Assessment of the need for routine intraoperative cell salvage in liver transplantation.

PURPOSE: This study aimed to assess the necessity of routine intraoperative cell salvage in liver transplantations. METHODS: A total of 327 liver transplants performed between 2014 and 2016 was included in the analysis. Patient data, including pre-transplant examinations, intraoperative red blood cell transfusions, and procedural information, were collected. RESULTS: The median age of the patients was 54 years old, with 67% (219) being male. The most prevalent ABO blood type was O, accounting for 48% (155) of cases. The leading causes of liver disease were hepatitis C (113 cases, 34.6%) and alcohol-related liver disease (97 cases, 29.7%). Out of the 327 liver transplants, allogeneic red blood cell transfusions were administered in 110 cases (34%) with a median of two units of red blood cells per case. Cell salvage was employed in 237 transplants (73%), and successful blood recovery was achieved in 221 cases (93%). Among the group that recovered more than 200 mL of blood, the median volume of recovered blood was 417 mL, with no transfusion of allogeneic blood required. A total of 90 transplants was performed without utilizing cell salvage, and, among these cases, 19 required blood transfusions, with a median of zero units transfused. CONCLUSIONS: This study suggests that routine cell salvage is unnecessary for all liver transplantations. The most suitable indication for its use is in patients presenting with portal vein thrombosis and abnormal creatinine levels.

Impact of Intraoperative Salvaged Blood Autotransfusion During Obstetric Hemorrhage on the Coagulation Function: A Retrospective Cohort Analysis.

OBJECTIVE: This study aimed to explore the effect of intraoperative blood salvage (autotransfusion) on coagulation function in the rescue of an obstetric hemorrhage. METHODS: A total of 65 pregnant women who were diagnosed with placenta previa in our Hospital and gave birth in the hospital were enrolled in the study. All the patients underwent thromboelastography, routine blood tests, and blood coagulation series + D-dimer before and within 30 min of the autologous blood transfusion. The differences in various indicators were evaluated. RESULTS: (1) After the autotransfusion, the hemoglobin and neutrophil counts were significantly higher than beforehand, and the platelet count was significantly reduced; the differences were statistically significant (p < .05). (2) There were no significant differences in prothrombin time (PT), fibrinogen, and D-dimer levels before and after the autotransfusion (p > .05). The activated partial thromboplastin time after autotransfusion was shorter than that beforehand, and the difference was statistically significant (p < .05). (3) There were no significant differences in the R value, K value, α value, and MA value of the thromboelastogram before and after the autotransfusion (p > .05). CONCLUSION: After the recovery autotransfusion, the hemoglobin of patients with a massive obstetric hemorrhage increased significantly, while the platelet count decreased, but the coagulation function and thromboelastogram did not change significantly, indicating the autotransfusion did not affect the coagulation function of the obstetric hemorrhage rescue. Thus, it would appear that intraoperative blood salvage can be safely used in the clinical rescue of massive hemorrhaging during cesarean section.

Application of ultrasound during electrode implantation for sacral neuromodulation in patients with neurogenic bladder secondary to spinal cord disease: a retrospective study.

PURPOSE: To compare the use of intraoperative ultrasound with X-ray fluoroscopy during sacral neuromodulation lead electrode placement in patients with neurogenic bladder secondary to spinal cord disease. METHODS: We reviewed the medical records of 52 patients who underwent sacral neuromodulation (SNM) lead electrode implantation under fluoroscopy or ultrasound guidance from July 2016 to July 2019. The operating time, number of electrode contacts with stimulus responses, minimum voltage that causes a stimulus response, and rate of standard lead electrode placement were used to assess the differences between the two methods. All patients were evaluated by recording bladder diaries, postvoid residual volumes before and during the testing period. Permanent SNM implantation is acceptable if symptoms improve by at least 50%. RESULTS: The operating time decreased from 87.1 ± 25.19 min in the X-ray group to 68.2 ± 25.20 min (p < 0.05) in the ultrasound group. The number of electrode contacts with stimulus responses, rate of standard lead electrode placement, and implantable pulse generator (IPG) placement rate were not significantly different between the two groups (p > 0.05). There was no radiation exposure during the operation in the ultrasound group. No incisional infections, hematomas, or other critical complications were reported in either groups. CONCLUSION: Ultrasound can be applied to safely place lead electrode for sacral neuromodulation and leads to no radiation exposure to the patient, surgeon, and operating room staff and a shortened operating time while maintaining the same efficacy as X-ray.

Intraoperative collection of autologous platelet-rich plasma from the cardiopulmonary bypass circuit upon initiation of extracorporeal circulation.

OBJECTIVES: The aim of this study is to evaluate the possibility of the autologous platelet-rich plasma (PRP) collection from the cardiopulmonary bypass (CPB) circuit and to evaluate its effect on the aggregative function. METHODS: For seventy-two patients undergoing cardiac surgery with CPB, an autologous PRP was prepared using the Haemonetics Component Collection System® by drawing blood from the CPB circuit immediately after CPB was established. The blood samples were taken at three points for examination, A: beginning of surgery, B: immediately after heparin reversal with protamine following discontinuation of CPB, C: after the collected autologous PRP was returned to the patient. Platelet count and platelet aggregation ability were analyzed. RESULTS: The mean platelet count in autologous PRP was 5.5 (range: 3-14) units. Platelet count decreased by 115.0 (±27.3) × 1000/µl from A to B and increased by 27.3 ± 17.2 (× 1000/µl) from B to C. When platelet aggregation was measured by Adenosine Diphosphate (ADP) 3.0 µM, it decreased by 42.6% ± 12.1% from A to B and increased by 8.7% ± 7.4% from B to C. CONCLUSIONS: Autologous PRP can be safely collected by drawing blood from the CPB circuit, platelet count and aggregation ability significantly decreased after CPB including autologous PRP collection. Some improvement was detected in the number of the platelets count and platelet aggregation ability by administrating an autologous PRP even if autologous PRP is collected from CPB circuit. TRIAL REGISTRATION: UMI-CTR, UMIN000023776 . Registered 1 October 2016.

Time-to-contact perception in the brain.

Time-to-contact (TTC) perception refers to the ability of an observer to estimate the remaining time before an object reaches a point in the environment, and is of crucial importance in daily life. Noninvasive correlational approaches have identified several brain areas sensitive to TTC information. Here we report the results of two studies, including one during an awake brain surgery, that aimed to identify the specific areas causally engaged in the TTC estimation process. In Study 1, we tested 40 patients with brain tumor in a TTC estimation task. The results showed that four of the six patients with impaired performance had tumors in right upper parietal cortex, although this tumoral location represented only six over 40 patients. In Study 2, 15 patients underwent awake brain surgery electrostimulation mapping to examine the implication of various brain areas in the TTC estimation process. We acquired and normalized to MNI space the coordinates of the functional areas that influenced task performance. Our results seem to demonstrate that the early stage of the TTC estimation process involved specific cortical territories in the ventral region of the right intraparietal sulcus. Downstream processing of TTC could also involve the frontal eye field (middle frontal gyrus) related to ocular search. We also found that deactivating language areas in the left hemisphere interfered with the TTC estimation process. These findings demonstrate a fine grained, cortical representation of TTC processing close to the ventral right intraparietal sulcus and complement those described in other human studies.

Management of highly recurrent bladder neck contractures via transurethral resection combined with intra- and post-operative triamcinolone acetonide injections.

PURPOSE: To present our preliminary experience in managing patients with highly recurrent bladder neck contractures (BNCs) after transurethral resection of the prostate (TURP). METHODS: Between February 2015 and March 2018, 28 patients with highly recurrent BNCs who had failed multiple prior to endoscopic treatments were managed with transurethral resection and intra- and post-operative triamcinolone acetonide injections. The scar tissue was resected to the circular fiber at the bladder neck, and triamcinolone acetonide (2 mL, 40 mg/mL) was injected at the incision sites (8 points) using a cystoscopic injection needle. The cystoscopy-guided injections were repeated every four weeks for total three times after surgery. The patients were followed up at 3, 6, 12 months after surgery, and in July-August 2019. RESULTS: The recurrent interval before the treatments was 2.2 ± 1.2 months, without any BNC recurrence in the first 12 weeks after transurethral resection. The urinary flow rate increased significantly and was maintained during the follow-up period. Adequate voiding function was reported in 25 of 28 patients at a median follow-up of 2.8 (1.7, 3.9) years. One of the three patients with decreased urinary flow rate had underactive detrusor and no BNC recurrence. The complications were mild and tolerable. CONCLUSION: Transurethral resection of the scar tissue combined with intra- and post-operative triamcinolone acetonide injections resulted in a success rate of 92.9% in patients with highly recurrent BNC following TURP. It is a simple, safe, and effective treatment for highly recurrent BNCs.

Effect of therapeutic suggestions during general anaesthesia on postoperative pain and opioid use: multicentre randomised controlled trial.

OBJECTIVE: To investigate the effect of therapeutic suggestions played to patients through earphones during surgery on postoperative pain and opioid use. DESIGN: Blinded randomised controlled study. SETTING: Five tertiary care hospitals in Germany. PARTICIPANTS: 385 of 400 patients consecutively recruited from January to December 2018 who were to undergo surgery for 1-3 hours under general anaesthesia. In the per protocol analysis 191 patients were included in the intervention group and 194 patients in the control group. INTERVENTION: The intervention comprised an audiotape of background music and positive suggestions based on hypnotherapeutic principles, which was played repeatedly for 20 minutes followed by 10 minutes of silence to patients through earphones during general anaesthesia. Patients in the control group were assigned to a blank tape. MAIN OUTCOME MEASURES: The main outcome was dose of opioid administered by patient controlled analgesia or nurse controlled analgesia within the first postoperative 24 hours, based on regular evaluation of pain intensity on a numerical rating scale (range 0-10, with higher scores representing more severe pain). RESULTS: Compared with the control group, the intervention group required a significantly (P=0.002) lower opioid dose within 24 hours after surgery, with a median of 4.0 mg (interquartile range 0-8) morphine equivalents versus 5.3 (2-12), and an effect size (Cohen's d) of 0.36 (95% confidence interval 0.16 to 0.56). The number of patients who needed opioids postoperatively was significantly (P=0.001) reduced in the intervention group: 121 of 191 (63%, 95% confidence interval 45% to 70%) patients in the intervention group versus 155 of 194 (80%, 74% to 85%) in the control group. The number needed to treat to avoid postoperative opioids was 6. Pain scores were consistently and significantly lower in the intervention group within 24 hours after surgery, with an average reduction of 25%. No adverse events were reported. CONCLUSIONS: Therapeutic suggestions played through earphones during general anaesthesia could provide a safe, feasible, inexpensive, and non-drug technique to reduce postoperative pain and opioid use, with the potential for more general use. Based on the finding of intraoperative perception by a considerable number of patients, surgeons and anaesthetists should be careful about background noise and conversations during surgery. TRIAL REGISTRATION: German Clinical Trial Register DRKS00013800.

Clinical outcomes of globus pallidus deep brain stimulation for Parkinson disease: a comparison of intraoperative MRI- and MER-guided lead placement.

OBJECTIVE: Deep brain stimulation (DBS) lead placement is increasingly performed with the patient under general anesthesia by surgeons using intraoperative MRI (iMRI) guidance without microelectrode recording (MER) or macrostimulation. The authors assessed the accuracy of lead placement, safety, and motor outcomes in patients with Parkinson disease (PD) undergoing DBS lead placement into the globus pallidus internus (GPi) using iMRI or MER guidance. METHODS: The authors identified all patients with PD who underwent either MER- or iMRI-guided GPi-DBS lead placement at Emory University between July 2007 and August 2016. Lead placement accuracy and adverse events were determined for all patients. Clinical outcomes were assessed using the Unified Parkinson's Disease Rating Scale (UPDRS) part III motor scores for patients completing 12 months of follow-up. The authors also assessed the levodopa-equivalent daily dose (LEDD) and stimulation parameters. RESULTS: Seventy-seven patients were identified (MER, n = 28; iMRI, n = 49), in whom 131 leads were placed. The stereotactic accuracy of the surgical procedure with respect to the planned lead location was 1.94 ± 0.21 mm (mean ± SEM) (95% CI 1.54-2.34) with frame-based MER and 0.84 ± 0.007 mm (95% CI 0.69-0.98) with iMRI. The rate of serious complications was similar, at 6.9% for MER-guided DBS lead placement and 9.4% for iMRI-guided DBS lead placement (RR 0.71 [95% CI 0.13%-3.9%]; p = 0.695). Fifty-seven patients were included in clinical outcome analyses (MER, n = 16; iMRI, n = 41). Both groups had similar characteristics at baseline, although patients undergoing MER-guided DBS had a lower response on their baseline levodopa challenge (44.8% ± 5.4% [95% CI 33.2%-56.4%] vs 61.6% ± 2.1% [95% CI 57.4%-65.8%]; t = 3.558, p = 0.001). Greater improvement was seen following iMRI-guided lead placement (43.2% ± 3.5% [95% CI 36.2%-50.3%]) versus MER-guided lead placement (25.5% ± 6.7% [95% CI 11.1%-39.8%]; F = 5.835, p = 0.019). When UPDRS III motor scores were assessed only in the contralateral hemibody (per-lead analyses), the improvements remained significantly different (37.1% ± 7.2% [95% CI 22.2%-51.9%] and 50.0% ± 3.5% [95% CI 43.1%-56.9%] for MER- and iMRI-guided DBS lead placement, respectively). Both groups exhibited similar reductions in LEDDs (21.2% and 20.9%, respectively; F = 0.221, p = 0.640). The locations of all active contacts and the 2D radial distance from these to consensus coordinates for GPi-DBS lead placement (x, ±20; y, +2; and z, -4) did not differ statistically by type of surgery. CONCLUSIONS: iMRI-guided GPi-DBS lead placement in PD patients was associated with significant improvement in clinical outcomes, comparable to those observed following MER-guided DBS lead placement. Furthermore, iMRI-guided DBS implantation produced a similar safety profile to that of the MER-guided procedure. As such, iMRI guidance is an alternative to MER guidance for patients undergoing GPi-DBS implantation for PD.

Accuracy of transition zone in contrast enema to predict intraoperative aganglionosis level in patients with Hirschsprung disease.

OBJECTIVE: While frozen section methods have been widely conducted to determine aganglionosis segment during transanal endorectal pull-through (TEPT) for Hirschsprung disease (HSCR) patients in most institutions, some hospitals still rely on contrast enema to predict aganglionosis segments due to unavailability of frozen section facilities. We determined the accuracy of transition zone in contrast enema to predict aganglionosis segments during TEPT. We retrospectively reviewed all contrast enema and frozen sections for HSCR patients under 2 years of age who underwent TEPT at our institution. RESULTS: We recruited 36 HSCR patients: twenty-six patients (72.2%) had radiographic transition zones limited to rectum, while ten subjects (27.8%) were limited to rectosigmoid. The rectum subgroup of patients showed a concordance of 30.8%, whereas the rectosigmoid subgroup had a concordance of 100%. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of contrast enema compared with intraoperative histopathological findings for aganglionosis level were 100% (95% CI 0.60-1.0), 35.7% (95% CI 0.19-0.56), 30.8% (95% CI 0.15-0.52), 100% (95% CI 0.66-1.0), and 50% (95% CI 0.33-0.67), respectively. In conclusions, contrast enema has low accuracy to predict intraoperative aganglionosis segments in HSCR patients, indicating that it might not be utilized to determine aganglionosis level during TEPT.

Complementary role of 18F-FDG PET/CT for sentinel lymph node algorithm in endometrial cancer with high-risk factors for lymphatic metastasis.

OBJECTIVE: National Comprehensive Cancer Network (NCCN) sentinel lymph node (SLN) algorithm includes 'mandatory steps' for evaluating pelvic lymph nodes, but assessment of paraaortic area is left to surgeon's discretion. In this study, we aimed to investigate the complementary role of preoperative F-FDG PET/computed tomography (CT) scan in detecting pelvic and especially paraaortic lymphatic metastasis in endometrial cancer patients with high-risk factor(s) according to Mayo Clinic Criteria and underwent SLN algorithm. METHODS: Patients who underwent preoperative F-FDG PET/CT scan, intraoperative SLN algorithm followed by systematic lymphadenectomy (LND) and had at least one high-risk criterion for lymphatic metastasis were included in this study. F-FDG PET/CT and SLN algorithm were compared with final histopathological results of systematic LND. RESULTS: Thirty-eight patients were eligible for the study. Lymphatic metastasis was seen in 10 patients (26.3%). Four cases had paraaortic lymphatic metastases which were together with pelvic (n:2) or isolated (n:2) metastases. SLN algorithm was able to detect all pelvic lymph node metastases. However, isolated paraaortic metastases were diagnosed only by F-FDG PET/CT. In 76 hemipelvises, sensitivity and negative predictive value of SLN algorithm for diagnosis of pelvic nodal metastasis were 100%, while sensitivity, specificity, positive predictive value and negative predictive value of F-FDG PET/CT were 45.4, 95.3, 62.5 and 91.1%, respectively. CONCLUSIONS: Although SLN algorithm has an excellent diagnostic value for pelvic nodal metastasis, paraaortic metastasis might be underdiagnosed. F-FDG PET/CT may be a feasible tool to exclude paraaortic lymphatic metastasis in high-risk patients for lymphatic metastasis who will undergo SLN algorithm.

Pain during and after-hernioplasty in raquidian or locorregional anesthesia by locking peripheral nerves.

PURPOSE: To analyze pain scores after surgery in a group of patients submitted to inguinal hernia repair under peripheral nerve block with local or spinal anesthesia. METHODS: Fifty patients were divided into two groups (both with 25 patients each). In the first group the patients were submitted to herniorrhaphy under peripheral block and local anesthesia (LG) and in the other group the patients were submitted to the same procedure under spinal anesthesia (RG). The pain was assessed using the international visual analog pain scale at four different moments. The analysis cost of the procedure was performed using the hospital's average final cost, without including medical expenses. RESULTS: The groups were homogeneous in relation to the epidemiological and clinical features. There was no significant difference between the pain in the intraoperative period and in the return visit for both groups (p = 0.17 and p = 0.18). In the immediate postoperative period, both groups reported no pain at all. In general, the RG reported a greater pain score (16% for RG and 12% for LG). Complications were more frequent in patients submitted to spinal anesthesia (40% versus 8%) (p = 0.008). The surgical time was higher in the LG (39.3 ± 9.2 min) versus (28.7 ± 7.5 min) (p = 0.01). The average final cost of the procedure was US$ 100.98 for the LG and US$ 166.19 for the RG (p = 0.00). CONCLUSION: The inguinal hernioplastia under local anesthesia plus sedation is a safe method, with a low incidence of complications, great acceptance by patients and less expensive.

Nerves in the Areas Posterior to the Prostate Base Contribute to Erectile Function: An Intraoperative Electrical Stimulation Assessment.

OBJECTIVE: To confirm the distribution of functional nerves involved in erectile function at the posterior of the prostate base, intraoperative nerve stimulation was performed during robot-assisted radical prostatectomy (RARP) METHODS: Several points at the posterior of the prostate and the posterolateral typical neurovascular bundle (NVB) were electrically stimulated at the level of the prostate base during RARP in patients with clinically localized prostate cancer. The prostate pedicle (PP), medial side of the PP (MPP), Denonvilliers' fascia (DF), and typical NVB were stimulated using bipolar electrodes. The changes in pressure at the middle of the urethra were measured using an inserted balloon-catheter to detect the increase in cavernosal pressure. RESULTS: Although the study included only 12 patients, each stimulation of the PP, MPP, and NVB induced evident urethral pressure responses in all patients. The median amplitude of the pressure responses was 5.49 (IQR 3.11-8.42), 6.00 (IQR 3.70-8.30), and 3.22 (IQR 2.48-7.19) cm H2O at the PP, MPP, and NVB, respectively. The amplitude of responses at the PP and MPP was not small compared with the responses at the typical NVB. Stimulations at the DF induced unstable weak urethral response alone or no response in all patients. CONCLUSION: We showed that electrostimulation of the PP and MPP increases the cavernosal pressure similar to the typical NVB stimulation. These findings indicate that maximal preservation of the tissues at the posterior area of the prostate base can contribute to optimal recovery of postoperative erectile function after nerve-sparing RARP.

Topical Anesthesia in Children With Intraoperative Adjustable Strabismus Surgery.

PURPOSE: To evaluate strabismus surgery with intraoperative adjustment of sutures under topical anesthesia in children. METHODS: Nineteen children with horizontal deviation underwent a one-stage surgical technique performed under topical anesthesia. Surgery consisted of unilateral or bilateral recession and/or resection of horizontal muscles or the medial or lateral rectus muscles, with intraoperative adjustment of sutures based on alternate prism cover test. Follow-up was done at 1 day and 1, 3, and 6 months postoperatively. RESULTS: Mean age at surgery was 12.68 ± 2.50 years (range: 8 to 16 years). Mean preoperative angle of deviation was 24.21 ± 11.20 prism diopters (PD) (range: -50 to +30 PD) at distance. Mean postoperative angle of deviation at 6 months was 4.11 ± 2.87 PD (range: -10 to +10 PD) at distance. In esotropic patients, the average angle of deviation decreased from +23.80 ± 5.89 PD preoperatively to +4.80 ± 3.35 PD at 6 months, whereas in exotropic patients it decreased from -24.36 ± 12.76 to -3.86 ± 2.77 PD. Seventeen of 19 patients (89%) remained comfortable during surgery, whereas 2 needed an intravenous injection of propofol. The success rate, defined by a postoperative residual angle of deviation of ±8 PD or less, was 89% at 6 months. CONCLUSIONS: Strabismus surgery with intraoperative suture adjustment under topical anesthesia in children is a tolerable procedure with encouraging outcomes, representing an alternative to general anesthesia in well-selected children. Clinical evaluation of children and parents is fundamental to predict a likely poor collaboration of the child during surgery, which, if present, would require surgery under general anesthesia. [J Pediatr Ophthalmol Strabismus. 2019;56(3):173-177.].

Added value of intra-operative ultrasound to determine the resectability of locally advanced pancreatic cancer following FOLFIRINOX chemotherapy (IMAGE): a prospective multicenter study.

BACKGROUND: Determining the resectability of locally advanced pancreatic cancer (LAPC) after FOLFIRINOX chemotherapy is challenging because CT-scans cannot reliably assess vascular involvement. This study evaluates the added value of intra-operative ultrasound (IOUS) in LAPC following FOLFIRINOX induction chemotherapy. METHODS: Prospective multicenter study in patients with LAPC who underwent explorative laparotomy with IOUS after FOLFIRINOX chemotherapy. Resectability was defined according to the National Comprehensive Cancer Network guidelines. IOUS findings were compared with preoperative CT-scans and pathology results. RESULTS: CT-staging in 38 patients with LAPC after FOLFIRINOX chemotherapy defined 22 patients LAPC, 15 borderline resectable and one resectable. IOUS defined 19 patients LAPC, 13 borderline resectable and six resectable. In 12/38 patients, IOUS changed the resectability status including five patients from borderline resectable to resectable and five patients from LAPC to borderline resectable. Two patients were upstaged from borderline resectable to LAPC. Tumor diameters were significantly smaller upon IOUS (31.7 ± 9.5 mm versus 37.1 ± 10.0 mm, p = 0.001) and resectability varied significantly (p = 0.043). Ultimately, 20 patients underwent resection of whom 14 were evaluated as (borderline) resectable on CT-scan, and 17 on IOUS. DISCUSSION: This prospective study demonstrates that IOUS may change the resectability status up to a third of patients with LAPC following FOLFIRINOX chemotherapy.

Intraoperative brachytherapy for resected brain metastases.

Brain metastases are the most common intracranial malignancies in adults. Surgical resection is the preferred treatment approach when a pathological diagnosis is required, for symptomatic patients who are refractory to steroids, and to decompress lesions causing mass effect. Radiotherapy is administered to improve local control rates after surgical resection. After a brief review of the literature describing the treatment of brain metastases using whole-brain radiotherapy, postoperative stereotactic radiosurgery, preoperative radiosurgery, and brachytherapy, we compare patient-related, technical, practical, and radiobiological considerations of each technique. Finally, we focus our discussion on intraoperative brachytherapy, with an emphasis on the technical aspects, benefits, efficacy, and outcomes of studies utilizing permanent Cs-131 implants.

A Randomized, Double-Blind, Sham-Controlled Study Assessing Electroacupuncture for the Management of Postoperative Pain after Percutaneous Nephrolithotomy.

INTRODUCTION: Percutaneous nephrolithotomy (PCNL) is the gold standard procedure for large renal calculi but postoperative (PO) pain remains a concern. Modifications of the PCNL technique and intraoperative and PO strategies have been tested to reduce pain. PO pain control reducing risk of long-term pain medication and narcotic use is of considerable importance. Acupuncture is a common medical procedure shown to alleviate PO pain. Some benefits are that it is nonpharmacologic, easy to administer, and safe. The purpose of this study was to evaluate the effects of electroacupuncture (EA) on PO pain in patients undergoing PCNL. MATERIALS AND METHODS: This was a randomized, double-blind, sham-controlled study. The study was Institutional Review Board approved and performed under standard ethical guidelines. Fifty-one patients undergoing PCNL by a single surgeon were randomized to one of the three groups: true EA (n = 17), sham EA (SEA, n = 17), and no acupuncture (control, n = 17). The EA and SEA were performed by a single licensed acupuncturist <1 hour before operation. PCNL was performed without the use of intraoperative nerve block(s) or local anesthetic. Pain scores (visual analog scale [VAS]), narcotic use (morphine equivalents), and side effects were recorded at set intervals postoperatively. RESULTS: Mean VAS scores for flank and abdomen pain were lower at all time periods in the EA compared with the SEA and control groups. Mean cumulative opioid usage was lower in the EA group immediately postoperatively compared with both SEA and control groups. Two patients in the EA group did not require any PO narcotics. No differences between groups were found for PO nausea and vomiting. No adverse effects of EA or SEA were noted. CONCLUSIONS: EA significantly reduced PO pain and narcotic usage without any adverse effects after PCNL. This promising treatment for managing PO pain warrants further investigation.

Preoperative Oral Branched-Chain Amino Acid Supplementation Suppresses Intraoperative and Postoperative Blood Lactate Levels in Patients Undergoing Major Hepatectomy.

BACKGROUND: Lactate production is exacerbated by surgical stress. We sought to determine whether branched-chain amino acid (BCAA) supplementation could decrease blood lactate levels in patients undergoing hepatectomy. METHODS: A total of 275 consecutive patients who underwent hepatectomy of ≥2 segments were retrospectively reviewed. Blood lactate levels in patients treated with BCAA supplementation before hepatectomy (December 2011 to December 2016) were compared with levels in patients who were not pretreated (January 2008 to November 2011). RESULTS: Postoperative lactate levels were significantly lower in patients who received preoperative BCAA supplementation than in those who did not (2.6 vs 3.4 mmol/L; P < .001). Intraoperative blood lactate levels, which were evaluated after induction of general anesthesia, were also lower in those who received BCAA supplementation than in those who did not (1.1 vs 1.5 mmol/L, respectively; P < .001). A multiple regression analysis revealed that preoperative BCAA supplementation was independently associated with decreased postoperative and intraoperative lactate levels (P = .030 and P < .001, respectively). CONCLUSION: Preoperative BCAA supplementation decreased intraoperative and postoperative blood lactate levels in patients undergoing major hepatectomy.

Contemporary use of intra-aortic balloon pumps during percutaneous coronary intervention: insights from the Veterans Affairs Clinical Assessment, Reporting, and Tracking program.

BACKGROUND: Intra-aortic balloon pumps (IABP) support nonemergent and emergent percutaneous coronary intervention (PCI). Recent studies have not showed a routine benefit to this practice. We sought to evaluate the temporal trends in balloon pump utilization and site-level variation within a large integrated healthcare system. PATIENTS AND METHODS: We identified all patients that underwent PCI in the Veterans Affairs Healthcare System between 1 January 2008 and 31 December 2015. Procedural information was ascertained from the medical record and stratified by the concomitant use of an IABP. Site-specific variation was determined with mixed logistic regression models and reported as a median odds ratio. RESULTS: There were 88 851 interventions performed on 71 529 patients across 71 hospitals with 1289 (1.5%) of these utilizing an IABP. Patients that underwent an intervention with this device had more medical comorbidities, as reflected by an increase in the median National Cardiovascular Data Registry CathPCI mortality score (34 vs. 15, P<0.001). The overall utilization of balloon pumps was constant throughout the study period (P=0.446). However, there was a significant decline (P=0.027) in its use during emergent cases with a significant increase (P=0.009) during nonemergent cases. Furthermore, there was site variation in use independent of patient or procedural characteristics (median odds ratio: 1.82, 95% confidence interval: 1.58-2.16). CONCLUSION: In the largest integrated healthcare system in the USA, there was a significant decline in IABP use among emergent cases and a significant increase during nonemergent cases. Residual site variation suggests an opportunity to standardize a procedural approach consistent with currently available data.

Three Distraction Methods for Pain Reduction During Cystoscopy: A Randomized Controlled Trial Evaluating the Effects on Pain, Anxiety, and Satisfaction.

BACKGROUND: Cystoscopy is a safe diagnostic procedure commonly used to evaluate lower urinary tract symptoms. This can cause pain, anxiety, and dissatisfaction in patients undergoing cystoscopy. OBJECTIVES: The aim of this study was to compare the effects on pain, anxiety, and satisfaction of distraction methods used during cystoscopy. DESIGN: Single-center, open-label, randomized, parallel-group trial. SETTING: Cystoscopy unit of a training and research hospital in Turkey. PARTICIPANTS: Male patients ≥18 years of age who underwent rigid cystoscopy for the first time. METHODS: A total of 120 male patients were recruited and randomized into four groups as music, stress ball, video, and control group. Data were collected using visual analog scale for pain and satisfaction, State-Trait Anxiety Inventory for anxiety, and hemodynamic parameters. The primary outcome was the difference with respect to pain scores among intervention groups. Other outcome measures were anxiety and satisfaction scores. RESULTS: Pain severity during cystoscopy was found to be significantly lower in the intervention groups than the control group. In the video group, the severity of pain during cystoscopy was also found to be significantly lower than music and stress ball groups (p = 0.006, p < 0.001). After cystoscopy, anxiety levels were significantly lower and satisfaction levels were significantly higher in the intervention groups than in the control group. Anxiety levels were significantly lower in the video group than music and stress ball groups (p < 0.001, p < 0.001). Satisfaction levels were also significantly higher after cystoscopy in the video group than in the music and stress ball groups (p = 0.018, p = 0.018). CONCLUSIONS: According to this study, distraction methods used during rigid cystoscopy were found to have a reducing effect on pain, anxiety, and dissatisfaction. As the results of the study are evaluated, video should be recommended to be the first preferred distraction method during rigid cystoscopy.