Open Gastrointestinal Surgery Research Articles

Plastic Wound Protector vs Surgical Gauze for Surgical Site Infection Reduction in Open GI Surgery

Surgical site infections (SSIs) are prevalent hospital-acquired infections with significant patient impacts and global health care burdens. The World Health Organization recommends using wound protector devices in abdominal surgery as a preventive measure to lower the risk of SSIs despite limited evidence. To examine the efficacy of a dual-ring, plastic wound protector in lowering the SSI rate in open gastrointestinal (GI) surgery irrespective of intra-abdominal contamination levels. This multicenter, patient-blinded, parallel-arm randomized clinical trial was conducted from August 2017 to October 2022 at 13 hospitals in an academic setting. Patients undergoing open abdominal bowel surgery (eg, for bowel perforation) were eligible for inclusion. Patients were randomized 1:1 to a dual-ring, plastic wound protector to protect the incision site of the abdominal wall (experimental group) or a conventional surgical gauze (control group). The primary end point was the rate of SSI within 30 days of open GI surgery. A total of 458 patients were randomized; after 1 was excluded from the control group, 457 were included in the intention-to-treat analysis (mean [SD] age, 58.4 [12.1] years; 256 [56.0%] male; 341 [74.6%] with a clean-contaminated wound): 229 in the wound protector group and 228 in the surgical gauze group. The overall SSI rate in the intention-to-treat analysis was 15.7% (72 of 458 patients). The SSI rate for the wound protector was 10.9% (25 of 229 patients) compared with 20.5% (47 of 229 patients) with surgical gauze. The wound protector significantly reduced the risk of SSI, with a relative risk reduction (RRR) of 46.81% (95% CI, 16.64%-66.06%). The wound protector significantly decreased the SSI rate for clean-contaminated wounds (RRR, 43.75%; 95% CI, 3.75%-67.13%), particularly for superficial SSIs (RRR, 42.50%; 95% CI, 7.16%-64.39%). Length of hospital stay was similar in both groups (mean [SD], 15.2 [10.5] vs 15.3 [10.2] days), as were the overall postoperative complication rates (20.1% vs 18.8%). This randomized clinical trial found a significant reduction in SSI rates when a plastic wound protector was used during open GI surgery compared with surgical gaze, supporting the World Health Organization recommendation for use of wound protector devices in abdominal surgery. ClinicalTrials.gov Identifier: NCT03170843.

A prospective study of post-operative surgical site infections after open gastrointestinal surgeries

Background: Surgical site infections (SSIs) are infections of the tissues, organs, or spaces exposed by surgeons while performing an invasive procedure. SSI is one of the most common healthcare-associated infections, but its importance as a health-care priority is not fully understood, and limited work has been published defining the role of surgeons in SSIs. Aims and Objectives: In the present study, we assess the burden of SSI after gastrointestinal (GI) surgery in a tertiary care hospital in the Central India. Materials and Methods: The present study was conducted on patients admitted to Gandhi Medical College-affiliated Hamidia Hospital, Bhopal, in the General Surgery Department. The study included 207 patients who underwent emergency/routine GI surgeries between September 2020 and April 2022. Patient characteristics and laboratory data were recorded on a pre-designed form, and all patients were evaluated postoperatively for soakage along with culture and antibiotic testing. Results: The overall incidence of SSI was 42.51% and its distributions between emergency and routine surgeries were 22.7% and 19.8%, respectively. SSI was predominant in male patients. White blood cell level was significantly associated between emergency and routine surgeries, while Hb level, serum protein level, and the time required for surgery were insignificant. SSI under contaminated dirty wounds was prevalent in both emergency and routine surgeries. Klebsiella was the most commonly isolated organism, followed by Escherichia coli. The commonly susceptible antibiotics have been found to be meropenem, pipzo, amikacin, and imipenem. Commonly resistant antibiotics were amoxiclav, ceftriaxone, linezolid, and doxycycline. Conclusion: This paper presents the incidence of SSI in the hospital setting of Central India and the factors that may contribute to the high incidence of SSI. Further research needs to be done to better understand how specific risk factors are responsible for post-operative wound infections in open GI surgery.

Differences in Analgesia Methods for Open Gastrointestinal Surgery Are Not Associated With Initial Postoperative Ambulation.

A characteristic of modern medical care is the reduction in the length of hospital stay, and several facilities across Japan are working towards this goal. The presence of postoperative pain is correlated with the number of days to hospital discharge. Therefore, this study investigated the relationship between the analgesic methods used in clinical practice and the initial ambulation of postoperative laparotomy patients with severe postoperative worked incisional pain to enable better analgesic management in the future. This retrospective study collected information from the medical records of 117 patients who underwent laparotomy between December 1, 2019, and October 13, 2020, at the Department of Gastroenterology of the International University of Health and Welfare Mita Hospital. Based on the failure or success of the ambulation process, the patients were divided into the delayed and successful groups, respectively. In the delayed group, patient-controlled epidural analgesia (PCEA) was used in 32 patients, intravenous patient-controlled analgesia (IV-PCA) was used in two patients, continuous worked incisional infiltration anesthesia was used in one patient, and transvenous acetaminophen was used in one patient for postoperative analgesia. In the successful group, PCEA was used in 66 patients, IV-PCA was used in 11 patients, continuous worked incisional infiltration anesthesia was used in three patients, and acetaminophen administered intravenously at patient's request was used in one patient (P = 0.094). No significant differences were observed between different postoperative analgesia methods, suggesting that there may be no association between postoperative ambulation and the postoperative analgesia method.

FACTORS AFFECTING SURGICAL SITE INFECTION IN OPEN GASTROINTESTINAL SURGERY

Surgical site infection is more prevalent in open gastrointestinal surgery which will affect hospital stay and morbidity and mortality of patients.In our study,we are comparing the factors which will directly or indirectly causes SSI.By knowing the factors which causing SSI,We can decreases the incidence of surgical site infection.

Clinical Impact of Two-Week Placement of a Subcutaneous Suction Drain in Preventing Incisional Surgical Site Infection in Open Gastrointestinal Surgery with Class 4 Dirty Wound: A Retrospective Study.

Background: Two recent randomized controlled trials demonstrated the beneficial effects of subcutaneous drainage in preventing incisional surgical site infection (SSI) in colorectal surgery. This study aimed to evaluate the efficacy of subcutaneous suction drains (SSDs) compared with primary skin closure (PC) in class 4 dirty wound surgery. Patients and Methods: Eighty-one patients undergoing open gastrointestinal surgery with class 4 dirty wounds were enrolled in this study, 30 of whom underwent SSD insertion, whereas the other 51 were treated with PC. Because several studies have reported that the median onset of the development of incisional SSI was eight to 13 days after surgery, we used a two-week placement of an SSD. Comparison of patients treated with SSD and PC and multivariable analysis were performed to test the ability of SSD in decreasing the SSI rate. Results: No differences were observed between the two groups in terms of gender, body mass index, American Society of Anesthesiology score, steroid use, presence of diabetes mellitus, peri-operative transfusion, and surgery type. Surgical site infection incidence was lower in the SSD group (6.6%; 2/30) than that in the PC group (23.5%; 12/51; p = 0.069). Multivariable analysis revealed that the presence of diabetes mellitus was an important independent risk factor for incisional SSI, and the placement of an SSD has substantial preventive effects on incisional SSI (p = 0.018 and p = 0.014, respectively). Conclusions: This study suggested the potential importance of a two-week placement of an SSD for preventing incisional SSI in class 4 dirty wound surgery.

Local infrared radiation combined with skin regenerative medical technology for treatment of incision infection after open gastrointestinal surgery: Efficacy and influence on IL-4/IL-13/STAT6 signaling pathway

Local infrared radiation combined with skin regenerative medical technology for treatment of incision infection after open gastrointestinal surgery: Efficacy and influence on IL-4/IL-13/STAT6 signaling pathway

Ultrasound-Guided Quadratus Lumborum Block Enhances the Quality of Recovery after Gastrointestinal Surgery: A Randomized Controlled Trial

Background Quadratus lumborum block (QLB) has been used to reduce postoperative acute pain and opioid consumption. However, the efficacy of QLB on the quality of recovery (QoR) after gastrointestinal surgery has not been established. The aim of this study was to evaluate the ability of QLB to enhance the postoperative QoR in patients undergoing open gastrointestinal surgery. Methods Eighty-four patients undergoing open gastrointestinal surgery were randomized to receive ultrasound-guided QLB with either 20 ml of 0.375% ropivacaine or saline. The primary outcome was the QoR-15 score at 24 h after surgery. The secondary outcomes were the postoperative pain intensity, opioid consumption, the incidence of nausea, vomiting, and chronic pain. Results The global QoR-15 score at 24 h postoperatively was significantly higher in the QLB group than in the control group (mean difference: 16.9; 95% CI: 11.9–21.9). Additionally, the QoR-15 scores for five dimensions were significantly higher in the QLB group than in the control group. The cumulative oxycodone consumption was significantly lower in the QLB group during 0–6, 6–24, 0–24, 24–48, and 0–48 h postoperatively than in the control group. At rest or during coughing, the pain verbal rating scale scores were significantly lower at 1, 3, 6, 12, and 24 h after surgery in the QLB group than in the control group. The incidence of postoperative nausea was significantly different between the groups, but postoperative vomiting was not. Conclusion Single-injection posteromedial QLB with ropivacaine enhanced the QoR at 48 h after surgery and improved analgesia during the early postoperative period in patients undergoing gastrointestinal surgery.

Analgesic effects of sufentanil in combination with flurbiprofen axetil and dexmedetomidine after open gastrointestinal tumor surgery: a retrospective study

BackgroundTo investigated the effects of sufentanil in combination with flurbiprofen axetil and dexmedetomidine for patient-controlled intravenous analgesia (PCIA) on patients after open gastrointestinal tumor surgery, and compared this combination with traditional PCIA with pure opioids or epidural analgesia (PCEA).MethodsPatients (n = 640) who underwent open gastrointestinal tumor surgery and received patient-controlled analgesia (PCA) were included. According to the type of PCA, patients were assigned to three groups: MPCIA (PCIA with sufentanil, flurbiprofen axetil, dexmedetomidine and metoclopramide), OPCIA (PCIA with sufentanil, tramadol and metoclopramide) and PCEA group (PCEA with sufentanil and ropivacaine). The characteristics of patients, intraoperative use of analgesics, postoperative visual analogue scale (VAS), postoperative adverse reactions and postoperative recovery were collected. The primary outcome was postoperative VAS score. One-way ANOVA, Kruskal-Wallis H test, Fisher exact probability method, and binary logistic regression analysis were used for analysis.ResultsThere were no significant differences in the characteristics of patients, operation time, tumor site and the use of postoperative rescue analgesics among the groups. In the first two days after open gastrointestinal tumor surgery, the VAS (expressed by median and interquartile range) of MPCIA (24th h, resting: 1,1; movement: 3,2. 48th h, resting: 0,1; movement: 2,1.) and PCEA (24th h, resting: 0,1; movement: 2,1. 48th h, resting: 0,1; movement: 2,2.) groups were significantly lower than those of OPCIA group (24th h, resting: 2.5,2; movement: 4,2. 48th h, resting: 1.5,1.75; movement: 3,1.) (all p < 0.01). The incidence of postoperative nausea and vomiting in MPCIA group was 13.6% on the first day after surgery, which was significantly higher than that in PCEA group. There was no significant difference in the incidence of other postoperative adverse events. Higher intraoperative sufentanil dosage (OR (95%CI) = 1.017 (1.002–1.031), p = 0.021), lower body mass index (OR (95%CI) = 2.081 (1.059–4.089), p = 0.033), and tumor location above duodenum (OR (95%CI) = 2.280 (1.445–3.596), p < 0.001) were associated with poor postoperative analgesia.ConclusionsThe analgesic effects of PCIA with sufentanil in combination with flurbiprofen axetil and dexmedetomidine on postoperative analgesia was better than that of traditional pure opioids PCIA, and similar with that of PCEA.

Goal-directed fluid therapy in gastrointestinal cancer surgery

Objective: To investigate the effects of perioperative goal-directed fluid therapy (GDFT) on intraoperative fluid balance, postoperative morbidity, and mortality. Methods: This is a prospective randomized study, and 90 patients who underwent elective open gastrointestinal cancer surgery between April 2017 and May 2018 were included. Patients were randomized into 2 groups that received liberal fluid therapy (the LFT group, n=45) and goal-directed fluid therapy (the GDFT group, n=45). Patients’ Colorectal Physiologic and Operative Severity Score for the enUmeration of Mortality and Morbidity (CR-POSSUM) physiological score, Charlson Comorbidity Index (CCI), perioperative vasopressor and inotrope use, postoperative AKIN classification, postoperative intensive care unit (ICU) hospitalization, hospital stay, and 30-day mortality were recorded. Results: The volume of crystalloid used perioperatively and the total volume of fluid were significantly lower in the GDFT group compared to the LFT group (P&lt;0.05). CR-POSSUM physiological score and CCI were significantly higher in the GDFT group (P&lt;0.05). Although perioperative vasopressor and inotrope use was significantly higher in the GDFT group (P&lt;0.05), postoperative acute kidney injury development was not affected. Postoperative mortality was determined to be similar in both groups (P&gt;0.05). Conclusion: Although GDFT was demonstrated to be a good alternative method to LFT in open gastrointestinal cancer surgery, and it can prevent perioperative fluid overload, and the postoperative results are comparable in the two groups.

Preoperative carbohydrate loading and intraoperative goal-directed fluid therapy for elderly patients undergoing open gastrointestinal surgery: a prospective randomized controlled trial

BackgroundThe effect of a combination of a goal-directed fluid protocol and preoperative carbohydrate loading on postoperative complications in elderly patients still remains unknown. Therefore, we designed this trial to evaluate the relative impact of preoperative carbohydrate loading and intraoperative goal-directed fluid therapy versus conventional fluid therapy (CFT) on clinical outcomes in elderly patients following gastrointestinal surgery.MethodsThis prospective randomized controlled trial with 120 patients over 65 years undergoing gastrointestinal surgery were randomized into a CFT group (n = 60) with traditional methods of fasting and water-deprivation, and a GDFT group (n = 60) with carbohydrate (200 ml) loading 2 h before surgery. The CFT group underwent routine monitoring during surgery, however, the GDFT group was conducted by a Vigileo/FloTrac monitor with cardiac index (CI), stroke volume variation (SVV), and mean arterial pressure (MAP). For all patients, demographic data, intraoperative parameters and postoperative outcomes were recorded.ResultsPatients in the GDFT group received significantly less crystalloids fluid (1111 ± 442.9 ml vs 1411 ± 412.6 ml; p < 0.001) and produced significantly less urine output (200 ml [150–300] vs 400 ml [290–500]; p < 0.001) as compared to the CFT group. Moreover, GDFT was associated with a shorter average time to first flatus (56 ± 14.1 h vs 64 ± 22.3 h; p = 0.002) and oral intake (72 ± 16.9 h vs 85 ± 26.8 h; p = 0.011), as well as a reduction in the rate of postoperative complications (15 (25.0%) vs 29 (48.3%) patients; p = 0.013). However, postoperative hospitalization or hospitalization expenses were similar between groups (p > 0.05).ConclusionsFocused on elderly patients undergoing open gastrointestinal surgery, we found perioperative fluid optimisation may be associated with improvement of bowel function and a lower incidence of postoperative complications.Trial registrationChiCTR, ChiCTR1800018227. Registered 6 September 2018 - Retrospectively registered.

Chylous ascites in the setting of internal hernia: a reassuring sign.

Chylous ascites is often reported in cases with lymphatic obstruction or after lymphatic injuries such as intraabdominal malignancies or lymphadenectomies. However, chylous ascites is also frequently encountered in operations for internal hernias. We sought to characterize the frequency and conditions when chylous ascites is encountered in general surgery patients. Data from patients who underwent operations for CPT codes related to open and laparoscopic abdominal and gastrointestinal surgery in our tertiary hospital from 2010 to 2019 were reviewed. Patients with the postoperative diagnosis of internal hernia were identified and categorized into three groups: Internal Hernia with chylous ascites, non-chylous ascites, and no ascites. Demographics, prior surgical history, CT findings, source of internal hernia, open or laparoscopic surgery, and preoperative labs were recorded and compared. Fifty-six patients were found to have internal hernias and were included in our study. 80.3% were female and 86% had a previous Roux-en-Y gastric bypass procedure (RYGBP). Laparoscopy was the main approach for all groups. Ascites was present in 46% of the cases. Specifically, chylous ascites was observed in 27% of the total operations and was exclusively (100%) found in patients with gastric-bypass history. Furthermore, it was more commonly associated with Petersen's defect (p < 0.001), while the non-chylous fluid group was associated with herniation through the mesenteric defect (p < 0.001). Chylous ascites is a common finding during internal hernia operations. Unlike other more morbid conditions, identification of chylous ascites during an internal hernia operation appears innocuous. However, in the context of a patient with a history of RYGBP, the presence of chylous fluid signifies the associated small bowel obstruction is likely related to an internal hernia through a patent Petersen's defect.

The Effects of Body Mass Index on the Use of Patient-Controlled Intravenous Analgesia After Open Gastrointestinal Tumor Surgery: A Retrospective Analysis.

PurposeTo investigate the impact of body mass index (BMI) on the analgesic effects and adverse reactions of patient-controlled intravenous analgesia (PCIA).MethodsFrom 2017 to 2018, 390 patients undergoing open gastrointestinal surgery were reviewed at West China Hospital, Sichuan University. All used PCIA of sufentanil combined with dexmedetomidine and flurbiprofen axetil. According to their BMIs, they were placed into six groups: group A (BMI < 18.5kg/m2, 29), group B (18.5kg/m2 ≤ BMI< 22kg/m2, 124), group C (22kg/m2 ≤ BMI < 24kg/m2, 99), group D (24kg/m2 ≤ BMI < 26kg/m2, 69), group E (26kg/m2 ≤ BMI < 28kg/m2, 46) and group F (BMI ≥28kg/m2, 23). Main data of the perioperative use of analgesics, postoperative visual analogue score (VAS), and adverse reactions were collected.ResultsTwenty-four hours (h) after surgery, patients in group A had a higher resting VAS than the other groups, especially B (pA-B = 0.011). VAS of patients during activity in group B was lower than those in group C 48 h after surgery (p = 0.013). Compared with groups B to F, group A had a significantly lower incidence of hypertension (p = 0.012) and a significantly higher incidence of vomiting 24 h after surgery (p = 0.009). Binary logistic analysis found that higher age was a risk factor for vomiting 24 h after surgery (OR 1.158, p = 0.045).ConclusionUsing the same PCIA, patients with BMIs of less than 18.5 kg/m2 had worse analgesia on the first day after surgery and were more likely to vomit. Postoperative analgesia and related experiences in patients with BMIs of less than 18.5 kg/m2 need to be improved.

Prospective longitudinal cohort study of patient recovery after major gastrointestinal surgery: is there a difference between minimally invasive and open approaches?

Surgeons use the absence of post-operative complications to define recovery while patients define recovery as return to normal function. We aimed to better define the recovery process after minimally invasive surgery (MIS) and open gastrointestinal surgery. Patients scheduled for open or MIS pancreaticoduodenectomy, esophagectomy, colectomy, and proctectomy were prospectively enrolled. Patient-reported outcomes (PROs) were collected using validated PROMIS and LASA scales pre-operatively, on post-operative days 2, 7, 14, 30, and monthly until 6months. Patients were also asked if they felt fully recovered. Descriptive statistics and area under the curve (AUC) were used to compare approaches. Multivariable mixed-effects repeated measures models and logistic regression were used to control for covariates. 340 patients met inclusion criteria (158 open and 182 MIS). Median age was 60years with 44% women. The PRO showed improved post-operative QOL scores in MIS compared to open on all measures by AUC. None of these difference persisted at 6-months. After adjusting for covariates, MIS had higher overall QOL scores at day 14 (Estimate + 0.58, p = 0.02) and 30 (+ 0.56, p = 0.03). Differences did not persist at 3 and 6months (both p > 0.05). At 1, 3, and 6months, 20%, 47%, and 61% of patients reported feeling completely recovered. On adjusted analysis there was no difference in odds of complete recovery in MIS at 1 (OR 1.07 [95% CI 0.53-2.14] and 3months (1.12 [0.63-2.01]) compared to open. MIS patients were more likely to report complete recovery at 6months (1.87 [1.05-3.33]). MIS patients reported improved PRO on selected QOL measures early in the recovery period compared to open. There was no difference in long-term QOL data between MIS and open patients. Two-thirds (61%) of patients reported being fully recovered at 6months with MIS patients being more likely to report a complete recovery.

Effect of intraoperative warming on muscle relaxation recovery of cisatracurium in patients undergoing gastrointestinal surgery

Objective: To investigate the effect of intraoperative warming on the postoperative relaxation recovery of cisatracurium in patients undergoing gastrointestinal surgery. Methods: Sixty ASA Ⅰ-Ⅱ patients, aged 20 to 60, undergoing elective gastrointestinal surgery in Cancer Hospital Chinese Academy of Medical Sciences from October, 2016 to March, 2019 were selected and they were randomly divided into two groups (n=30), N group and H group by random number table. N group was non-heat preserving group, and H group was heat preserving group. Tracheal intubation was induced by general anesthesia with cisatracurium 0.15 mg/kg, and the nasopharyngeal temperature were continuously monitored and recorded. Cisatracurium were infused 1-3 μg·kg(-1)·min(-1) by venous pump during operation with T1 at 1%-10% and stopped infusion 30 minutes before the end of surgery. The time when T1 recovered from 25% to 75%(muscle relaxation recovery index), and the time of T1 recovered to 25% to TOF ratios (TOFR, the ratio of the fourth muscle twitch height to T1 in TOF) recovery to 90% (full recovery time), cumulative drug use and surgery time were recorded. Results: There was no significant difference between the two groups in the cumulative drug dosage and operation time (P>0.05).The body temperature N group (35.7±0.2) ℃ was significantly lower than the H group (36.2±0.1) ℃ (t=13.940, P<0.01). The recovery index of N group (16.5±1.8) min was significantlyhigher than H group (10.5±2.1) min (t=12.094, P<0.01) and complete recovery time in N group (26.9±4.1) min was obviously longer than those in H group (15.0±2.9) (t=13.082, P<0.01). Conclusions: Patients with open gastrointestinal surgery are prone to hypothermia during surgery and heat protection is helpful to muscle relaxation recovery of cisatracurium.

Multi-parametric functional hemodynamic optimization improves postsurgical outcome after intermediate risk open gastrointestinal surgery: a randomized controlled trial.

Perioperative goal directed therapy (pGDT) using flow monitoring has been associated with improved outcomes. However, its protocols are often based on stroke volume only: as a target for fluid loading, inotropic support and vasopressors (via mathematical coupling of systemic vascular resistance). In this trial, we have tested the multi-parametric pGDT protocol based on esophageal Doppler variables (corrected flow time, peak velocity) in intermediate-to-high risk patients undergoing gastrointestinal surgery. Intermediate-to-high risk patients undergoing gastrointestinal surgery were randomized to standard care (control) or multi-parametric pGDT (intervention). Postoperative complications and death rate as well as hospital length of stay were assessed as primary and secondary outcomes. Overall, 140 patients (intervention, N.=71, and control, N.=69) were included and randomized out of 197 eligible. Higher vasoactive/inotropic drug use and lower fluid balance were observed in the intervention group leading to favorable hemodynamic profile. The pGDT intervention was associated with improved primary outcome (28 days mortality and morbidity defined as occurrence of any defined complication) - 20 patients (28.2%) versus 32 (46.4%) in the control group (P=0.036); RR 0.61 (95% CI: 0.39-0.95), P=0.03. No differences in mortality and hospital length of stay were observed between groups. In this monocentric trial the multi-parametric pGDT protocol based on domain specific functional hemodynamic parameters was associated with lower rate of postoperative complications in intermediate-to-high risk patients undergoing scheduled gastrointestinal procedures.

Efficacy of Nalbuphine with Flurbiprofen on Multimodal Analgesia with Transverse Abdominis Plane Block in Elderly Patients Undergoing Open Gastrointestinal Surgery: A Randomized, Controlled, Double-Blinded Trial.

Objective To assess different doses of nalbuphine with flurbiprofen compared to sufentanil with flurbiprofen in multimodal analgesia efficacy for elderly patients undergoing gastrointestinal surgery with a transverse abdominis plane block (TAPB). Methods 158 elderly patients scheduling for elective open gastrointestinal surgery under general anesthesia and TAPB were randomly assigned to four groups according to different doses of nalbuphine with flurbiprofen in postoperative intravenous analgesia (PCIA). Postoperative pain intensity, effective pressing numbers of PCIA, and adverse effects were recorded at 6, 12, 24, and 48 hours after surgery. Results Postoperative pain intensity, effective pressing numbers, and the incidence of postoperative nausea and vomiting (PONV) were similar among the four groups after surgery, while the severity of PONV was decreased in Group L compared with Group S at 6, 12, and 48 h after surgery. No individual experienced pruritus, respiratory depression, or hypotension. Conclusions Low dose of nalbuphine (15 μg·kg−1·ml−1) combined with flurbiprofen is superior for elderly patients undergoing elective open gastrointestinal surgery with TAPB in terms of the efficient postoperative analgesia and decreased severity of PONV. This trial is registered with NCT02984865.

Accuracy and inter-operator variability of small bowel length measurement at laparoscopy.

Measurement of bowel length is an essential surgical skill for laparoscopic and open gastrointestinal surgery in order to achieve favorable outcomes and avoid long-term complications. Variations in accuracy between the two surgical approaches may exist. However, only few studies have tried to assess these differences. Our aim was to assess reliability and inter-rater variability of small bowel length assessment during laparoscopy in an in vivo porcine model. This is a single-institution, double-blinded, technical assessment study in a porcine in vivo model. Fourteen participants (ten senior surgeons with >1000 laparoscopic procedures and four junior surgeons) had to assess and mark lengths of small bowel in both laparoscopic and open surgical approaches. Each participant was assigned to measure and mark specific, randomized distances (range 25-197cm) in both laparoscopic and open approaches using color-coded vessel loops. Actual participant-marked distances were compared to the assigned distances followed by Bland-Altman plots and linear regression analysis to determine accuracy and proportional error trends. Study data were further compared to available data sets from previously published studies. Laparoscopy measurements were significantly shorter than required (difference 33.8±28.7cm, P<0.001, 95% CI 17.8-49.7). The measuring error was proportional to the length of the measured segment (63% of the required distances, IQR 58.9-79.0%, P=0.02). At laparotomy, mean difference and standard deviation were lower (1.5cm±SD 15cm) and not statistically significant (P=0.7). Re-analysis of previously published data sets validated the observed errors in laparoscopic bowel measurement (P<0.01). Small bowel length assessment during laparoscopy is inaccurate and associated with substantial variability. There is a need to develop a standardized laparoscopic technique for measuring small bowel length which is simple, reproducible, and easy to learn.

Use of an Image Acquisition Stabilizer Improves Sidestream Dark Field Imaging of the Serosa during Open Gastrointestinal Surgery

Aim: To investigate whether an image acquisition stabilizer (IAS) mounted on the sidestream dark field camera (SDF) during gastrointestinal surgery improves image stability and acquisition. Methods: Serosal SDF imaging was compared with SDF imaging combined with an IAS (SDF + IAS) during gastrointestinal surgery. Stability was assessed as the image drift in pixels and the time to obtain stable images. The success rate was determined as the percentage of analyzable images after recording. The effect of negative pressure from the IAS was determined during single-spot measurements and by comparing microvascular parameters between groups. Data are presented as mean ± SD. Results: Sixty serosal measurements were performed per group; 87% were successful in the SDF group and 100% in the SDF + IAS group (p = 0.003). Image drift in the SDF group was 148 ± 36 versus 55 ± 15 pixels in the SDF + IAS group; p < 0.001. Time to stable image was 96 ± 60 s in the SDF group versus 57 ± 31 s in the SDF + IAS group; p = 0.03. No effect of negative pressure was seen. Conclusion: The use of an IAS mounted on an SDF camera during serosal microvascular assessment improves the success rate of image acquisition and stability and reduces the time to stable image with no effect on the microcirculation.

Opposite Associations Between the rs3845446 Single-Nucleotide Polymorphism of the CACNA1E Gene and Postoperative Pain-Related Phenotypes in Gastrointestinal Surgery Versus Previously Reported Orthognathic Surgery.

Cav2.3 (R-type) voltage-activated Ca(2+) channels (VACCs), encoded by the calcium channel, voltage-dependent, R-type, α1E subunit (CACNA1E) gene, are responsible for transmission of somatic inflammatory pain, and activation of antinociception elicited by visceral inflammatory pain stimuli. Carriers of the minor G allele of the rs3845446 single-nucleotide polymorphism (SNP) of the CACNA1E gene reportedly exhibit a decrease in opioid requirements to control typical somatic inflammatory pain after orthognathic surgery (ie, a painful cosmetic surgery), suggesting the downregulation of Cav2.3 VACC function that is responsible for transmission of somatic inflammatory pain in these carriers. Gastrointestinal surgery involves somatic and visceral inflammatory pain, in which visceral inflammatory pain stimuli activate Cav2.3 VACC-mediated antinociception. Unknown is whether pain-related phenotypes after gastrointestinal surgery are affected in these carriers. The present study used a correlational design to examine the effect of the rs3845446 SNP on postoperative pain-related phenotypes in 2 groups of patients who underwent gastrointestinal surgery. Carriers of the minor G allele had greater opioid requirements after laparoscopic colectomy when intravenous patient-controlled analgesia was used, and reported higher pain scores after open gastrointestinal surgery when postoperative analgesia was managed with continuous epidural analgesia and rescue analgesics. These results suggest that pain-related phenotypes after gastrointestinal surgery are enhanced in carriers of the minor G allele of the rs3845446 SNP, possibly through impairment of Cav2.3 VACC function that is responsible for the activation of visceral inflammatory pain stimulus-elicited antinociception. Carriers of the minor allele of the rs3845446 SNP of the CACNA1E gene required more opioid or reported higher pain scores after gastrointestinal surgery, and required less opioid after orthognathic surgery. The difference may result from the presence of visceral inflammatory pain stimulus that activates Cav2.3 VACCs-mediated antinociception.

Influence of high body mass index on mortality and infectious outcomes in patients who underwent open gastrointestinal surgery: A meta-analysis

The influence of high body mass index (BMI) on mortality and infectious outcomes of patients following open gastrointestinal surgery was unclear. This meta-analysis aimed to resolve this controversy. PubMed and EMBASE were searched by 2 researchers. High and normal BMIs were defined as ≥25 and 18.5-24.99, respectively. Odds ratios (ORs) were calculated to compare the pooled effect sizes. The primary outcome was mortality. The secondary outcome was infectious outcomes, including surgical site, pulmonary infections, and urinary tract infections. Eleven eligible articles with 51,307 patients total were included. Compared with normal BMIs, high BMIs did not increase the risk of mortality (OR, 0.78; 95% confidence interval [CI], 0.58-1.06; P = .12). The secondary outcome indicated a significantly higher risk of infectious outcomes in high-BMI patients (OR, 1.34; 95% CI; 1.13-1.58; P = .0007). Among high-BMI patients, the risks of surgical site infections (OR, 1.75; 95% CI, 1.33-2.3; P < .0001) and pulmonary infections (OR, 1.2; 95% CI, 1.02-1.40; P = .03) increased significantly; urinary tract infections (OR, 1.10; 95% CI, 0.92-1.31; P = .30) did not show statistical difference. High BMI was associated with higher risks of infectious outcomes, including surgical site infections and pulmonary infections after open gastrointestinal surgery, but no association was observed between high BMI and urinary tract infections.