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Neurological paraneoplastic syndrome is a relatively rare condition in patients with malignant tumors. Recently, it has been reported that anti-Aquaporin 4 (AQP4) antibody is highly specific for neuromyelitis optica. The patient was a 76-year-old man. He underwent right upper lobectomy for squamous cell carcinoma of the lung. Although the immediate postoperative course was uneventful, neurological symptoms became apparent from postoperative day (POD) 4. Magnetic resonance imaging showed longitudinally extended edematous lesions in the spinal cord, and a cerebrospinal fluid examination was positive for anti-AQP4 antibody, leading to the diagnosis of paraneoplastic neuromyelitis optica. Despite multiple rounds of steroid pulse therapy and plasma exchange, the neurological symptoms worsened and the patient died on POD 46. The development of neuromyelitis optica in the early postoperative period could be related to the influence of surgical stress or epidural anesthesia.

Background Most surgeons are unaware that idiopathic neuropathy, which occurs independently of mechanical injury, can present as postoperative peripheral neuropathy. The aim of this study was to reveal the presence of postoperative neuropathy considered to be induced by surgical stress and to make surgeons aware that idiopathic neuropathy can occur postoperatively. Methods We conducted a survey among orthopedic surgeons regarding patients with postoperative neuropathies of unknown cause. For each case, the type of neuropathy, preceding surgery and anesthesia, patient background, clinical findings, and clinical course were investigated. Results Seven patients were identified. The mean time from surgery to the onset of neuropathy was 9.3 days (range 1–15 days). Five of the patients fully recovered spontaneously within 1 year, while the remaining two underwent neurolysis. One patient presented with hourglass-like constrictions in the radial nerve. No inflammatory cells were found in the epineurium of the affected nerve. Conclusions Although it is rare, postoperative idiopathic neuropathy occurs in clinical practice, and it is crucial that surgeons recognize the existence of this neuropathy to elucidate its pathogenesis as well as to reduce the risk of litigation.

The gold standard treatment of end-stage liver disease continues to be liver transplantation (LT). The challenges of LT require skilled anesthesiologists to anticipate physiologic changes associated with end-stage liver disease and surgical considerations that affect multiple organ systems. While on the waiting list, patients may be placed on new anticoagulation medications that can confound already complex coagulopathy in LT patients. Pain management often is an afterthought for such a complex procedure, but appropriate medications can help control pain while limiting opioid medications. Surgical stress and medications for immunosuppression can affect perioperative glucose management in ways that have implications for patient and graft survival. The coronavirus disease 2019 pandemic in 2020 provided a new challenge for anesthesiologists. The uncertainty of the novel respiratory virus challenged providers beyond just LT patients.

Purpose of the research was to analyze the various options of postoperative analgesia in terms of their influence on the symptoms of surgical stress response in order to optimize the method of analgesia. Patients (n = 105) were divided into three groups depending on the method of postoperative analgesia. We have monitored the performance of the heart rate variability, the level of daily urine cortisol, as well as changes in the level of blood glucose. The study showed the activation of the regions of the autonomic nervous system in the control group was not significant. In group II, autonomic dysfunction with an increased tone of parasympathetic area has been detected. The use of TAP-block has been characterized by the activation of the regions of the autonomic nervous system. Postoperative hyperglycemia was observed in all groups. The highest rates were in the control group, in group II and III glucose level was lower. Indicators of urine cortisol excretion in the control group were 3 times higher than normal ones. In group II and III — 2.1 and 2.2 times higher, respectively. Increased excretion of daily cortisol indicates the presence of surgical stress in the postoperative period. The use of TAP-block in the postoperative period is characterized by the preservation of adaptive-compensatory reactions in response to surgical intervention, which has an obvious advantage over other methods of postoperative analgesia.

Метою даної роботи була оцінка впливу мінімально інвазивної J-подібної стернотомії і поздовжньої серединної стернотомії (ПСС) на ступінь вираженості операційного стресу і системної запальної реакції при протезуванні аортального клапана (ПАК). На підставі обстеження 44 пацієнтів із застосуванням мінімально інвазивного доступу (МІД) і 54 пацієнтів із застосуванням ПСС було показано, що у разі застосування МІД спостерігається менш виражена системна запальна реакція організму, що підтверджується більш низькими концентраціями в плазмі ключових прозапальних цитокінів (фактора некрозу пухлини альфа — у середньому на 5,8 пг/мл (в 1,6 раза), інтерлейкіну-6 — у середньому на 5,3 пг/мл (у 2,3 раза)) та деяких протеїнів гострої фази запалення (С-реактивного протеїну — у середньому на 23,5 мг/л (в 1,8 раза) та концентрації фібриногену — у середньому на 1,3 г/л (в 1,3 раза)). До того ж під час роботи було визначено, що застосування мінімально інвазивного доступу для виконання ПАК порівняно з традиційною поздовжньою серединною стернотомією супроводжується менш вираженою стрес-індукованою перебудовою гормонального гомеостазу, що також об’єктивно підтверджує перевагу мінімально інвазивного доступу над поздовжньою серединною стернотомією.

Background/Aim. Surgical stress itself, as well as hypothermia induced by general anesthesia and low ambient temperature, activates stress hormone response with changes in catecholamines and counter-regulatory hormones. The aim of this study was to investigate the acute hormone stress response in patients who underwent major surgical procedures and the efficiency of external and internal warming methods in alleviating these changes. Methods. The study included a total of 60 patients who underwent major open abdominal surgical procedures and were randomly divided into 4 groups: control non-warmed (C), externally warmed using forced-air warming mattress (W), internally warmed using intravenous amino acids (A), and warmed with a combination of external and internal method (A+W). Esophageal temperature was used as a measure of core temperature. Concentrations of epinephrine, norepinephrine, cortisol, prolactin, and testosterone were measured. Blood samples for hormone measurement were obtained at two time points for catecholamines ? 90 min before and 120 min after finishing the surgery, and at additional two-time points for cortisol, prolactin, and testosterone (24 and 48 hrs after surgery). Results. In the W and A+W groups, the temperatures did not significantly differ between time points but constantly decreased in the C and A groups, with a statistically significant difference between the anesthesia induction and the 120th min (35.61 ? 042 vs. 33.86 ? 0.71?C; p < 0.000 and 35.81 ? 0.54 vs. 34.45 ? 0.41?C; p < 0.000, respectively). Catecholamine concentrations in all groups showed a significant increase during surgery, with the highest values recorded in the non-warmed group (777.07 ? 800.08 after vs. 106.13 ? 89.63 pg/mL before surgery for epinephrine and 1,349.67 ? 984.16 vs. 580.53 ? 465.38 for norepinephrine, p < 0.000). Concentrations of cortisol and prolactin also showed a significant increase at the same time point, with a tendency to normalize after 48 hrs. On the contrary, testosterone concentrations showed a decrease after 120 min without normalization throughout the entire period of observation. Except for testosterone, changes in all stress hormones were attenuated in warmed groups compared to controls. Conclusions. Regarding both features of surgical stress investigated in this study (hypothermia and stress hormone response), the combination of endogenous amino acid-induced thermogenesis and external air warming mattress is most effective in its prevention.

Background: Surgical stress and pain result in activation of hypothalamus-pituitary-adrenal axis. The aim of this study was to establish the effects of postoperative pain and various modalities of analgesic administration on salivary and serum cortisol levels, as well as to establish the validity of salivary cortisol as a stress indicator in surgical patients. Methods: A randomized controlled trial involved 60 patients scheduled for elective abdominal aortic aneurysm surgery. Patients were randomly divided into two groups depending on the model of postoperative analgesia. The first group (MI – morphine intermittently) included patients given morphine doses 0.1 mg/kg/6h s.c. intermittently. The second group (MPCA – morphine patient-controlled analgesia) included patients who received morphine via the PCA system – intravenous administration of morphine adjusted to a dose of 1 mg per shot and a lockout interval of 6 minutes. Results: The intensity of pain did not significantly vary until the hour 10 post-surgery. However, in the period from hour 10 to hour 18 post-surgery, higher intensity of pain was reported in group MPCA (P < 0.05). Hemodynamic instability was more prevalent in the MI group (40.0% vs 6.7%, P = 0.0048). Serum cortisol levels were almost identical in both groups (MI 509.4 nmol/L vs MPCA 511.0 nmol/L, P = 0.1473). Higher values of salivary cortisol were recorded in group MPCA; however, the difference was not statistically significant (47.1 nmol/L vs 116.3 nmol/L, P = 0.0970). Conclusion: Our study confirmed that salivary cortisol is a more sensitive stress biomarker in surgical patients as compared to blood cortisol. Uvod: Hirur{ki stres i bol su uzrok aktivacije hipotalamus- no-hipofizno-nadbubre`ne osovine. Cilj ove studije bio je da se utvrdi uticaj postoperativnog bola i razli~itih vidova administracije analgetika na vrednosti kortizola u serumu i salivi, kao i da se utvrdi da li je salivarni kortizol dobar poka- zatelj stresa kod hirur{kih pacijenata. Metode: Randomizovana kontrolisana studija koja je uklju- ~ila 60 pacijenata primljenih za elektivnu operaciju ane- urizme abdominalne aorte. Pacijenti su metodom slu~ajnog izbora podeljeni u dve grupe u zavisnosti od modela post- operativne analgezije. Prvu grupu (MI – intermitentna pri- mena morfina) su ~inili pacijenti koji su dobijali morfin intermitentno u dozi od 0.1 mg/kg/6h s.c. U drugoj grupi (MPCA – analgezija morfinom kontrolisana od strane paci- jenta) su bili pacijenti koji su dobijali morfin takozvanom PCA metodom – intravenska primena morfina 1 pritisak/1 mg, interval 6 minuta. Rezultati: Intenzitet bola se nije zna~ajno razlikovao do desetog sata nakon operacije. Me|utim, u periodu od de- setog do osamnaestog sata nakon operacije bol je bio izra`eniji u MPCA grupi (P < 0.05). Hemodinamska nesta- bilnost je bila zastupljenija u grupi MI (40.0% vs 6.7%, P = 0.0048). Serumski kortizol bio je gotovo identi~an po gru- pama (MI 509.4 nmol/L vs MPCA 511.0 nmol/L, P = 0.1473). Salivarni kortizol je bio vi{i u grupi MPCA ali razika nije statisti~ki zna~ajna (47.1 nmol/L vs 116.3 nmol/L, P = 0.0970). Zaklju~ak: Na{a studija je pokazala da je salivarni kortizol senzitivniji biomarker stresa kod hirur{kih pacijenata u odnosu na serumski kortizol.

Background The Enhanced Recovery Program after surgery is a multimodal, evidence-based protocol of care developed to minimize the response to surgical stress. Data on the influence of ERP on outcomes, particularly according to the complexity of liver surgery, are lacking. Methods A prospective multicenter cohort of patients undergoing liver surgery and exposed to Enhanced Recovery Program from 2016 to 2020 in France was analyzed. High Enhanced Recovery Program compliance was defined as more than 70% of items (15 out of 21). The outcomes were the rate of complications, length of stay, and functional recovery according to Enhanced Recovery Program compliance. Results A total of 297 patients were included in the study, and they had 61.9% overall compliance (median = 13 items, interquartile range 11–15). Complications were observed in 32.2% (n = 95) of cases, and the mean length of hospital stay was 7.28 (±7.15) days overall. A longer duration of liver surgery was associated with an increase in the complication rate, while high compliance was independently associated with a reduced risk of complications in the multivariable analysis. Conclusion High Enhanced Recovery Program compliance was associated with a lower rate of postoperative complications.

Objective To improve lateral thyroarytenoid (TA) muscle atrophy after laryngeal paralysis, reconstruction of the vascular network of the atrophied muscle is necessary. We therefore evaluated whether the controlled release of basic fibroblast growth factor (bFGF) with autologous fascia implantation could affect vascular reconstruction in the lateral TA muscle. Study design Animal experiment. Setting Laboratory. Methods Unilateral laryngeal paralysis was induced in 20 rats. The rats were implanted with autologous fascia and a gelatin hydrogel sheet with or without 1 µg of bFGF (fascia and bFGF + fascia groups; n = 5 each) and with only a gelatin hydrogel sheet with bFGF (bFGF group: n = 5). Another group remained untreated (n = 5) at 4 months after paralysis. At 3 months since transplantation, intra- and intergroup comparisons of the muscle volumes and total area of blood vessels in the lateral TA muscle were performed. Results When compared with the untreated group, the bFGF + fascia group showed a significant increase in muscle volume (P =.0008) and vascular area (P =.0002) in the lateral TA muscle, whereas the other 2 treated groups demonstrated an insufficient effect. Conclusion bFGF + fascia implantation showed histologic improvement in severe laryngeal paralysis. We demonstrated that the decrease in lateral TA muscle mass after paralysis might be countered by the reconstruction of the vascular network. Our findings indicate that hypovascular and denervated areas of the laryngeal muscle can be regenerated by the implantation of growth factors and scaffolds with surgical stress. Level of evidence 5.

BACKGROUND: Endoscopic rhinosinus surgery in children is associated with a high anesthetic risk because of intraoperative stress. This study aimed to, considering the dynamic picture of the biochemical markers of surgical stress, to assess the effectiveness of regional methods of combined anesthesia in rhinosinus surgery in children. MATERIALS AND METHODS: A comparative study was conducted in parallel groups composed of 100 patients aged 617 years who had undergone an assessment of their physical condition using the ASA I-II scales and planned endoscopic endonasal surgery lasting up to 2 h under combined anesthesia. In all groups, the introductory anesthesia was combined, i.e., inhalation of sevoflurane in an oxygenair mixture in combination with intravenous administration of propofol. To ensure the patency of the respiratory tract, endotracheal anesthesia was administered. Patients were divided into two groups of 50 people each, depending on the method of maintaining anesthesia. Group 1 received inhalation of sevoflurane in an airoxygen mixture with a target value of the minimum alveolar concentration of (MAC) 0.70.9, and regional blockage was performed bilaterally, i.e., pterygopalatine anesthesia with palatine access (palatinal) and infra-orbital intraoral access with ropivacaine solution. Group 2 received inhalation of sevoflurane in an airoxygen mixture with a target value of 1.5 МАС, and 5% tramadol solution was used intravenously for analgesia. RESULTS: Data on the dynamics of glucose, lactate, and cortisol levels in both groups proved the effectiveness and stability of the anesthesia methods used. However, the concentration of the inhaled anesthetic agent in the tramadol group was used was twice as high as the concentration in the regional anesthetic group. DISCUSSION: The dynamics and deviations of biochemical markers of surgical stress were not significantly different in the intergroup and intragroup interstage parameters beyond the reference values. CONCLUSIONS: The proposed anesthesia methods did not induce stress reactions to surgical intervention, and the anesthesia methods in both groups were adequate and effective.

Liver cancer is one of the most common malignant tumors. Partial hepatectomy is the most basic and effective treatment for hepatocellular carcinoma because of its high operative effect and perioperative safety. Open surgery is the most traditional hepatectomy. Although it can completely remove tumor lesions and prolong patient survival, it has disadvantages such as large trauma and long postoperative recovery time. Meanwhile, long-term bed rest can increase the risk of complications such as venous thrombosis and infection. The advantages of laparoscopic partial hepatectomy, such as clear operative field, simple operation, little trauma, light surgical stress, quick postoperative recovery, and low complications, can avoid damage to vital organs, blood vessels, and nerves, which has been widely accepted and recognized in clinical practice.

Surgical stress response, fluid and nutritional balance, and pain management are among the key factors influencing on the postoperative period. These areas are reflected in the Enhanced Recovery After Surgery (ERAS) concept, which is based on a set of measures aimed at minimizing the surgical stress response. The lack of ERAS recommendations for the pediatric population of surgical patients prompts to search for a solution of adaptation and implementation of the ERAS programs in children. The aim of the study. To determine the effectiveness of the complex application of the enhanced recovery after surgery by studying its influence on the factors of the surgical stress response in pediatric patients undergoing limp surgery. Materials and methods. The prospective randomized study included 47 patients aged 1 to 17 years. In the study group (n = 22), the ERAS program was used, which consisted of 14 components of preoperative, intraoperative and postoperative measures. In the control group (n = 25), the complex of all ERAS components was not purposefully applied. We compared glycaemic stress index (GSI) and length of hospital stay after surgery (LOS) as a primary outcome; secondary outcomes were fasting time after drinking fluids before induction of anesthesia, estimated fluid deficiency just before induction of anesthesia, hemodynamic parameters, the need for opioids during and after surgery, blood glucose and beta-hydroxybutyrate in the beginning and in the end of the surgery and next day morning after surgery, postoperative nausea and vomiting. Results. GSI was significantly less in the study group (1,62 ± 0,78 vs 2,12 ± 0,93, р=0,046). LOS in the study group was 37.5% less than in the control group (p = 0.002). The period of preoperative fasting and fluid deficit in the patients of the study group were shorter. The needs of fentanyl intraoperatively in the study group was 47% less (p

To investigate the acute phase response to surgical stress in patients with rheumatoid arthritis (RA) treated with tofacitinib, a Janus kinase (JAK) inhibitor.A retrospective matched pair analysis of 34 patients treated with tofacitinib and 34 patients treated with conventional disease-modifying anti-rheumatic drugs (csDMARDs) was performed. Patients were matched for age, sex, and type of surgery; body temperature, C-reactive protein (CRP) level, and white blood cell (WBC) count, neutrophil count, and lymphocyte count were compared between the tofacitinib and csDMARDs groups within 2 weeks after orthopedic surgery. Postoperative complications within 90 days were also assessed.No surgical site infection or delayed wound healing was observed in the tofacitinib group; whereas, one case of superficial infection was noted in the csDMARDs group. A similar postoperative increase in body temperature and CRP level was observed in both the groups. Postoperatively, the tofacitinib group showed an increase in WBC and neutrophils counts and a decrease in lymphocyte count, unlike the csDMARDs group. In contrast to two patients (2.6%) in the csDMARDs group, seven patients (20.6%) in the tofacitinib group had lymphocyte counts below 500 cells/μL within 2 weeks postoperatively.Tofacitinib did not suppress postoperative increase in body temperature and CRP level. Because of the postoperative decrease in lymphocyte count in patients treated with tofacitinib, the timing for resuming tofacitinib treatment after surgery should be carefully considered. Key Points • This study is the first to report the complications and systemic inflammatory responses after orthopedic surgery in patients treated with tofacitinib in comparison with matched pairs treated with conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs) • While tofacitinib does not suppress postoperative increase in body temperature and CRP level, the postoperative decrease in lymphocyte count in patients treated with tofacitinib is significant compared with patients treated with csDMARDs • Attention should be paid to a reduced lymphocyte count when to resume tofacitinib after surgery.

Partial hepatectomy under general anesthesia is prone to hemodynamic alterations, and stress reactions are the main contributing factors to postoperative cognitive function in elderly partial hepatectomy patients. Postoperative cognitive dysfunction increases the incidence of postoperative complications and long-term morbidity and mortality in elderly patients. With the increasing trend of aging population and the gradual increase of elderly people undergoing surgical treatment, it is especially important to study the corresponding prevention and treatment measures. In this study, a total of 90 patients with primary liver cancer who received hepatectomy in our hospital from July 2020 to July 2021 were included as the research subject. The changes in hemorheology, stress-related indexes, cognitive function, postoperative pain, and gastrointestinal function were compared between the two groups The results showed that SGB combined with general anesthesia can effectively reduce hemodynamic fluctuations in elderly partial hepatectomy patients, alleviate surgical stress, promote postoperative recovery of cognitive function and gastrointestinal function with high safety, and is worthy of clinical promotion.

The aim of the study was to evaluate the effectiveness of the use of photobiomodulation therapy (PBMT) to minimize acute pain in the early postoperative period in patients after septoplasty. In total, 62 patients underwent septoplasty under general anesthesia (40 men and 22 women, 18–44 years old) followed by nasal tamponade. Patients of the 1st group did not undergo PBMT, and patients of the 2nd group received PBMT 3, 6, and 24 h after septoplasty (infrared pulsed laser radiation, λ = 0.890 μm, P = 10 W, 2 min in the projection of the wings of the nose). After 48 h, after the removal of tampons, intranasal PBMT with a nozzle in the red range, with λ = 0.63 μm, P = 8 mW, 2 min. ULF, HF, LF, and total power of heart rate variability (HRV), pain syndrome was assessed. ULF, LF, HF, total HRV power were significantly lower in group 2, compared to group 1. In the period from 6 to 24 h after septoplasty, patients of group 1 experienced higher pain than patients with PBMT (p < 0.001). The use of PBMT after septoplasty against the background of nasal tamponade helps to reduce the severity of pain syndrome and the inflammatory response to surgical stress and, consequently, leads to less pronounced changes in the autonomic nervous system in response to surgical stress.

Enhanced Recovery After Surgery (ERAS) is a paradigm shift in perioperative care and incorporates patient-centered, evidence-based, and multidisciplinary team-developed pathways for a surgical specialty. ERAS pathways aim to reduce the patient's surgical stress response, optimize their physiologic function, facilitate recovery, and reduce the length of stay. The bariatric program at our institution was previously managed by many surgeons with anecdotal preferences, resulting in increased costs, lengths of stay, and opioid prescribing.To describe a standardized ERAS pathway for patients undergoing a laparoscopic sleeve gastrectomy procedure in order to enhance perioperative care and reduce opioid usage.ERAS bariatric program in New Jersey.The ERAS bariatric program at our institution was implemented in January 2018. All patients who underwent sleeve gastrectomy from January 2016 to November 2017 (preimplementation) as well as from February 2018 to October 2020 (postimplementation) were included in this retrospective study, with those undergoing procedures in December 2017 and January 2018 excluded due to the transition to the ERAS protocol. Differences in lengths of stay, direct costs, and 30-day readmission rates were compared between the pre- and postimplementation periods. The primary goal of our ERAS pathway was to optimize patient care with reduced opioid usage, and the secondary goal was to reduce the costs for care.A total of 1988 patients who underwent sleeve gastrectomy were identified, with 789 patients in the preimplementation group and 1199 patients in the postimplementation group. In a multivariate analysis, the mean length of a hospital stay in the postimplementation period was 18% lower (95% confidence interval [CI], 14-22) than that of the preimplementation period (P.001), while the average opioid morphine milligram equivalents administered in the postoperative period was 61% (95% CI, 57%-65%) less than that of the preimplementation period (P.001). Average direct costs decreased by $155 (95% CI, -$358 to $48) per case in the postimplementation period (P = .133), and there was no significant difference in the 30-day readmission rate between the pre- and postimplementation periods (3.8% versus 3.0%, respectively; odds ratio, .81; 95% CI, .49-1.35; P = .413).In this study, patient outcomes after ERAS pathway implementation were significantly better than in historical cases. Implementing the bariatric ERAS program for laparoscopic sleeve gastrectomy at our institution has led to rapid postoperative recovery of patients, shorter lengths of stay, reduced opioid usage, and decreased costs per case, thereby increasing the overall cost savings to the hospital. ERAS pathways in bariatric surgery represent an opportunity to enhance patient care while decreasing overall costs. We propose that cost-effective, tailor-made ERAS pathways for sleeve gastrectomy should be implemented in all designated centers of excellence, as they can have a great economic impact on the healthcare system.

Background: Estimation of percentage of change of blood glucose concentration (BGC) at 30- and 60-min after single dose of intravenous midazolam injection and at end of surgery in relation to pre-injection concentration. Aim of Study: Estimation of percentage of changes of blood glucose concentration (BGC) at 30- and 60-min after intravenous injection of single dose of midazolam and at end of surgery in relation to pre-injection BGC. Patients and Methods: 100 type-2 diabetic patients with fasting BGC of ³200mg/dl, ASA grade II or III and assigned for cataract surgery were evaluated clinically and received midazolam injection in a dose of 0. 0 1-0. 1 mg/kg, up to a total dose of 2.5mg, over two minutes or until patient was sedated and achieved Ramsy score 2 or 3. BGC was estimated before midazolam injection and at 30-min, 60-min after injection and at end of surgery. Then, patients received peribulbar and subtenon local anesthetic infiltration was performed. Results: All surgeries were conducted uneventfully within a mean operative time of 62.6±8.8 min. BGC showed progres-sive increases during surgery reaching a maximum at 60-min after injection and declined at end of surgery, but with non-significant differences between the three estimations and the pre-injection levels. Median value of percentage of increase of BGC at 60-min was significantly higher in comparison to median values of other estimations, with significantly higher percentage of increase at end of surgery than at 30-min after injection. Conclusion: Preemptive administration of midazolam for diabetic patients could control the surgery-induced hypergly-cemic effect and thus could protect patients against postoper-ative hyperglycemic complications.

INTRODUCTION The aim of study was to assess the impact of an enhanced recovery after surgery (ERAS) protocol and minimally invasive approaches on short-term outcomes in rectal surgery. PATIENTS AND METHODS A consecutive series of patients that underwent open or minimally invasive rectal resections in a single institution between January 2015 and April 2020 were included in the study. An ERAS program was introduced in April 2016. The study cohort was divided into three groups: open surgery without ERAS, open surgery with ERAS, and minimally invasive surgery with ERAS. Outcome measures compared were recovery parameters, surgical stress parameters, 30-day morbidity and mortality, oncological radicality and length of hospital stay. RESULTS A total of 202 patients were included: 43 in the open non-ERAS group, 92 in the open ERAS group and 67 in the minimally invasive ERAS group. All recovery parameters apart from postoperative nausea and vomiting were significantly improved in both ERAS groups. Surgical stress parameters, prolonged postoperative ileus, and hospital stay were significantly reduced in the minimally invasive ERAS group. The overall 30-day morbidity and mortality and oncological radicality did not significantly differ among the three groups. CONCLUSIONS Minimally invasive approaches and enhanced recovery care in rectal surgery improve short-term outcomes. Their combination leads to an improvement in recovery parameters and a reduction of prolonged postoperative ileus and hospital stay.

BACKGROUND Patients with adrenal insufficiency are at risk of adrenal crisis, a potentially life-threatening emergency in the peri-operative period due to their attenuated ability to mount a cortisol response. There is a lack of standardization regarding peri-operative stress-dose glucocorticoids in paediatric clinical practice with the absence of agreed protocols. For the individual patient, the risk of adrenal crisis must be weighed against the potential adverse clinical outcomes associated with unnecessary or supra-physiologic glucocorticoid dosing in susceptible patients. Specific clinical concerns in the paediatric population include osteopenia, growth restriction and increased risk of cardiovascular disease in adulthood. This review aimed to identify and evaluate available literature in the field of peri-operative stress-dose glucocorticoids. METHODS A comprehensive literature search was conducted to construct a narrative review. RESULTS The outcome of this review identified that paediatric patients, unlike adults, do not show a graded response to surgical stress with implications for glucocorticoid stress dose regimens for general anaesthesia and less invasive surgical procedures. The studies highlight a lack of information on physiological steroid responses to stress situations and differences in the approach to glucocorticoid replacement strategies in the paediatric population. CONCLUSION The review identified there is a lack of high-quality paediatric-specific studies evaluating appropriate stress-dose glucocorticoid regimens in paediatric patients with or at risk of adrenal insufficiency. Further research is needed to establish clear evidence-based clinical guidelines for paediatric peri-operative practice regarding steroid stress dosing in adrenal insufficiency. Current knowledge would suggest that a balanced view of risks and benefits should be taken appropriate to the clinical context, to dictate peri-operative stress-dose glucocorticoids use that permits safe perioperative management.

Objectives Systemic inflammatory response is strongly associated with poor oncological outcome in colorectal cancer (CRC). Perioperative inflammation caused by surgical stress can lead to the development of postoperative infectious complications (PIC) as well as cancer-related inflammation. We aimed to evaluate the prognostic potential of perioperative systemic inflammation by calculating the time-dependent cumulative C-reactive protein (CRP) levels during the perioperative period. Methods We analyzed clinicopathological data from 540 patients with CRC who underwent potentially curative surgery at our institution. The time-dependent aggregated CRP level was denoted "cumulative CRP," which represents the area under the line of time (days) and the CRP levels preoperatively and on postoperative days 1, 3, and 7. Results Cumulative CRP was significantly higher in patients with CRC undergoing open surgery than in patients undergoing laparoscopic surgery. In multivariate analysis, high cumulative CRP was an independent prognostic factor for disease-free survival (DFS) and overall survival (OS) in both the laparoscopic and open surgery groups. Patients with CRC and high cumulative CRP had significantly poorer DFS and OS than those with low cumulative CRP, including those patients without PIC. Conclusions Cumulative CRP is an independent predictive marker of OS and DFS in patients with CRC who undergo curative surgery.

BACKGROUND: To date, surgical interventions continue to be accompanied by a high proportion of complications and even death. In half of the cases, mortality and serious postoperative complications could have been prevented. After a comprehensive study of the factors affecting the prolongation of hospitalization and rehabilitation (Kehlet H., 1997; Kehlet H., Wilmore D., 2002), surgical stress response was identified as the most significant inducer of dysfunction among various organs and systems. General anesthesia, in its classical sense, is not able to provide patients with complete protection against surgical trauma. Comprehensive protection can be obtained through a combination of general and local anesthesia and stress-protective drugs. OBJECTIVE: The aim of this study was to evaluate the efficacy and safety of the proposed scheme of stress-limiting anesthesia in ophthalmic surgery patients with corneal transplantation. MATERIALS AND METHODS: This study provides a comparative characterization of the severity of the stress response and pain syndrome in patients operated under the conditions of classical general anesthesia (group K) and those who received the scheme of stress-limiting anesthesia (group DB). Multicomponent anesthesia was administered in both groups. Sibazone was used for sedation in group K, whereas dexmedetomidine was used in group DB. The patients in group DB underwent local anesthesia before surgery. The main criteria for assessing the results were as follows: hemodynamic stability, blood glucose, level of venous blood leukocytes, and severity of pain according to the VAS in the postoperative period. RESULTS: Both schemes helped avoid pronounced fluctuations in hemodynamic and gas exchange parameters at all stages of the study. The analysis of blood glucose and leukocyte counts showed that patients in group K had a more significant deviation for both indicators from the preoperative level than those in group DB. In the study of pain syndrome, group K showed higher levels of pain according to the VAS than group DB. CONCLUSION: The scheme of stress-limiting anesthesia enables the control of postoperative pain without the additional use of narcotic analgesics and blockades in the postoperative period.

Introduction. Optimization of the intraoperative fluid therapy is one of the elements of the ERAS program. The strategy of avoiding fluid overload has shown positive results in adults, but still remains unexplored in children. Fluid requirements in children are higher than in adults and they vary with age. It’s still not clear whether it is possible or not to extrapolate the data of studies obtained in adults to children and to use similar recommendations. The aim of this study is to compare intraoperative fluid approaches from the point of view of surgical stress response in children undergoing orthopaedic surgery. Material and Methods: The study included 60 pediatric patients over 1 year of age who had undergone orthopaedic surgery. Рatients were stratified into two groups depending on the volume of intraoperative base crystalloid infusion. First group of patients received 7 ml/kg/h. We evaluated intraoperatively changes of blood pressure, heart rate, urine output, Hb, Ht, blood glucose, acidbase status. After surgery we estimated lactate, insulin, insulin resistance index HOMA-IR (homeostatic model assessment) and insulin sensitivity index QUICKI. Mean data was compared with Mann-Whitney U-test. Results of the study: After stratification two groups were identified. The first group of patients (n=30) received 10.7 ± 3.03 ml/kg/h and the second one 2 (n=30) – 5.07 ± 1.15 ml/kg/h of intraoperative crystalloid fluids as a basic fluid therapy. We did not find significant changes in blood pressure, heart rate, Hb, Ht, acid-base status in both groups. But the urine output was decreased in the group 2 (0.43 ± 0.59 ml/kg/h) in comparison with the group 1 (1.16 ± 0.89, p=0.009). The concentration of blood glucose was insignificantly increased in both groups, but the level of insulin and HOMA-IR was significantly higher in group 2 (insulin 5.39 ± 3.93 vs 8.94 ± 6.15 mU/L, p=0.006; HOMAIR 1.30 ± 1.05 vs 2.39 ± 2.14, p=0.004), and index QUICKI was lower (0.39 ± 0.05 vs 0.35 ± 0.04, p=0.004). We also found the tendency to lactation increase in group 2 (1.46 ± 0.62 vs 1.90 ± 0.69, p=0.07), even though that was not significant. Conclusion: This study revealed the tendency to insulin resistance of tissues as one of the signs of a surgical stress response in children who were limited in intraoperative fluid therapy during orthopaedic surgery. Results of the study suggest that the limitation of intraoperative fluids is not applicable for children, and the volume of base crystalloids must be more than at least 7 ml/kg/h during paediatric orthopaedic surgery. Further research is necessary to determine what minimum volume is acceptable in other types of paediatric surgeries.

The majority of rectal cancer patients are elderly. Biological age, not chronological age alone, is the main risk factor of postoperative morbidity in this group. Therefore, based on the Comprehensive Geriatric Assessment, we can differentiate three groups of patients: fit, pre-frail and frail. In the fit group, a standard multimodal oncologic treatment can be offered. In the pre-frail group, prerehabilitation should be recommended to improved resilience to surgical stress. In frail patients, a tailored approach should be discussed in a geriatric multidisciplinary team meeting. At present, a whole range of multimodal tailored approaches can be offered to rectal cancer patients. In this group, of much more importance is postoperative functional recovery, including both organ-specific outcomes and the ability to regain independence than currently used outcome indicators. Therefore, as important as cancer staging and tumour biology, it is crucial to understand the health status of an older patient with rectal cancer.

Objective Because of their anatomical features, treatment for paraclinoid aneurysms has remained to be challenging. Thus, the aim of this report is to prove the validity of our surgical method for unruptured paraclinoid aneurysms, together with surgical videos. Study Design Between August 2017 and November 2019, we were able to perform surgical clipping for 11 patients with unruptured paraclinoid aneurysm using a completely unified method. This study investigated the effect of surgery on multiple measures, including visual impairment, brain contusion, temporalis muscle atrophy, and multiple neurocognitive functions. Results Of the 67 unruptured aneurysms treated at our hospital, 17 were identified to be paraclinoid aneurysm, and 11 of them were treated by direct clipping using anterior clinoidectomy. Three were ophthalmic artery aneurysms, three were superior hypophyseal artery aneurysms, and five were anterior carotid wall aneurysms without branch projection. Only one patient had asymptomatic mild enlargement of the Marriott blind spots postoperatively. No brain contusion and temporalis muscle atrophy were observed in any cases. Only the Trail Making test (TMT) showed a significant worsening in the acute postoperative period: mean pre- and postoperative TMT scores were 59.1 ± 29.1 and 72.7 ± 37.3 for Part A (p = 0.018) and 80.5 ± 35.5 and 93.8 ± 39.9 for Part B (p = 0.030), respectively. However, it improved in the chronic phase. Conclusion We can conclude that our surgical method is safe and can be considered an acceptable treatment. Although surgical stress can cause temporary executive dysfunction shortly after surgery, this decline is temporary.

As life expectancy increases, an increasing older population may require surgery with perioperative nutritional management. While little is known about the combined effect of age and stress on amino acid metabolism during enteral nutrition, we hypothesized that blood amino acid bioavailability may be influenced not only by the characteristics of the ingested protein but also by intestinal ageing and splanchnic sequestration of amino acids. Plasma amino acid kinetics were thus evaluated in aged and adult rats receiving continuous enteral nutrition before and after standardized surgical stress.Sixteen 5-month-old and sixteen 21-month-old male rats were used. After a gastrostomy, the insertion of a jugular vein catheter and a one-week recovery, the animals were enterally fed with commercially available formulas containing whole milk proteins or a whey hydrolysate for 24 h before (healthy state) and 18 h after a standardized laparotomy (surgical stress). Data were analyzed by 3-factor ANOVA.In all rats, enteral nutrition was associated with a marked increase in plasma alanine, threonine, lysine and proline (+50 to +150 μmol/L; p 0.001), and a decrease in glycine (≈-80 μmol/L; p 0.01). For most amino acids, their availability depended first on the amino acid composition of each protein and second on surgical stress. Aging was only associated with higher tyrosine and threonine availability (p 0.001). There was only limited statistical interaction between age and surgical stress.In rats, plasma amino acid availability during continuous enteral nutrition is determined by the nature of the protein source and the occurrence of stress. The effects of aging on plasma amino acid availability seem very limited. Commonly used formulas therefore appear to be as suitable for elderly patients as for adult patients.

Introduction: Copeptin is known to be associated with heart damage, while melatonin is a regulatory hormone related to circadian rhythm and represents the levels of inflammation in the body. Methods and Patients: The aim of the study was to measure in different surgeries the levels of copeptin and melatonin at different times before and after surgery in 56 patients aged from 5 days to 13.6 years. We measured copeptin in 50-microL serum and plasma samples from patients before surgery, immediately after surgery, and 24 hours after surgery. The measured levels are aligned with the published GC / MS data, and the sensitivity of the analysis is such that serum and plasma levels can only be measured by rapid extraction. The measurement was made before surgery, immediately after surgery, and 24 hours after surgery. Results: The multifactorial statistical analysis revealed a statistically significant difference between the 24-hour postoperative copeptin values in group 1 (mild-moderate gravity surgery) and group 2 (severe surgery) of the severity of the surgery. Post-hoc tests with Tukey correction for age groups in multiple comparisons of the multifactorial analysis revealed a statistically significant difference (p Discussion: In summary, copeptin is a reliable biomarker for assessing a patient's health both preoperatively and postoperatively. Copeptin and melatonin are two independent agents and are not related to each other, and more studies will be needed with more patients of the same age and with the same underlying disease to assess their diagnostic value. Finally, melatonin could be considered an indicator of inflammation on its own and based on pre-and post-surgery values to determine a patient's health status and take appropriate actions.

Purpose of review Surgery remains integral to treating solid cancers. However, the surgical stress response, characterized by physiologic perturbation of the adrenergic, inflammatory, and immune systems, may promote procancerous pathways. Anesthetic technique per se may attenuate/enhance these pathways and thereby could be implicated in long-term cancer outcomes. Recent findings To date, clinical studies have predominantly been retrospective and underpowered and, thus limit meaningful conclusions. More recently, prospective studies of regional anesthesia for breast and colorectal cancer surgery have failed to demonstrate long-term cancer outcome benefit. However, based on the consistent observation of protumorigenic effects of surgical stress and that of volatile anesthesia in preclinical studies, supported by in vivo models of tumor progression and metastasis, we await robust prospective clinical studies exploring the role of propofol-based total intravenous anesthesia (cf. inhalational volatiles). Additionally, anti-adrenergic/anti-inflammatory adjuncts, such as lidocaine, nonsteroidal anti-inflammatory drugs and the anti-adrenergic propranolol warrant ongoing research. Summary The biologic perturbation of the perioperative period, compounded by the effects of anesthetic agents, renders patients with cancer particularly vulnerable to enhanced viability of minimal residual disease, with long-term outcome consequences. However, low level and often conflicting clinical evidence equipoise currently exists with regards to optimal oncoanesthesia techniques. Large, prospective, randomized control trials are urgently needed to inform evidence-based clinical practice guidelines.

Background. One of the most common responses to surgical stress is the activation of the sympathetic nervous system, leading to a dramatic increase in circulating adrenaline and norepinephrine, which can potentially accelerate the spread of the tumor process in cancer patients. In this regard, it is relevant to review the results of studies devoted to the determination of the antitumor effect of β-blockers and their use in the perioperative treatment of cancer patients. Purpose – to analyze and summarize data on the oncogenic effects of catecholamines and to highlight the experience of using β-blockers in the perioperative treatment of cancer patients. Materials and methods. We used the electronic resources of Vernadsky National Library of Ukraine, Cochrane library and databases (Pubmed, Scopus). We analysed the results of studies conducted before August 2020. Results. A summary of the mechanisms by which excessive release of catecholamines may facilitate metastasis is provided. The analysis of clinical trials devoted to the study of the effects of perioperative use of propranolol and its combination with COX-2 inhibitors in cancer patients is conducted. Conclusions. Short-term perioperative therapy with propranolol and its combination with anti-inflammatory drugs may have antimetastatic effects and neutralize the immunosuppressive effects of surgical stress. Further elucidation of the clinical significance of perioperative propranolol treatment in cancer patients requires a 3–5-year study to assess the long-term relapse-free survival of cancer patients., Актуальність. Однією з найбільш явних відповідей на хірургічний стрес є активація симпатичної нервової системи, що веде до різкого збільшення циркулюючих адреналіну і норадреналіну, які можуть потенційно прискорити поширення пухлинного процесу в онкологічних хворих. У зв’язку з цим актуальним є огляд результатів робіт, спрямованих на визначення протипухлинної дії β-адреноблокаторів та їх застосування у періопераційному лікуванні онкологічних хворих. Мета роботи – провести аналіз та узагальнення даних щодо онкогенних ефектів катехоламінів та висвітлити досвід застосування β-блокаторів при періоперційному лікуванні онкологічних хворих. Матеріали та методи. З метою пошуку даних для огляду використовували електронні ресурси Національної бібліотеки України ім. В. І. Вернадського, Cochrane library і баз даних Pubmed, Scopus. Проаналізовано результати досліджень, виконаних до серпня 2020 року. Результати та їх обговорення. Наведено короткі відомості про механізми, за допомогою яких надлишкове звільнення катехоламінів може полегшувати метастазування. Проведено аналіз клінічних випробувань, присвячених дослідженню ефектів періопераційного застосування пропранололу та його комбінації з інгібіторами ЦОГ-2 в онкологічних хворих. Висновки. Короткострокова періопераційна терапія пропранололом та його комбінацією з антизапальними препаратами може надавати антиметастатичні ефекти та нівелювати імуносупресивні ефекти хірургічного стресу. Подальше з’ясування клінічної значущості періопераційного лікування пропранололом у онкологічних пацієнтів вимагає проведення 3–5-річних досліджень стосовно оцінки тривалої безрецидивної виживаності онкологічних хворих.

Objectives: Surgeries can trigger stress responses including metabolic and hormonal changes. It is important to suppress stress response during surgery. We compared the effects of isoflurane and sevoflurane on surgical stress in intracranial tumor surgery. Methods: Thirty ASA physical status I, II, III patients, scheduled for elective craniotomies, were enrolled in this prospective, randomized study. Anesthesia was induced with sodium thiopental fentanyl and vecuronium bromide and maintained with a 50% oxygen-air mixture along with isoflurane or sevoflurane. Venous blood was sampled to measure cortisol, ACTH and prolactin levels 24 hours before surgery, 1 min before anesthesia induction, during tumor removal, 1 min after extubation, at 3, 6, 12, 24, 48 hours. Results: There was no statistically significant difference between two groups regarding demographic characteristics of patients. In group I, ACTH levels were significantly higher 1 min after extubation, at 3 and 6 hours. In Group S, significant increases were observed during tumor removal, 1 min after extubation, at 3 and 6 hours. Cortisol levels were significantly higher in both group after tumor removal, 1 min after extubation, at 3, 6, 12 and 24 hours. Prolactin levels were significantly higher in Group I during tumor removal, after extubation, at 3 and 6 hours. In group S, significant increase in prolactin level was observed only during tumor removal and 1 min after extubation. There were no significant differences in ACTH, cortisol and prolactin values between the two groups. Conclusions: Using isoflurane or sevoflurane for anesthesia during intracranial tumor surgery are not superior to each other regarding hemodynamic and hormonal stress response.

Estimation of physiologic ability and surgical stress system (E-PASS) has been shown to be effective in predicting morbidity after surgery for perihilar cholangiocarcinoma (PHCC). Nevertheless, E-PASS does not include an assessment of the disease specific risk factors. The aim of the study was to estimate the combined impact of E-PASS and specific preoperative factors on major morbidity for PHCC patients.A retrospective analysis of a prospectively collected data was performed. Severe morbidity according to complication comprehensive index was defined as ≥40 points. A value of comprehensive risk score (CRS) ≥1 was taken as critical.Multivariate analysis of perioperative data from 122 patients revealed significant impact of five factors (CRS ≥1, future liver remnant volume50%, T4 stage, moderate and severe cholangitis, INR) on the risk of severe morbidity after resection. The AUC for the combination of these factors was classified as good predictive value (0.810, 95% CI 0.729-0.891) and poor predictive value (0.673, 95% CI 0.573-0.773) for CRS alone (p = 0.040).A combination of E-PASS with disease specific risk factors is a reliable predictive model for major morbidity for patients undergoing radical surgery for PHCC.

Background: Coronary artery bypass grafting (CABG) is a major surgery that may cause severe surgical stress response (SR). Although the presence of family members in intensive care unit (ICU) is known to benefit intensive care patients socially and emotionally, its effects on surgical SR are unknown. Objectives: To investigate the effect of an informed family member (IFM)’s presence in the awakening process in ICU on patients’ SR after CABG. Methods: A nonrandomized controlled clinical study was completed with a total of 73 patients: 37 patients in the control (CG) and 36 in the intervention group (IG) underwent CABG surgery. In the CG patients, no family members were taken into the ICU during the awakening process and routine care and treatment practices were continued. In the IG patients, besides routine care and treatment practices, an IFM was taken into the ICU during the awakening process in accordance with the research method. Groups were statistically compared in terms of serum cortisol level which is the one of the main indicators of surgical SR, state anxiety, sedative drug requirements, and duration of intubation, sedation, and ICU stay. A p value

Preoperative patient care optimisation appears to be crucial for obtaining good surgical outcomes. Enhanced Recovery After Surgery (ERAS) underlines the necessity to recognize and treat malnutrition perioperatively and to prehabilitate with interventions that can modulate the lean body mass before and after surgery. This procedure has been extensively reported in colorectal cancer patients but in Inflammatory Bowel Disease (IBD) it has not yet been clearly evaluated. The aim of this study was to implement the perioperative nutritional items in surgical Crohn's disease (CD) and ulcerative colitis (UC) patients electively operated in an ERAS setting, thus to clarify the impact of a long-lasting prehabilitation program in IBD.Consecutive adult patients (age ≥18) were included as soon as scheduled for elective surgery for CD or UC. The nutritional intervention included personalized dietary counseling and oral nutritional supplements when necessary. Data prospectively recorded in each phase were: FFM, FM, FFMI and phase angle detected with BIVA, weight, BMI, unintended weight loss, DASI, energy and nutritional intake, gastrointestinal symptoms and bowel functions. Nutritional risk was detected according to the NRS 2002 screening tool. The impact of early oral nutrition on postoperative recovery was analysed.A total of 61 IBD patients (45 CD and 16 UC) were included. Muscle wasting was present at baseline assessment in 28% of cases, significantly associated with the presence of ileostomy (p 0.011) and of a previous IBD surgery (p 0.011). During the preoperative phase, there was a significant improvement in weight, BMI, FFM (CD p = 0.035; UC p = 0.017), FFMI (CD ns; UC p = 0.011) and phase angle (CD p = 0.014; UC p = 0.027). During the intra-hospital phase, weight and FFM decreased due to the catabolic effect of surgery, but in the whole perioperative period, both CD and UC patients did not change significantly in terms of body composition. Patients with earlier resumption of oral feeding had a significantly shorter hospital stay and a faster recovery of bowel function with no significant relationship with early postoperative complications.Nutritional prehabilitation positively modulated the body composition of IBD patients scheduled for elective surgery and therefore could represent a beneficial strategy to attenuate the impact of the surgical stress response on lean tissue in an ERAS setting. This effect is even more evident in high nutritional risk patients. Early postoperative oral feeding seems feasible and well tolerated in IBD. This approach positively influences the restoration of bowel function and the duration of hospital stay.

Development of minimally invasive cardiac surgery (MICS) served the purpose of performing surgery while avoiding the surgical stress triggered by a full median sternotomy. Minimizing surgical trauma is associated with improved cosmesis and enhanced recovery leading to reduced morbidity. However, it has to be primarily appreciated that the extracorporeal circulation (ECC) stands for the basis of nearly all MICS procedures. With some fundamental modification and advancement in perfusion techniques, the use of ECC has become the enabling technology for the development of MICS. Less invasive cardiopulmonary bypass (CPB) techniques are based on remote cannulation and optimization of perfusion techniques with assisted venous drainage and use of centrifugal pump, so as to facilitate the demanding surgical maneuvers, rather than minimizing the invasiveness of the CPB. This is reflected in the increased duration of CPB required for MICS procedures. Minimal invasive Extracorporeal Circulation (MiECC) represents a major breakthrough in perfusion. It integrates all contemporary technological advancements that facilitate best applying cardiovascular physiology to intraoperative perfusion. Consequently, MiECC use translates to improved end-organ protection and clinical outcome, as evidenced in multiple clinical trials and meta-analyses. MICS performed with MiECC provides the basis for developing a multidisciplinary intraoperative strategy towards a “more physiologic” cardiac surgery by combining small surgical trauma with minimum body’s physiology derangement. Integration of MiECC can advance MICS from non-full sternotomy for selected patients to a “more physiologic” surgery, which represents the real face of modern cardiac surgery in the transcatheter era.

The anesthetic-surgical stress response consists of metabolic, neuroendocrine, hemodynamic, immunological, and behavioral adaptations through chemical mediators such as the adrenocorticotropic hormone, growth hormone, antidiuretic hormone, cortisol, aldosterone, angiotensin II, thyroid-stimulating hormone, thyroxine, triiodothyronine, follicle-stimulating hormone, luteinizing hormone, catecholamines, insulin, interleukin (IL)-1, IL-6, tumor necrosis factor-alpha, and prostaglandin E-2. Behavioral changes include adopting the so-called prayer posture, altered facial expressions, hyporexia or anorexia, drowsiness, sleep disorders, restriction of movement, licking or biting the injured area, and vocalizations. Overall, these changes are essential mechanisms to counteract harmful stimuli. However, if uncontrolled surgical stress persists, recovery time may be prolonged, along with increased susceptibility to infections in the post-operative period. This review discusses the neurobiology and most relevant organic responses to pain and anesthetic-surgical stress in dogs and cats. It highlights the role of stress biomarkers and their influence on autonomous and demeanor aspects and emphasizes the importance of understanding and correlating all factors to provide a more accurate assessment of pain and animal welfare in dogs and cats throughout the surgical process.

Introduction Compliance to ERAS protocols is a process quality measure that is associated with better outcomes. The main objective of this study is to analyze the association between protocol compliance, surgical stress and functional recovery. The secondary objective is to identify independent factors associated with functional recovery. Methods A prospective observational single-center study was performed. Patients who had scheduled colorectal surgery within an ERAS program from January 2017 to June 2018 were included. We analyzed the relationship between protocol compliance percentage and surgical stress (defined by C-reactive protein [CRP] blood levels on postoperative 3rd day), and functional recovery (defined by the proportion of patients who met the discharge criteria on the 5th PO day or before). Multivariate analysis was performed to assess independent factors associated with functional recovery. Results 313 patients were included. For every additional percentage point of compliance to the protocol 3rd day, C-reactive protein plasma level decreased 1.46 mg/dL and the probability to meet the discharge criteria increased 7% (P Conclusion Better compliance with ERAS protocol in colorectal surgery decreases surgical stress and accelerates functional recovery.

Purpose The purpose of this study was to investigate associations between postoperative delirium (POD) and unplanned perioperative hypothermia (UPH) among adults undergoing noncardiac surgery. Design A retrospective, exploratory design was used. Methods A retrospective, exploratory study was conducted using electronic medical record data abstracted from a purposive convenience sample of adult patients undergoing noncardiac surgery from January 2014 to June 2017. Findings The analyzed data set included 22,548 surgeries, of which 9% experienced POD. Logistic regression indicated that American Society of Anesthesiologists (ASA) class was the strongest predictor of POD (χ2 = 1,207.11, df = 4, inclusive of all ASA class terms). A significant relationship between UPH and POD (χ2 = 54.94, df = 4, inclusive of all UPH terms) and a complex relationship among UPH, patient age, ASA class, and POD were also found. Conclusions Results support a relationship between UPH and POD. Notably, there is also a complex relationship in the noncardiac surgery population among UPH, age, ASA class, and POD. Preliminary understanding of this relationship is based on the pathophysiological response to surgical stress. Further research is indicated.

Glucocorticoid preparations, adreno-cortical steroids, with strong anti-inflammatory and immunosuppressive effects, are widely used for treating various diseases. The number of patients exposed to steroid therapy prior to surgery is increasing. When these patients present for surgery, the anesthesiologist must decide whether to administer perioperative steroid supplementation. Stress-dose glucocorticoid administration is required during the perioperative period because of the possibility of failure of cortisol secretion to cope with the increased cortisol requirement due to surgical stress, adrenal insufficiency, hemodynamic instability, and the possibility of adrenal crisis. Therefore, glucocorticoids should be supplemented at the same level as that of normal physiological response to surgical stress by evaluating the invasiveness of surgery and inhibition of the hypothalamus-pituitary-adrenal axis. Various textbooks and research articles recommend the stress-dose of glucocorticoids during perioperative periods. It has been commonly suggested that glucocorticoids should be administered in an amount equivalent to about 100 mg of cortisol for major surgery because it induces approximately 5 times the normal secretion. However, more studies, with appropriate power, regarding the administration of stress-dose glucocorticoids are still required, and evaluation of patients with possible adrenal insufficiency and appropriate glucocorticoid administration based on surgical stress will help improve the prognosis.

Background Frailty is a syndrome where the ability to cope with acute physiological stress is compromised, although it is unclear what impact this stress has on long-term outcomes. Vascular-Physiological and Operative Severity Score for enumeration of Mortality and Morbidity is a validated method for calculating levels of stress associated with vascular procedures. We designed this study to evaluate the long-term impact of different levels of surgical stress among frail older patients undergoing vascular surgery procedures. Methods We identified all independently living patients who underwent prospective frailty assessment followed by an elective vascular surgery procedure captured in the Vascular Quality Initiative registry (endovascular abdominal aortic aneurysm [AAA] repair, thoracic endovascular aortic repair, suprainguinal and infrainguinal bypass, peripheral vascular intervention, carotid endarterectomy, and open AAA) at an academic institution between January 2016 and July 2018. Patient- and procedure-level data were obtained from our institutional data warehouse and Vascular Quality Initiative database, and used to calculate Vascular-Physiological and Operative Severity Score for enumeration of Mortality and Morbidity scores. The association between frailty and composite outcome of any major complications (surgical site infection; graft thrombectomy; major amputation; adverse cardiac, pulmonary, or neurologic event; acute renal insufficiency; and/or reoperation related to the index procedure), nonhome living status, or death within 1 year after low-, medium-, and high-stress vascular procedures was evaluated using bivariate and logistic regression models. Results A total of 163 patients were identified (70% male, mean age 67.8 years) who underwent open AAA repair (6%), endovascular AAA repair (21%), thoracic endovascular aortic repair (7%), suprainguinal bypass (5%), infrainguinal bypass (18%), carotid endarterectomy (18%), or peripheral vascular interventions (25%), which included 44 (27%) patients diagnosed with frailty before surgery. Overall, frail patients had significantly higher rates of the 1-year composite outcome (48% frail versus 27% nonfrail; P = 0.012) when compared with nonfrail patients, with a significant dose-dependent effect as the level of stress increased. In comparison, increasing levels of surgical stress had a negligible effect on long-term outcomes among nonfrail patients. The interaction between frailty and high surgical stress was found in adjusted regression models to be a significant predictor of adverse outcomes within 1 year after vascular surgery (odds ratio, 3.3; 95% confidence interval, 1.3–8.6; P Conclusions Frail patients who undergo high-stress vascular procedures have a significantly higher rate of complications leading to loss of functional independence and mortality within the year after their surgery. These data suggest that estimates of surgical stress should be incorporated into clinical decision making for frail older patients before and after surgery.

Enhanced recovery after surgery (ERAS), a series of evidence-based optimization measures during the perioperative period, to reduce patients’ physical and psychological traumatic stress responses, to reduce complications, to shorten the length of hospital stay, to reduce the risk of readmission and mortality, and ultimately to promote rapid patient resuscitation, is adopted. The negative emotional experience of patients may aggravate the surgical stress response, interfere with the endocrine system and nervous system, cause the imbalance of internal environment, and have a negative impact on the surgical effect. This paper uses the concept of ERAS in combination with psychological stress interventions, perioperative psychological nursing instruction, reduces the laparoscopic surgery in patients with psychological stress reaction on the immune function of cells, improves the body’s immune function, improves the body of bacteria such as vitamin attack resistance, reduces the risk of complications such as infection, and accelerates the process of patient rehabilitation. Here is the report.

Background: Laparoscopic gastrectomy for gastric cancer shortens the recovery period without decreasing long-term survival. However, clinical evidence on whether laparoscopic radical gastrectomy reduces the surgical stress and improves the short- and long-term outcomes of obese patients with gastric cancer is lacking. We compared the short- and long-term outcomes of gastric cancer patients with visceral obesity (VO) who underwent laparoscopic gastrectomy (LG) or open gastrectomy (OG). Methods: We prospectively collected data from 578 patients who underwent radical gastrectomy in two centers between January 2014 and December 2016. The visceral fat area (VFA) was measured on the umbilicus level, and VFA ≥100 cm2 was defined as VO. The section bias was reduced by conducting a propensity score matching analysis. The short- and long-term outcomes were further compared between patients who underwent OG and those who underwent LG. Results: Overall, 245 patients (42.61%) were classified as having VO, of whom 102 were included for further analysis after matching. There were no significant differences in clinical characteristics between the two groups in the matched cohort. The LG group had significantly fewer overall complications (P

Twenty dairy cows with left abomasal displacement were used to investigate the effects of vitamin E and selenium treatment on blood cortisol in dairy cows stressed by omentopexy. The cows were randomly divided into two groups. Ten hours before surgery 6 g of DL-α-tocopheryl acetate (6 mg.kg−1) and 67 mg of natrium selenite (0.1 mg.kg−1) in a volume of 40 ml were administered subcutaneously to 10 cows; the control animals (n = 10) received an equivalent volume of injectable water (40 ml). The injection of vitamin E and selenium produced a rapid rise (P < 0.05) in blood α-tocopherol and selenium concentrations. The serum vitamin E increased several times ten hours after vitamin E and Se injection and raised continuously to the highest average concentration of 21.6 mg.l−1 at hour 24 after the surgery. The highest selenium concentration was seen ten hours after selenium administration with holding the increased concentrations in comparison to initial ones during the whole study. Serum cortisol increased in both groups after surgery. The highest cortisol concentrations were reached at one hour after surgery in the experimental and control group (56.7 ± 28.8 and 65.3 ± 26.1 μg.l−1, respectively). A return to the levels similar to the initial ones was recognized 24 hours after the surgery. The ANOVA revealed a significant effect of vitamin E and selenium injection on serum cortisol (P < 0.05). In conclusion, we have demonstrated that abdominal surgery resulted in typical stress changes with a weaker cortisol response to the abdominal surgery in animals treated with vitamin E and selenium.

Aims and Objectives: Takotsubo cardiomyopathy (TCMP) is an acquired cardiomyopathy associated with physical, emotional, and surgical stress. Current literature on TCMP in liver transplant recipients (LTRs) is limited to case reports and case series. Methods: The Nationwide Readmission Database was utilized to identify all adults with an index admission for LT between 2010 and 2014 who developed TCMP. The prevalence of TCMP at the LT admission or readmission within the calendar year was examined. Predictors of development and health-care utilization of patients with and without TCMP in LTR were compared. Multivariable regression analysis was performed. Results: The prevalence of TCMP in LTRs was found to be 0.5% (141/28,067). Most of these patients developed early TCMP on the index admission for LT (n = 115; 82%). Older (57.5 ± 1.3 vs. 55.1 ± 0.3 years, P < 0.001) females (adjusted odds ratio [aOR]: 2.27; confidence interval [CI]: 1.20–4.27; P = 0.01) with ≥4 Elixhauser comorbidity (aOR: 2.36; CI: 1.15–4.83; P = 0.02) were predisposed to develop TCMP in LTRs. LT at a medium-sized center (aOR: 0.17; CI: 0.03–0.88) has a protective effect on the development of TCMP. Increased health-care utilization in the form of mechanical ventilation, hemodialysis, vasopressors, and intra-aortic balloon pumps is observed in patients with TCMP. This resulted in increased length of stay and cost in patients with TCMP. Moreover, increased mortality was seen in patients who developed TCMP within the same calendar year. Conclusion: This is the first report showing the prevalence of TCMP in LTRs to be 0.5%. Older females with increased comorbidity are predisposed to TCMP. Patients who developed TCMP necessitate a higher acuity of medical care and cause an increased health-care burden and ultimately experience an increase in mortality.

Surgical stress is followed by oxidative stress, where reactive oxygene species may act as regulators of pathways related to cancer cell survival and metastatic ability. Furthermore, reactive oxygene species may cause DNA and RNA damage. The aim of this study was to examine whether laparoscopic colon cancer surgery causes oxidative stress and dysregulation of related pathways. Methods: Patients undergoing elective laparoscopic surgery for colon cancer were included. Blood and urine samples were drawn on the day prior to surgery and on day 1 and 10 after surgery. Results: Twenty-six patients were included. Out of 140 genes previously identified as sensitive to regulation by reactive oxygene species, 46 were significantly differentially expressed on day 1 after surgery (FDR < 0.05). Upregulated genes were related to cellular immune suppression, proliferation, migration and epithelial to mesenchymal transition. Downregulated genes were related to IFN pathways and cytotoxic immunological reactions. Genes related to DNA repair were primarily downregulated on day one after surgery, and urinary excretion of 8oxdG was decreased on day two after (p = 0.004), and increased on day 10 after surgery (p = 0.01). Conclusion: Laparoscopic colon cancer surgery causes oxidative stress, and impaired DNA repair. Gene expression profiling indicates that reactive oxygen species may act as regulators of pathways related to increased risk of metastasis and cellular immune suppression after surgery. Measures of intracellular oxidative stress, indicates impaired DNA repair on day two after surgery, and sustained oxidative stress on day 10 after surgery.

Multiple biological parameters were proposed to evaluate the surgical stress response in the early postoperative period. Granulocyte/lymphocyte (G/L) ratio may be a useful marker and widely available. Measuring some of known surgical stress related markers together with G/L ratio we tried to confirm the superiority of laparoscopic approach and efficiency of the G/L ratio monitoring in this period. Materials and methods: 52 colorectal cancer patients who underwent elective surgery in a private clinical hospital were evaluated preoperatively and postoperatively (day 1 and day 5) for the: TNF-α, cortisol, C reactive protein (CRP) and G/L ratio. Results: Only CRP levels were significantly lower in the laparoscopy group in day 1 (74.07 vs 50.32, p=0.0461) and day 5 (18.37 vs 7.32, p=0.0001). The G/L ratio showed strong correlation with CRP levels in all measurements. Conclusions: Measurement of postoperative CRP levels confirmed the reduced surgical stress of laparoscopic colectomy for colorectal cancer in our clinic.

Surgical resection is a common therapeutic option for primary solid tumors. However, high cancer recurrence and metastatic rates after resection are the main cause of cancer related mortalities. This implies the existence of a “fertile soil” following surgery that facilitates colonization by circulating cancer cells. Myeloid-derived suppressor cells (MDSCs) are essential for premetastatic niche formation, and may persist in distant organs for up to 2 weeks after surgery. These postsurgical persistent lung MDSCs exhibit stronger immunosuppression compared with presurgical MDSCs, suggesting that surgery enhances MDSC function. Surgical stress and trauma trigger the secretion of systemic inflammatory cytokines, which enhance MDSC mobilization and proliferation. Additionally, damage associated molecular patterns (DAMPs) directly activate MDSCs through pattern recognition receptor-mediated signals. Surgery also increases vascular permeability, induces an increase in lysyl oxidase and extracellular matrix remodeling in lungs, that enhances MDSC mobilization. Postsurgical therapies that inhibit the induction of premetastatic niches by MDSCs promote the long-term survival of patients. Cyclooxygenase-2 inhibitors and β-blockade, or their combination, may minimize the impact of surgical stress on MDSCs. Anti-DAMPs and associated inflammatory signaling inhibitors also are potential therapies. Existing therapies under tumor-bearing conditions, such as MDSCs depletion with low-dose chemotherapy or tyrosine kinase inhibitors, MDSCs differentiation using all-trans retinoic acid, and STAT3 inhibition merit clinical evaluation during the perioperative period. In addition, combining low-dose epigenetic drugs with chemokine receptors, reversing immunosuppression through the Enhanced Recovery After Surgery protocol, repairing vascular leakage, or inhibiting extracellular matrix remodeling also may enhance the long-term survival of curative resection patients.

BACKGROUND Pancreaticobiliary malignant diseases are primarily treated by surgical resection. However, the surgical indications for elderly patients, especially for pancreaticoduodenectomy (PD), must be carefully considered due to patient compliance. Whether PD can contribute to better prognoses in elderly patients remains unclear. Therefore, we aimed to evaluate the complications, compliance, and survival of elderly and non-elderly patients who underwent PD in our department. METHODS We retrospectively analyzed 282 patients who underwent PD from 2000 to 2017 and divided them into non-elderly (aged ≤ 79 years, n = 238) and elderly (aged ≥ 80 years, n = 44) groups. The estimation of physiologic ability and surgical stress (E-PASS) system was used to evaluate morbidity and mortality using preoperative risk score (PRS), surgical stress score (SSS), and comprehensive risk score (CRS). RESULTS Preoperative risk score was higher in the elderly group than in the non-elderly group, although SSS and CRS were similar. No significant differences were detected in the occurrence of postoperative complications. In the elderly group, CRS was higher in patients with complications than in those without. Long-term outcomes evaluated by overall and disease-specific survival were not significantly different. CONCLUSIONS In the elderly patients, E-PASS especially CRS can predict the occurrence of complications. The safety and prognoses of elderly patients after PD are comparable with those of non-elderly patients.

The stress of surgery is characterized by an inflammatory response with immune suppression resulting from many factors, including the type of surgery and the kind of anesthesia, linked with the drugs that are used and the underlying disease of the patient. The trauma of surgery triggers a cascade of reactions involving the immune response and nociception. As strong analgesics, opioids provide the analgesic component of general anesthesia with bi-directional effect on the immune system. Opioids influence almost all aspects of the immune response in regards to leukocytes, macrophages, mast cells, lymphocytes, and NK cells. The suppressive effect of opioids on the immune system is limiting their use, especially in patients with impaired immune response, so the possibility of using multimodal anesthesia without opioids, known as opioid-free anesthesia (OFA), is gaining more and more sympathizers. The idea of OFA is to eliminate opioid analgesia in the treatment of acute pain and to replace it with drugs from other groups that are assumed to have a comparable analgesic effect without affecting the immune system. Here, we present a review on the impact of anesthesia, with and without the use of opioids, on the immune response to surgical stress.

This study aimed to investigate perioperative intestinal motility using a novel bowel sound monitoring system in patients undergoing breast and neck surgery. This study enrolled 52 patients who underwent surgery for breast cancer, thyroid tumor, and parathyroid tumor at Kochi Medical School from May 2019 to June 2020. Perioperative bowel sound counts (BSCs) were recorded using a newly developed real-time analysis system in the operating theater. Clinical information and BSC per minute (cpm) data during the preanesthetic, preoperative, operative, postoperative periods, and period in recovery room were obtained to compare between each period. The Mann–Whitney U and Pearson Chi-square tests were used in data analysis. The BSCs during the intraoperative period and postoperative period were significantly decreased compared to those during the preanesthetic period (0.07 cpm versus [vs.]. 1.4 cpm, P = 0.002 and 0.1 cpm vs. 1.4 cpm, P = 0.025, respectively). The preoperative BSC with a preanesthetic BSC

Background: Tranexamic acid (TXA) reduces blood loss and transfusion requirements during craniosynostosis surgery in small children. Possible interaction from TXA on the inflammatory system is unknown. Objective: To evaluate the effect of TXA on a wide range of inflammatory markers in children receiving TXA in a randomized, blinded, and placebo controlled study design. Methods: Thirty children undergoing craniosynostosis surgery with significant blood loss received TXA (bolus dose of 10 mg kg−1 followed by 8 hours continuous infusion of 3 mg kg−1 h−1) or placebo in a randomized, double-blinded study design. Using a new proximity extension assays employing a panel of inflammatory biomarkers samples was used for analysis of blood samples obtained pre-operatively, 4 and 24 hours after operation. Results: Ninety-two inflammatory parameters were measured. TXA did not affect any of the measured parameters as compared with placebo. Among 34 of the 92 pro- and antiinflammatory parameters investigated changes were observed between pre-operative, 4 or 24 hours, respectively, reflecting immune activation during surgical stress. Conclusion: TXA administration in a low-dose regimen including bolus followed by 8 hours infusion during craniosynostosis surgery did not change any of 92 inflammatory markers as compared with placebo.

To investigate the action mechanisms of electroacupuncture (EA) on postoperative immunosuppression. Male C57BL/6 mice (5`-7 weeks old) were randomly divided into: the sham injury group, the surgical trauma stressed group, the EA group [surgery + 2/100 Hz EA at Neiguan (PC 6)], and the EA+ Nal (surgery + EA + intraperitoneal injection of naloxone). Abdominal surgical trauma stress mice model was established. EA was performed on bilateral PC 6 acupoints by an EA apparatus (2/100 Hz) for 20 min once a day for 3 days. The mRNA expressions of MOR, DOR, and KOR in thymus and L3`-L5 dorsal root ganglions (DRG) were determined by quantitative real-time polymerase chain reaction (qRT-PCR) and the protein expressions of MOR, DOR, and KOR in thymus were measured by Western blot. Flow cytometry assay was used to detect the levels of T lymphocyte subtypes in the peripheral blood. Surgical trauma induced decreased the mRNA expression level of MOR in both thymus (P 0.05). Furthermore, T lymphocyte population of CD3+ and CD4+ was decreased in the peripheral blood after surgical trauma (both P