Erroneous presentation of respiratory-hemodynamic disturbances and postsurgical inflammatory responses in patients having undergone abdominal cavity cancer surgery

In this letter to the editor,the authors discuss the findings and shortcomings of a published retrospective study,including 120 patients undergoing surgery for gastric or colon cancer under general anesthesia.The study focused on perioperative dynamic respiratory and hemodynamic disturbances and early postsurgical inflammatory responses.

Chinese Association for the Study of Pain:Expert consensus on chronic postsurgical pain

Chronic postsurgical pain is a common surgical complication that severely reduces a patient’s quality of life.Many perioperative interventions and management strategies have been developed for reducing and managing chronic postsurgical pain.Under the leadership of the Chinese Association for the Study of Pain,an editorial committee was formed for chronic postsurgical pain diagnosis and treatment by experts in relevant fields.The editorial committee composed the main content and framework of this consensus and established a working group.The working group conducted literature review(1989-2020)using key words such as“surgery”,“post-surgical”,“post-operative”,“pain”,“chronic”,and“persistent”in different databases including MEDLINE,EMBASE,PubMed,Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews.Only publications in the English language were included.The types of literature included systematic reviews,randomized controlled studies,cohort studies and case reports.This consensus was written based on clinical practice combined with literature evidence.The first draft of the consensus was rigorously reviewed and edited by all the editorial committee experts before being finalized.The level of evidence was assessed by methodological experts based on the Oxford Centre for Evidence-Based Medicine Levels of Evidence.The strength of recommendation was evaluated by all editorial committee experts,and the opinions of most experts were adopted as the final decision.The recommendation level“strong”generally refers to recommendations based on high-level evidence and consistency between clinical behavior and expected results.The recommendation level“weak”generally refers to the uncertainty between clinical behavior and expected results based on low-level evidence.

Multi-centric clinical study of the effect of intervention time on efficacy of gastroparesis external application prescription treatment of gastrointestinal tumor postsurgical gastroparesis

Objective:This intervention has been shown to be clinically efficacious and safe.The aim of this study was to determine the effect of different intervention times on the efficacy of gastroparesis external application prescription versus placebo for the treatment of gastrointestinal tumor postoperative,postsurgical gastroparesis.Methods:A multicenter,randomized,double-blind,placebo controlled phaseⅢclinical trial was designed to demonstrate superiority and conducted at four grade 3A hospitals in Beijing.Patients diagnosed with gastrointestinal tumor postsurgical gastroparesis and local cold syndrome in the abdomen were enrolled and received conventional treatment(nutritional support,gastrointestinal decompression,and prokinetic medication).Treatment and control groups respectively received gastroparesis external application prescription or placebo acupoint application over a treatment course of 14 days or until the primary efficacy endpoint(clinical efficiency)was achieved.Results:A total of 120 patients were enrolled in the treatment and control groups(n Z 60 per group),and 15 patients dropped out of the study because of skin allergies(n Z 7)or poor efficacy(nZ8).The efficacy among patients in Class B of Group A(treatment group)was marginally better than that of Group B(control group)(64.28%vs.55.56%)although the difference between the two groups was not significant.However,the efficacy among patients in Class C of Group A was significantly better than that of Group B(79.49%vs.43.33%).For Group A,the time for patients in the three classes to achieve the efficacy endpoint increased significantly with disease progression(3.00,6.78,and 8.29 days for Class A,B,and C,respectively).Conclusions:Gastroparesis external application prescription can effectively treat gastrointestinal tumor postsurgical gastroparesis and may be more efficacious in progressive disease compared placebo.Patients with gastrointestinal tumor postsurgical gastroparesis should therefore undergo intervention at an earlier stage.

Can High Dose Metamizol Medication Contribute to Postsurgical Hemorrhage:A Case Report

The use of metamizol significantly increased in the last decade, especially in non US countries [1]. Although metamizol is known to be a non selective COX inhibitor and therefore has platelet inhibiting potential, it is widely used in pain management in postsurgical setting. Methods: We present a case of bleeding after microsurgical decompression of a narrow lumbar spinal canal. Our patient developed a bleeding complication 3 days after the surgery. The bleeding spontaneously resolved after stopping the application of metamizol. Metamizol is a non selective COX inhibitor and is used as standard analgetic drug after surgery in our department, whereas other COX inhibitors are not. We made an intensive literature research to evaluate the prohaemorrhagic potential of metamizol. Metamizol has proven dose dependent platelet inhibiting effect. Conclusions: This is a quite ordinary case and there is no proof of metamizol being responsible for the bleeding in this case, it still poses questions at our daily routine and the question about a dose dependent clinically relevant prohaemorrhagic effect of metamizol remains unanswered. A proper study is needed.

Clinical effects of acupoints moxibustion therapy on postsurgical gastroparesis syndrome after resection of esophageal cardia cancer

OBJECTIVE:To evaluate effects of acupoints moxibustion therapy on postsurgical gastroparesis syndrome(PGS) after resection of esophageal cardia cancer.METHODS:60 patients with PGS after resection of esophageal cardia cancer,admitted to the second affiliated hospital to Nanyang medical college from August 2012 to August 2015,were selected and studied randomly.They were divided into the treatment group and the control group by single blind controlled method,30 cases in each group.The gastric paralysis main symptom index(GCSI,by symptom ratings quantitative score table) score,drainage volume of gastric juice and value of motilin were recorded respectively at 1,7,14 and 21 days after treatment in two groups.Apart from conventional therapies,acupoints moxibustion was given on Shenque,Guanyuan,Qihai,Zhongwan acupoints,twice a day,30 minutes once,7 days as a course of treatment and for 3 courses in the treatment group.In the control group,the conventional therapies were given,7 days as a course of treatment and for 3 courses.RESULTS:The GCSI score,drainage volume of gastric juice,value of motilin in the treatment group were better than that of the control group at 7,14,21 days respectively,and there were significant differences between two groups(P<0.05).The treatment group had a more sigi curative effect than that in the control group at 7,14 days respectively(P<0.05),but there was no significant difference at 21 day between the two groups(x^2=5.68,P<0.13);nevertheless,there were more recovery cases in the treatment group than those in the control group at 21 day(x^2=4.59,P<0.032).The total effective rate was 100.00% in treatment group,and 83.00% in the control group(P<0.05).CONCLUSIONS:Acupoints moxibustion has the advantageof addressing both the symptoms and root causes of PGS after resection of esophageal cardia cancer.

From the mathematical model to the patient: The scientific and human aspects of artificial intelligence in gastrointestinal surgery

Recent medical literature shows that the application of artificial intelligence(AI)models in gastrointestinal pathology is an exponentially growing field,with pro-mising models that show very high performances.Regarding inflammatory bowel disease(IBD),recent reviews demonstrate promising diagnostic and prognostic AI models.However,studies are generally at high risk of bias(especially in AI models that are image-based).The creation of specific AI models that improve diagnostic performance and allow the establishment of a general prognostic fo-recast in IBD is of great interest,as it may allow the stratification of patients into subgroups and,in turn,allow the creation of different diagnostic and therapeutic protocols for these patients.Regarding surgical models,predictive models of post-operative complications have shown great potential in large-scale studies.In this work,the authors present the development of a predictive algorithm for early post-surgical complications in Crohn's disease based on a Random Forest model with exceptional predictive ability for complications within the cohort.The pre-sent work,based on logical and reasoned,clinical,and applicable aspects,lays a solid foundation for future prospective work to further develop post-surgical prognostic tools for IBD.The next step is to develop in a prospective and mul-ticenter way,a collaborative path to optimize this line of research and make it applicable to our patients.

Effects of oral probiotics on inflammation and intestinal function in adult patients after appendectomy:Randomized controlled trial

BACKGROUND Appendectomy is an acute abdominal surgery that is often accompanied by severe abdominal inflammation.Oral probiotics are one of the postoperative treatments for rapid rehabilitation.However,there is a lack of prospective studies on this topic after appendectomy.AIM To investigate whether the postoperative probiotics can modulate the inflammatory response and restore intestinal function in patients following appendectomy.METHODS This was a prospective,randomized trial.A total of 60 emergency patients were randomly divided into a control group(n=30)and a probiotic group(n=30).Patients in the control group started to drink some water the first day after surgery,and those in the probiotic group were given water supplemented with Bacillus licheniformis capsules for 5 consecutive days postsurgery.The indices of inflammation and postoperative conditions were recorded,and the data were analyzed with RStudio 4.3.2 software.RESULTS A total of 60 participants were included.Compared with those in the control group,the C-reactive protein(CRP),interleukin 6 and procalcitonin(PCT)levels were significantly lower in the probiotic group at 2 d after surgery(P=2.224e-05,P=0.037,and P=0.002,respectively,all P<0.05).This trend persisted at day 5 post-surgery,with CRP and PCT levels remaining significantly lower in the probiotic group(P=0.001 and P=0.043,both P<0.05).Furthermore,probiotics0.028,both P<0.05).CONCLUSION Postoperative oral administration of probiotics may modulate the gut microbiota,benefit the recovery of the early inflammatory response,and subsequently enhance recovery after appendectomy.

Use of N,O-carboxymethyl chitosan to prevent postsurgical adhesions in a rabbit double uterine horn model： a randomized controlled design

In previous studies, N,O-carboxymethyl chitosan has been shown to decrease the incidence and intensity of abdominal adhesions. In the present study, adhesions were induced in 220 rabbits using a double uterine horn model. Rabbits were randomized to receive an operation only or an operation+medical chitosan intraperitoneally. Twenty-two rabbits from each group were euthanized at one of five different times(Day 3, 7, 14, 28, or 42), and adhesion formation was given gross and histopathological scores. Reductions were observed in adhesion extent(P=0.0337) and tenacity(P=0.0271) as well as inflammation(P<0.0001) on Day 3 when medical chitosan was applied. Prior to Day 14, fibrosis was less obvious in the medical chitosan group(P<0.0005). The tenacity scores were significantly lower in the medical chitosan group following Day 14(P<0.05), while the type scores were lower in the medical chitosan group following Day 28(P<0.03). Thus, medical chitosan decreased both the gross and the histopathological scores of the induced adhesions.

Increased risk of postsurgical macular edema in high stage idiopathic epiretinal membranes

Purpose:To assess the rate of occurrence and the risk factors of postsurgical macular edema(PSME)in eyes with idiopathic epiretinal membrane(iERM)or full-thickness macular hole(FTMH).Methods:Retrospective longitudinal analysis of all subjects scheduled for vitrectomy with or without combined cataract surgery over a 6-month period.Electronic medical charts and imaging data were analyzed preoperatively and at 1,3 and 6 months after surgery.Results:From 101 patients diagnosed with iERM or FTMH,71 patients were eligible for the study.Forty-nine eyes with iERM(69.0%)and 22 eyes with FTMH(31.0%)underwent vitrectomy either isolated(31.0%)or combined with cataract extraction(69.0%).The overall rate of PSME was 26.7%,without differences between the two groups(P=0.9479).Combined cataract extraction did not affect the overall occurrence of PSME rate in both groups(P=0.9255 in FTMH and P=0.8658 in iERM).If grouped by stage,eyes with stage 4 iERM though disclosed an increased rate of PSME(57.1%)compared to lower(1 to 3)stages(14.3%,P=0.0021),particularly when combined with cataract surgery(71.4%vs.15.4%in stages≤3,P=0.0021).The PSME odds ratio for a stage 4 iERM is 8(95%CI:1.933-33.1;P=0.0041)compared to stages 3 and below.Conclusions:PSME remains a clinically relevant and frequent event after surgery for iERM and FTMH.Patients with stage 4 iERM have an 8-fold higher likelihood of developing PSME in a 6-month postsurgical period compared to iERM in 1-3 stages,especially when combined with cataract extraction.

Risk factors of gastroparesis syndrome after abdominal nongastroduodenal operation and its prevention

Objective:To investigate risk factors of gastroparesis syndrome(PGS) after abdominal nongastroduodenal operation and its prevention.Methods:Clinical data of 22 patients with PGS after abdominal non-gastroduodenal operation was analyzed retrospectively,and compared with the patients of non-PGS after abdominal non-gastroduodenal operation during the same time.The possible influencing factors of PCS were analyzed by single factor analysis and logistic regression analysis.Results:All t3 selected factors related with PGS,including age,disease category (benign and malignant),operation time,intraoperative blood loss,postoperative analgesic pump, postoperative enteral nutrition time,postoperative parenteral nutrition time,perioperative blood glucose level,perioperative nutrition status(anaemia or lower proleinemia),pylorus obstruction before surgery,intra-abdominal infection after surgery,and spiritual factor were related with PGS.The statistical analysis showed that the difference was statistical significant(P【0.05),and gender had no correlation with PCS(P】0.05);non-conditional multivariate analysis showed that malignant tumor,perioperative nutrition status,pylorus obstruction,operation time,blood loss, intra-abdominal infection after surgery,and mental factor were significant related with PGS as dependent variable and related risk factors in single factor analysis as independent variables (P 【0.05).Conclusions:PGS is a result of multiple factors,and among these factors,malignant tumor,poor nutrition status,pylorus obstruction before surgery,longer operation—time,more blood loss,intra-abdominal infection after surgery,and mental factor are major risk factors of PGS.

Perioperative management of the patient with rheumatoid arthritis

A multidisciplinary approach is required to care for patients with rheumatoid arthritis(RA)in the perioperative period.In preparation for surgery,patients must have a cardiovascular risk assessment performed due to the high risk of heart disease in patients with RA.Treatment of RA is with immunomodulatory medications,which present unique challenges for the perioperative period.Currently,there is no consensus on how to manage disease modifying antirheumatic drug(DMARD)therapy in the perioperative setting.Much of the data to guide therapy is based on retrospective cohort data.Choices regarding DMARDs require an individualized approach with collaboration between surgeons and rheumatologists.Consensus regarding biologic therapy is to hold the therapy in the perioperative period with the length of time dictated by the half-life of the medication.Special attention is required at the time of surgery for potential need for stress dose steroids.Further,there must be close communication with anesthesiologists in terms of airway management particularly in light of the risk for cervical spine disease.There are no consensus guidelines regarding the requirement for cervical spine radiographs prior to surgery.However,history and exam alone cannot be relied upon toidentify cervical spine disease.Patients with RA who undergo joint replacement arthroplasty are at higher risk for infection and dislocation compared to patients with osteoarthritis,necessitating particular vigilance in postoperative follow up.This review summarizes available evidence regarding perioperative management of patients with RA.

Persistent post-surgical pain and neuropathic pain after total knee replacement

AIM: To study the prevalence of persistent post-surgical pain(PPSP) and neuropathic pain(NP) after total knee replacement(TKR).METHODS: MEDLINE and Embase databases were searched for articles published until December 2014 in English language. Published articles were included if they referred to pain that lasts at least 3 mo after primary TKR for knee osteoarthritis, and measured pain with pain specific instruments. Studies that referred to pain caused by septic reasons and implant malalignment were excluded. Both prospective and retrospective studies were included and only 14 studies that match the inclusion criteria were selected for this review.RESULTS: The included studies were characterized by the heterogeneity on the scales used to measure pain and pre-operative factors related to PPSP and NP. The reported prevalence of PPSP and NP seems to be relatively high, but it varies among different studies. There is also evidence that the prevalence of post-surgical pain is related to the scale used for pain measurement. The prevalence of PPSP is ranging at 6 mo from 16% to 39% and at 12 mo from 13.1% to 23% and even 38% of the patients. The prevalence of NP at 6 mo post-operatively is ranging from 5.2% to13%. Pre-operative factors related to the development of PPSP also differ, including emotional functioning, such as depression and pain catastrophizing, number of comorbidities, pain problems elsewhere and operations in knees with early grade of osteoarthritis.CONCLUSION: No firm conclusions can be reached regarding the prevalence of PPSP and NP and the related factors due to the heterogeneity of the studies.

Persistent Post-Surgical Pain after Total Knee Arthroplasty at a Tertiary Care Hospital of a Low-Middle Income Country

Background: Persistent post-surgical pain (PPSP) is pain that lasts for 3 months or more after a surgical intervention, where other causes of pain have been excluded. There is scarce knowledge about the prevalence of PPSP in low- and middle-income countries (LMICs). The aim of our study was to assess the prevalence of PPSP after total knee arthroplasty (TKA) at our university hospital and explore factors associated with it. Methods: It was a prospective cross-sectional study. Approval was obtained from the Ethics Review Committee. Patients undergoing elective unilateral total knee arthroplasty under general or regional anaesthesia were recruited over a six months period. A designated pain nurse called the patients three months after surgery and asked about the presence of pain, its location, type, degree and associated factors. Patients who reported pain at three months were called a year after the surgery and the same questions were asked. Results: Eighty-two patients had TKA during the study period. At the time of discharge, 57 (69.5%) patients were satisfied with their postoperative pain management. Three months after the surgery, 13 (15.8%) patients reported pain. Pain was mild in 11 and moderate in two patients. At one-year follow-up, three patients (3.6%) reported pain that was mild to moderate in intensity. Pain disturbed sleep in all three patients and disturbed daily life routines in one patient. No significant difference was found in any of the variables when compared with patients who did not report pain at three months. Conclusions: Although PPSP is a recognized adverse outcome after TKA, little is known about its prevalence in LMICs. In our patient population, 15.8% reported pain three months after TKA, while at one year, 3.6% of patients reported mild to moderate pain. Multicenter studies are recommended for determining the overall prevalence in our patient population and for getting directions for making targeted efforts towards its prevention and treatment.

Fatal fulminant herpes simplex hepatitis following surgery in an adult

We present a case of a healthy 72-year-old man with herpes simplex hepatitis (HSVH) development soon after ordinary surgery for biliary stones. A sudden onset of hepatitis associated with high fever and leukopenia emerged on postoperative day 5, followed by a rapid and lethal course (died on day 9), despite an acyclovir therapy on day 8. Postmortem liver biopsy revealed positive immunostaining for herpes simplex virus(HSV) type-1. The serum tests(available after the death) were negative for anti-HSV immunogloblulins, but positive for HSV DNA. A review of 15 cases of postsurgical HSVH along with 42 cases of non-surgical HSH showed that (1): A wide spectrum of surgical procedures was involved; and (2): High mortality (87%) associated with lower rates of ante-mortem diagnosis (20%) and acyclovir treatment (20%). Due to the difficulty in diagnosis and lethal nature, an early clinical suspension and prompt empirical anti-viral intervention are imperative for postsurgical hepatitis with undetermined etiology, characterized by fever and leucopenia.

Multiple Calcifying Epitheliomas of Malherbe’s of Axilla: A Case Report of Rare Variety

Pilomatrixoma, a rare benign tumour of sebaceous gland is commonly known as calcifying epithelioma of Malherbe or Tricholemmal cyst. We came across even the rarest form of this benign tumour of skin. Our case report was interestingly detected at a higher age group, unusual site of the body, multiple in nature following postoperative incision drainage of abscess in left axilla.

Clinical Analysis of 1593 Patients with Infectious Endophthalmitis： A 12-Year Study at a Tertiary Referral Center in Western China

Background： Infectious endophthalmitis is a severe ocular inflammation which can cause devastating visual loss. The aim of the study was to identify the demographic and clinical features of infectious endophthahnitis in Western China for better prophylaxis and treatment of this disease. Methods： A retrospective, cross-sectional study was conducted based on the medical records of inpatients having infectious endophthahnitis in a tertiary referral center in Western China between 2005 and 2016. Results： The common cause of infectious endophthahnitis was trauma （82.6%）, endogenous （7.8%）, ophthalmic surgery （6.9%）, and corneal ulcer with perforation （2.7%）. These four etiological groups differed in age, gender, enucleation rate, visual outcome, etc. The number of cases in the first 6 years accounted for 38.7% of the total collection, which in the second 6 years accounted for 61.3%. The etiology patterns were different between these two periods. Altogether 51.3% of patients received pars plana vitrectomy, 13.9% of patients underwent evisceration, and the remaining 34.8% received other treatments. Of the 670 cases that had culture results, 266 （39.7%） were culture positive and 177 （66.5%） were Gram-positive organisms, 64 （24.1%） were Gram-negative organisms, 11 （4.1%） had fungal infection, and 14 （5.3%） were infected by multiple pathogens. Conclusions： There was an upward trend of the occurrence of infectious endophthalmitis in Western China for the past decade. The demographic and clinical characteristics of infectious endophthahnitis in Western China had its own characteristics and differed from those of developed cotintries. Here, open globe trauma was the most common cause ofendophthalmitis, most traumatic endophthalmitis patients were male, and most of the injuries were work related, implicate that we should strengthen the education and application of ocular safety regulation specifically targeting the workplace.