stage of the patients, and COL4A2 was negatively correlated with TNM stage. GO and KEGG analyses revealed that cholesterol metabolism was important in NSCLC development. Conclusions: Lung adenocarcinoma may be distinguished from squamous cell carcinoma by the molecular profile of exosomes in the plasma samples. And, proteomics analysis suggested that cholesterol metabolism may play an important role of cancer progress in NSCLC.

Perioperative management of thoracic surgery in patients with lymphangioleiomyomatosis.

BACKGROUND: General surgery for patients with lymphangioleiomyomatosis (LAM) is infrequent, however, general surgeons also occasionally experience it. Only a few reports have described the specific perioperative management appropriate for patients with LAM. Hence, in this case series, we aimed to investigate the surgical outcomes of LAM patients and their characteristics. CASE PRESENTATION: Medical records of 4482 patients who underwent thoracic surgery between 2009 and 2017 at our institution were assessed. Twelve patients were diagnosed with LAM. Details of the postoperative courses and surgical outcomes of LAM patients were retrospectively examined. All LAM patients were female (age 41.3 ± 10.6 years). Surgeries were performed for patients undergoing biopsy (n = 4) and those with pneumothorax (n = 3), lung cancer (n = 2), and other conditions (n = 3). The mortality rate was 0% and the length of hospital stay was 27.4 ± 8.9 days. Ten postoperative complications occurred in six patients (50%): hypoxemia (n = 5), chylothorax (n = 2), and prolonged air leakage (n = 3). CONCLUSIONS: Thoracic surgery may pose a risk of postoperative complications and long hospitalization for patients with LAM, although it lowers the risk of fatality. Management of perioperative air and chyle leakages and lymphatic stasis in the lungs is important for preventing morbidities.

Comparison of desflurane and propofol in the speed and the quality of emergence from anesthesia in patients undergoing lung cancer surgery-a prospective, randomized study.

Background: Anesthesia with desflurane or propofol enables rapid emergence. In patients undergoing lung cancer surgery, however, the speed of emergence from desflurane, but not from propofol, may be affected by the deteriorated postoperative respiratory function. We prospectively compared the speed and quality of emergence between desflurane and propofol. Methods: We conducted a parallel study. Eighty patients scheduled for lung cancer surgery were randomly allocated to Desflurane group (Group D) and Propofol group (Group P). Combined general and epidural anesthesia was performed in the identical way except for the anesthetic. Results: There was no significant difference between the groups in the time to awakening, extubation, or orientation. However, emergence agitation (EA) occurred more frequently in Group D than in Group P (20/40 vs. 4/40, P<0.001). Numbers of patients not achieving full scores in respiration and circulation components of the modified Aldrete score 5 min after extubation were more in Group D (4/40 vs. 0/40, P=0.040; and 8/40 vs. 2/40, P=0.043, respectively). More patients required antiemetics during postoperative 24 hours in Group D (15/40 vs. 7/40, P=0.045). Conclusions: Desflurane was not inferior to propofol in the speed of emergence from anesthesia after lung cancer surgery, but it was slightly inferior to propofol in the quality of emergence. Trial Registration: UMIN-CTR identifier: UMIN000009221.

Systematic analysis of ferroptosis-related long non-coding RNA predicting prognosis in patients with lung squamous cell carcinoma.

Background: Ferroptosis is a novel iron-dependent cell death, and an increasing number of studies have shown that long non-coding RNA (lncRNAs) are involved in the ferroptosis process. However, studies on ferroptosis-related lncRNAs in lung squamous cell carcinoma (LUSC) are limited. In addition, the prognostic role of ferroptosis-related lncRNAs and their relationship with the immune microenvironment and methylation of LUSC is unclear. This study aimed to investigate the potential prognostic value of ferroptosis-related lncRNAs and their involved biological functions in LUSC. Methods: The Cancer Genome Atlas (TCGA) database and the FerrDb website were used to obtain ferroptosis-related genes for LUSC. The "limma" R package and Pearson analysis were used to find ferroptosis-related lncRNAs. The biological functions of the characterized lncRNAs were analyzed by Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG). We evaluated the prognostic power of this model using Kaplan-Meier analysis, receiver operating characteristic (ROC), and decision curve analysis (DCA). Univariate and multifactor Cox (proportional-hazards) risk model and a nomogram were produced using risk models and clinicopathological parameters for further verification. In addition, the relationship between characterized lncRNAs and tumor immune infiltration and methylation was also discussed. Results: We identified 29 characterized lncRNAs to produce prognostic risk models. Kaplan-Meier analysis revealed the high-risk group was associated with poor prognosis in LUSC (P<0.001), and ROC (AUC =0.658) and DCA suggested that risk models could predict prognosis. Univariate and multifactorial Cox as well as nomogram further validated the prognostic model (P<0.001). Gene set enrichment analysis (GSEA) showed that the high-risk group was associated with pro-tumor pathways and high-frequency mutations in TP53 were present in both groups. Single sample gene set enrichment analysis (ssGSEA) showed significant differences in immune cell infiltration subtypes and corresponding functions between the two groups. Some immune checkpoint and methylation-related genes were significantly different between the two groups (P<0.05). Conclusions: We investigated the potential mechanisms of LUSC development from the perspective of ferroptosis-related lncRNAs, providing new insights into LUSC research, and identified 29 lncRNAs as biomarkers to predict the prognosis of LUSC patients.

Continuing versus withholding angiotensin receptor blocker (ARB)/calcium channel blocker (CCB) combination tablets during perioperative periods in patients undergoing minor surgery: a single-blinded randomized controlled trial.

PURPOSE: This trial was conducted to compare effects of continuing versus withholding single-pill combination tablets consisting of angiotensin receptor blockers (ARBs) and calcium channel blockers (CCBs) on perioperative hemodynamics and clinical outcomes. METHODS: Patients undergoing minor abdominal or urological surgery (n = 106) were randomly assigned to Group C, in which ARB/CCB combination tablets were continued until surgery, or Group W, in which they were withheld within 24 h of surgery. Perioperative hemodynamics and clinical outcomes were compared between the Groups. RESULTS: The incidence of hypotension during anesthesia requiring repeated treatment with vasoconstrictors was higher in Group C than Group W (p = 0.0052). Blood pressure during anesthesia was generally lower in Group C than Group W (p < 0.05) despite significantly more doses of ephedrine and phenylephrine administrated in Group C (p = 0.0246 and p = 0.0327, respectively). The incidence of postoperative hypertension did not differ between Groups (p = 0.3793). Estimated glomerular filtration rate (eGFR) on the preoperative day did not differ between Groups (p = 0.7045), while eGFR was slightly lower in Group C than Group W on the first and third postoperative days (p = 0.0400 and p = 0.0088, respectively), although clinically relevant acute kidney injury did not develop. CONCLUSIONS: Continuing ARB/CCB combination tablets preoperatively in patients undergoing minor surgery increased the incidence of hypotension during anesthesia, increased requirements of vasoconstrictors to treat hypotension, and might deteriorate postoperative renal function, albeit slightly. These results suggest that withholding ARB/CCB tablets preoperatively is preferable to continuing them. CLINICAL TRIAL REGISTRATION: This trial is registered with the Japan Registry of Clinical Trials (jRCT) at Japanese Ministry of Health, Labour, and Welfare (Trial ID: jRCT1031190027).

Propofol decreases CD8+ T cells and sevoflurane increases regulatory T cells after lung cancer resection: a randomized controlled trial.

BACKGROUND: Anaesthetics generally have an immunosuppressive effect, which may be related to prognosis. We conducted to clarify the relationship between peri-operative immunosuppression and anaesthetic agents in patients undergoing lung cancer surgery, resulting in better selection of intraoperative anaesthesia. METHODS: Prospective randomized controlled study was performed in single-University hospital. Patients with lung cancer who were scheduled to undergo lung cancer resection between June 2018 and July 2019. Patients were randomly divided to three groups: desflurane (group D), sevoflurane (group S), and propofol (group P) groups. Peripheral blood mononuclear cells were separated from the blood samples. CD4+ and CD8+ T cells, programmed death 1 (PD-1) on CD4+ and CD8+ T cells, and regulatory T cells were measured by flow cytometry. The Wilcoxon signed rank sum test was used to compare pre- and post-operative values for each anaesthesia. RESULTS: Eighty-two patients were enrolled; samples from 64 individuals (20 in group D, 22 in group S, and 22 in group P) were analysed after exclusion. The number of CD8+ T cells was significantly lower after the operation than before the operation in the group P (P<0.05). The proportion of regulatory T cells was significantly increased after surgery, compared with before surgery in the group S (P<0.05). There was no difference in PD-1 on CD4+ and CD8+ T cells after lung surgery among the three groups. CONCLUSIONS: Propofol decreased the number of CD8+ T cells, while sevoflurane increased the proportion of regulatory T cells in patients after lung surgery; however, propofol, sevoflurane, and desflurane did not increase the proportion of PD-1 on CD4+ and CD8+ T cells after lung surgery. Sevoflurane and propofol may cause immunosuppression via different mechanisms after lung cancer surgery. TRIAL REGISTRATION: UMIN-CTR: UMIN000031911.

Thoracic Anesthesia during the COVID-19 Pandemic: 2021 Updated Recommendations by the European Association of Cardiothoracic Anaesthesiology and Intensive Care (EACTAIC) Thoracic Subspecialty Committee.

The novel coronavirus pandemic has radically changed the landscape of normal surgical practice. Lifesaving cancer surgery, however, remains a clinical priority, and there is an increasing need to fully define the optimal oncologic management of patients with varying stages of lung cancer, allowing prioritization of which thoracic procedures should be performed in the current era. Healthcare providers and managers should not ignore the risk of a bimodal peak of mortality in patients with lung cancer; an imminent spike due to mortality from acute coronavirus disease 2019 (COVID-19) infection, and a secondary peak reflecting an excess of cancer-related mortality among patients whose treatments were deemed less urgent, delayed, or cancelled. The European Association of Cardiothoracic Anaesthesiology and Intensive Care Thoracic Anesthesia Subspecialty group has considered these challenges and developed an updated set of expert recommendations concerning the infectious period, timing of surgery, vaccination, preoperative screening and evaluation, airway management, and ventilation of thoracic surgical patients during the COVID-19 pandemic.

Up-to-date information on polymyxin B-immobilized fiber column direct hemoperfusion for septic shock.

Endotoxin adsorption therapy by polymyxin B-immobilized fiber column direct hemoperfusion (PMX-DHP) has been used for the treatment of septic shock patients. Endotoxin, an outer membrane component of Gram-negative bacteria, plays an important role in the pathogenesis of septic shock. Endotoxin triggers a signaling cascade for leukocytes, macrophage, and endothelial cells to secrete various mediators including cytokines and nitric oxide, leading to septic shock and multiple organ dysfunction syndrome. PMX-DHP directly adsorbed not only endotoxin but also monocytes and anandamide. It reduced blood levels of inflammatory cytokines such as interleukin (IL)-1, IL-6, tumor necrosis factor-alpha and IL-17A, adhesion molecules, plasminogen activator inhibitor 1, and high mobility group box-1. As a result, PMX-DHP increased blood pressure and reduced the dose of vasoactive-inotropic agents. PMX-DHP improved monocyte human leukocyte antigen-DR expression in patients with severe sepsis and septic shock. A post hoc analysis of EUPHRATES (Evaluating the Use of Polymyxin B Hemoperfusion in Randomized Controlled Trial of Adults Treated for Endotoxemia and Septic Shock) trial has shown that PMX-DHP significantly reduced 28-day mortality compared with the control group in septic shock patients with endotoxin activity assay level between 0.60 and 0.89. Longer duration of PMX-DHP may be another strategy to bring out the beneficial effects of PMX-DHP. Further studies are needed to confirm the efficacy of PMX-DHP treatment for septic shock.

Well leg compartment syndrome following robot-assisted radical cystectomy in the lithotomy position: a case report.

BACKGROUND: The indications for robot-assisted urologic surgeries have expanded due to their low invasiveness. However, complicated surgical procedures lead to prolonged surgical duration, requiring patients to remain in the lithotomy position for an extended time. Well leg compartment syndrome (WLCS) is a known severe postoperative complication related to the lithotomy position. CASE PRESENTATION: We report a case of WLCS after robot-assisted radical cystectomy (RARC), in which the patient recovered without neurological sequelae. A 55-year-old, obese male who underwent RARC complained of right leg pain and paresthesia 3 h after the surgery that lasted for 481 min. Emergency evaluation revealed unilateral WLCS in the anterior and lateral compartments. Urgent fasciotomy was performed 4 h after symptom onset. He thereafter recovered completely and was discharged without any neuromuscular dysfunction. CONCLUSIONS: Early detection of WLCS, surgical treatment, and additional measures are crucial to prevent its life-threatening and/or disabling outcomes.