To the Editor: The supraglottic airway device (SAD) with an additional gastric drainage channel may be beneficial for patients needing gastric decompression during surgery, such as laparoscopic cholecystectomy and cesarean delivery.[1] Furthermore, addition of gastric drainage channel is a typical feature of second-generation SAD. However, all of second-generation SADs have a gastric tube channel opening at the center of the distal tip.[2] Such a design may cause some difficulty for insertion of the gastric tube if there is an inadequate position of the device tip in the upper esophageal aperture.[3] In normal anatomy, the upper esophageal aperture is actually inclined to the left side of the trachea.[4] Thus, we inferred that it should be much easier to insert a gastric tube into the esophagus, if the gastric drainage channel is placed at the left side of the SAD tip. To test this hypothesis, this pilot randomized controlled study was designed to assess the performances of gastric tube insertion via the modified Oro-Pharyngo-Laryngeal Airway Cap (OPLAC) (Xu Bang Corporation, Taiwan, China) by comparing with the laryngeal mask airway (LMA) Supreme (Teleflex Medical, Dublin Road, Athlone, Ireland) in the anesthetized adult patients by an experienced operator. After the study protocol was approved by the Ethical Committee of Beijing Friendship Hospital (No. 2011-041) and registered in Chinese Clinical Trial Registry (ChiCTR-TRC-11001337), patients undergoing elective laparoscopic cholecystectomy with general anesthesia were recruited. Exclusion criteria were as follows: patients refusing to sign the informed consents or those with head and neck tumor or abnormalities. After obtaining the written informed consents, patients were randomly allocated to receive the LMA Supreme (LMA Supreme group) or modified OPLAC device (OPLAC group). The modified OPLAC device was obtained by attaching a silicone tube with 5 mm internal diameter and 20 cm long by silicone glue to the left side of the tip of the expandable silicone membranous cap of the original version [Figure 1]. The attached silicone tube was used as a conduit for insertion of the gastric tube.Figure 1: A silicone tubing was added to the left side of the expandable silicone membranous cap of original Oro-Pharyngo-Laryngeal Airway Cap device as a conduit for insertion of gastric tube. (A) Modified version. (B) Original version.Anesthesia was induced with fentanyl 3 μg/kg, propofol 2 mg/kg, and atracurium 0.8 mg/kg. The patient's head was placed at the neutral position and an LMA Supreme or modified OPLAC device was inserted by an experienced operator. Both the selection of device size and the technique of insertion followed the manufacturer's recommendations. Then, the device was connected to the anesthesia ventilator for volume-controlled ventilation. The ventilation was adjusted to maintain end-tidal carbon dioxide levels in the range of 35 to 40 mmHg (1 mmHg = 0.133 kPa). The time required for device insertion was recorded as the time between the operator picking up the device and the establishment of adequate ventilation via the device. Correct positioning of the device was confirmed by bilateral chest movements and capnography. Three attempts were allowed for successful placement of the device.[5] During mechanical ventilation, the peak airway pressures and the expired tidal volumes were measured. A size F14 gastric tube was inserted through the drainage channel of the LMA Supreme or the conduit added to the modified OPLAC device. The ease of gastric tube insertion was assessed and scored as 1 (easy), 2 (difficulty, needing the force to overcome resistance), or 3 (very difficulty, needing adjustment of the device position to overcome resistance). Correct placement of the gastric tube was confirmed by aspiration of gastric fluid or detection of injected air by auscultation over the epigastrium.[6] Before and during pneumoperitoneum, at head up position and end of surgery, both airway sealing pressure and peak airway pressure were recorded in the two groups. Airway sealing pressure was detected by closing the adjustable pressure limiting valve against 5 L/min fresh gas flow, and recording the airway pressure at equilibrium or when an air leak was heard in the oropharynx, to a maximum airway pressure of 40 cmH2O (1 cmH2O = 0.098 kPa).[7] The primary endpoint of this study was the ease of gastric tube insertion. The sample size was calculated to detect a 10% difference in the rate of easy gastric tube insertion between devices with a type-1 error of 0.05 and a power of 90%, requiring 25 patients per group. We recruited 30 patients for each group to accommodate dropouts. Data distribution was analyzed using the Kolmogorov-Smirnov test. Normally distributed data were analyzed using the paired t test, with other data analyzed by the Chi-squared test or Mann-Whitney U test. Data were analyzed using SPSS version 20 (SPSS Inc., Chicago, IL, USA). A P < 0.05 was considered statistically significant. The demographic data including age, weight, height, gender ratio, and operating time were not significantly different between the two groups (all P > 0.05). The rates of smooth device insertion were similar between the two groups, but the OPLAC device took a significantly shorter insertion time than the LMA Supreme. The ease of gastric tube insertion was significantly improved with the modified OPLAC device (P = 0.038). There was no any significant difficulty encountered during gastric tube insertion via the modified OPLAC device, but there were one case of difficult insertion and seven cases of very difficult insertion in the LMA Supreme group. Both the airway sealing pressure and peak airway pressure were not significantly different between the two devices. All the other ventilation profiles during the operation were similar for both the devices [Table 1].Table 1: Comparisons of device insertion, gastric tube insertion, gastric insufflation, airway sealing pressure, and peak airway pressure between two groups.In this study, both the LMA Supreme and modified OPLAC device could be successfully inserted on the first attempt. It indicated that the addition of a gastric tube insertion accessory on the left side of expandable silicone membranous cap did not interfere with the insertion of the OPLAC device. As we had assumed, moreover, the ease of gastric tube insertion via the modified OPLAC device compared with the LMA Supreme was better, with a 100% success rate and without any difficulty. It indicated that gastric tube insertion channel placed at the left side of the ventilation mask could indeed facilitate the gastric tube insertion via the second-generation SAD. This might not be due to the better anatomical fit of ventilation mask design as the similar device, such as the I-gel, has behaved inferiorly to the LMA Supreme for gastric tube insertion in other studies.[2,8] Our results showed that both the airway seal pressure and peak airway pressure were similar for the LMA Supreme and modified OPLAC device in all observed points. Furthermore, the incidence of gastric insufflation was not significantly different between the two devices. However, the incidence of gastric insufflation was higher in this study than in the previous study with the original OPLAC device.[9] In fact, the airway sealing of the OPLAC device is mainly dependent on the accommodation of the external contour of its expandable silicone membranous cap to the pharyngeal wall. Thus, addition of a gastric tube insertion channel on the left side of the expandable silicone membranous cap may have interfered with the mechanism of its airway sealing. This suggested that additional structure of the gastric tube insertion channel should be designed not to interfere with the fitness of the ventilation mask of the device. In conclusion, this study demonstrates that both the LMA Supreme and modified OPLAC device can be successfully inserted by an experienced operator on the first attempt, but gastric tube insertion channel placed at the left side of the modified OPLAC device provides an easier gastric tube insertion compared to the LMA Supreme with a gastric tube channel opening at the center of the distal tip. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Conflicts of interest None.
Abstract Background: The endoscopic technique is the most widely utilised method for the diagnosis and treatment of upper gastrointestinal (GI) diseases. Tussis, which increases the incidence of airway spasm, aspiration, nausea, and vomiting, is a common complication faced during upper GI endoscopy. However, sedatives and analgesics exhibit inhibitory actions against airway reflexes to different degrees. Our assumption is that a combination of propofol and small doses of sufentanil, esketamine, or lidocaine, especially the combination of propofol and esketamine, might reduce tussis incidence. Method: The study will be performed as a randomized controlled three-blind, two-centre trial. Patients undergoing upper GI endoscopy, ≥ 18 years old, with American Society of Anesthesiologists (ASA) classification I–III will be randomized to four groups: P group (single administration of propofol), P + S group (administration of propofol and sufentanil in combination), P + K group (administration of propofol and esketamine in combination), and P + L group (administration of propofol and lidocaine in combination) (N = 100 per group). The primary outcome, reflecting effectiveness of sedation, The primary endpoints include the frequency of tussis, nausea and vomiting, and/or body movements observed at the insertion of the endoscope into the pharyngeal cavity or within 5 min of endoscope insertion. Secondary outcome parameters are recovery assessment, patients’ and endoscopists’ satisfaction with the procedure, MMSE scores, MET scores, and sleep condition and the number of sedation-related events. Data on sedation-related events are collected by recording of vital signs, including oxygen saturation (SpO2), respiratory rate (RR), heart rate (HR), arrhythmias (electrocardiogram (ECG)), and non-invasive blood pressure (NIBP). Satisfaction parameters and mental states are collected by means of questionnaires and evaluation scales before and after the procedure and on different following days. Discussion: Esketamine can reduce tussis occurrence with good tolerability and relax the bronchus, also provides high clearance rates and low possibility of adverse reactions. Unfortunately esketamine is also known for its psychotomimetic effects. We aim to demonstrate that the combination of esketamine with propofol for sedation in patients subjected to upper GI procedure is nevertheless superior to only administration of propofol or a combination of propofol with other anesthetics, such as opioids or lidocaine. Trial registration: ClinicalTrials.gov. NCT05497492, Registered 09 August 2022. http://www.ClinicalTrials.gov/NCT0549749
Objective Concluding the clinical feature and prognosis of primary testicular lymphoma to improve the understanding of this disease.Methods During 1995 and 2010,17 cases of primary testicular lymphoma treated in Beijing Friendship Hospital of Capital Medical University were retrospectively analyzed of its clinical features,diagnosis,treatment and prognosis.Results Seventeen patients with a mean age of 68 years complained the testicular sohd mass as their first symptoms.The mean tumor diameter was 4.7 cm,and all patients underwent orchidectomy,and testicular non- Hodgkin's lymphoma was confirmed by pathologic examination.Fourteen cases were diffuse large B cell type and 3 cases were anaplastic large cell type.The clinical stage of all the patients was IE.Fourteen cases were followed up (3 cases were lost)with mean follow-up time of 37.8 months by outpatient interview and telephone,all patients were treated with CHOP chemotherapy,and some of them were combined with rituximab and preventive lowdose pelvic radiotherapy.Five cases died of other chronic medical complications,1 case with contralateral testicular metastasis received surgery again.There were 9 tumor free survival cases in total.Conclusion Primary testicular lymphoma is rare and more common in older men.Postoperative pathologic diagnosis is gold standard.The systemic treatment and individual therapy is the first choice for primary testicular lymphoma.
Key words:
Primary testicular lymphoma; Orchidectomy; CHOP chemotherapy; Prognosis
Hypoxemia is a major complication in obese patients undergoing gastrointestinal endoscopy under intravenous anesthesia or sedation due to altered airway anatomy. We design this randomized controlled trial (RCT) to compare efficacy and safety of the Wei nasal jet tube (WNJT) and nasal prongs for supplement oxygen during gastroscopy with intravenous propofol anesthesia in obese patients. The study will be a single-center, prospective RCT. A total of 308 obese patients will be recruited and randomly assigned to receive either the WNJT (group A) or nasal prongs (group B). During gastroscopy with intravenous propofol anesthesia, 5 L/min of oxygen will be delivered through the jet port of the WNJT in the group A and via the nasal prongs in the group B. The primary outcome is the incidence of hypoxemia and severe hypoxemia. The secondary outcomes are adverse events during the gastroscopy, postoperative complications, and satisfaction of the anesthetist, physician, and patient. This RCT aims to clarify whether the WNJT can result in reduced incidences of hypoxemia and complications and provide improved satisfaction to the anesthetist, physician, and patient. Thus, it can be determined if the WNJT is a useful tool for supplement oxygen in obese patients undergoing gastroscopy with intravenous propofol anesthesia. The results will provide the evidence for anesthesiologists to make a decision regarding the choice of supplementary oxygen methods in this condition. Chinese Clinical Trial, ChiCTR-IOR-17013089 . Registered on 23 October 2017.
Background A wealth of evidence from randomized controlled trials (RCTs) has indicated that hypertonic saline (HS) is at least as effective as, if not better than, mannitol in the treatment of increased intracranial pressure(ICP). However, there is little known about the effects of HS in patients during neurosurgery. Thus, this meta-analysis was performed to compare the intraoperative effects of HS with mannitol in patients undergoing craniotomy. Methods According to the research strategy, we searched PUBMED, EMBASE and Cochrane Central Register of Controlled Trials. Other sources such as the internet-based clinical trial registries and conference proceedings were also searched. After literature searching, two investigators independently performed literature screening, quality assessment of the included trials and data extraction. The outcomes included intraoperative brain relaxation, intraoperative ICP, total volume of fluid required, diuresis, hemodynamic parameters, electrolyte level, mortality or dependence and adverse events. Results Seven RCTs with 468 participants were included. The quality of the included trials was acceptable. HS could significantly increase the odds of satisfactory intraoperative brain relaxation (OR: 2.25, 95% CI: 1.32–3.81; P = 0.003) and decrease the mean difference (MD) of maximal ICP (MD: −2.51mmHg, 95% CI: −3.39—1.93mmHg; P<0.00001) in comparison with mannitol with no significant heterogeneity among the study results. Compared with HS, mannitol had a more prominent diuretic effect. And patients treated with HS had significantly higher serum sodium than mannitol-treated patients. Conclusions Considering that robust outcome measures are absent because brain relaxation and ICP can be influenced by several factors except for the hyperosmotic agents, the results of present meta-analysis should be interpreted with cautions. Well-designed RCTs in the future are needed to further test the present results, identify the impact of HS on the clinically relevant outcomes and explore the potential mechanisms of HS.
Objective: The epidural anesthesia and general anesthesia are the most commonly used in lung surgery through video-assisted thoracic surgery (VATS). Each of these methods has their advantages and disadvantages, so the aim of this meta-analysis is to identify which anesthesia is more conducive to lung surgery under VATS and rehabilitation of patients.Materials and Methods: The Cochrane Library Database (Issue 12, 2013), PubMed (1966–2015), and China National Knowledge Infrastructure (1950–2015) were searched without language restrictions. Meta-analyses were conducted using Review Manager 5.2 software (The Cochrane Collaboration, Software Update, Oxford). We calculated odds ratio (OR) and its confidence interval (95% CI) to estimate the difference between epidural anesthesia and general anesthesia through finishing of the collected data.Results: Due to our search results, 7 studies were included in our study. Studies among them show that different contents of these articles are not all the same about research direction. Our findings suggested that epidural anesthesia had more advantages than general anesthesia for operative time (mean difference = − 23.85, 95% CI: − 29.67–− 18.03, P = 0.0001). More than that, epidural anesthesia showed a good surgical outcome on postoperative hospital stay (mean difference = − 0.43, 95% CI: − 0.85–− 0.01, P = 0.04) than general anesthesia. But we found that there were no different on numbers of people with complications (OR = 0.45, 95% CI: 0.23–0.89, P = 0.97) and headache occurrence (OR = 2.69, 95% CI: 0.62–11.70, P = 0.91) between epidural anesthesia and general anesthesia.Conclusion: These results indicated that epidural anesthesia can save operating time and postoperative hospital stay time. But epidural anesthesia and general anesthesia have the same effect on complications.
Abstract Background Tussis, which increases the incidence of airway spasm, aspiration, nausea, and vomiting, is a common complication faced during upper gastrointestinal (GI) endoscopy. However, sedatives and analgesics exhibit inhibitory actions against airway reflexes to different degrees. Our assumption is a combination of propofol and small doses of sufentanil, esketamine, or lidocaine, especially the combination of propofol and esketamine, might reduce tussis incidence. Method The study will be performed as a randomised controlled three-blind, two-centre trial. Patients undergoing upper GI endoscopy, ≥ 18 years old, with American Society of Anesthesiologists (ASA) classification I–III will be randomised to four groups: P group (single administration of propofol), P + S group (administration of propofol and sufentanil in combination), P + K group (administration of propofol and esketamine in combination), and P + L group (administration of propofol and lidocaine in combination) ( N = 100 per group). The primary endpoints include the frequency of tussis, nausea and vomiting, and/or body movements observed at the insertion of the endoscope into the pharyngeal cavity or within 5 min of endoscope insertion. Secondary outcomes are recovery assessment, patients’ and endoscopists’ satisfaction with the procedure, MMSE scores, MET scores, sleep condition, and the number of sedation-related events. Data on sedation-related events are collected by recording of vital signs. Satisfaction parameters and mental states are collected by means of questionnaires and evaluation scales before and after the procedure and on different following days. Discussion Esketamine can reduce tussis occurrence with good tolerability and relax the bronchus and also provides high clearance rates and low possibility of adverse reactions. We aim to demonstrate that the combination of esketamine with propofol for sedation in patients subjected to upper GI procedure is nevertheless superior to only administration of propofol or a combination of propofol with other anaesthetics, such as opioids or lidocaine. Trial registration ClinicalTrials.gov. NCT05497492 , Registered 09 August 2022.
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