Postoperative major bleeding risk in patients using oral antiplatelets and/or anticoagulants after laparoscopic gastric cancer surgery

Purpose@#The use of antiplatelet and/or anticoagulant therapies has become common. In rare cases, these therapies may increase the risk of dangerous postoperative bleeding. We investigated the association of antiplatelets and/or anticoagulants with postoperative major bleeding risk in laparoscopic gastric cancer surgery. @*Methods@#We retrospectively enrolled 3,663 gastric cancer patients (antiplatelet/anticoagulant group, 518; control group, 3,145) who had undergone laparoscopic surgery between January 2012 and December 2017. To minimize selection bias, 508 patients in each group were matched using propensity score matching (PSM) method. The primary outcome was postoperative major bleeding. Secondary outcomes were intraoperative, postoperative transfusion and early complications. @*Results@#After PSM, postoperative major bleeding occurred in 10 (2.0%) and 3 cases (0.6%) in the antiplatelets/ anticoagulants and control groups, respectively (P = 0.090). Intraoperative and postoperative transfusions were not significantly different between 2 groups (2.4% vs. 1.4%, P = 0.355 and 5.5% vs. 4.3%, P = 0.469). Early complications developed in 58 (11.4%) and 43 patients (8.5%) in the antiplatelets/anticoagulants and control groups, respectively (P = 0.142). The mean amounts of intraoperative and postoperative transfusions were not significantly different between the groups (366.67 ± 238.68 mL vs. 371.43 ± 138.01 mL, P = 0.962; 728.57 ± 642.25 mL vs. 508.09 ± 468.95 mL, P = 0.185). In multivariable analysis, male (P = 0.008) and advanced stage (III, IV) (P = 0.024) were independent significant risk factors for postoperative major bleeding. @*Conclusion@#Preoperative antiplatelets and/or anticoagulants administration did not significantly increase the risk of postoperative major bleeding after laparoscopic gastric cancer surgery.

Usefulness of articulating laparoscopic instruments during laparoscopic gastrectomy for gastric adenocarcinoma

Purpose@#Conventional straight-shaped laparoscopic surgical instruments have limitations that, unlike robotic surgery, the wrist joint cannot be used. This study aimed to analyze the short-term safety and feasibility of ArtiSential (Livsmed), a new articulating laparoscopic instrument, which obviates the limitations of conventional laparoscopic surgery and allows the wrist joint to be used freely over 360° as in robotic surgery. @*Methods@#The study included patients who underwent conventional laparoscopy or laparoscopy with the ArtiSential instrument. Patients who underwent laparoscopic gastrectomy for primary gastric adenocarcinoma in our institution were retrospectively reviewed. The groups were propensity score matched in a 1:1 ratio. Primary endpoint was incidence of early postoperative complication (postoperative 30-day morbidity and mortality) and secondary endpoints were operative outcomes. @*Results@#A total of 327 patients (147 of the conventional group and 180 of the ArtiSential group) were propensity score matched. After propensity score matching was performed, each group comprised of 122 patients. Both groups were comparable with regard to operation time, estimated blood loss, number of retrieved lymph nodes, and length of hospital stay. The ArtiSential group had a faster time to a fluid diet (2.6 ± 1.3 days vs. 2.3 ± 0.6 days, p = 0.015). There was no statistically significant difference in early postoperative complications between the two groups (the conventional group, 23.0%; the ArtiSential group, 26.2%; p = 0.656) @*Conclusion@#The current study showed that the use of ArtiSential is a safe and feasible option without increasing operation time, length of hospital stay, and intraoperative bleeding.

Sex-specific Associations Between Serum Hemoglobin Levels and the Risk of Cause-specific Death in Korea Using the National Health Insurance Service-National Health Screening Cohort (NHIS HEALS) / 예방의학회지

OBJECTIVES@#The purpose of this study was to determine the associations between blood hemoglobin (Hgb) levels and the risk of death by specific causes.@*METHODS@#Using the National Health Insurance Services-National Health Screening Cohort (n=487 643), we classified serum Hgb levels into 6 sex-specific groups. Cox regression analysis was used to analyze the associations between Hgb levels and the risk of cause-specific death.@*RESULTS@#Hgb levels in male population showed a U-shaped, J-shaped, or inverse J-shaped association with the risk of death from ischemic heart disease, acute myocardial infarction, liver cancer, cirrhosis and chronic obstructive pulmonary disease (COPD) (all non-linear p<0.05; hazard ratio [HR]; 95% confidence interval [CI]) for the lowest and the highest Hgb levels for the risk of each cause of death in male population: HR, 1.14; 95% CI, 0.98 to 1.34; HR, 2.87; 95% CI, 1.48 to 5.57; HR, 1.16; 95% CI, 0.96 to 1.40; HR, 3.05; 95% CI, 1.44 to 6.48; HR, 1.36; 95% CI, 1.18 to 1.56; HR, 2.11; 95% CI, 1.05 to 4.26; HR, 3.64; 95% CI, 2.49 to 5.33; HR, 5.97; 95% CI, 1.44 to 24.82; HR, 1.62; 95% CI, 1.14 to 2.30; HR, 3.84; 95% CI, 1.22 to 12.13, respectively), while in female population, high Hgb levels were associated with a lower risk of death from hypertension and a higher risk of death from COPD (overall p<0.05; HR, 1.86; 95% CI, 1.29 to 2.67 for the lowest Hgb levels for hypertension; overall p<0.01, HR, 6.60; 95% CI, 2.37 to 18.14 for the highest Hgb levels for COPD). For the risk of lung cancer death by Hgb levels, a linear negative association was found in male population (overall p<0.01; the lowest Hgb levels, HR, 1.17; 95% CI, 1.05 to 1.33) but an inverse J-shaped association was found in female population (non-linear p=0.01; HR, 1.25; 95% CI, 0.96 to 1.63; HR, 2.58; 95% CI, 1.21 to 5.50).@*CONCLUSIONS@#Both low and high Hgb levels were associated with an increased risk of death from various causes, and some diseases showed different patterns according to sex.

Laparoscopic Treatment of Gastric Subepithelial Tumor: Finding Ways to Manage with Shorter Hospitalization Days

PURPOSE: The standard treatment for gastric subepithelial tumor (SET) is surgical resection, which is primarily performed via laparoscopy. The aims of this study were firstly to evaluate factors influencing morbidity and hospitalization after treatment of gastric SET, and secondly, to figure out the factors how to make shorter hospitalization with equal safety. METHODS: We retrospectively enrolled 229 consecutive patients who underwent laparoscopic gastric wedge resection (LGWR) for gastric SET between August 2003 and December 2015. Patients were divided into two groups: the 3 days or less hospitalization group (N=82, group A) and the greater than 3 days hospitalization group (N=147, group B). RESULTS: Median tumor size was 3.0 cm (range, 0.2~13.0 cm) and mean postoperative hospitalization was 4.27±2.15 days. There were 6 complications (2.6%), with no cases of mortality. In group A, tumors were smaller (3.0±1.1 cm vs. 3.6±1.9 cm, p<0.01) and more likely to be located on the greater curvature (28% vs. 15%, p<0.01) compared with group B. The tumor growth pattern (exophytic tumor: 72% in group A vs. 65% in group B, p=0.25) was not different between the two groups. Multivariate analysis showed that tumor size larger than 5 cm and posterior wall tumor location were risk factors for longer hospital stay. CONCLUSION: We could reduce the hospitalization of patients with gastric SET less than 5cm sized and located on other than the posterior wall within 3days. Those patients could be a candidate for day surgery.

Experience of hemostasis in tracheal bleeding very close to the carina by the bronchial blocker: a case report / 대한마취과학회지

Massive hemoptysis is respiratory compromise which should be managed as a life-threatening condition. In our case, the bronchial blocker played a role in hemostasis of tracheal bleeding very close to the carina and prevented further spillage into the contralateral lung. Right-sided one-lung isolation in an 87-year-old female, who received cardiopulmonary resuscitation due to myocardial infarction, was requested due to hemoptysis. Right-sided bronchial bleeding was suspected on auscultation, but esophageal and tracheal bleeding due to violent intubation with a stylet was also considered. We attempted one-lung isolation with the bronchial blocker. The bronchial blocker was inadvertently advanced to the left mainstem bronchus, but the inflated balloon of the bronchial blocker compressed the site of bleeding, which was within 1 cm proximal and left posterior to the carina. Tracheal bleeding stopped, and we confirmed that hemostasis was achieved with the balloon of the bronchial blocker using a fiberoptic bronchoscope.

Comparison of volume-controlled and pressure-controlled ventilation in the Trendelenburg position for gynecological laparoscopic surgery

BACKGROUND: Minimal invasive gynecologic surgery usually requires pneumoperitoneum and Trendelenburg positioning, which results in adverse effects on respiratory and hemodynamic parameters. The aim of this study was to investigate the effects of volume-controlled ventilation (VCV) and pressure-controlled ventilation (PCV) introduced sequentially in patients who underwent gynecological laparoscopy on respiratory mechanics, cardiovascular responses, and gas exchange. METHODS: Forty patients who were scheduled for gynecologic laparoscopic surgery were enrolled. Baseline ventilation of their lungs was performed with VCV with a tidal volume (TV) of 8 ml/kg ideal body weight (IBW). Forty minutes after pneumoperitoneum and Trendelenburg positioning, the ventilation mode was changed to PCV, and airway pressure was set to provide a TV of 8 ml/kg IBW without exceeding 35 cmH2O. Respiratory mechanics and hemodynamic and gas exchange parameters were recorded at 10 minutes after induction, 30 minutes after CO2 pneumoperitoneum and Trendelenburg positioning, 30 minutes after PCV, and 30 minutes after desufflation and supine position. RESULTS: After pneumoperitoneum and Trendelenburg positioning, there were significant increases in systolic blood pressure, diastolic blood pressure, central venous pressure, peak airway pressure (PAP), mean airway pressure (Pmean), whereas lung compliance and PaO2 significantly decreased. The decrease in PAP and increases of Pmean, lung compliance and PaO2 were observed during PCV compared with VCV (P < 0.05). There were no differences in hemodynamic parameters between VCV and PCV. CONCLUSIONS: Our results demonstrated that PCV may be an effective method of ventilation during gynecologic laparoscopy in terms of improved oxygenation and minimizing adverse respiratory mechanics.