Prevention of dexmedetomidine on postoperative delirium and early postoperative cognitive dysfunction in elderly patients undergoing hepatic lobectomy / 中南大学学报(医学版)

OBJECTIVES@#Postoperative delirium (POD) and postoperative cognitive dysfunction (POCD) are common operative neurocognitive disorders, which places a heavy burden on patients, families and society. Therefore, it is very important to search for preventive drugs. Previous studies have demonstrated that perioperative use of dexmedetomidine resulted in a decrease the incidence of POD and POCD. But the specific effect of dexmedetomidine on elderly patients undergoing hepatic lobectomy and its potential mechanism are not clear. This study aims to evaluate the efficacy of intraoperative use of dexmedetomidine on preventing POD and POCD in elderly patients undergoing hepatic lobectomy and the influence on the balance between proinflammation and anti-inflammation.@*METHODS@#This trial was designed as a single-center, prospective, randomized, controlled study. One hundred and twenty hospitalized patients from January 2019 to December 2020, aged 60-80 years old with American Society of Anesthesiologists (ASA) II-III and scheduled for hepatic lobectomy, were randomly allocated into 3 groups (n=40) using a random number table: A C group, a Dex1 group, and a Dex2 group. After anesthesia induction, saline in the C group, dexmedetomidine [0.3 μg/(kg·h)] in the Dex1 group, and dexmedetomidine [0.6 μg/(kg·h)] in the Dex2 group were infused until the end of operation. The incidences of hypotension and bradycardia were compared among the 3 groups. Confusion Assessment Method (CAM) for assessing POD and Mini Mental State Examination (MMSE) for evaluating POCD were recorded and venous blood samples were obtained for the determination of neuron specific enolase (NSE), TNF-α, IL-1β, and IL-10 at the different time below: the time before anesthesia (T0), and the first day (T1), the third day (T2), the fifth day (T3), and the seventh day (T4) after operation.@*RESULTS@#Compared with the C group, the incidences of bradycardia in the Dex1 group or the Dex2 group increased (both P<0.05) and there was no difference in hypotension in the Dex1 group or the Dex2 group (both P>0.05). The incidences of POD in the C group, the Dex1 group, and the Dex2 group were 22.5%, 5.0%, and 7.5%, respectively. The incidences of POD in the Dex1 group or the Dex2 group declined significantly as compared to the C group (both P<0.05). However, there is no difference in the incidence of POD between the Dex1 group and the Dex2 group (P>0.05). The incidences of POCD in the C group, the Dex1 group, and the Dex2 group were 30.0%, 12.5%, and 10.0%, respectively. The incidences of POCD in the Dex1 group and the Dex2 group declined significantly as compared to the C group (both P<0.05). And no obvious difference was seen in the incidence of POCD in the Dex1 group and the Dex2 group (P>0.05). Compared with the C group, the level of TNF-α and IL-1β decreased and the level of IL-10 increased at each time points (from T1 to T4) in the Dex1 group and the Dex2 group (all P<0.05). Compared with the Dex1 group, the level of IL-1β at T2 and IL-10 from T1 to T3 elevated in the Dex2 group (all P<0.05). Compared with the T0, the concentrations of NSE in C group at each time points (from T1 to T4) and in the Dex1 group and the Dex2 group from T1 to T3 increased (all P<0.05). Compared with the C group, the level of NSE decreased from T1 to T4 in the Dex1 group and the Dex2 group (all P<0.05).@*CONCLUSIONS@#Intraoperative dexmedetomidine infusion can reduce the incidence of POCD and POD in elderly patients undergoing hepatic lobectomy, and the protective mechanism appears to involve the down-regulation of TNF-α and IL-1β and upregulation of IL-10 expression, which lead to rebalance between proinflammation and anti-inflammation.

Effect of acute normovolemic hemodilution combinded with enhanced recovery after surgery on immune function in patients undergoing hepatic lobectomy / 实用医学杂志

Objective To observe the effect of acute normovolemic hemodilution(ANH)combined with enhanced recovery after surgery(ERAS)on immune function in patients undergoing hepatic lobectomy. Methods 80 patients were divided into two groups:ERAS group(group E),ANH combined with ERAS group(group AE). bleeding volume,blood transfusion,infused fluid volume,urine output during operation and clinical index after surgery were recorded. Exhaust and defecation time ,fluid intake time and hospitalization duration were also record-ed. Blood samples were obtained from the patients at 30 min before anesthesia induction(T1),immediately(T2), 24 h(T3),3 d(T4)and 7 d(T5)after the end of operation for determination of the expression of CD3+,CD4+, CD8+ on T cells and natural killer cell. Results In group E ,CD3+,CD4+ T-lymphocytes and NK cells at T2-3 decreased as compared with T0. Compared with group E ,no allogeneic blood transfusion cases were found and clinical index duration was shorter in group AE. CD3+,CD4+T-lymphocytes and NK cells at T2-3 increased in group AE as compared with those in Group E. The difference is significant (P < 0.05). Conclusion ANH combined with ERAS can decrease allogenic blood transfusion and increase post-operation immunologic function ,shorten the postoperative hospitalization time.

Influence of Propofol Combined with Sevoflurane Anesthesia on Nitric Oxide/Endothelin-1 Ratio in the Pa-tients with Hepatic Lobectomy / 中国药师

Objective:To investigate the influence of propofol combined with sevoflurane anesthesia on nitric oxide/endothelin-1 ratio in the patients with hepatic lobectomy. Methods:Totally 84 patients with hepatic lobectomy were divided into two groups by the digital random method. Among them,42 patients received propofol combined with sevoflurane anesthesia as the observation group,and another 42 patients received midazolam anesthesia as the control group. Nitric oxide,endothelin-1,liver function indices(AST,ALT) and inflammatory factors (IL-1,IL-10,TNF-α) were detected respectively before hepatic portal occlusion,after hepatic portal occlu-sion and on postoperative third day. Results: Before hepatic portal occlusion, there were no significant differences between the two groups in above indicators (P >0.05). After hepatic portal occlusion, NO and IL-10 decreased significantly, while endothelin-1, AST,ALT,IL-1 and TNF-α increased significantly in the two groups.The differences between the two groups were statistically signifi-cant (P<0.01). All indices at postoperative 3 d in two groups recovered to the level before hepatic portal occlusion.Conclusion:Propofol combined with sevoflurane anesthesia contributes to adjusting nitric oxide/endothelin-1 ratio in the patients with hepatic lobec-tomy,which can improve liver function and inhibit the release of inflammatory cytokines.

The observation on effect of laparoscopic left hepatic lobe resection in the treatment of bile duct stones / 中国医学装备

Objective: To investigate the safety and feasibility of Laparoscopic left hepatic lobe resection in the treatment of bile duct stones. Methods: Eighty cases in our hospital with bile duct stones for left hepatic lobectomy were randomly divided into control group and experimental group. The control group was received open left hepatic lobectomy. The experimental group was received laparoscopic left hepatic lobectomy. The operative time, incision length, blood loss, hospital stay, hospital costs and incidence of postoperative complications were compared of two groups. Results: The incision length and length of hospital stay of experimental group was significantly shorter than control group. The difference was statistically significant (t=4.46, t=5.38; P0.05). Conclusion:Laparoscopic left hepatic lobe resection is safe and feasible in the treatment of bile duct stones with the advantage of less trauma and quicker recovery. It’s worthy of clinical widely used.

Hepatic seginentectomy by regional vascular occlusion at hepatic hilum / 国际外科学杂志

Objective To study the experience on a variety of hepatectomy by occluding the branches of hepatic artery and portal vein to the liver lobe,segment at hilar H fissure.Methods A total of three hun-dred and ninteen patients accepted hepatectomy in Hunan provincial people's hospital from Decemember 2006 to Decemember 2007 were involved in this study for retrospective analysis.Results There were no perioperative deaths and liver function failure in this series of patients.The average amount of blood loss was 70 15ml,and 302 (95 %)cases did not receive transfusion.Postoperative complications such as liver necro-sis,bile leaking,bleeding were not found.Subphrenic abscesses were found in 3 cases,which were cured conservatively.Conclusion Selective regional occlusion of hepatic blood flow during bepatectomy avoided the risk of ischemia-reflow injury of remnant liver,which is safe and effective to prevent massive bleeding and to reduce the incidence of liver failure.

Central Venous Pressure and Its Effect on Blood Loss during Hepatic Lobectomy / 대한마취과학회지

BACKGROUND: Some studies reported that lowering central venous pressure (LCVP) during liver resection could significantly reduce the intra-operative blood loss, however it is still controversial concerning LCVP induced renal dysfunction, hypovolemia, hemodynamic instability. This study evaluated the association of low central venous pressure with blood loss during liver resection comparing the control group. METHODS: A total 62 patients aged 20 to 70 underwent hepatectomy by the same group of surgeon were randomized into group L (CVP 10 mmHg, n = 32) during dissection and lobectomy period. Data such as age, sex, concurrent disease, liver resection site (right or left), pre-, intra- and postoperative day 3 hemoglobin, blood urea nitrogen, creatinine, bleeding time, prothrombin time, activated partitial thromboplastin time, intraoperative blood loss, urine output, transfusion volume, length of hospital stay were collected and compared between the two groups and t-test was used for comparison of results. RESULTS: The difference of total blood loss between two groups was 193.6 +/- 432.2 ml (group L; 589.1 +/- 380.8 ml, group C; 782.7 +/- 316.7 ml), however statistically insignificant (P value = 0.1243). Additionally, there were no significant differences in other data including the length of hospital stay. CONCLUSIONS: Our results suggest maintaining CVP under 10 mmHg is not effective in reducing blood loss during liver resection.

A Case of Simple Type Caroli's Disease Confined to Right Lobe of the Liver / 대한소화기학회지

Caroli's disease is a rare congenital hepatobiliary disease characterized by multifocal segmental dilatation of intrahepatic bile ducts affecting all or parts of the liver. Two forms of Caroli's disease are described, the pure form and that associated with periportal fibrosis. The disease may diffusely affect the liver or be localized to one lobe or segment. Less than 20% of all reported cases of Caroli's disease are monolobar type. We report a case of simple type Caroli's disease confined to right lobe of the liver in a 22 year old man. He was admitted due to right upper abdominal pain and diagnosed by magnetic resonance cholangiopancreatography. He was treated with right hepatic lobectomy and recovered completely.

Surgical Treatment of the Intrahepatic Lithiasis Combined with High Hepatic Duct Strictures / 中国普外基础与临床杂志

Objective To discuss the effective surgical treatment of intrahepatic lithiasis combined with high hepa-t ic duct strictures. Methods Two hundreds and sixteen cases of intra hepatic lithiasis and high hepatic duct strictures treated in this hospital fr om January 1993 to October 2002 were analysed retrospectively.Results One hundred and eighty- three cases underwent different selective operation by selected time; 33 case s complicated with acute obstructive suppurative cholangitis underwent emergency were performed single biliary drainage, in which 30 cases were re-operated. Th e operative procedure were: hepatic lobectomy,high cholangiotomy and plastic repair,exposure of hepatic duct of the 2nd and the 3rd order,and plastic re pair with own patch and choledochojejunostomy.Two hundreds and six cases w ere cured,the curative rate was 95.4%; 8 cases improved (3.7 %), and 2 cases died (0.9%).Conclusion The best effective surgical treat ment of intrahpatic lithiasis is hepatic lobectomy. Exposure of hepatic duct of the 2nd and the 3rd order is a satisfactory to release the hepatic duct str ictures and to clear the intrahepatic lithiasis. For patients with normal extr ahepatic bile duct and Oddi's function, plastic repair of bile duct with own patch is possible to keep the normal form and function. Cholang ioscopy may play an important role in the treatment of intrahepatic tr act lithiasis during operation.

Right Hepatic Lobectomy in the Treatment of Right-sided Hepatolithiasis

BACKGROUND: Right-sided hepatolithiasis has been diagnosed in 14-25% of all hepatolithiasis cases and right hepatic resection contributes only 5-9% of all hepatic resections for hepatolithiasis. Outcomes of otherwise treatment modalities were unsatisfactory resulting high incidence of remnant stone and high recurrence rate. General indications for hepatic resection in hepatolithiasis include localized intrahepatic calculi with irreversible biliary strictures, atrophied segment or lobe of the liver, multiple cholangitis abscess and possible presence of cholangiocarcinoma. PURPOSE: In this study, we presented the outcome of right hepatic lobectomy in right-sided hepatolithiasis patients, especially focused on the rationale and indications of this procedure. METHODS: We reviewed 15 cases undergone right lobectomy for right-sided hepatolithiasis from January 1995 to June 1997 with median follow-up of 23 months. RESULTS: Mean age of the patients was 49 years old. Clinical manifestations included signs of cholangitis in 7 (47%), abdominal pain in 5 (33%), jaundice in 1 (7%) and nonspecific symptoms in 2 (13%) cases. Criteria for indications of right lobectomy were overt biliary strictures in 9 (60%), marked atrophy of the right lobe in 7 (47%), multiple cholangitis abscess in 6 (40%) and suspected cholangiocarcinoma in 2 (13%) cases. Mean indocyanine green retention rate at 15 minutes was 7.6 4.5% and mean weight of resected specimen was 352 185 gm. Operative stone clearance rate was 100% for 14 isolated right-sided hepatolithiasis cases and choledochoscopic stone removal was followed for 1 both-sided case. Overall stone clearance rate was also 100%. Rate of stone recurrence was 0% at median follow-up of 23 months. Operative complications occurred in 4 cases without hepatic function-associated complication or operative mortality. CONCLUSIONS: Right hepatic lobectomy is indicated in patients who have localized right-sidedhepatolithiasis with irreversible biliary strictures involving the right hepatic duct, an atrophied right lobe of the liver, multiple cholangitis abscesses, or possible presence of cholangiocarcinoma.