Postoperative delirium:A tragedy for elderly cancer patients

In this editorial,we comment on the article by Hu et al entitled“Predictive modeling for postoperative delirium in elderly patients with abdominal malignancies using synthetic minority oversampling technique”.We wanted to draw attention to the general features of postoperative delirium(POD)as well as the areas where there are uncertainties and contradictions.POD can be defined as acute neurocognitive dysfunction that occurs in the first week after surgery.It is a severe postoperative complication,especially for elderly oncology patients.Although the underlying pathophysiological mechanism is not fully understood,various neuroinflammatory mechanisms and neurotransmitters are thought to be involved.Various assessment scales and diagnostic methods have been proposed for the early diagnosis of POD.As delirium is considered a preventable clinical entity in about half of the cases,various early prediction models developed with the support of machine learning have recently become a hot scientific topic.Unfortunately,a model with high sensitivity and specificity for the prediction of POD has not yet been reported.This situation reveals that all health personnel who provide health care services to elderly patients should approach patients with a high level of awareness in the perioperative period regarding POD.

Changes in postoperative depression and anxiety and their relationship with recovery from femoral head necrosis:A longitudinal study

BACKGROUND Femoral head necrosis(FHN)can significantly affect patients'psychological well-being and functional outcomes.However,the long-term relationship between postoperative depression,anxiety,and functional recovery in patients with FHN remains unclear.AIM To investigate the dynamic changes in postoperative depression and anxiety and their relationship with functional recovery in patients with FHN for 3 years.METHODS Ninety-three patients with FHN who underwent surgical treatment in March 2020 to 2023 were enrolled in this longitudinal study.Depression and anxiety status were assessed using the hospital anxiety and depression scale(HADS)at baseline,6 months,1,2,and 3 years postoperatively.Functional recovery was evaluated using the Harris hip score(HHS).The dynamic changes in HADS and HHS were analyzed using repeated measures ANOVA;the relationship between depre-ssion/anxiety status and functional recovery was examined using Pearson’s correlation analysis.RESULTS The mean HADS-depression(HADS-D)and HADS-anxiety(HADS-A)scores significantly improved over time(P<0.001).The prevalence of depression and anxiety decreased from 36.6%and 41.9%at baseline to 10.8%and 12.9%,respectively,at 3 years postoperatively.The mean HHS increased sig-nificantly from 52.3±10.5 at baseline to 88.1±7.2 at 3 years postoperatively(P<0.001).Significant negative correl-ations were found between HADS-D/HADS-A scores and HHS at all time points(P<0.05).CONCLUSION The severity of depression and anxiety negatively correlated with functional recovery,highlighting the importance of psychological interventions in the management of patients with FHN.

Predicting short-term major postoperative complications in intestinal resection for Crohn’s disease:A machine learning-based study

BACKGROUND Due to the complexity and numerous comorbidities associated with Crohn’s disease(CD),the incidence of postoperative complications is high,significantly impacting the recovery and prognosis of patients.Consequently,additional stu-dies are required to precisely predict short-term major complications following intestinal resection(IR),aiding surgical decision-making and optimizing patient care.AIM To construct novel models based on machine learning(ML)to predict short-term major postoperative complications in patients with CD following IR.METHODS A retrospective analysis was performed on clinical data derived from a patient cohort that underwent IR for CD from January 2017 to December 2022.The study participants were randomly allocated to either a training cohort or a validation cohort.The logistic regression and random forest(RF)were applied to construct models in the training cohort,with model discrimination evaluated using the area under the curves(AUC).The validation cohort assessed the performance of the constructed models.RESULTS Out of the 259 patients encompassed in the study,5.0%encountered major postoperative complications(Clavien-Dindo≥III)within 30 d following IR for CD.The AUC for the logistic model was 0.916,significantly lower than the AUC of 0.965 for the RF model.The logistic model incorporated a preoperative CD activity index(CDAI)of≥220,a diminished preoperative serum albumin level,conversion to laparotomy surgery,and an extended operation time.A nomogram for the logistic model was plotted.Except for the surgical approach,the other three variables ranked among the top four important variables in the novel ML model.CONCLUSION Both the nomogram and RF exhibited good performance in predicting short-term major postoperative complic-ations in patients with CD,with the RF model showing more superiority.A preoperative CDAI of≥220,a di-minished preoperative serum albumin level,and an extended operation time might be the most crucial variables.The findings of this study can assist clinicians in identifying patients at a higher risk for complications and offering personalized perioperative management to enhance patient outcomes.

Predictive modeling for postoperative delirium in elderly patients with abdominal malignancies using synthetic minority oversampling technique

BACKGROUND Postoperative delirium,particularly prevalent in elderly patients after abdominal cancer surgery,presents significant challenges in clinical management.AIM To develop a synthetic minority oversampling technique(SMOTE)-based model for predicting postoperative delirium in elderly abdominal cancer patients.METHODS In this retrospective cohort study,we analyzed data from 611 elderly patients who underwent abdominal malignant tumor surgery at our hospital between September 2020 and October 2022.The incidence of postoperative delirium was recorded for 7 d post-surgery.Patients were divided into delirium and non-delirium groups based on the occurrence of postoperative delirium or not.A multivariate logistic regression model was used to identify risk factors and develop a predictive model for postoperative delirium.The SMOTE technique was applied to enhance the model by oversampling the delirium cases.The model’s predictive accuracy was then validated.RESULTS In our study involving 611 elderly patients with abdominal malignant tumors,multivariate logistic regression analysis identified significant risk factors for postoperative delirium.These included the Charlson comorbidity index,American Society of Anesthesiologists classification,history of cerebrovascular disease,surgical duration,perioperative blood transfusion,and postoperative pain score.The incidence rate of postoperative delirium in our study was 22.91%.The original predictive model(P1)exhibited an area under the receiver operating characteristic curve of 0.862.In comparison,the SMOTE-based logistic early warning model(P2),which utilized the SMOTE oversampling algorithm,showed a slightly lower but comparable area under the curve of 0.856,suggesting no significant difference in performance between the two predictive approaches.CONCLUSION This study confirms that the SMOTE-enhanced predictive model for postoperative delirium in elderly abdominal tumor patients shows performance equivalent to that of traditional methods,effectively addressing data imbalance.

Double-nylon purse-string suture in closing postoperative wounds following endoscopic resection of large(≥3 cm)gastric submucosal tumors

BACKGROUND Endoscopic full-thickness resection(EFTR)of gastric submucosal tumors(SMTs)is safe and effective;however,postoperative wound management is equally important.Literature on suturing following EFTR for large(≥3 cm)SMTs is scarce and limited.AIM To evaluate the efficacy and clinical value of double-nylon purse-string suture in closing postoperative wounds following EFTR of large(≥3 cm)SMTs.METHODS We retrospectively analyzed the data of 85 patients with gastric SMTs in the fundus of the stomach or in the lesser curvature of the gastric body whose wounds were treated with double-nylon purse-string sutures after successful tumor resection at the Endoscopy Center of Renmin Hospital of Wuhan University.The operative,postoperative,and follow-up conditions of the patients were evaluated.RESULTS All tumors were completely resected using EFTR.36(42.35%)patients had tumors located in the fundus of the stomach,and 49(57.65%)had tumors located in the body of the stomach.All patients underwent suturing with double-nylon sutures after EFTR without laparoscopic assistance or further surgical treatment.Postoperative fever and stomach pain were reported in 13(15.29%)and 14(16.47%)patients,respectively.No serious adverse events occurred during the intraoperative or postoperative periods.A postoperative review of all patients revealed no residual or recurrent lesions.CONCLUSION Double-nylon purse-string sutures can be used to successfully close wounds that cannot be completely closed with a single nylon suture,especially for large(≥3 cm)EFTR wounds in SMTs.

Analysis of factors impacting postoperative pain and quality of life in patients with mixed hemorrhoids:A retrospective study

BACKGROUND Hemorrhoids are among the most common and frequently encountered chronic anorectal diseases in anorectal surgery.They are venous clusters formed by con-gestion,expansion,and flexion of the venous plexus in the lower part of the rec-tum.Mixed hemorrhoids bleed easily and recurrently,and this can result in severe anemia.Hence,they may have a negative effect on the health of the patient and surgical treatment is required.Milligan-Morgan hemorrhoidectomy has been widely used since 1937 for the treatment of grade III and IV hemorrhoids.How-ever,most patients experience different degrees of postoperative pain that may cause anxiety.with mixed hemorrhoids post-surgery.METHODS The clinical data of patients with mixed hemorrhoids who underwent Milligan-Morgan hemorrhoidectomy were collected retrospectively.The basic character-istics of the enrolled patients with mixed hemorrhoids were recorded,and based on the Goligher clinical grading system,the hemorrhoids were classified as grades III or IV.The endpoint of this study was the disappearance of pain in all patients.Quantitative data were presented as mean±SD,such as age,pain score,and QoL score.Student’s t-test was used to compare the groups.RESULTS A total of 164 patients were enrolled.The distribution of the visual analog scale pain scores of all patients at 3,7,14 and 28 d after surgery showed that post-surgery pain was significantly reduced with the passage of time.Fourteen days after the operation,the pain had completely disappeared in some patients.Twenty-eight days after the surgery,none of the patients experienced any pain.Comparing the World Health Or-ganization Quality of Life-BREF self-reporting questionnaire scores of patients between 14 and 28 d after surgery,we observed that the quality-of-life scores of the patients post-surgery had significantly improved.There were six items that were compared at 14-and 28-d post-surgery.The mean QoL score 28 d after surgery(4.79±0.46)was higher than that at 14 d post-surgery(3.79±0.57).The mean health condition score 28 d after surgery(4.80±0.41)was also higher than that at 14 d post-surgery(4.01±0.62).The mean physical health score 28 d after surgery(32.10±2.96)was significantly higher than that at 14 d post-surgery(23.41±2.85).The mean psychological health score 28 d after surgery(27.22±1.62)was significantly higher than that at 14 d post-surgery(21.37±1.70).The mean social relations score 28 d after surgery(12.21±1.59)was significantly higher than that at 14 d post-surgery(6.32±1.66).The mean surrounding environment score 28 d after surgery(37.13±2.88)was significantly higher than that at 14 d post-surgery(28.42±2.86).The differences in quality-of-life scores at day 14 and day 28 post-surgery were ob-served to be statistically significant(P<0.001).CONCLUSION Milligan-Morgan hemorrhoidectomy can significantly improve the postoperative QoL of patients.Age,sex,and the number of surgical resections were important factors influencing Milligan-Morgan hemorrhoidectomy.

Metabolomic Analysis in Saliva and Different Brain Regions of Older Mice with Postoperative Delirium Behaviors

Objective Postoperative delirium(POD)has become a critical challenge with severe consequences and increased incidences as the global population ages.However,the underlying mechanism is yet unknown.Our study aimed to explore the changes in metabolites in three specific brain regions and saliva of older mice with postoperative delirium behavior and to identify potential non-invasive biomarkers.Methods Eighteen-month-old male C57/BL6 mice were randomly assigned to the anesthesia/surgery or control group.Behavioral tests were conducted 24 h before surgery and 6,9,and 24 h after surgery.Complement C3(C3)and S100 calcium-binding protein B protein(S100beta)levels were measured in the hippocampus,and a metabolomics analysis was performed on saliva,hippocampus,cortex,and amygdala samples.Results In total,43,33,38,and 14 differential metabolites were detected in the saliva,hippocampus,cortex,and amygdala,respectively.“Pyruvate”“alpha-linolenic acid”and“2-oleoyl-1-palmitoy-snglycero-3-phosphocholine”are enriched in one common pathway and may be potential non-invasive biomarkers for POD.Common changes were observed in the three brain regions,with the upregulation of 1-methylhistidine and downregulation of D-glutamine.Conclusion Dysfunctions in energy metabolism,oxidative stress,and neurotransmitter dysregulation are implicated in the development of POD.The identification of changes in the level of salivary metabolite biomarkers could aid in the development of noninvasive diagnostic methods for POD.

Anesthesia,Anesthetics,and Postoperative Cognitive Dysfunction in Elderly Patients

Postoperative cognitive dysfunction(POCD)remains a major issue that worsens the prognosis of elderly surgery patients.This article reviews the current research on the effect of different anesthesia methods and commonly utilized anesthetics on the incidence of POCD in elderly patients,aiming to provide an understanding of the underlying mechanisms contributing to this condition and facilitate the development of more reasonable anesthesia protocols,ultimately reducing the incidence of POCD in elderly surgery patients.

Combinative approach of transzonular triamcinolonemoxifloxacin and perioperative drops to minimize postoperative complications of cataract surgery

AIM: To investigate the effectiveness of combinationtherapy with transzonular triamcinolone-moxifloxacin andconventional perioperative drops in reducing postoperativecomplications of cataract surgery. METHODS: Electronic medical records of cataractsurgery patients (single surgeon) were reviewed fromJanuary 2018 to September 2021. The rate of postoperativecomplications including prolonged and/or recurrentpostoperative inflammation, endophthalmitis, cystoid macularedema (CME), and intraocular pressure (IOP) was comparedbetween the patients receiving combinative therapy andpatients receiving drops only. RESULTS: Totally 596 patients and 1057 eyes(Combinative-Therapy group 493 and Drop-Only group 564)were included in this study. Using combination therapyreduced the relative risk of postoperative inflammationby 26.9% (16.6% Combinative-Therapy vs 22.7% Drop-Only, P=0.013). The incidence of endophthalmitis was 0in Combinative-Therapy group vs 0.5% in Drop-Only group(relative risk reduction 100%), although not statisticallysignificant (P=0.10). The incidence of severe IOP spikeswas not significantly different between Combinative-Therapy (2.4%) and Drop-Only (1.6%) groups (P=0.33).The relative risk of postoperative CME was 51.4% less inthree months follow up visit in Combinative-Therapy group,although not statistically significant (P=0.07). The visualoutcome 1-month postop. (best corrected visual acuity) wassignificantly better in Combinative-Therapy (logMAR 0.10)compared to Drop-Only (logMAR 0.14) groups (P=0.02) whilethe baseline visual acuity was not significantly different. CONCLUSION: The combinative approach oftranszonular triamcinolone-moxifloxacin plus perioperativeeyedrops is an effective method to minimize postoperativeinflammation, with better visual outcomes. It couldpotentially reduce the risk of postoperative endophthalmitisand CME (near-significant P-values;larger studies couldanalyze better considering low incidence).

Recombinant chitinase-3-like protein 1 alleviates learning and memory impairments via M2 microglia polarization in postoperative cognitive dysfunction mice

Postoperative cognitive dysfunction is a seve re complication of the central nervous system that occurs after anesthesia and surgery,and has received attention for its high incidence and effect on the quality of life of patients.To date,there are no viable treatment options for postoperative cognitive dysfunction.The identification of postoperative cognitive dysfunction hub genes could provide new research directions and therapeutic targets for future research.To identify the signaling mechanisms contributing to postoperative cognitive dysfunction,we first conducted Gene Ontology and Kyoto Encyclopedia of Genes and Genomes pathway enrichment analyses of the Gene Expression Omnibus GSE95426 dataset,which consists of mRNAs and long non-coding RNAs differentially expressed in mouse hippocampus3 days after tibial fracture.The dataset was enriched in genes associated with the biological process"regulation of immune cells,"of which Chill was identified as a hub gene.Therefore,we investigated the contribution of chitinase-3-like protein 1 protein expression changes to postoperative cognitive dysfunction in the mouse model of tibial fractu re surgery.Mice were intraperitoneally injected with vehicle or recombinant chitinase-3-like protein 124 hours post-surgery,and the injection groups were compared with untreated control mice for learning and memory capacities using the Y-maze and fear conditioning tests.In addition,protein expression levels of proinflammatory factors(interleukin-1βand inducible nitric oxide synthase),M2-type macrophage markers(CD206 and arginase-1),and cognition-related proteins(brain-derived neurotropic factor and phosphorylated NMDA receptor subunit NR2B)were measured in hippocampus by western blotting.Treatment with recombinant chitinase-3-like protein 1 prevented surgery-induced cognitive impairment,downregulated interleukin-1βand nducible nitric oxide synthase expression,and upregulated CD206,arginase-1,pNR2B,and brain-derived neurotropic factor expression compared with vehicle treatment.Intraperitoneal administration of the specific ERK inhibitor PD98059 diminished the effects of recombinant chitinase-3-like protein 1.Collectively,our findings suggest that recombinant chitinase-3-like protein 1 ameliorates surgery-induced cognitive decline by attenuating neuroinflammation via M2 microglial polarization in the hippocampus.Therefore,recombinant chitinase-3-like protein1 may have therapeutic potential fo r postoperative cognitive dysfunction.

Overcoming neutrophil-induced immunosuppression in postoperative cancer therapy: Combined sialic acid-modified liposomes with scaffold-based vaccines

Immunotherapy is a promising approach for preventing postoperative tumor recurrence and metastasis. However, inflammatory neutrophils, recruited to the postoperative tumor site, have been shown to exacerbate tumor regeneration and limit the efficacy of cancer vaccines. Consequently, addressing postoperative immunosuppression caused by neutrophils is crucial for improving treatment outcomes. This study presents a combined chemoimmunotherapeutic strategy that employs a biocompatible macroporous scaffold-based cancer vaccine (S-CV) and a sialic acid (SA)-modified, doxorubicin (DOX)-loaded liposomal platform (DOX@SAL). The S-CV contains whole tumor lysates as antigens and imiquimod (R837, Toll-like receptor 7 activator)-loaded PLGA nanoparticles as immune adjuvants for cancer, which enhance dendritic cell activation and cytotoxic T cell proliferation upon localized implantation. When administered intravenously, DOX@SAL specifically targets and delivers drugs to activated neutrophils in vivo, mitigating neutrophil infiltration and suppressing postoperative inflammatory responses. In vivo and vitro experiments have demonstrated that S-CV plus DOX@SAL, a combined chemo-immunotherapeutic strategy, has a remarkable potential to inhibit postoperative local tumor recurrence and distant tumor progression, with minimal systemic toxicity, providing a new concept for postoperative treatment of tumors.

Managing crawling-type gastric adenocarcinoma with endoscopic techniques and postoperative monitoring

Crawling-type gastric adenocarcinoma is a rare subtype of gastric cancer with diagnostic and therapeutic challenges due to its flat,ill-defined lesions.Advanced diagnostic techniques,such as narrow-band imaging and linear endoscopic ultrasonography,improve detection,but endoscopic submucosal dissection poses a risk of incomplete resection.Despite negative resection margins,vigilant postoperative monitoring is crucial due to the potential for recurrence.This letter highlights the importance of refined diagnostic criteria,individualized treatment approaches,and continuous follow-up to optimize management of this unique gastric cancer subtype.

Effect of transcranial direct current stimulation on postoperative sleep disturbance in older patients undergoing lower limb major arthroplasty:a prospective,double-blind,pilot,randomised controlled trial

Background Postoperative sleep disturbance(PSD)is a common and serious postoperative complication and is associated with poor postoperative outcomes.Aims This study aimed to investigate the effect of transcranial direct current stimulation(tDCS)on PSD in older patients undergoing lower limb major arthroplasty.Methods In this prospective,double-blind,pilot,randomised,sham-controlled trial,patients 65 years and over undergoing lower limb major arthroplasty were randomly assigned to receive active tDCS(a-tDCS)or sham tDCS(s-tDCS).The primary outcomes were the objective sleep measures on postoperative nights(N)1 and N2.Results 116 inpatients were assessed for eligibility,and a total of 92 patients were enrolled;47 received a-tDCS and 45 received s-tDCS.tDCS improved PSD by altering the following sleep measures in the a-tDCS and s-tDCS groups;the respective comparisons were as follows:the promotion of rapid eye movement(REM)sleep time on N1(64.5(33.5-105.5)vs 19.0(0.0,45.0)min,F=20.10,p<0.001)and N2(75.0(36.0-120.8)vs 30.0(1.3-59.3)min,F=12.55,p<0.001);the total sleep time on N1(506.0(408.0-561.0)vs 392.0(243.0-483.5)min,F=14.13,p<0.001)and N2(488.5(455.5-548.5)vs 346.0(286.5-517.5)min,F=7.36,p=0.007);the deep sleep time on N1(130.0(103.3-177.0)vs 42.5(9.8-100.8)min,F=24.4,p<0.001)and N2(103.5(46.0-154.8)vs 57.5(23.3-106.5)min,F=8.4,p=0.004);and the percentages of light sleep and REM sleep on N1 and N2(p<0.05 for each).The postoperative depression and anxiety scores did not differ significantly between the two groups.No significant adverse events were reported.Conclusion In older patients undergoing lower limb major arthroplasty,a single session of anodal tDCS over the left dorsolateral prefrontal cortex showed a potentially prophylactic effect in improving postoperative short-term objective sleep measures.However,this benefit was temporary and was not maintained over time.

Effect of nursing on postoperative respiratory function and mental health of lung cancer patients

BACKGROUND Both pulmonary rehabilitation training and psychological care have been shown to have a positive effect on the postoperative recovery of patients with lung cancer.However,few studies have combined the two to explore their combined effect.Therefore,this study aimed to investigate the effects of pulmonary rehabil-itation training combined with psychological care on postoperative respiratory function and mental health in lung cancer patients.AIM To investigate effect of nursing on postoperative respiratory function and mental health of lung cancer patients.METHODS 122 cases of lung cancer patients who underwent surgical treatment in our hospital and were treated in our department from January 2022 to April 2023 were selected and randomly divided into the control group and observation group.The control group performed the routine care intervention.The obser-vation group was given pulmonary rehabilitation training and psychological care based on conventional nursing interventions.Forced expiratory volume,forced vital capacity.Maximum ventilatory volume(MVV)in one second was measured,and the patient's 6-min walking distance and dyspnoea index scale were used to assess the patient's respiratory condition.The Connor-Davidson resilience scale(CD-RISC),self-rating anxiety scale(SAS),and self-rating depression scale(SDS)were used to evaluate the mental health of the patients.RESULTS There was no difference between the two groups regarding age,gender,education level,surgical procedure,type of pathology,and treatment(P>0.05).After treatment,MVV,6-min walking distance,toughness,strength,optimism,and total CD-RISC scores were significantly higher in the observation group(P<0.05),dyspnoea scores,SAS,and SDS scores were substantially lower in the control group compared to the observation group(P<0.05).CONCLUSION Pulmonary rehabilitation training combined with psychological care for patients after lung cancer resection could improve lung function,enhance daily activities,effectively relieve negative emotions such as anxiety and depression,and reduce complications.

Effect of different anesthetic modalities with multimodal analgesia on postoperative pain level in colorectal tumor patients

BACKGROUND According to clinical data,a significant percentage of patients experience pain after surgery,highlighting the importance of alleviating postoperative pain.The current approach involves intravenous self-control analgesia,often utilizing opioid analgesics such as morphine,sufentanil,and fentanyl.Surgery for colo-rectal cancer typically involves general anesthesia.Therefore,optimizing anes-thetic management and postoperative analgesic programs can effectively reduce perioperative stress and enhance postoperative recovery.The study aims to analyze the impact of different anesthesia modalities with multimodal analgesia on patients'postoperative pain.AIM To explore the effects of different anesthesia methods coupled with multi-mode analgesia on postoperative pain in patients with colorectal cancer.METHODS Following the inclusion criteria and exclusion criteria,a total of 126 patients with colorectal cancer admitted to our hospital from January 2020 to December 2022 were included,of which 63 received general anesthesia coupled with multi-mode labor pain and were set as the control group,and 63 received general anesthesia associated with epidural anesthesia coupled with multi-mode labor pain and were set as the research group.After data collection,the effects of postoperative analgesia,sedation,and recovery were compared.RESULTS Compared to the control group,the research group had shorter recovery times for orientation,extubation,eye-opening,and spontaneous respiration(P<0.05).The research group also showed lower Visual analog scale scores at 24 h and 48 h,higher Ramany scores at 6 h and 12 h,and improved cognitive function at 24 h,48 h,and 72 h(P<0.05).Additionally,interleukin-6 and interleukin-10 levels were significantly reduced at various time points in the research group compared to the control group(P<0.05).Levels of CD3+,CD4+,and CD4+/CD8+were also lower in the research group at multiple time points(P<0.05).CONCLUSION For patients with colorectal cancer,general anesthesia coupled with epidural anesthesia and multi-mode analgesia can achieve better postoperative analgesia and sedation effects,promote postoperative rehabilitation of patients,improve inflammatory stress and immune status,and have higher safety.

Effect of intraoperative injection of esketamine on postoperative analgesia and postoperative rehabilitation after cesarean section

BACKGROUND Following cesarean section,a significant number of women encounter moderate to severe pain.Inadequate management of acute pain post-cesarean section can have far-reaching implications,adversely impacting maternal emotional wellbeing,daily activities,breastfeeding,and neonatal care.It may also impede maternal organ function recovery,leading to escalated opioid usage,heightened risk of postpartum depression,and the development of chronic postoperative pain.Both the Chinese Enhanced Recovery After Surgery(ERAS)guidelines and the American ERAS Society guidelines consistently advocate for the adoption of multimodal analgesia protocols in post-cesarean section pain management.Esketamine,functioning as an antagonist of the N-Methyl-D-Aspartate receptor,has been validated for pain management in surgical patients and has exhibited effectiveness in depression treatment.Research has suggested that incorporating esketamine into postoperative pain management via pain pumps can lead to improvements in short-term depression and pain outcomes.This study aims to assess the efficacy and safety of administering a single dose of esketamine during cesarean section.AIM To investigate the effect of intraoperative injection of esketamine on postoperative analgesia and postoperative rehabilitation after cesarean section.METHODS A total of 315 women undergoing elective cesarean section under combined spinal-epidural anesthesia were randomized into three groups:low-dose esketamine(0.15 mg/kg),high-dose esketamine(0.25 mg/kg),and control(saline).Postoperative Visual Analog Scale(VAS)scores were recorded at 6 hours,12 hours,24 hours,and 48 hours.Edinburgh Postnatal Depression Scale(EPDS)scores were noted on 2 days,7 days and 42 days.Ramsay sedation scores were assessed at specified intervals post-injection.Postoperative adverse reactions were also recorded.RESULTS Low-dose group and high-dose group compared to control group,had significantly lower postoperative VAS pain scores at 6 hours 12 hours,and 24 hours(P<0.05),with reduced analgesic usage(P<0.05).EPDS scores and postpartum depression rates were significantly lower on 2 days and 7 days(P<0.05).No significant differences in first exhaust and defecation times were observed(P>0.05),but ambulation times were shorter(P<0.05).Ramsay scores were higher at 5 minutes,15 minutes,and upon room exit(P<0.05).Low-dose group and high-dose group had higher incidences of hallucination,lethargy,and diplopia within 2 hours(P<0.05),and with low-dose group had lower incidences of hallucination,lethargy,and diplopia than high-dose group(P<0.05).CONCLUSION Esketamine enhances analgesia and postpartum recovery;a 0.15 mg/kg dose is optimal for cesarean sections,balancing efficacy with minimized adverse effects.

Foot and ankle surgery:Tourniquet placement site to cause as little postoperative pain as possible

There is controversy in the literature on where to place the tourniquet(thigh,calf,ankle)for foot and ankle surgery.While some authors prefer the ankle tourniquet to the calf tourniquet,others state that the surgeon can decide between using the thigh tourniquet or the ankle tourniquet,since there was no difference in postoperative pain between them.Where to place the tourniquet during foot and ankle surgery to cause the least possible postoperative pain to the patient as a result of the tourniquet is a common question in clinical practice.The reality is that,unfortunately,there is no consensus on this issue.Perhaps the only possible way to answer this question would be to conduct a comparative study with sufficient statistical power to reach scientifically sound conclusions.It does not seem easy to carry out such a study,but it would be important to be able to answer the question posed in the title of this Editorial once and for all.

Global research trends in postoperative ileus from 2011 to 2023:A scientometric study

BACKGROUND Postoperative ileus(POI)is a common complication after abdominal surgery with high morbidity,which hinders patient recovery,prolongs hospitalization,and increases healthcare costs.Therefore,POI has become a global public health challenge.POI triggering is multifactorial.Autonomic and hormonal mechanisms are generally involved in POI pathogenesis.Recent studies have shown that beta adrenergic signaling of enteric glia is a POI trigger.Currently,the status quo,trends,and frontiers of global research on POI remain unclear.AIM To explore the current status,trends,and frontiers of POI research from 2011 to the present based on bibliometric analysis.METHODS Publications published on POI research from 2011 to 2023 were retrieved on June 1,2023,from the Web of Science Core Collection.CiteSpace 6.2.R2 and VOSviewer were used to conduct bibliometric visualization.RESULTS In total,778 POI records published from 2011 to 2023 were retrieved.Over the past few decades,the annual cumulative number of related articles has linearly increased,with China and the United States of America contributing prominently.All publications were from 59 countries and territories.China and the University of Bonn were the top contributing country and institution,respectively.Neurogastroenterology&Motility was the most prolific journal.The Journal of Gastrointestinal Surgery had the highest number of citations.Wehner Sven was the most productive author.Burst keywords(e.g.,colon,prolonged ileus,acupuncture,paralytic ileus,pathophysiology,rectal cancer,gastrointestinal function,risk)and a series of reference citation bursts provided evidence for the research frontiers in recent years.CONCLUSION This study demonstrates trends in the published literature on POI and provides new insights for researchers.It emphasizes the importance of multidisciplinary cooperation in the development of this field.

Ultrasound-guided serratus anterior plane block enhances postoperative analgesia and recovery in thoracoscopic surgery

BACKGROUND The serratus anterior muscle,located in the lateral aspect of the thorax,plays a crucial role in shoulder movement and stability.Thoracoscopic surgery,while minimally invasive,often results in significant postoperative pain,complicating patient recovery and potentially extending hospital stays.Traditional anesthesia methods may not adequately address this pain,leading to increased complications such as agitation due to inadequate pain management.AIM To evaluate the application value of ultrasound-guided serratus anterior plane block(SAPB)in patients undergoing thoracoscopic surgery,focusing on its effects on postoperative analgesia and rehabilitation.METHODS Eighty patients undergoing thoracoscopic surgery between August 2021 and December 2022 were randomly divided into two groups:An observation group receiving ultrasound-guided SAPB and a control group receiving standard care without SAPB.Both groups underwent general anesthesia and were monitored for blood pressure,heart rate(HR),oxygen saturation,and pulse.The primary outcomes measured included mean arterial pressure(MAP),HR,postoperative visual analogue scale(VAS)scores for pain,supplemental analgesic use,and incidence of agitation.RESULTS The observation group showed significantly lower cortisol and glucose concentrations at various time points post-operation compared to the control group,indicating reduced stress responses.Moreover,MAP and HR levels were lower in the observation group during and after surgery.VAS scores were significantly lower in the observation group at 1 h,4 h,6 h,and 12 h post-surgery,and the rates of analgesic supplementation and agitation were significantly reduced compared to the control group.CONCLUSION Ultrasound-guided SAPB significantly improves postoperative analgesia and reduces agitation in patients undergoing thoracoscopic surgery.This technique stabilizes perioperative vital signs,decreases the need for supplemental analgesics,and minimizes postoperative pain and stress responses,underscoring its high application value in enhancing patient recovery and rehabilitation post-thoracoscopy.

Smoking cessation prior to elective total joint arthroplasty results in sustained abstinence postoperatively

BACKGROUND Tobacco use is a well-documented modifiable risk factor for perioperative complications.AIM To determine the tobacco abstinence rates of patients who made cessation efforts prior to a total joint arthroplasty(TJA)procedure.METHODS A retrospective evaluation was performed on 88 self-reported tobacco users who underwent TJA between 2014-2022 and had tobacco cessation dates within 3 mo of surgery.Eligible patients were contacted via phone survey to understand their tobacco use pattern,and patient reported outcomes.A total of 37 TJA patients participated.RESULTS Our cohort was on average 61-years-old,60%(n=22)women,with an average body mass index of 30 kg/m^(2).The average follow-up time was 2.9±1.9 years.A total of 73.0%(n=27)of patients endorsed complete abstinence from tobacco use prior to surgery.Various cessation methods were used perioperatively including prescription therapy(13.5%),over the counter nicotine replacement(18.9%),cessation programs(5.4%).At final follow up,43.2%(n=16)of prior tobacco smokers reported complete abstinence.Patients who were able to maintain cessation postoperatively had improved Patient-Reported Outcomes Measurement Information System(PROMIS)-10 mental health scores(49 vs 58;P=0.01),and hip dysfunction and osteoarthritis outcome score for joint replacement(HOOS.JR)scores(63 vs 82;P=0.02).No patients in this cohort had a prosthetic joint infection or required revision surgery.CONCLUSION We report a tobacco cessation rate of 43.2%in patients undergoing elective TJA nearly 3 years postoperatively.Patients undergoing TJA who were able to remain abstinent had improved PROMIS-10 mental health scores and HOOS.JR scores.The perioperative period provides clinicians a unique opportunity to assist active tobacco smokers with cessation efforts and improve postoperative outcomes.