Long-term survival differences between sevoflurane and propofol use in general anesthesia for gynecologic cancer surgery.

BACKGROUND: This study aimed to evaluate the influence of anesthetic management with propofol or sevoflurane on the prognosis of patients undergoing gynecologic cancer surgery. METHODS: This retrospective cohort study included patients who underwent gynecologic cancer (cervical, endometrial, and ovarian cancer) surgery between 2006 and 2018 at the National Hospital Organization Osaka National Hospital. Patients were grouped according to anesthesia type for maintenance of anesthesia: propofol or sevoflurane. After propensity score matching, Kaplan-Meier survival curves were constructed for overall survival, cancer-specific survival, and recurrence-free survival. Univariate and multivariate cox regression models were used to compare hazard ratios for recurrence-free survival. RESULTS: A total of 193 patients with propofol and 94 with sevoflurane anesthesia were eligible for analysis. After propensity score matching, 94 patients remained in each group. The sevoflurane group showed significantly lower survival rates than the propofol group with respect to 10-year overall survival (89.3% vs. 71.6%; p = 0.007), 10-year cancer-specific survival (91.0% vs 80.2%; p = 0.039), and 10-year recurrence-free survival (85.6% vs. 67.7%; p = 0.008). Sevoflurane anesthesia was identified as an independent risk factor for recurrence-free survival. Furthermore, distant recurrence was significantly more frequent in the sevoflurane group than in the propofol group (p < 0.001). CONCLUSION: In patients undergoing gynecologic cancer surgery, sevoflurane anesthesia was associated with worse overall, cancer-specific, and recurrence-free survival than propofol anesthesia.

Longer time to extubation after general anesthesia with desflurane in patients with obstructive respiratory dysfunction: a retrospective study.

BACKGROUND: The prospect of patients with obstructive respiratory dysfunction undergoing surgery has increased with the growth in the elderly population; however, there have been few investigations about the recovery profile from volatile anesthesia. This study aimed to investigate the impact of obstructive respiratory dysfunction on recovery from desflurane anesthesia. METHODS: A retrospective cohort study included patients who underwent orthopedic lower limb surgery between September 2018 and March 2020. Patients were divided into two groups: those whose preoperative forced expiratory volume in 1 s/forced vital capacity ratio was <70% (obstructive respiratory dysfunction group, n = 180) or ≥70% (control group, n = 45). Time from discontinuation of desflurane to extubation (extubation time) was compared between the two groups. Univariate and multivariable Cox regression models were used to compare odds ratios for prolonged extubation (≥10 min). RESULTS: A total of 45 patients with obstructive respiratory dysfunction and 180 control patients were eligible for analysis. Extubation time was significantly longer in patients in the obstructive respiratory dysfunction group than those in the control group. In the multivariable Cox model, male sex (HR = 2.00, 95% CI 1.12-3.57; P = 0.020) and obstructive respiratory dysfunction (HR = 2.07, 95% CI 1.05-4.08; P = 0.036) were associated with prolonged extubation. CONCLUSIONS: This retrospective study indicated that extubation time was longer in patients with obstructive respiratory function than in patients without obstructive respiratory function. Male sex and obstructive respiratory function were factors that contributed to extubation time.

Increase in Intraoperative Urine Output During Tympanoplasty: A Retrospective Cohort Study.

OBJECTIVE: We sometimes encounter cases with unexpected increase in intraoperative urine output during tympanoplasty. However, no previous study has evaluated whether intraoperative urine output during tympanoplasty is higher than that during other surgeries. Thus, this study aimed to evaluate the association between tympanoplasty and intraoperative urine output. METHODS: This single-center retrospective cohort study was conducted by assessing the records of patients who underwent tympanoplasty, sinus surgery, or thyroidectomy under general anesthesia between April 2013 and March 2017. We defined intraoperative polyuria as a urine output rate of ≥ 2.5 mL/kg/h. The factors associated with high urine output were investigated using multivariable analysis. The influence of tympanoplasty on intraoperative urine output was evaluated after propensity score matching that excluded confounding factors, except the surgical procedure. RESULTS: Intraoperative polyuria occurred in 48 of 173 patients (27.7%) who underwent tympanoplasty. Multivariable analysis revealed that tympanoplasty (p = 0.001), operative time of ≥ 3 h (p = 0.010), and fluid infusion volume of ≥ 5 mL/kg/h (p = 0.029) were risk factors for polyuria. Among the study patients, 100 who underwent tympanoplasty (tympanoplasty group) and 100 who underwent sinus surgery or thyroidectomy (control group) were matched by propensity score analysis. The intraoperative urine output rate was significantly higher in the tympanoplasty group than in the control group (1.2 [0.51-2.20] mL/kg/h vs. 0.70 [0.32-1.60] mL/kg/h, p = 0.010). CONCLUSION: Our findings indicate that intraoperative urine output is higher during tympanoplasty than that during other otologic surgeries.

Oesophageal submucosal hematoma after flow diverter embolization with favourable outcome treated by discontinuing postoperative antiplatelet therapy for only three days: a case report.

BACKGROUND: Oesophageal submucosal hematoma is a rare perioperative complication. When this complication develops after endovascular surgery, which requires postoperative antiplatelet therapy, whether to stop antiplatelet therapy or not is controversial. If antiplatelet therapy is discontinued, the appropriate time to resume antiplatelet therapy is unclear. CASE PRESENTATION: A 75-year-old woman (height 134 cm, weight 37 kg) underwent flow diverter embolization for unruptured cerebral aneurysm under general anaesthesia. The patient received dual antiplatelet therapy before surgery and anticoagulation therapy intraoperatively. After surgery, the patient developed hematemesis and was diagnosed with oesophageal submucosal hematoma. Conservative treatment was initiated after discontinuing antiplatelet therapy, which was resumed 3 days after surgery. The patient showed good recovery even after the resumption of antiplatelet therapy. CONCLUSIONS: In our case, we successfully treated oesophageal submucosal hematoma developing after endovascular surgery with early resumption of postoperative antiplatelet therapy.

Intractable hyperkalemia caused by hepatic infarction developed during laparoscopic gastrectomy in a patient with end-stage renal failure: a case report.

BACKGROUND: Patients with renal failure are susceptible to electrolyte disturbances including life-threatening hyperkalemia, and intraoperative hepatic damage exacerbates it. We report a case on hemodialysis who developed intraoperative remarkable hyperkalemia caused by hepatic damage during laparoscopic gastrectomy. CASE PRESENTATION: A 48-year-old man underwent laparoscopic gastrectomy for gastric cancer. He had been on hemodialysis for chronic renal failure. Serum K+ continued to increase to a maximum level of 7.4 mEq/L, despite the infusion of glucose with insulin during surgery. Postoperative computed tomography revealed hepatic infarction. Combined with increased hepatic enzymes, hepatic infarction caused by intraoperative mechanical traction would have exacerbated hyperkalemia. CONCLUSIONS: We report a case on hemodialysis who developed intraoperative hyperkalemia due to hepatic damage. Our case highlights hepatic damage during laparoscopic gastrectomy as a potential cause of hyperkalemia.

[Retrospective analysis of perioperative cardiovascular complications in patients with low left ventricular function undergoing noncardiac surgery].

BACKGROUND: Regarding patients for noncardiac surgery with low left ventricular function, we have little information about perioperative cardiovascular complications, making it difficult to evaluate such patients preoperatively and to inform them of their perioperative course. METHODS: We retrospectively investigated the patients undergoing noncardiac surgery under general anesthesia in our hospital from January 2008 to December 2011. The subjects were 52 patients with low left ventricular function defined as left ventricular ejection fraction under 40%. Patients with perioperative complications were compared with those without them in about 14 factors which might influence their perioperative course. RESULTS: Only one patient had severe hypotension intraoperatively. Postoperatively, five patients had cardiovascular complications in a week and three more in a month. Compared with those with complications and those without them, significant differences were found in 3 of 14 factors : type of surgery (P = 0.006), operation time (P = 0.013), and amount of intraoperative transfusion (P = 0.039). CONCLUSIONS: Regarding patients for noncardiac surgery with low left ventricular function, high risk of perioperative cardiovascular complications was found in a surgery which is highly invasive, long lasting, or requiring massive transfusion.

[Perioperative management for a case of carotid artery stenting].

A 70-year-old male patient with severe cardiac dysfunction underwent carotid artery stenting for severe left carotid artery stenosis under monitored anesthetic care. He was sedated with propofol and fentanyl, and was monitored with ECG, pulse-oximeter and direct blood pressure measurement. He breathed spontaneously without severe hypoxia during the procedure. Followed by insertion of transient ventricular pacing wire against expected severe bradycardia, a guidewire was introduced into left internal carotid artery lesion via the right femoral artery. Soon after dilating the stenotic portion with a ballon catheter, sudden hypotension and bradycardia were recognized, which were successfully managed with bolus injections of vasoconstrictors and atropine sulphate. Even after stenting, hypotension continued for two days in spite of continuous administration of dopamine. Postoperative examination showed that the blood flow of the left carotid artery was doubled. Two weeks after the operation, he was discharged uneventfully.

[A case of the complications following glycerin enema which suggested malignant hyperthermia].

We experienced a case of the complications following glycerin enema which suggested malignant hyperthermia. A 73-year-old man with knee osteoarthritis was scheduled for total knee arthroplasty under general and epidural anesthesia. The patient received glycerin enema before surgery. After epidural catheterization, anesthesia was induced with thiopental, fentanyl, vecuronium and sevoflurane. The trachea was intubated and the patient was ventilated with sevoflurane-air-oxygen. Then, cola-like urine was drained and he became febrile up to 37.9 degrees C. Although there were no other symptoms suggesting malignant hyperthermia, the surgery was cancelled. We suspected not only hemolysis by the color of the serum and the blood chemistry, but also rhabdomyolysis by increased levels of serum creatine phosphokinase and myoglobin as well as urine myoglobin. He recovered uneventfully. On the third day, perirectal abscess and anal fissure were diagnosed, which were considered to be the cause of the fever. It is well-known that glycerin enema could cause hemolysis, but rabdomyolysis as a complication of glycerin enema has rarely been reported. We speculate that injection of hypertonic glycerin into the perirectal tissue could have caused rhabdomyolysis as well as hemolysis, which led to cola-like urine. The complications following glycerin enema can be incorporated to a differential diagnosis of malignant hyperthermia.

[Comparison of Cormack/Lehane classification grades decided by novice residents and those by board certified anesthesiologists].

BACKGROUND: Tracheal intubation training is one of the most important ones in anesthesia training. But it is difficult to evaluate from the outside whether the laryngeal view obtained with the laryngoscope is appropriate or not. METHODS: We chose a total of 389 cases of tracheal intubation performed by 12 novice residents in 2 months, and compared the grades of Cormack/Lehane classification of the same patients decided by novice residents and board certified anesthesiologists. RESULTS: During the 2-month period, the average number of tracheal intubation performed by a novice resident was 32 +/- 12 cases (mean +/- SD). A significant difference was found between Cormack/Lehane classification (P<0.05) decided by novice residents and those by board certified anesthesiologists. When the number of intubation performed by a novice resident was fewer than 30, the grade was grade II > III > I > IV. On the contrary, when it was more than 30, the ratio of grades I and II (appropriate laryngeal view) increased and the distribution changed to grade II > I >III > IV. CONCLUSIONS: We considered it useful in the tracheal intubation training that certified anesthesiologists evaluate patients' Cormack/Lehane classification grades before novice residents do, because we can obtain necessary information on laryngeal view and intubation difficulty in advance.

[Study of analgestic efficacy of ropivacaine-fentanyl patient-controlled epidural analgesia after upper abdominal gynecological surgery].

BACKGROUND: Most of the patients who undergo radical or subradical hysterectomy with paraaortic lymphadenectomy suffer from postoperative pain for upper abdominal incision. They also complain of postoperative nausea and vomiting (PONV) frequently, which are increased by opioids. METHODS: Reducing total fentanyl dose to 0.6 mg, frequency of moving pain complaints increased gradually. Therefore, we introduced patient-controlled epidural analgesia (PCEA) for suppressing pain on moving. We investigated analgestic efficacy of 0.2% ropivacaine-fentanyl PCEA in twelve patients undergoing upper abdominal gynecological surgery. Postoperative analgesic effects were evaluated by visual analogue scale (VAS) at rest and on moving, times of bolus infusion, side effects, and degrees of satisfication by patient's self-assessments. Continuous epidural infusion of 0.6 mg fentanyl in 288 ml 0.2% ropivacaine was started at a rate of 4 ml x hr(-1) with a bolus dose of 2 ml. RESULTS: VAS was maintained below 20 mm at rest but was elevated to the maximum of 45 mm on moving with few bolus requests. Ninty-two percents of the patients answered satisfied but fifty percents of them had PONV. CONCLUSIONS: We conclude that ropivacaine-fentanyl PCEA is effective after upper abdominal gynecological surgery, and we can decrease the dose of fentanyl by explaining PCEA system more effectively to the patients for suppressing the pain on moving and PONV.