Use of Early Goal-Directed Therapy in the Emergency Department before and after the Sepsis Trilogy

The management of sepsis evolved recently with the publication of three large trials (referred to as the sepsis trilogy) investigating the efficacy of early goal-directed therapy (EGDT). Our goal was to determine if the publication of these trials has influenced the use of EGDT when caring for patients with severe sepsis and septic shock in the emergency department (ED). In February 2014, we surveyed a sample of board-certified emergency medicine physicians regarding their use of EGDT in the ED. A follow-up survey was sent after the publication of the sepsis trilogy. Data was analyzed using 95% confidence intervals to determine if there was a change in the use of EGDT following the publication of the above trials. Subgroup analyses were also performed with regard to academic affiliation and emergency department volume. Surveys were sent to 308 and 350 physicians in the pre-and post-publication periods, respectively. Overall, ED use of EGDT did not change with publication of the sepsis trilogy, 48.7% (CI 39.3% - 58.2%) before and 50.5% (CI 40.6% - 60.3%) after. Subgroup analysis revealed that academic-affiliated EDs significantly decreased EGDT use following the sepsis trilogy while nonacademic departments significantly increased EGDT use. Use of EGDT was significantly greater in community departments versus academic departments following the publication of the sepsis trilogy. There was no change overall in the use of EGDT protocols when caring for patients with severe sepsis and septic shock, but subgroup analyses revealed that academic departments decreased their use of EGDT while community departments increased use of EGDT. This may be due to varying rates of uptake of the medical literature between academic and community healthcare systems.

The effect of intraoperative goal-directed fluid therapy in patients under anesthesia for gastrointestinal surgery

BACKGROUND Intraoperative fluid management is an important aspect of anesthesia mana-gement in gastrointestinal surgery.Intraoperative goal-directed fluid therapy(GDFT)is a method for optimizing a patient's physiological state by monitoring and regulating fluid input in real-time.AIM To evaluate the efficacy of intraoperative GDFT in patients under anesthesia for gastrointestinal surgery.METHODS This study utilized a retrospective comparative study design and included 60 patients who underwent gastrointestinal surgery at a hospital.The experimental group(GDFT group)and the control group,each comprising 30 patients,received intraoperative GDFT and traditional fluid management strategies,respectively.The effect of GDFT was evaluated by comparing postoperative recovery,com-plication rates,hospitalization time,and other indicators between the two patient groups.RESULTS Intraoperative blood loss in the experimental and control groups was 296.64±46.71 mL and 470.05±73.26 mL(P<0.001),and urine volume was 415.13±96.72 mL and 239.15±94.69 mL(P<0.001),respectively.The postoperative recovery time was 5.44±1.1 days for the experimental group compared to 7.59±1.45 days(P<0.001)for the control group.Hospitalization time for the experimental group was 10.87±2.36 days vs 13.65±3 days for the control group(P<0.001).The visual analogue scale scores of the experimental and control groups at 24 h and 48 h INTRODUCTION Gastrointestinal surgery is one of the most common procedures in the field of general surgery[1],involving the stomach,intestines,liver,pancreas,spleen,and other internal abdominal organs[2,3].With advancements in surgical technology and anesthesia methods,the safety and success rates of surgery have significantly improved[4,5].However,intraop-erative fluid management remains a critical challenge[6].Traditional fluid management strategies often rely on experience and basic physiological parameters,which may lead to excessive or insufficient fluid input,thereby affecting postoperative recovery and complication rates.Intraoperative goal-directed fluid therapy(GDFT)is an emerging fluid management strategy that dynamically adjusts fluid input volume by monitoring the patient's hemodynamic parameters in real-time to optimize the patient's physiological state[7,8].GDFT has shown superiority in many surgical fields;however,its application in gastrointestinal surgery requires further research and verification[9,10].The application of intraoperative GDFT in clinical settings has gradually increased in recent years[11,12].Studies have demonstrated that GDFT can optimize tissue perfusion and oxygenation by precisely controlling fluid input and reducing the occurrence of postoperative complications[13,14].For example,in cardiac and major vascular surgeries,GDFT significantly reduced the incidence of postoperative acute kidney injury and cardiovascular events[15,16].Similarly,in abdominal surgery,GDFT effectively reduced postoperative infections and expedited recovery[17].However,studies on the utilization of GDFT in gastrointestinal surgery are relatively limited and they are confounded by contradictory findings[18].Traditional fluid management strategies typically rely on estimating fluid input volume based on the patient's weight,preoperative status,and basic physiological parameters[19].However,this method lacks real-time dynamic adjustment,which may result in either insufficient or excessive fluid input,consequently affecting postoperative recovery.Insufficient fluid input can lead to hypovolemia and inadequate tissue perfusion,whereas excessive fluid input can cause tissue edema and postoperative complications,such as pulmonary edema and heart failure.GDFT involves dynamically adjusting fluid input volume by monitoring the patient's hemodynamic parameters in real-time,such as cardiac output,pulse pressure variability,and central venous pressure.Commonly used monitoring equipment include esophageal Doppler and pulse wave profile analyzers[20].These devices provide real-time hemo-dynamic data to assist anesthesiologists in tailoring fluid therapy to a patient's specific condition.Firstly,the patient's volume responsiveness is assessed by preloading fluid;secondly,fluid input volume is dynamically adjusted based on real-time monitoring data;finally,vasoactive and inotropic drugs are administered in combination to further optimize the patient’s hemodynamic status.Through personalized fluid management,GDFT can more accurately maintain intraop-erative hemodynamic stability and reduce complications[21].Gastrointestinal surgery involves procedures on multiple organs,often requiring prolonged operative times and extensive tissue trauma,which presents challenges for intraop-erative fluid management.Surgical procedures can lead to significant bleeding and fluid loss,requiring prompt and effective fluid replenishment.In addition,the slow recovery of gastrointestinal function after surgery and susceptibility to complications such as intestinal obstruction and delayed gastric emptying elevate the necessity for postoperative fluid management.

Hepatic Perfusion Alterations in Septic Shock Patients： Impact of Early Goal-directed Therapy

Background： Early goal-directed therapy （EGDT） has become an important therapeutic management in early salvage stage of septic shock. However, splenic organs possibly remained hypoperfused and hypoxic despite fluid resuscitation. This study aimed to evaluate the effect of EGDT on hepatic perfusion in septic shock patients. Methods： A prospective observational study was carried out in early septic shock patients who were admitted to Intensive Care Unit within 24 h after onset and who met all four elements of the EGDT criteria after treatment with the standard EGDT procedure within 6 h between December 1, 2012 and November 30, 2013. The hemodynamic data were recorded, and oxygen metabolism and hepatic functions were monitored. An indocyanine green clearance test was applied to detect the hepatic perfusion. The patients＇ characteristics were compared before treatment （TO）, immediately after EGDT （T 1 ）, and 24 h after EGDT （T2）. This study is registered at ClinicalTrials.org, NCT02060773. Results： Twenty-one patients were included in the study; however, the hepatic perfusion data were not included in the analysis for two patients： therefore, 19 patients were eligible for the study. Hemodynamics data, as monitored by pulse-indicator continuous cardiac output, were obtained from 16 patients. There were no significant differences in indocyanine green plasma disappearance rate （ICG-PDR） and 15-min retention rate （Rl 5） at TO （ 11.9 ±5.0%/min and 20.0 ±13.2%）, T1 （ 11.4 ± 5.1%/min and 23.6 ± 14.9%）, and T2 （ 11.0 ±4.5%/rain and 23.7 ± 15.3%） （all P 〉 0.05）. Both of the alterations of ICG-PDR and R l 5 showed no differences at TO, T1, and T2 in the patients of different subgroups that achieved different resuscitation goal numbers when elected （P 〉 0.05）.

Present and future of new systemic therapies for early and intermediate stages of hepatocellular carcinoma

Hepatocellular carcinoma(HCC)is a high mortality neoplasm which usually appears on a cirrhotic liver.The therapeutic arsenal and subsequent prognostic outlook are intrinsically linked to the HCC stage at diagnosis.Notwithstanding the current deployment of treatments with curative intent(liver resection/local ablation and liver transplantation)in early and intermediate stages,a high rate of HCC recurrence persists,underscoring a pivotal clinical challenge.Emergent systemic therapies(ST),particularly immunotherapy,have demonstrate promising outcomes in terms of increase overall survival,but they are currently bound to the advanced stage of HCC.This review provides a comprehensive analysis of the literature,encompassing studies up to March 10,2024,evaluating the impact of novel ST in the early and intermediate HCC stages,specially focusing on the findings of neoadjuvant and adjuvant regimens,aimed at increasing significantly overall survival and recurrence-free survival after a treatment with curative intent.We also investigate the potential role of ST in enhancing the downstaging rate for the intermediate-stage HCC initially deemed ineligible for treatment with curative intent.Finally,we critically discuss about the current relevance of the results of these studies and the encouraging future implications of ST in the treatment schedules of early and intermediate HCC stages.

Intraoperative Blood Pressure Lability Acts as a Key Mediator in the Impacts of Goal-Directed Fluid Therapy on Postoperative Complications in Patients Undergoing Major Spine Surgery

Objective Although goal-directed fluid therapy(GDFT)has been proven to be effective in reducing the incidence of postoperative complications,the underlying mechanisms remain unknown.The aim of this study was to examine the mediating role of intraoperative hemodynamic lability in the association between GDFT and the incidence of postoperative complications.We further tested the role of this mediation effect using mean arterial pressure,a hemodynamic indicator.Methods This secondary analysis used the dataset of a completed nonrandomized controlled study to investigate the effect of GDFT on the incidence of postoperative complications in patients undergoing posterior spine arthrodesis.We used a simple mediation model to test whether there was a mediation effect of average real variability between the association of GDFT and postoperative complications.We conducted mediation analysis using the mediation package in R(version 3.1.2),based on 5,000 bootstrapped samples,adjusting for covariates.Results Among the 300 patients in the study,40%(120/300)developed postoperative complications within 30 days.GDFT was associated with fewer 30-day postoperative complications after adjustment for confounders(odds ratio:0.460,95%CI:0.278,0.761;P=0.003).The total effect of GDFT on postoperative complications was-0.18(95%CI:-0.28,-0.07;P<0.01).The average causal mediation effect was-0.08(95%CI:-0.15,-0.04;P<0.01).The average direct effect was-0.09(95%CI:-0.20,0.03;P=0.17).The proportion mediated was 49.9%(95%CI:18.3%,140.0%).Conclusions The intraoperative blood pressure lability mediates the relationship between GDFT and the incidence of postoperative complications.Future research is needed to clarify whether actively reducing intraoperative blood pressure lability can prevent postoperative complications.

Aluminum phosphate gel reduces early rebleeding in cirrhotic patients with gastric variceal bleeding treated with histoacryl injection therapy

BACKGROUND Esophageal-gastro varices bleeding(EGVB)is the most widely known cause of mortality in individuals with cirrhosis,with an occurrence rate of 5%to 15%.Among them,gastric varices bleeding(GVB)is less frequent than esophageal varices bleeding(EVB),but the former is a more critical illness and has a higher mortality rate.At present,endoscopic variceal histoacryl injection therapy(EVHT)is safe and effective,and it has been recommended by relevant guidelines as the primary method for the treatment of GVB.However,gastric varices after endoscopic treatment still have a high rate of early rebleeding,which is mainly related to complications of its treatment,such as bleeding from drained ulcers,rebleeding of varices etc.Therefore,preventing early postoperative rebleeding is very important to improve the quality of patient survival and outcomes.AIM To assess the efficacy of aluminium phosphate gel(APG)combined with proton pump inhibitor(PPI)in preventing early rebleeding after EVHT in individuals with GVB.METHODS Medical history of 196 individuals with GVB was obtained who were diagnosed using endoscopy and treated with EVHT in Shenzhen People's Hospital from January 2016 to December 2021.Based on the selection criteria,101 patients were sorted into the PPI alone treatment group,and 95 patients were sorted into the PPI combined with the APG treatment group.The incidences of early rebleeding and corresponding complications within 6 wk after treatment were compared between both groups.Statistical methods were performed by two-sample t-test,Wilcoxon rank sum test andχ2 test.RESULTS No major variations were noted between the individuals of the two groups in terms of age,gender,Model for End-Stage Liver Disease score,coagulation function,serum albumin,hemoglobin,type of gastric varices,the dose of tissue glue injection and EV that needed to be treated simultaneously.The early rebleeding rate in PPI+APG group was 3.16%(3/95),which was much lower than that in the PPI group(12.87%,13/101)(P=0.013).Causes of early rebleeding:the incidence of gastric ulcer bleeding in the PPI+APG group was 2.11%(2/95),which was reduced in comparison to that in the PPI group(11.88%,12/101)(P=0.008);the incidence of venous bleeding in PPI+APG group and PPI group was 1.05%(1/95)and 0.99%(1/101),respectively,and there was no significant difference between them(0.999).The early mortality rate was 0 in both groups within 6 wk after the operation,and the low mortality rate was related to the timely hospitalization and active treatment of all patients with rebleeding.The overall incidence of complications in the PPI+APG group was 12.63%(12/95),which was not significantly different from 13.86%(14/101)in the PPI group(P=0.800).of abdominal pain in the PPI+APG group was 3.16%(3/95),which was lower than that in the PPI group(11.88%,12/101)(P=0.022).However,due to aluminum phosphate gel usage,the incidence of constipation in the PPI+APG group was 9.47%(9/95),which was higher than that in the PPI group(1.98%,2/101)(P=0.023),but the health of the patients could be improved by increasing drinking water or oral lactulose.No patients in either group developed spontaneous peritonitis after taking PPI,and none developed hepatic encephalopathy and ectopic embolism within 6 wk of EVHT treatment.CONCLUSION PPI combined with APG can significantly reduce the incidence of early rebleeding and postoperative abdominal pain in cirrhotic patients with GVB after taking EVHT.

Goal-directed therapy in intraoperative fluid and hemodynamic management

Intraoperative fluid management is pivotal to the outcome and success of surgery, especially in high-risk proce- dures. Empirical formula and invasive static monitoring have been traditionally used to guide intraoperative fluid management and assess volume status. With the awareness of the potential complications of invasive procedures and the poor reliability of these methods as indicators of volume status, we present a case scenario of a patient who underwent major abdominal surgery as an example to discuss how the use of minimally invasive dynamic monitoring may guide intraoperative fluid therapy.

Scoliosis in Children: Impact of Goal-Directed Therapies on Intraoperative and Postoperative Outcomes

Background: Scoliosis is among interventions with high postoperative complication rates due to the characteristics of the surgery, where blood loss, transfusion and fluid requirements can be increased. A monocentric retrospective observational study was undertaken earlier to determine predictors of intraoperative and postoperative outcomes in surgical patients. In this initial cohort, there were patients who underwent scoliosis surgery, and a secondary analysis to describe outcomes in these patients was realized and presented here. Objective: To describe intraoperative and postoperative outcomes in patients under 18 years old in scoliosis surgery included in the initial study and to propose improvement and implementation measures. Methods: A secondary analysis of patients undergoing scoliosis surgery from 1 January 2014 to 17 May 2017 was undertaken in our institution—Necker Enfants Malades university hospital. The study was approved by the Ethics Committee. Results: There were 116 patients with a mean age of 147.5 ± 40.2 months. Twenty-eight patients (24.1%) presented intraoperative and/or postoperative complications. The most common intraoperative complication was hemorrhagic shock in 3 patients (2.6%). The most common postoperative organ failure was neurologic in seven patients (6%), respiratory in 3 patients (2.6%), cardio-circulatory in 2 patients (1.7%) and renal failure in 1 patient (0.9%). The most common postoperative infection was surgical wound sepsis in 8 patients (6.9%), urinary sepsis in 3 patients (2.6%), and abdominal sepsis and septicemia in 2 patients (1.7%). 12 patients (10.3%) had reoperations. Fifty-six patients (48.3%) had intraoperative transfusion. There was no in-hospital mortality. Conclusion: The portion of patients with intraoperative and or postoperative complications was 24.1%, integrating goal-directed therapies in this surgical setting could improve postoperative outcomes.

Intraoperative Goal-Directed Therapies in Femoral and Pelvic Osteotomies in Children and In-Hospital Postoperative Outcomes

Background: Femoral and pelvic osteotomies are potential hemorrhagic interventions where transfusion requirements can be necessary. Objective: We undertook a secondary analysis of patients who underwent femoral and pelvic osteotomy in the initial cohort. The objective of this secondary analysis was to describe intraoperative and postoperative outcomes and to describe intraoperative management in these patients in terms of blood product management and fluid and hemodynamic therapy with the aim of implementing optimization management protocols for postoperative outcome improvement. Methods: A secondary analysis of patients who underwent femoral and pelvic osteotomy surgery was included in the initial retrospective study. Results: There were eighteen patients with a mean age of 104 ± 47.1 months. Four (22.2%) patients had intraoperative and/or postoperative complications. One patient (5.6%) had an intraoperative hemorrhagic shock, two patients (11.1%) had postoperative neurologic failure, and one patient (5.6%) had postoperative wound sepsis. The transfusion rate was 50% in nine patients. Conclusion: Femoral and pelvic osteotomies are interventions where blood, transfusion and fluid requirements can be increased;thus, this implies the necessity of a global patient blood management protocol with point-of-care tests and fluid- and hemodynamic-guided protocols with validated tools in children for intraoperative and postoperative outcome optimization.

Effects of fluid therapy combined with a preoperative glucose load regimen on postoperative recovery in patients with rectal cancer

BACKGROUND Patients with rectal cancer undergoing radical resection often have poor post-operative recovery due to preoperative fasting and water deprivation and the removal of diseased tissue,and have a high risk of complications.Therefore,it is of great significance to apply appropriate rehydration regimens to patients un-dergoing radical resection of rectal cancer during the perioperative period to improve the postoperative outcomes of patients.AIM To analyze the effects of goal-directed fluid therapy(GDFT)with a preoperative glucose load regimen on postoperative recovery and complications in patients undergoing radical resection for rectal cancer.METHODS Patients with rectal cancer who underwent radical resection(n=184)between January 2021 and December 2023 at our hospital were randomly divided into either a control group or an observation group(n=92 in each group).Both groups received a preoperative glucose load regimen,and routine fluid replacement and GDFT were additionally implements in the control and observation groups,res-pectively.The operative conditions,blood levels of lactic acid and inflammatory markers,postoperative recovery,cognitive status,hemodynamic indicators,brain oxygen metabolism,and complication rates were compared between the groups.RESULTS The colloidal fluid dosage,total infusion,and urine volume,as well as time to first exhaust,time to food intake,and postoperative length of hospital stay,were lower in the observation group(P<0.05).No significant differences were observed between the two groups in terms of operation time,bleeding volume,crystalloid liquid consumption,time to tracheal extubation,complication rate,heart rate,or mean arterial pressure(P>0.05).Compared with the control group,in the ob-servation group the lactic acid level was lower immediately after the surgery(P<0.05);the Mini-Mental State Examination score was higher on postoperative day 3(P<0.05);the pulse pressure variability(PPV)was lower at 30 min after pneumoperitoneum(P<0.05),though the differences in the PPV of the two groups was not significant at the remaining time points(P>0.05);tumor necrosis factor-αand interleukin-6 levels were lower on postoperative day 3(P<0.05);and the left and right regional cerebral oxygen saturation was higher immediately after the surgery and 30 min after pneumoperitoneum(P<0.05).CONCLUSION GDFT combined with the preoperative glucose load regimen is a safe and effective treatment strategy for im-proving postoperative recovery and risk of complications in patients with rectal cancer undergoing radical re-section.

Goal-directed fluid therapy in gastrointestinal cancer surgery:A prospective randomized study

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<0.05).CR-POSSUM physiological score and CCI were significantly higher in the GDFT group(P<0.05).Although perioperative vasopressor and inotrope use was significantly higher in the GDFT group(P<0.05),postoperative acute kidney injury development was not affected.Postoperative mortality was determined to be similar in both groups(P>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.

Simplified Intraoperative Goal-Directed Therapy Using the FloTrac/Vigileo System: An Analysis of Its Usefulness and Safety

Purpose: We investigated whether the simplified intraoperative Goal-Directed Therapy (GDT) could improve the factors affecting medical costs, and contribute in standardizing intraoperative fluid management. Methods: The enrolled patients underwent esophagectomy, pancreatoduodenectomy, or aortic stent grafting in 2012, and between March 2013 and October 2014. We conducted a comparison study on the effects of GDT, between the before-GDT historical control group (n = 100) and GDT group (n = 100). The hemodynamic indices used for control group patients were conventional: Blood pressure, heart rate, and urine output. For GDT group, additionally, we used stroke volume variation (SVV) and stroke volume index (SVI). The primary outcomes were the length of intensive care unit (ICU) stay and hospital stay (LOS). Regression analysis was used to identify factors affecting LOS. The secondary outcomes were the albumin use, the fluid amount administered, and the variation in the fluid administration rate. Results: The control and GDT groups comprised 96 and 99 patients, respectively. The patient characteristics were similar. The length of ICU stay was significantly shorter (2.1 ± 2.1 days vs. 2.8 ± 1.9 days, P = 0.0009) and LOS was shorter but without statistical significance (24.5 ± 17.7 days vs. 27.7 ± 20.1 days, P = 0.21) in the GDT group than in the control group. The fluid amount administered and the presence/ absence of albumin use were factors affecting LOS. The variation of the fluid administration rate was significantly lower in the GDT group. Conclusion: The simplified GDT may contribute to the improvement of medical economics and standardize the fluid management.

Effect of Goal-Directed Fluid Therapy on Lung Function, Cognitive Function and Inflammatory Response in Patients Undergoing Radical Esophageal Cancer Surgery under One-Lung Ventilation

Objective: To explore the effects of goal-directed fluid therapy (GDFT) on lung function, cognitive function and inflammatory response in patients undergoing radical esophageal cancer surgery under one-lung ventilation. Methods: Sixty-seven patients undergoing radical esophageal cancer surgery were divided into GDFT group (GDFT therapy) and control group (conventional liquid therapy). The changes in patients’ pulmonary function, cognitive function and inflammatory response were evaluated. Results: Both alveolar-arterial oxygen partial pressure difference [P(A-a)O2] and respiratory index (RI) increased at one-lung ventilation for 30 minutes (T2) and decreased at one-lung ventilation for 60 minutes (T3), and after surgery (T4) in the two groups, and the GDFT group was lower than the control group (P < 0.05);theoxygenation index (OI) of the two groups decreased at T2, T3, and T4 compared with that at T1 (before one-lung ventilation), and the GDFT group was higher than the control group (P < 0.05). At T4 and T5, the tumor necrosis factor α (TNF-α), interleukin 6 (IL-6), central nervous system specific protein (S100β), and neuron specific enolase (NSE) in the GDFT group were lower compared to the control group (P < 0.05), while interleukin-10 (IL-10) was higher compared to the control group (P < 0.05);the incidence of perioperative neurocognitive disorder (PND) in the GDFT group was lower than that in the control group (P < 0.05). Conclusion: GDFT can help prevent lung injury during radical esophageal cancer surgery under one-lung ventilation, reduce the body’s inflammatory response, and reduce the incidence of perioperative cognitive disorder to a certain extent.

Advances in early diagnosis and therapy of pancreatic cancer

BACKGROUND: Pancreatic cancer remains a devastating disease with a 5-year survival rate of less than 5%. Recent advances in diagnostic methods and therapeutic approaches have increased the possibility of improving the existing poor prognosis. DATA SOURCES: English-language articles reporting early diagnosis and therapy of pancreatic cancer were searched from the MEDLINE and PubMed databases, Chinese-language articles were from CHKD (China Hospital Knowledge Database) RESULT: The current literature about pancreatic cancer was reviewed from three aspects: statistics, screening and early detection, and therapy. CONCLUSIONS: Early detection and screening of pancreatic cancer currently should be limited to high risk patients Surgical resection is the only curative approach available, with some recent improvement in outcomes. Gemcitabine has been a standard treatment during the last decade. Gemcitabine based combination treatment, especially combined with newer molecular targeted agents, is promising. The rationale for radiotherapy is controversial, but with the recent development of modern radiation delivery techniques, radiotherapy should be intensified. Patients with borderline pancreatic cancer could benefit from neoadjuvant therapy but more evidence is needed and the best neoadjuvant regimen is still to be determined.

Effects of early rehabilitation therapy on patients with mechanical ventilation

BACKGROUND: For patients in intensive care unit(ICU), mechanical ventilation is an effective treatment to survive from acute illness and improve survival rates. However, long periods of bed rest and restricted physical activity can result in side effects. This study aimed to investigate the feasibility of early rehabilitation therapy in patients with mechanical ventilation.METHODS: A randomized controlled trial was carried out. Sixty patients, with tracheal intubation or tracheostomy more than 48 hours and less than 72 hours, were admitted to the ICU of the Affiliated Hospital of Medical College, Qingdao University, from May 2010 to May 2012. These patients were randomly divided into a rehabilitation group and a control group. In the rehabilitation group, rehabilitation therapy was performed twice daily, and the training time and intensity were adjusted according to the condition of the patients. Early rehabilitation therapy included heading up actively, transferring from the supine position to sitting position, sitting at the edge of the bed, sitting in chair, transferring from sitting to standing, and ambulating bedside. The patient's body mass index, days to first out of bed, duration of mechanical ventilation, length of ICU stay, APACHE II score, highest FiO2, lowest PaO2/FiO2 and hospital mortality of patients were all compared between the rehabilitation group and the control group. The differences between the two groups were compared using Student's t test.RESULTS: There was no significant difference in body mass index, APACHE II score, highest FiO2, lowest PaO2/FiO2 and hospital mortality between the rehabilitation group and the control group(P>0.05). Patients in the rehabilitation group had shorter days to first out of bed(3.8±1.2 d vs. 7.3±2.8 d; P=0.00), duration of mechanical ventilation(5.6±2.1 d vs. 12.7±4.1 d; P=0.005) and length of ICU stay(12.7±4.1 d vs. 15.2±4.5 d; P=0.01) compared with the control group.CONCLUSION: Early rehabilitation therapy was feasible and effective in improving the outcomes of patients with mechanical ventilation.

Feasible endoscopic therapy for early gastric cancer

AIM: To analyze the relationship between lymph node metastasis and clinical pathology of early gastric cancer(EGC) in order to provide criteria for a feasible endoscopic therapy.METHODS: Clinical data of the 525 EGC patients who underwent surgical operations between January 2009 and March 2014 in the West China Hospital of Sichuan University were analyzed retrospectively. Clinical pathological features were compared between different EGC patients with or without lymph node metastasis, and investigated by univariate and multivariate analyses for possible relationships with lymph node metastasis.RESULTS: Of the 2913 patients who underwent gastrectomy with lymph node dissection, 529 cases were pathologically proven to be EGC and 525 cases were enrolled in this study, excluding 4 cases of gastric stump carcinoma. Among 233 patients with mucosal carcinoma, 43(18.5%) had lymph node metastasis. Among 292 patients with submucosal carcinoma, 118(40.4%) had lymph nodemetastasis. Univariate analysis showed that gender, tumor size, invasion depth, differentiation type and lymphatic involvement correlated with a high risk of lymph node metastasis. Multivariate analysis revealed that gender(OR = 1.649, 95%CI: 1.091-2.492, P = 0.018), tumor size(OR = 1.803, 95%CI: 1.201-2.706, P = 0.004), invasion depth(OR = 2.566, 95%CI: 1.671-3.941, P = 0.000), histological differentiation(OR = 2.621, 95%CI: 1.624-4.230, P = 0.000) and lymphatic involvement(OR = 3.505, 95%CI: 1.590-7.725, P = 0.002) wereindependent risk factors for lymph node metastasis. Comprehensive analysis showed that lymph node metastasis was absent in patients with tumor that was limited to the mucosa, size ≤ 2 cm, differentiated and without lymphatic involvement.CONCLUSION: We propose an endoscopic therapy for EGC that is limited to the mucosa, size ≤ 2 cm, differentiated and without lymphatic involvement.

Research of goal-directed fluid therapy on laparoscopic liver resection

Objective To explore the application effect of goal-directed fluid therapy(GDFT)on laparoscopic liver resection.Methods From July 2023 to December 2023,48 patients who underwent laparoscopic liver resection were randomly divided into the GDFT group and the CLCVP(controlled low central venous pressure)group.The patients in the GDFT group were guided by stroke volume variability(SVV)during surgery,while those in the CLCVP group were guided by a controlled low central venous pressure technique during fluid replacement surgery.Intraoperative bleeding volume,fluid replacement volume,urine output,liver blood flow obstruction time,postoperative exhaust time,length of hospital stays,and incidence of complications were recorded and compared between the two groups of patients.Results There was a difference between the two groups in terms of crystal fluid,colloid fluid,total fluid volume,and urine volume(P>0.05).However,the bleeding volume in the GDFT group(515.61±246.71)mL was lower than that in the CLCVP group(389.37±187.35)mL(P<0.05);and the blockade time of liver blood flow in the GDFT group(46.33±7.26)min was shorter than that of the CLCVP group(41.84±6.24)min(P<0.05);the postoperative exhaust time of patients in the GDFT group(4.86±1.24)d was shorter than that of patients in the CLCVP group(6.42±1.05)d(P<0.05);the hospitalization days of patients in the GDFT group(9.21±2.15)d were fewer than those in the CLCVP group(11.04±4.29)d(P<0.05).There were no statistically significant differences in the incidence of postoperative complications between the two groups of patients(P>0.05).Conclusion GDFT guided by SVV can stabilize intraoperative hemodynamics in patients undergoing laparoscopic liver resection,reduce intraoperative bleeding,and reduce liver blood flow blockage time.It is safer and more reliable than traditional fluid therapy.

Endoscopic Mucosal Resection: Therapy for Early Colorectal Cancer

We review the use of Endoscopic Mucosal Resection in the treatment of early colorectal cancer. Newer endoscopic imaging modalities have lead to earlier detection of advanced lesions thus enabling endoscopic curative therapy of lesions that would otherwise need surgery. Early outcomes data suggest promising results. But further long term prospective studies are needed.

Early rehabilitation and neuroprotective drug therapy outcomes in elderly patients with acute stroke

Sixty elderly patients, viro cluffered from acute stroke and were admitted within a 1-year period to the Department of Geriatrics in the First Affiliated Hospital of School of Medicine, Zhejiang University, China, underwent early rehabilitation in combination with neuroprotective drug therapy. Limb movement, cognitive functions and daily life self-care ability in elderly patients upon admission and discharge were assessed using the Hunt-Hess scale, functional independence measures and mini-mental state examination. The mean duration of hospital stay among the 60 patients was 35 days. Upon discharge, 42 （75%） of the patients exhibited cognitive impairment to varying degrees, and 25 （45%） of the 56 stroke patients who underwent rehabilitation evaluation attained independence in daily living activities, 11 （20%） required intermittent supervision, and 20 （36%） required 24-hour constant supervision during performance of these activities. Results demonstrated that early rehabilitation treatment in combination with neuroprotective therapy for acute stroke was effective.

Youngest case of an early gastric cancer after successful eradication therapy

A 28-year-old woman visited our clinic with a chief complaint of epigastralgia. She had received successful Helicobacter pylori (H. pylori ) eradication therapy 5 years before. We repeated esophagogastroduodenoscopy, and a discolored depressed area with reddish spots and converging folds, 20 mm in size, was detected. No atrophic change including intestinal metaplasia or nodular gastritis was seen endoscopically. Two endoscopic biopsies revealed undifferentiated adenocarcinoma. No H. pylori was found, and the 13 C-urea breath test was also negative. Abdominal computed tomography demonstrated no nodal involvement, distant metastasis or fluid collection. She underwent a laparoscopyassisted distal gastrectomy. Histologically, the resected specimen revealed an early undifferentiated gastric cancer that had invaded deeply into the submucosal layer. Nodal involvement was histologically confirmed.No atrophic change or H. pylori infection was evident histologically. This is the youngest patient ever reported to have developed a node-positive early gastric cancer after eradication of H. pylori .