The effects of epidural versus intravenous patient-controlled analgesia on postoperative outcomes in elderly patients who have undergone gastrectomy: a retrospective trial

BACKGROUND: Efforts for improving surgical outcomes in elderly patients should include the prevention of perioperative complications and proper postoperative pain management. Epidural analgesia is effective in decreasing perioperative stress and postoperative complications, and in improving recovery. Recently, it has been suggested that epidural analgesia may attenuate immune suppression during the perioperative period and lead to reductions in cancer recurrence and improvements in overall survival. Assuming that these effects of epidural analgesia are present in vulnerable elderly patients, we compared the efficacy of epidural patient-controlled analgesia and intravenous patientcontrolled analgesia on postoperative outcomes in elderly patients who had undergone gastrectomy. METHODS: We evaluated 214 elderly patients who had undergone elective open gastrectomy for gastric cancer from 2011 to 2014. The demographic characteristics, analgesic efficacy, complications within the first 30 postoperative days, hospital stay, 24-month postoperative morbidity, cancer recurrence, and mortality were studied retrospectively. RESULTS: Two-hundred and five patients were analyzed. Eighty-five patients received epidural patient-controlled analgesia (EPCA group) and 120 patients received intravenous patient- controlled analgesia (IVPCA group). The maximum pain scores were decreased to a greater extent in the EPCA group on the day of the operation (P < 0.001) and on the first postoperative day (P = 0.001) when compared to the IVPCA group. The patients in the EPCA group also required less analgesics on the day of the operation (P = 0.033) than those in the IVPCA group. The effect of EPCA on complications within the first 30 postoperative days, 24-month postoperative morbidity, cancer recurrence, and mortality were negligible in our study. CONCLUSIONS: EPCA provided more effective pain control than IVPCA in elderly patients who had undergone elective gastric cancer surgery, but did not affect postoperative outcomes.

The effects of epidural versus intravenous patient-controlled analgesia on postoperative outcomes in elderly patients who have undergone gastrectomy: a retrospective trial

BACKGROUND: Efforts for improving surgical outcomes in elderly patients should include the prevention of perioperative complications and proper postoperative pain management. Epidural analgesia is effective in decreasing perioperative stress and postoperative complications, and in improving recovery. Recently, it has been suggested that epidural analgesia may attenuate immune suppression during the perioperative period and lead to reductions in cancer recurrence and improvements in overall survival. Assuming that these effects of epidural analgesia are present in vulnerable elderly patients, we compared the efficacy of epidural patient-controlled analgesia and intravenous patientcontrolled analgesia on postoperative outcomes in elderly patients who had undergone gastrectomy. METHODS: We evaluated 214 elderly patients who had undergone elective open gastrectomy for gastric cancer from 2011 to 2014. The demographic characteristics, analgesic efficacy, complications within the first 30 postoperative days, hospital stay, 24-month postoperative morbidity, cancer recurrence, and mortality were studied retrospectively. RESULTS: Two-hundred and five patients were analyzed. Eighty-five patients received epidural patient-controlled analgesia (EPCA group) and 120 patients received intravenous patient- controlled analgesia (IVPCA group). The maximum pain scores were decreased to a greater extent in the EPCA group on the day of the operation (P < 0.001) and on the first postoperative day (P = 0.001) when compared to the IVPCA group. The patients in the EPCA group also required less analgesics on the day of the operation (P = 0.033) than those in the IVPCA group. The effect of EPCA on complications within the first 30 postoperative days, 24-month postoperative morbidity, cancer recurrence, and mortality were negligible in our study. CONCLUSIONS: EPCA provided more effective pain control than IVPCA in elderly patients who had undergone elective gastric cancer surgery, but did not affect postoperative outcomes.

Congenital Heart Disease: a Pictorial Illustration of Putting Segmental Approach into Practice

The human heart is a complex organ in which many complicated congenital defects may happen and some of them require surgical intervention. Due to the vast complexity of varied anatomical presentations, establishing an accurate and consistent nomenclature system is utmost important to facilitate effective communication among pediatric cardiologists, cardiothoracic surgeons and radiologists. The Van Praagh segmental approach to the complex congenital heart disease (CHD) was developed in the 1960s and has been used widely as the language for describing complex anatomy of CHD over the decades. It utilizes a systematic and sequential method to describe the cardiac segments and connections which in turn allows accurate, comprehensive and unambiguous description of CHD. It can also be applied to multiple imaging modalities such as echocardiogram, cardiac CT and MRI. The Van Praagh notation demonstrates a group of three letters, with each letter representative for a key embryologic region of cardiac anatomy: the atria, ventricles and great vessels. By using a 3-steps approach, we can evaluate complex CHD precisely and have no difficulties in communicating with other medial colleague. This pictorial essay revisits the logical steps of segmental approach, followed by a pictorial illustration of its application.

Anesthetic management of a parturient for combined cesarean section and surgical removal of pituitary tumor: A case report / 대한마취과학회지

A 40-year-old woman was referred to our hospital because of bitemporal hemianopsia at 23 weeks of gestation. A brain magnetic resonance imaging showed a pituitary tumor having suprasellar extension. At 30 weeks of gestation, she complained of rapidly deteriorating vision and bitemporal hemianopsia in both eyes and the ensuing radiological examination revealed increased tumor size, displaced tumor location and compressed optic chiasm. The cesarean section was performed at 31 weeks and 3 days of gestation and simultaneous surgical removal of pituitary tumor was carried out due to the risk of irreversible blindness. Anesthetic management for combined cesarean section and brain surgery can be more complex and challenging for anesthesiologists, and the aim was to achieve both the control of intracranial pressure and fetal well being at the same time. In this case, maternal outcome was somewhat improved after the procedure, and neonatal complications were not detected.

Highly increased blood pressure following stellate ganglion block: A case report

Stellate ganglion block (SGB) is a procedure that is widely used for many diseases associated with sympathetically-maintained pain in the head, neck, and upper extremities. Various hemodynamic changes may occur after SGB. Among them, we experienced two patients who developed highly increased blood pressure after SGB. We suspect that the spread of local anesthetics produced parasympathetic blockade of the vagus nerve, an imbalance between the sympathetic and parasympathetic activities and deafferentiation of the glossopharyngeal and vagus nerve, which both innervated the carotid sinus, as the mechanism of this increased blood pressure.

Maintenance of nitric oxide inhalation to a patient with hemoperitonium and acute respiratory distress syndrome during anesthesia: A case report / 대한마취과학회지

Inhaled nitric oxide (NO) is occasionally used to treat hypoxemia for patients with acute respiratory distress syndrome (ARDS) in the intensive care unit (ICU). However, it is controversial whether or not to maintain inhalation of NO during general anesthesia because of complications, such as nitrogen dioxide (NO2) production, methemoglobinemia, and inhibition of platelet aggregation. In this case, a 67-year-old male fell from a roof and was brought to an emergency care center. During management, he vomited gastric contents and aspirated. In spite of tracheal intubation and mechanical ventilation with high oxygen therapy, the hypoxia did not improve. NO inhalation with mechanical ventilation was performed to treat hypoxemia due to ARDS in the ICU. We maintained the NO inhalation during the surgery for a hemoperitonium. The surgery was completed without intra-operative hemodynamic instability or any complications.

Left Adrenal Sarcoidosis

We present a 50-year-old woman with left adrenal sarcoidosis. She visited our hospital for right upper quadrant discomfort; she was then evaluated for right upper quadrant discomfort. She had no abnormal findings in the laboratory examination, including hormone study, but a mass was detected at left adrenal gland, incidentally. Initially, we thought the mass as nonfunction adrenal adenoma. After she had undergone laparoscopic left adrenalectomy, she was diagnosed with left adrenal sarcoidosis from her histological findings. Adrenal sarcoidosis is a very rare disease. This case provides insight to the experience of left adrenal sarcoidosis.

Spinal cord stimulation for neuropathic pain following idiopathic transverse myelitis: A case report / 대한마취과학회지

We present a patient with intractable neuropathic pain because of idiopathic transverse myelitis unresponsive to medical treatment. After a successful trial of spinal cord stimulation, a permanent stimulator was implanted. Improvement was noted in visual analogue scale, medication usage and daily function. Spinal cord stimulation may offer a therapeutic option for patients with neuropathic pain resulting from transverse myelitis and should be considered when other treatments are failed.

Cement leakage into subcutaneous tissue after kyphoplasty: A case report

We describe a case of cement leakage from the pedicle of vertebrae to the subcutaneous tissue after kyphoplasty.We attempted to remove all cement leakage, but residual cement remained in the paraspinal tissue without any neurological complications.This case illustrates the importance of the right timing of cement injection and when to detach the bone-filler device from the cement.

A Case of Paraplegia Associated with Epidural Anesthesia: A case report / 대한통증학회지

Paraplegia is a relatively rare complication of epidural anesthesia. Several possible factors may contribute to the development of paraplegia including arachnoiditis, trauma and ischemia. We experienced a case where paraplegia had developed after epidural anesthesia for cesarean section. So we present the case and consider the possible etiologies. A 30-year-old previously healthy woman was referred to our hospital for postpartum motor weakness of the lower limbs. Six days prior, the patient was admitted at a local obstetric clinic for delivery at 39 weeks gestation. The patient underwent a Cesarean section under epidural anesthesia induced with 20 ml 2% lidocaine and 5 ml 0.5% bupivacaine. In the early morning of the day following the Cesarean section, a motor and sensory deficit in both lower extremities was noted. A lumbar MRI showed diffuse enhancement along the cauda equina and spinal cord surface in the lower lumbar spine, suggesting diffuse arachnoiditis.

Effect of the Preoperative Intercostal Nerve Block in a Rat Model of Postthoracotomy Pain / 대한통증학회지

BACKGROUND: Chronic pain after thoracotomy has been recently reproduced in a rat model that allows investigating the effect of potentially beneficial drugs that might reduce the incidence of allodynia or alleviate pain. Local anesthetics produce antinociception in normal animals and alleviate mechanical allodynia in animals with nerve injury although their mechanisms of action may differ in these situations. Our purpose of this study was to test whether the preoperative intercostal nerve block of bupivacaine could prevent the development of allodynia in a rat model of chronic postthoracotomy pain. METHODS: All male Sprague-Dawley rats were anesthetized and the right 4th and 5th ribs were exposed surgically. The pleura were opened between the ribs to which a retractor was placed and was opened 10 mm in width. Retraction was maintained for one hour. Total 1 mg of 0.5% bupivacaine was injected at the intercostal nerves before (n = 17) or after (n = 16) surgery. A control group (n = 25) that underwent rib retraction did not receive any drug. Rats were tested for mechanical allodynia using calibrated von Frey filaments applied around the incision site during the three weeks following surgery. RESULTS: The incidence of development of mechanical allodynia in the group that received intercostal injection with bupivacaine before surgery was significantly lower than that in the control group (P < 0.05). CONCLUSIONS: Preoperative intercostal nerves block around the surgical incision before thoracotomy may decrease the incidence of postthoracotomy pain syndrome.

Ketamine Infusion Therapy in a Patient of Posttraumatic Syringomyelia / 대한통증학회지

The clinical syndrome of posttraumatic syringomyelia can complicate major spinal trauma and develops many months after spinal injury. The 50-90% of patients experienced the pain and especially the component of central pain. In patients with central pain following spinal cord injury, ketamine has been shown to be an effective analgesic. We report a case of posttraumatic syringomyelia in a 30-year-old woman who complained of central pain, weakness of both legs and dysesthesia. She had not responded to pulsed radiofrequency, or lidocaine infusion therapy, but a continuous intravenous infusion of ketamine, an N-methyl-D-asparate receptor antagonist, reduced her severe central pain. In conclusion, a ketamine infusion therapy resulted in a significant reduction of central pain without decreasing of motor power and function.

RECIST Criteria for Tumor Response in the Patients with Breast Cancer Who Had Neoadjuvant Chemotherapy

PURPOSE: This study compared the response evaluation using the WHO (World Health Organization) criteria for patients with breast cancer with that of the RECIST (Response Evaluation Criteria In Solid Tumor) criteria in order to determine the significance of the RECIST criteria in breast cancer. METHODS: Between 2001 and 2005, 42 patients with measurable lesions radiologically receiving neoadjuvant chemotherapy for a breast carcinoma were enrolled in this study. The results were compared using a kappa test as a concordance measure between the two response criteria. RESULTS: With the WHO criteria, the overall response and progression rate were 35.7% (CR 0, PR 15) and 16.6% (PD 7) respectively. On the other hand, the overall response and progression rate using the RECIST criteria were 38.0% (CR 0, PR 16) and 7% (PD 3) respectively. The kappa value as a concordance measure between two response criteria was 0.718. CONCLUSION: The RECIST criteria are comparable to the WHO criteria in evaluating the response of breast cancer patients who have undergone neoadjuvant chemotherapy. A comparison of these results with other studies of more common tumor types supports the implementation of RECIST as the standard criteria for evaluating the treatment response but also for monitoring progression.

A Case of Benign Retroperitoneal Cyst of Mullerian Type in Kidney Transplant Patient / 대한이식학회지

Retroperitoneal cysts are rare, usually asymptomatic, lesions. Mullerian cyst of the retroperitoneum is one of extremely rare disease entities and is considered to be a subtype of urogenital cysts. We present the case of a 38-year-old woman with retroperitoneal Mullerian cyst which was found during her second cadaveric kidney transplantation operation. The two-fist sized cyst was found in left retroperitoneal pelvic space extended from left common iliac artery to pre-vesical region, which compromised iliac vessels for vascular anastomosis during kidney transplantation. After complete cyst excision, the kidney transplant operation could be performed. Histologically, the cyst was lined with benign Mullerian-type epithelium. We report the pathologic findings in a rare case of benign retroperitoneal cyst of Mullerian type which was incidentally found during kidney transplant surgery.

The Effect of ATP-sensitive Potassium Channel on R-PIA Induced Mechanical Antiallodynia in a Peripheral Neuropathic Rat / 대한통증학회지

BACKGROUND: Nerve ligation injury may produce mechanical allodynia, but this can be reversed after an intrathecal administration of adenosine analogues. In many animal and human studies, ATP-sensitive potassium channel blockers have been known to reverse the antinociceptive effect of various drugs. This study was performed to evaluate the mechanical antiallodynic effects of spinal R-PIA (Adenosine A1 receptor agonist) and the reversal of these effects due to pretreatment with glibenclamide (ATP-sensitive potassium channel blocker). Thus, the relationship between the antiallodynic effects of R-PIA and ATP-sensitive potassium channel were investigated in a neuropathic model. METHODS: Male Sprague Dawley rats were prepared by tightly ligating the left lumbar 5th and 6th spinal nerves and implantation of a chronic lumbar intrathecal catheter for drug administration. The mechanical allodynia was measured by applying von Frey filaments ipsilateral to the lesioned hind paw. And the thresholds for paw withdrawal assessed. In study 1, either R-PIA (0.5, 1 and 2microgram) or saline were administered intrathecally for the examination of the antiallodynic effect of R-PIA. In study 2, glibenclamide (2, 5, 10 and 20 nM) was administered intrathecally 5 min prior to an R-PIA injection for investigation of the reversal of the antiallodynic effects of R-PIA. RESULTS: The antiallodynic effect of R-PIA was produced in a dose dependent manner. In study 1, the paw withdrawal threshold was significantly increased with 2microgram R-PIA (P < 0.05). In study 2, the paw withdrawal threshold with 2microgram R-PIA was significantly decreased almost dose dependently by intrathecal pretreatment of 5, 10 and 20 nM glibenclamide (P < 0.05). CONCLUSIONS: These results demonstrated that an intrathecal injection of ATP-sensitive potassium channel blockers prior to an intrathecal injection of adenosine A1 receptors agonist had an antagonistic effect on R-PIA induced antiallodynia. The results suggest that the mechanism of mechanical antiallodynia, as induced by an intrathecal injection of R-PIA, may involve the ATP-sensitive potassium channel at both the spinal and supraspinal level in a rat nerve ligation injury model.

Effects of Non Steroidal Anti-inflammatory Drugs on the Evans Blue Extravasation and Pain Behaviors Evoked by Mustard Oil Induced Visceral Pain in Mice: Comparison with Morphine / 대한마취과학회지

BACKGROUND: Visceral pain is characterized by its spontaneous pain and referred hyperalgesia. Our aim was to examine the inhibitory effects of various NSAIDs on the pain behaviors, both spontaneously and mechanically evoked, and evans blue extravasation induced by intracolonic mustard oil in mice. METHODS: 50 mg/kg of evans blue was injected to adult male ICR mice via tail vein for subsequent determination of plasma extravasation. The animals in the control group were given subcutaneous saline and those in experimental groups were given one of the following drugs: 1, 3, 10 mg/kg of morphine; 10, 100 mg/kg of ketoprofen; 5, 50 mg/kg of ketorolac; 2, 20 mg/kg of DFU (cyclooxygenase-2 inhibitor). Visceral pain-related behaviors were counted for 20 minutes after intracolonic administration of 50 microliter of 1.5% mustard oil. In order to test referred hyperalgesia, before intracolonic administration and 20 min after the administration, the frequency of withdrawal responses to the application of von Frey hairs to the abdomen, foot and tail was tested. The colon was removed post-mortem and evans blue content was measured. RESULTS: Visceral pain-related behaviors were significantly inhibited in the groups administered with 3 and 10 mg/kg of morphine, 50 mg/kg of ketorolac, 100 mg/kg of ketoprofen and 20 mg/kg of DFU (P < 0.05), respectively. Response frequencies to the application of von Frey hairs were decreased in the groups administered with 3 and 10 mg/kg of morphine (P < 0.05) but not any doses of ketorolac, ketoprofen and DFU. Evans blue content was decreased by 100 mg/kg of ketoprofen and 20 mg/kg DFU (P < 0.05) but not in the other groups. CONCLUSIONS: These results suggest that the analgesic effects of NSAIDs on visceral pain could be mainly mediated by peripheral mechanism, reflected by inhibition of the pain behaviors and inflammation but not centrally mediated mechanism reflected by referred hyperalgesia.

Effect of Adrenal Gland Transplantation on Mechanical Hyperalgesia Induced by Freund's Complete Adjuvant in Rats / 대한마취과학회지

BACKGROUND: The transplantation of adrenal medullary tissue into the CNS of the rat can reduce pain. This results from the release of opioid peptides and catecholamines from the transplanted chromaffin cells. However, whether the adrenal gland transplanted in peripheral tissue can also reduce the pain is not well documented. The purpose of this study was to assess the potential for theadrenal gland implanted into the peripheral tissue of the rat to reduce mechanical hyperalgesia induced by inflammation. METHODS: Fifteen male Wistar rats were divided into three groups; one for implantation of the adrenal gland (AG), another for the kidney (Kd), and the other for a Sham operation (S). Tissues for transplantation were harvested from Sprague-Dawley rats. Two weeks after surgery, inflammation was induced by injecting 0.05 ml of Freund's Complete Adjuvant (FCA) into the dorsum of the rat's hind paw. Mechanical hyperalgesia was assessed using automated Randall-Sellito algesiometer at 6 hr, 1, 2, 3, 7 and 14 days after injecting FCA. RESULTS: Paw withdrawal thresholds against mechanical stimuli were 84.8 6.9%, 112.1 4.6%, 86.3 8.5%, 93.6 7.4%, 90.5 3.8%, 96.9 3.8%, respectively, in the AG group, and 71.3 10.8%, 93.3 11.3%, 79.1 10.3%, 73.7 8.1%, 62.6 6.4%, 77.7 6.2%, respectively, in Kd group, and 67.2 8.3%, 88.1 11.7%, 67.7 8.1%, 69.6 8.2%, 74.5 8.5%, 81.2 6.6%, respectively, in the S group. The AG group showed less pain sensitivity compared with that of the Kd and S groups especially 7 and 14 days after injecting the drug. CONCLUSIONS: This study indicates that the transplanted adrenal gland into the peripheral tissue may provide analgesic effect for a long time after it is transplanted in the rat.

Effect of Adrenal Gland Transplantation on Mechanical Hyperalgesia Induced by Freund's Complete Adjuvant in Rats / 대한마취과학회지

BACKGROUND: The transplantation of adrenal medullary tissue into the CNS of the rat can reduce pain. This results from the release of opioid peptides and catecholamines from the transplanted chromaffin cells. However, whether the adrenal gland transplanted in peripheral tissue can also reduce the pain is not well documented. The purpose of this study was to assess the potential for theadrenal gland implanted into the peripheral tissue of the rat to reduce mechanical hyperalgesia induced by inflammation. METHODS: Fifteen male Wistar rats were divided into three groups; one for implantation of the adrenal gland (AG), another for the kidney (Kd), and the other for a Sham operation (S). Tissues for transplantation were harvested from Sprague-Dawley rats. Two weeks after surgery, inflammation was induced by injecting 0.05 ml of Freund's Complete Adjuvant (FCA) into the dorsum of the rat's hind paw. Mechanical hyperalgesia was assessed using automated Randall-Sellito algesiometer at 6 hr, 1, 2, 3, 7 and 14 days after injecting FCA. RESULTS: Paw withdrawal thresholds against mechanical stimuli were 84.8 6.9%, 112.1 4.6%, 86.3 8.5%, 93.6 7.4%, 90.5 3.8%, 96.9 3.8%, respectively, in the AG group, and 71.3 10.8%, 93.3 11.3%, 79.1 10.3%, 73.7 8.1%, 62.6 6.4%, 77.7 6.2%, respectively, in Kd group, and 67.2 8.3%, 88.1 11.7%, 67.7 8.1%, 69.6 8.2%, 74.5 8.5%, 81.2 6.6%, respectively, in the S group. The AG group showed less pain sensitivity compared with that of the Kd and S groups especially 7 and 14 days after injecting the drug. CONCLUSIONS: This study indicates that the transplanted adrenal gland into the peripheral tissue may provide analgesic effect for a long time after it is transplanted in the rat.

Effect of Glucose on Isolated Rat Sciatic Nerve Compound Action Potentials / 대한마취과학회지

BACKGROUND: When performing spinal anesthesia, glucose is frequently added to control the extent of the anesthesia by increasing the specific gravity of the local anesthetic solution. It is not clearly known whether the added glucose directly affects the nerve blockade or not. The purpose of this study is to examine the effect of glucose solution on isolated nerve fibers in vitro. METHODS: Compound action potentials (CAPs) of A-fiber range were recorded from isolated nerves of adult Sprague-Dawley rats (300 400 gm). Tonic (0.5 Hz) and phasic (30 Hz) supramaximal stimuli were repeatedly applied to one end of the nerves and the recordings were made on the other end. Nerves were perfused with modified Krebs solution for 45 minutes initially to get baseline data and then perfused with test solutions containing different concentrations of glucose (2.5%, 5%, 7.5%) for 30 minutes. The same experiments were repeated with mannitol at the same osmolality as the glucose. RESULTS: Glucose produced a decrease in the amplitude of CAPs in a dose-dependent manner (79.2 +/- 3.4, 50.3 +/- 3.7, 34.6 +/- 4.0 for 2.5%, 5%, 7.5% glucose solutions, respectively). At each of the same concentration levels, the degree of nerve conduction blockade did not have any significant difference within the glucose groups and mannitol groups. CONCLUSIONS: Glucose, in clinically employed concentration range, directly depressed peripheral nerve conduction in vitro, probably via osmotic effect.

The Comparison of Cryoanalgesia and Epidural Analgesia in Thoracotomy / 대한마취과학회지

BACKGROUND: Cryoanalgesia provides postoperative analgesia following thoracotomy without serious complications compared with epidural analgesia, but little data indicates which one is better in terms of postoperative analgesia, side effects or associated complications. METHODS: Forty patients undergoing lateral thoracotomy, were randomized to receive a mixture of fentanyl and 0.15% bupivacaine at 0.5 microgram/kg/h of fentanyl via thoracic epidural catheter (Group E) or cryotherapy on the 4th, 5th, 6th, or 7th intercostal nerves using Frigitronics (Group C). Postoperative pain was assessed everyday for 7 days after the thoracotomy by a visual analog scale (VAS). The side effects and patient satisfaction of analgesia were assessed by a system of 4 grades. RESULTS: The VAS scores at rest in group C were significantly higher than those in group E. There was no side effect except numbness in group C, which continued for 3 months on the average. The incidences of side effects (nausea, vomiting, pruritus, sedation, urinary retention) were 15-35% in group E. The 35% of patients in group C were satisfied with postoperative analgesia compared with 95% in group E (P < 0.05). CONCLUSIONS: Epidural fentanyl provided a better analgesic effect than cryoanalgesia for thoracotomy, but there is a clinical advantage in cryoanalgesia over epidural fentanyl with respect to incidences of serious side effects not including. (Korean J Anesthesiol 2000; 39: 83-90)