Gradient local anesthesia for percutaneous endoscopic interlaminar discectomy at the L5/S1 level: a feasibility study.

BACKGROUND: During the process of shearing the ligamentum flavum, rotating the working channel, and manipulating the annulus fibrosis, the sinuvertebral nerve and the spinal nerve root can be irritated, inducing intolerable back and leg pain. Thus, general anesthesia is recommended and well accepted by most surgeons when performing percutaneous endoscopic lumbar discectomy (PELD) via the interlaminar approach. The aim of our study was to explore the efficacy and safety of percutaneous endoscopy interlaminar lumbar discectomy with gradient local anesthesia (LA) in patients with L5/S1 disc herniation. METHODS: This retrospective study was conducted between December 2017 and June 2018. The study included 50 consecutive patients who met the study criteria, had single-level L5/S1 disc herniation, and underwent PELD via the interlaminar approach under gradient LA. Different concentrations of local anesthetic compound (LAC) were injected into different tissues inside and outside the ligamentum flavum to complete gradient LA. The evaluation criteria included the intraoperative satisfaction score, visual analog scale (VAS) score, Oswestry Disability Index (ODI), complications, and adverse reactions. RESULTS: The intraoperative satisfaction score was consistently over 7, with an average score of 9.3 ± 0.7, indicating that LAC can achieve satisfactory pain control throughout the PELD operation without additional anesthesia. The postoperative VAS score and ODI were dramatically improved at each follow-up interval (P < 0.001, respectively). There was no serious complication such as dural rupture caused by puncture, dural laceration caused by manipulation under endoscopy, total spinal anesthesia, iatrogenic nerve root injury, epidural hematoma, infections, or local anesthetic-related adverse reactions. Three patients experienced transient postoperative dysesthesia of the lower limbs that gradually recovered within 24 h. CONCLUSIONS: Gradient local anesthesia can satisfactorily and safely control intraoperative pain during the PELD via the interlaminar approach. It can not only improve intraoperative satisfaction, but also reduce local anesthesia-related adverse reactions and surgery-related complications.

Metabolomic profiles illuminate the efficacy of Chinese herbal Da-Cheng-Qi decoction on acute pancreatitis in rats.

BACKGROUND AND OBJECTIVES: Chinese herbal drug Da-Cheng-Qi decoction (DCQD) has been widely used for decades to treat acute pancreatitis (AP). Previous trials are mostly designed to state the potential mechanisms of the therapeutic effects rather than to detect its whole effect on metabolism. This study aimed to investigate the efficacy of DCQD on metabolism in AP. METHODS: Twenty-two male adult Sprague-Dawley rats were randomized into three groups. AP was induced by retrograde ductal infusion of 3.5% sodium taurocholate solution in DCQD and AP group, while 0.9% saline solution was used in sham operation (SO) group. Blood samples were obtained 12 h after drug administration and a 600 MHz superconducting Nuclear Magnetic Resonance (NMR) spectrometer was used to detected plasma metabolites. Principal Components Analysis (PCA) and Partial Least Squares-Discriminant Analysis after Orthogonal Signal Correction (OSC-PLS-DA) were applied to analyze the Longitudinal Eddy-delay (LED) and Carr-Purcell-Meiboom-Gill (CPMG) spectra. RESULTS: Differences in concentrations of metabolites among the three groups were detected by OSC-PLS-DA of 1HNMR spectra (both LED and CPMG). Compared with SO group, DCQD group had higher levels of plasma glycerol, glutamic acid, low density lipoprotein (LDL), saturated fatty acid (FA) and lower levels of alanine and glutamine, while the metabolic changes were reversed in the AP group. CONCLUSIONS: Our results demonstrated that DCQD was capable of altering the changed concentrations of metabolites in rats with AP and 1HNMR-based metabolomic approach provided a new methodological cue for systematically investigating the efficacies and mechanisms of DCQD in treating AP.

Effect of formula compatibility on the pharmacokinetics of components from Dachengqi Decoction [See Text] in rats.

OBJECTIVE: To investigate the effect of prescription compatibility on the pharmacokinetics of components from Dachengqi Decoction (DCQD, ) in rats. METHODS: Twenty-four male rats were randomly and equally divided into the DCQD group, Dahuang (Radix et Rhizoma Rhei, Polygonaceae) group, Houpo (Magnolia officinalis Rehd., Magnoliaceae) group, and Zhishi (Fructus Aurantii Immaturus, Rutaceae) group. The blood samples were collected before dosing and subsequently at 10, 15, 20, 30, 45 min, 1, 2, 4, 8, and 12 h following gavage. The levels of aloe-emodin, rhein, emodin, chrysophanol, honokiol, magnolol, hesperidin, and naringin in rat serum were quantified using a liquid chromatography tandem mass spectrometry (LC-MS/MS) method for pharmacokinetic study. RESULTS: The area under the curve (AUC), mean retention time (MRT), the peak concentration (C(max)) of aloe-emodin, rhein, emodin, and chrysophanol in the DCQD group were significantly different compared with the Dahuang group (P <0.05, respectively). The mean plasma concentration, C(max), and the absorption of Dahuang's component in the DCQD group were obviously lower at each time point than those in the Dahuang group, while the elimination process of Dahuang's component was obviously delayed (P <0.05). Half-lives of aloe-emodin, chrysophanol, and rhein were also extended in the DCQD group (P <0.05, respectively). In the DCQD group, the mean plasma concentration, AUC, C(max) and absorption of honokiol, and magnolol were significantly lower (P <0.01, respectively) at each time point than those in the Houpo group, while the drug distribution half-life time (T(1/2α)), the drug eliminated half-life time (T(1/2ß)), MRT, and time of peak concentration (T(max)) were significantly delayed (P <0.05, respectively). Pharmacokinetic parameters of hesperidin and naringin in the Zhishi group were not significantly different as compared with the DCQD group (P >0.05, respectively), while the MRT of naringin was significantly longer. CONCLUSIONS: The compatibility in Chinese medicine could affect the drug's pharmacokinetics in DCQD, which proves that the prescription compatibility principle of Chinese medicine formulations has its own pharmacokinetic basis.

Modified Da-Cheng-Qi Decoction reduces intra-abdominal hypertension in severe acute pancreatitis: a pilot study.

BACKGROUND: Intra-abdominal hypertension (IAH) is a recognized prognostic marker for severity of severe acute pancreatitis (SAP) and has a strong impact on the clinical course of SAP. Previous studies indicate that a Da-Cheng-Qi Decoction (DCQD) is beneficial in the treatment of SAP. The purpose of this study was to evaluate the effect of modified DCQD on IAH in patients with SAP. METHODS: Between January 2008 and December 2008, 42 patients from the West China Hospital were randomized into either the DCQD or control group (n = 21 in each group). Mortality, intra-abdominal pressure (IAP), Acute Physiology and Chronic Health Evaluation II (APACHE II) score, C-reactive protein (CRP), oxygenation index, Balthazar CT score, rate of renal failure, decompression rate, intensive care unit (ICU) transfer rate, and length of hospital stay (LOS) were compared between the two groups. RESULTS: Compared to the control group, the modified DCQD treatment significantly decreased IAP (P < 0.05) and APACHE II (P < 0.05) scores on days 4 - 8, CRP on day 8 (P < 0.01), renal failure rate (P < 0.05), and LOS (P < 0.05). The oxygenation index was significantly improved in the DCQD group compared with the control group (P < 0.05). No significant differences in the Balthazar CT score, shock rate, ICU transfer rate, or mortality occurred between the two groups. CONCLUSIONS: The modified DCQD can effectively relieve IAH and decrease LOS for patients with SAP. Larger clinical trials are needed to confirm these findings.

[The influnence of dachengqi tang on acute lung injury and intra abdominal hypertension in rats with acute pancreatitis].

OBJECTIVE: To test the hypothesis "lung and large intestine are interior exteriorly related" through investgating into the effect of Dacheng qi tang (DCQT) on intra abdominal hypertension (IAH) and acute lung injury (ALI) in rats with acute pancreatitis. METHODS: Male SD rats were randomly divided into three groups with ten rats for each group: rats with sham-operations (SO); rats with acute necrosis pancreatitis (ANP); rats with ANP plus DCQT treatment. ANP was induced by retrograde infusion of 5% taurocholic acid into pancreatic duct. Two hours after operations, 10 mL/kg of normal saline was orally adminstered to the rats in both SO and ANP groups, whereas 10 mL/kg DCQT was adminstered to the rats in the treatment group. Aterial blood, pancreas and lung tissues were collected for biomarkers and histopathology 24 hours after operations. Intra-abdominal pressure and intestinal propulsion rate were also measured. RESULTS; DCQT treatment reduced intra-abdominal pressure and improved intestinal propulsion rate compared with those treated with saline (P < 0.05). The ANP rats treated with DCQT had lower wet to dry weight ratio, and milder myeloperoxidase activity and histopathology changes in pancreas and lung than those treated with saline (P < 0.05). Higher pressure of oxygen (PO2) was found in the rats treated with DCQT, while no difference in PCO2 was found between the DCQT and ANP groups (P > 0.05). Only two rats in the ANP group died. CONCLUSION: DCQT can effectively relieve IAH and cure ALI at the same time in rats with acute pancreatitis. The result provides evidence to support the hypothesis "lung and large intestine are interior exteriorly related".

Summary of integrative medicine for severe acute pancreatitis: 26-year clinical experiences and a report of 1 561 cases.

OBJECTIVE: To investigate the changing trends of clinical management for severe acute pancreatitis (SAP) with integrative medicine. METHODS: Clinical data of 1 561 patients with SAP from 1980 to 2005 was retrospectively analyzed. The mortality and morbidity of complications were compared. RESULTS: Of the 1 561 patients, 400 patients accepted surgical operation, while the rest were treated conservatively with integrative medicine. There was a change toward conservative management together with Chinese purgative herbal medication use after 1990 (22.4% from 1980-1990 compared with 45.5% from 1991-1993) because of high postoperative mortality. From 1994-2005, the treatment integrating Western medicine with Chinese herbal medications came to be preferred over the classic Western operation-based method. This change was associated with decreased morbidity (35.4% in 1980-1990 compared with 24.7% in 1991-1993 and 11.0% in 1994-2005, P<0.05) and lower mortality (40.52% of 1980-1990 compared with 17.17% of 1991-1993 and <10.25% of 1994-2005, P<0.05). CONCLUSION: The combination of conservative management with Chinese herbal medicines is preferable to classic Western medicine treatment to reduce morbidity and mortality of SAP, while surgery becomes a supplemental option.

Clinical observation on the effect of dexamethasone and Chinese herbal decoction for purgation in severe acute pancreatitis patients.

OBJECTIVE: To investigate the effect of dexamethasone (Dx) combined with modified Dachengqi Decoction (DCQD), a Chinese herbal decoction for purgation, on patients with severe acute on patients with severe acute, a Chinese herbal decoction for purgation, on patients with severe acute pancreatitis (SAP) accompanied with systematic inflammatory response syndrome (SIRS). METHODS: A total of 81 patients diagnosed as SAP were randomly assigned to a control group or treatment group according to a random number table generated from an SPSS software. The patients in the control group (38 cases) received standard treatment and Chinese herbal decoction for purgation; those in the treatment group (43 cases) received additional 1 mg/(kg·d) dexamethasone (Dx) treatment for three days based on the above treatment. The mortality rate, acute respiratory distress syndrome (ARDS), renal failure, hemorrhage, sepsis, pancreatic pseudocyst, pancreatic abscess, operability, and days of hospitalization were compared between the two groups. RESULTS: Three patients in the control group and eight patients in the treatment group dropped out from the study with a drop-out rate of 7.8% and 18.6%, respectively, and no statistics difference was shown between the two groups (P>0.05). Dx treatment significantly reduced ARDS rate and shortened the length of hospitalization compared to those in the control group (7/35, 20.0% versus 15/35, 42.9%, P=0.0394; 32.5±13.2 days versus 40.2±17.5 days, P=0.0344). Other parameters including the mortality rate were not significant different between the two groups. CONCLUSION: Dx combined with DCQD could decrease the risk of developing ARDS in SAP patients with SIRS and shorten their length of hospitalization.

Effect of severe acute pancreatitis on pharmacokinetics of Da-Cheng-Qi Decoction components.

AIM: To investigate the effect of severe acute pancreatitis (SAP) on pharmacokinetics of Da-Cheng-Qi Decoction (DCQD) components in rats. METHODS: Rats were divided into SAP group and sham-operation group as a control group (n = 6). Rhein, chrysophanol, rheochrysidin, magnolol, hesperidin and naringin in DCQD were quantified in rat serum by high performance liquid chromatography tandem mass spectrometry for studying their pharmacokinetics. RESULTS: Early absorption of each DCQD component was tended to degrade in SAP group after treatment with DCQD by gavage. The C(max) (chrysophanol, P = 0.0059; rheochrysidin, P = 0.0288; magnolol, P = 0.0487; hesperidin, P = 0.0277; naringin, P = 0.0023) and AUC (rhein, P = 0.0186; chrysophanol, P = 0.0013; magnolol, P = 0.001; hesperidin, P = 0.0081; naringin, P = 0.0272) of DCQD component were obviously lower in SAP group than in control group. The T(1/2alpha) of chrysophanol and rheochrysidin (P = 0.0467 and 0.0005, respectively) and T(max) of chrysophanol and rheochrysidin (P = 0.0101 and 0.0037, respectively) lasted longer in SAP group than in control group. CONCLUSION: SAP can significantly impact the absorption of DCQD components in rats and their pharmacokinetic parameters.

[Effects of ranitidine on pharmacokinetics of rhein from Dachengqi Decoction in rats after oral administration].

OBJECTIVE: To explore the effects of ranitidine on pharmacokinetics of rhein in rats after oral administration of Dachengqi Decoction (DCQD), a compound traditional Chinese herbal medicine. METHODS: Twelve male Sprague-Dawley rats were divided into DCQD group and DCQD plus ranitidine group, and were orally administered with DCQD at a dose of 10 g/kg or DCQD (10 g/kg) combined with ranitidine (150 mg/kg), respectively. Blood samples were gathered after a series of time intervals. Metabolism of rhein was determined with a reversed-phase high-performance liquid chromatography with internal standard of 1, 8-dihydroxyanthraquinone and the data were analyzed with DAS 2.1 program. The pharmacokinetic parameters were compared between the two groups. RESULTS: The pharmacokinetic parameters of rhein in the DCQD group, including peak concentration (C(max)), area under the plasma concentration-time curve (AUC), distribution phase half-life (t(1/2alpha)), elimination rate constant (K(10)) and central to peripheral transfer rate constant (K(12)), were significantly different to those in the DCQD plus ranitidine group (P<0.05, P<0.01). There were no significant differences in the other parameters between the two groups. CONCLUSION: Ranitidine can influence the pharmacokinetics of rhein in rats after oral administration of DCQD.

[Dachengqi Decoction induces pancreatic acinar cell apoptosis in experimental acute pancreatitis in rats].

OBJECTIVE: To explore the effects of Dachengqi Decoction (DCQD), a compound traditional Chinese herbal medicine, on pancreatic acinar cell apoptosis in a rat model of experimental acute pancreatitis. METHODS: A total of 36 Sprague-Dawley rats were randomly divided into sham-operated group, untreated group and DCQD-treated group (12 rats in each group). Acute pancreatitis was induced in 24 rats by retrograde injection of 3.5% sodium taurocholate into pancreatic bile duct. The other 12 rats were allocated as sham-operated group. After the operation, the spray-dried DCQD (2 g/mL of crude drugs) or normal saline at 10 mL/kg body weight of rats were orally administered. The rats were sacrificed by decapitation 12 h and 24 h after the administration, and samples were collected. Amylase activity in serum, nitric oxide (NO) content and inducible NO synthetase (iNOS) activity in pancreatic tissue were measured respectively. Pancreatic acinar cell apoptosis was identified by terminal deoxy-nucleotidyl transferase mediated dUTP nick end-labeling, and pathological scores of pancreatic tissues were determined under a light microscope. RESULTS: At the two time points after treatment, the activities of serum amylase in the treated group were significantly lower than those in the untreated group (P<0.05), while the contents of pancreatic NO and activities of iNOS were higher than those in the untreated group (P<0.05), respectively. The pancreatic acinar cell apoptosis rates in the treatment group at 12 h and 24 h were higher than those in the untreated group, and the mean pancreatic pathomorphologic scores decreased correspondingly (P<0.05). CONCLUSION: DCQD can induce pancreatic acinar cell apoptosis by increasing NO content and iNOS activity in the pancreas of experimental acute pancreatitis, which helps attenuate the pancreatic pathomorphology.