Reduced local immune response with continuous positive airway pressure during one-lung ventilation for oesophagectomy.

BACKGROUND: Transthoracic oesophagectomy requires prolonged one-lung ventilation causing systemic and local inflammatory responses. Application of continuous positive airway pressure (CPAP) to the collapsed lung potentially reduces pulmonary damage, hypoxia, and consequent inflammation. This randomized controlled trial studied the influence of CPAP applied to the collapsed right lung during thoracoscopic oesophagectomy on local and systemic inflammatory response. METHODS: Broncho-alveolar lavage fluid (BALF) from the right collapsed and left ventilated lung and serum samples were obtained during surgery from 30 patients undergoing thoracolaparoscopic oesophagectomy for cancer who were randomized for one-lung ventilation with or without CPAP applied to the collapsed right lung. Concentrations of cytokines and chemokines, in BALF and serum, were determined with Luminex. RESULTS: Patients from the control (no CPAP) group had significantly increased concentrations of interleukin (IL)-1α, IL-1ß, IL-10, tumour necrosis factor-alpha, macrophage inflammatory protein (MIP)-1α, pulmonary and activation-regulated chemokine (PARC), and IL-8 in the collapsed (right) lung when compared with patients from the CPAP group (P<0.05). The ventilated (left) lung of the control group showed increased concentrations of monocyte chemoattractant protein (MCP)-1 and MIP-1α (P<0.05). Serum concentrations of cytokines and chemokines increased during surgery, but did not differ between the control and CPAP groups. CONCLUSIONS: A significantly lower local immune response was observed during one-lung ventilation when CPAP was applied to the collapsed lung. The findings suggest a beneficial effect of CPAP on the collapsed lung during oesophagectomy with one-lung ventilation.

Robot-assisted thoracoscopic oesophagectomy for cancer.

BACKGROUND: Thoracoscopic oesophagectomy was introduced to reduce the morbidity of transthoracic oesophagectomy. The aim was to assess the short- and mid-term results of robot-assisted thoracoscopic oesophagectomy for oesophageal cancer. METHODS: Between October 2003 and May 2007, 47 patients with resectable oesophageal cancer underwent robot-assisted thoracoscopic oesophagectomy. Clinical data were collected prospectively. RESULTS: Conversion to thoracotomy was necessary in seven patients. Median operating time was 450 min and median blood loss 625 ml. Median postoperative ventilation time was 1 day, intensive care stay 3 days and hospital stay 18 days. Twenty-one of 47 patients had pulmonary complications. Three patients died in hospital. A median of 29 (range 8-68) lymph nodes was dissected and R0 resection was achieved in 36 patients. Twenty-three patients had stage IVa disease. After a median follow-up of 35 months, median disease-free survival was 15 (95 per cent confidence interval 12 to 18) months. CONCLUSION: Robot-assisted thoracoscopic oesophagectomy was oncologically acceptable. Operating time, blood loss and pulmonary complications might decrease with further experience.

A double blind comparison of lidocaine 2% with or without glucose for spinal anesthesia.

The aim of the study was to compare lidocaine 2% plain to lidocaine 2% with glucose 8% for spinal anesthesia. Forty male patients scheduled for urologic surgery participated. The patients were randomly divided into two groups: the plain (P) group received 4 ml of glucose-free lidocaine 2%, the heavy (H) group received 4 ml of lidocaine 2% containing 8% glucose. After the injection, the patients remained in the sitting position for three minutes before they were placed supine. The onset and maximum level of sensory blockade were similar with both preparations (T7-T8). In both groups there were respectively 3 (P) and 4 (H) patients who did not acquire a sensory level above T10. There was a tendency towards a longer duration of sensory blockade in the P group. The patients in both groups developed an almost complete motor blockade within approximately 10 minutes. Duration of complete motorblockade of the lower extremities was significantly shorter for the H group: 59.1 +/- 6.5 minutes (mean +/- SEM) than the P group: 89.5 +/- 6.4 minutes. We consider lidocaine 2% with or without glucose a suitable agent for subarachnoid anesthesia for short procedures. As hyperbaric lidocaine results in a more rapid recovery of motor blockade, it may have advantages for patients in day-case settings.

Epidural bupivacaine, sufentanil or the combination for post-thoracotomy pain.

Analgesia with epidural bupivacaine, sufentanil or the combination was studied in 50 patients who had undergone thoracotomy. During operation all patients received an initial dose of bupivacaine 0.5% with adrenaline 5 micrograms.ml-1 (5-10 ml) by thoracic epidural catheter. One hour later the patients were divided into three groups: the bupivacaine group (bupivacaine 0.125%), the sufentanil group (50 micrograms sufentanil in 60 ml normal saline) and the combination group (50 micrograms sufentanil in 60 ml bupivacaine 0.125%). Analgesia in the three groups was provided by a continuous epidural infusion (5-10 ml.h-1) for 3 days. The mean dose of bupivacaine was significantly higher (P less than 0.05) in the bupivacaine group (12.07 mg.h-1 (s.e.mean 0.97 mg.h-1)), compared with the combination group (9.82 mg.h-1 (s.e.mean 0.43 mg.h-1)). The mean dose of sufentanil in the sufentanil group was similar to the combination group (6.37 micrograms.h-1 (s.e.mean 0.23 micrograms.h-1) and 6.52 micrograms.h-1 (s.e.mean 0.28 micrograms.h-1), respectively. The pain scores on the inverse visual analogue scale of most patients in the bupivacaine group were unacceptably low. The sufentanil group had much better pain scores, but on exercise these patients experienced more pain than the combination group. The combination group had, overall, better pain scores. In the combination group, there were better respiratory results.