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Olsen AA, Burgdorf S, Bigler DR, Siemsen M, Aasvang EK, Goetze JP, Svendsen MBS, Svendsen LB, Achiam MP. Digital thermography complements Laser Speckle Contrast Imaging for the diagnosis of quantified severe mesenteric traction syndrome - A prospective cohort study. Microvasc Res 2024; 154:104690. [PMID: 38670452 DOI: 10.1016/j.mvr.2024.104690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 04/09/2024] [Accepted: 04/16/2024] [Indexed: 04/28/2024]
Affiliation(s)
- August A Olsen
- Department of Surgery and Transplantation, Rigshospitalet, Copenhagen University Hospital, Denmark.
| | - Stefan Burgdorf
- Department of Surgery and Transplantation, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Dennis Richard Bigler
- Department of Cardiothoracic Anesthesiology, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Mette Siemsen
- Department of Cardiothoracic Surgery, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Eske K Aasvang
- Department of Anesthesiology, Rigshospitalet, Copenhagen University Hospital, Denmark; Institute of Clinical Medicine, University of Copenhagen, Denmark
| | - Jens P Goetze
- Department of Clinical Biochemistry, Rigshospitalet, Copenhagen University Hospital, Denmark
| | | | - Lars Bo Svendsen
- Department of Surgery and Transplantation, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Michael Patrick Achiam
- Department of Surgery and Transplantation, Rigshospitalet, Copenhagen University Hospital, Denmark
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Romanzi A, Dragani TA, Adorni A, Colombo M, Farro A, Maspero M, Zamburlini B, Vannelli A. Neuraxial anesthesia for abdominal surgery, beyond the pandemic: a feasibility pilot study of 70 patients in a suburban hospital. Updates Surg 2023; 75:1691-1697. [PMID: 37278936 PMCID: PMC10242600 DOI: 10.1007/s13304-023-01554-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 05/31/2023] [Indexed: 06/07/2023]
Abstract
The aim of this study is to establish the feasibility of awake laparotomy under neuraxial anesthesia (NA) in a suburban hospital. A retrospective analysis of the results of a consecutive series of 70 patients undergoing awake abdominal surgery under NA at the Department of Surgery of our Hospital from February 11th, 2020 to October 20th, 2021 was conducted. The series includes 43 cases of urgent surgical care (2020) and 27 cases of elective abdominal surgery on frail patients (2021). Seventeen procedures (24.3%) required sedation to better control patient discomfort. Only in 4/70 (5.7%) cases, conversion to general anesthesia (GA) was necessary. Conversion to GA was not related to American Society of Anesthesiology (ASA) score or operative time. Only one of the four cases requiring conversion to GA was admitted to the Intensive Care Unit (ICU) postoperatively. Fifteen patients (21.4%) required postoperative ICU support. A statistically non-significant association was observed between conversion to GA and postoperative ICU admission. The mortality rate was 8.5% (6 patients). Five out of six deaths occurred while in the ICU. All six were frail patients. None of these deaths was related to a complication of NA. Awake laparotomy under NA has confirmed its feasibility and safety in times of scarcity of resources and therapeutic restrictions, even in the most frail patients. We believe that this approach should be considered as an useful asset, especially for suburban hospitals.
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Affiliation(s)
- Andrea Romanzi
- Department of General Surgery, Valduce Hospital, via Dante Alighieri 11, 22100, Como, Italy.
| | - Tommaso A Dragani
- Department of Research, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Adele Adorni
- Department of Anesthesiology and Critical Care, Valduce Hospital, Como, Italy
| | - Martina Colombo
- Department of Clinical and Biomedical Sciences "Luigi Sacco", University of Milan, Milan, Italy
| | - Antonio Farro
- Department of Clinical and Biomedical Sciences "Luigi Sacco", University of Milan, Milan, Italy
| | - Mosè Maspero
- Department of Clinical and Biomedical Sciences "Luigi Sacco", University of Milan, Milan, Italy
| | - Beatrice Zamburlini
- Department of Clinical and Biomedical Sciences "Luigi Sacco", University of Milan, Milan, Italy
| | - Alberto Vannelli
- Department of General Surgery, Valduce Hospital, via Dante Alighieri 11, 22100, Como, Italy
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Suzuki M, Shibata J, Mochizuki T, Bito H. Contribution of prophylactic administration of flurbiprofen for mesenteric traction syndrome to postoperative leakage or bleeding in gastrointestinal surgery: a retrospective observational study. Langenbecks Arch Surg 2023; 408:337. [PMID: 37632575 DOI: 10.1007/s00423-023-03077-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 08/17/2023] [Indexed: 08/28/2023]
Abstract
PURPOSE Mesenteric traction syndrome (MTS) sometimes occurs during abdominal surgery. Prophylactic administration of flurbiprofen, a non-steroidal anti-inflammatory drug, prevents the development of MTS. However, administration of non-steroidal anti-inflammatory drugs for postoperative pain increases the incidence of postoperative bleeding. Our aim was to examine the effect of prophylactic flurbiprofen administration on postoperative leakage or bleeding after gastrointestinal surgery. METHODS A retrospective observational study on patients who underwent open or laparoscopic abdominal surgery was conducted. Perioperative, anesthesia and medical records were reviewed. Patients who did (Flurbio-Group) or did not receive (Control-Group) prophylactic flurbiprofen administration were compared. Then, the Flurbio-Group and Control-Group were each divided into two groups according to whether the patients did or did not develop MTS (Flurbio-MTS-Group and Flurbio-no-MTS-Group, respectively, Control-MTS-Group and Control-no-MTS-Group, respectively). RESULTS This study included 188 patients (Flurbio-MTS-Group, 1 patient; Flurbio-no-MTS-Group, 31 patients; Control-MTS-Group, 59 patients; Control-no-MTS-Group, 97 patients). Seventeen patients developed postoperative leakage or bleeding. Eleven Flurbio-MTS-Group patients (18.6%), 4 Flurbio-no-MTS-Group patients (12.9%, 4/31), and only 2 Control-no-MTS-Group patients (2%, 2/97) developed postoperative leakage or bleeding. Multivariate logistic regression analysis demonstrated that there was a qualitative interaction effect between prophylactic administration of flurbiprofen and the development of MTS on postoperative leakage or bleeding. CONCLUSION Prophylactic flurbiprofen administration increased the risk of postoperative leakage or bleeding among patients who did not develop MTS.
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Affiliation(s)
- Manzo Suzuki
- Department of Anesthesiology, Musashikosugi Hospital Nippon Medical School, 1-396 Kosugi-Cho Nakahara-Ku, Kawasaki, Kanagawa, 211-8533, Japan.
- Department of Anesthesiology and Resuscitology (Okazaki Medical Center), Fujita Health University School of Medicine, 1 Gotanda Harizaki-Cho, Okazaki Aichi, 444-0827, Japan.
| | - Junpei Shibata
- Department of Anesthesiology and Resuscitology (Okazaki Medical Center), Fujita Health University School of Medicine, 1 Gotanda Harizaki-Cho, Okazaki Aichi, 444-0827, Japan
| | - Toshiaki Mochizuki
- Department of Anesthesiology and Resuscitology (Okazaki Medical Center), Fujita Health University School of Medicine, 1 Gotanda Harizaki-Cho, Okazaki Aichi, 444-0827, Japan
| | - Hiroyasu Bito
- Department of Anesthesiology and Resuscitology (Okazaki Medical Center), Fujita Health University School of Medicine, 1 Gotanda Harizaki-Cho, Okazaki Aichi, 444-0827, Japan
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Gregersen JS, Bazancir LA, Johansson PI, Sørensen H, Achiam MP, Olsen AA. Major open abdominal surgery is associated with increased levels of endothelial damage and interleukin-6. Microvasc Res 2023; 148:104543. [PMID: 37156371 DOI: 10.1016/j.mvr.2023.104543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 04/19/2023] [Accepted: 04/25/2023] [Indexed: 05/10/2023]
Abstract
OBJECTIVE To examine changes in biomarkers of endothelial glycocalyx shedding, endothelial damage, and surgical stress following major open abdominal surgery and the correlation to postoperative morbidity. INTRODUCTION Major abdominal surgery is associated with high levels of postoperative morbidity. Two possible reasons are the surgical stress response and the impairment of the glycocalyx and endothelial cells. Further, the degree of these responses may correlate with postoperative morbidity and complications. METHODS A secondary data analysis of prospectively collected data from two cohorts of patients undergoing open liver surgery, gastrectomy, esophagectomy, or Whipple procedure (n = 112). Hemodynamics and blood samples were collected at predefined timestamps and analyzed for biomarkers of glycocalyx shedding (Syndecan-1), endothelial activation (sVEGFR1), endothelial damage (sThrombomodulin (sTM)), and surgical stress (IL6). RESULTS Major abdominal surgery led to increased levels of IL6 (0 to 85 pg/mL), Syndecan-1 (17.2 to 46.4 ng/mL), and sVEGFR1 (382.8 to 526.5 pg/mL), peaking at the end of the surgery. In contrast, sTM, did not increase during surgery, but increased significantly following surgery (5.9 to 6.9 ng/mL), peaking at 18 h following the end of surgery. Patients characterized with high postoperative morbidity had higher levels of IL6 (132 vs. 78 pg/mL, p = 0.007) and sVEGFR1 (563.1 vs. 509.4 pg/mL, p = 0.045) at the end of the surgery, and of sTM (8.2 vs. 6.4 ng/mL, p = 0.038) 18 h following surgery. CONCLUSION Major abdominal surgery leads to significantly increased levels of biomarkers of endothelial glycocalyx shedding, endothelial damage, and surgical stress, with the highest levels seen in patients developing high postoperative morbidity.
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Affiliation(s)
| | - Laser Arif Bazancir
- Department of Surgery and Transplantation, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Pär Ingemar Johansson
- Department of Clinical Immunology, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Henrik Sørensen
- Department of Anesthesiology, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Michael Patrick Achiam
- Department of Surgery and Transplantation, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - August Adelsten Olsen
- Department of Surgery and Transplantation, Rigshospitalet, Copenhagen University Hospital, Denmark
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Olsen AA, Burgdorf S, Bigler DR, Siemsen M, Aasvang EK, Goetze JP, Svendsen MBS, Svendsen LB, Achiam MP. Laser Speckle Contrast Imaging-based diagnosis of severe mesenteric traction syndrome: Hemodynamics and prostacyclin - A prospective cohort study. Microvasc Res 2023; 147:104505. [PMID: 36801270 DOI: 10.1016/j.mvr.2023.104505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 02/03/2023] [Accepted: 02/10/2023] [Indexed: 02/18/2023]
Abstract
BRIEF ABSTRACT Today, the diagnosis and grading of mesenteric traction syndrome relies on a subjective assessment of facial flushing. However, this method has several limitations. In this study, Laser Speckle Contrast Imaging and a predefined cut-off value are assessed and validated for the objective identification of severe mesenteric traction syndrome. BACKGROUND Severe mesenteric traction syndrome (MTS) is associated with increased postoperative morbidity. The diagnosis is based on an assessment of the developed facial flushing. Today this is performed subjectively, as no objective method exists. One possible objective method is Laser Speckle Contrast Imaging (LSCI), which has been used to show significantly higher facial skin blood flow in patients developing severe MTS. Using these data, a cut-off value has been identified. This study aimed to validate our predefined LSCI cut-off value for identifying severe MTS. METHODS A prospective cohort study was performed on patients planned for open esophagectomy or pancreatic surgery from March 2021 to April 2022. All patients underwent continuous measurement of forehead skin blood flow using LSCI during the first hour of surgery. Using the predefined cut-off value, the severity of MTS was graded. In addition, blood samples for prostacyclin (PGI2) analysis and hemodynamics were collected at predefined time points to validate the cut-off value. MAIN RESULTS Sixty patients were included in the study. Using our predefined LSCI cut-off value, 21 (35 %) patients were identified as developing severe MTS. These patients were found to have higher concentrations of 6-Keto-PGFaα (p = 0.002), lower SVR (p < 0.001), lower MAP (p = 0.004), and higher CO (p < 0.001) 15 min into surgery, as compared with patients not developing severe MTS. CONCLUSION This study validated our LSCI cut-off value for the objective identification of severe MTS patients as this group developed increased concentrations of PGI2 and more pronounced hemodynamic alterations compared with patients not developing severe MTS.
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Affiliation(s)
- August Adelsten Olsen
- Department of Surgery and Transplantation, Rigshospitalet, Copenhagen University Hospital, Denmark.
| | - Stefan Burgdorf
- Department of Surgery and Transplantation, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Dennis Richard Bigler
- Department of Cardiothoracic Anesthesiology, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Mette Siemsen
- Department of Cardiothoracic Surgery, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Eske Kvanner Aasvang
- Department of Anesthesiology, Rigshospitalet, Copenhagen University Hospital, Denmark; Institute of Clinical Medicine, University of Copenhagen, Denmark
| | - Jens P Goetze
- Department of Clinical Biochemistry, Rigshospitalet, Copenhagen University Hospital, Denmark
| | | | - Lars Bo Svendsen
- Department of Surgery and Transplantation, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Michael Patrick Achiam
- Department of Surgery and Transplantation, Rigshospitalet, Copenhagen University Hospital, Denmark
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Olsen AA, Bazancir LA, Dahl S, Fukumori D, Shiwaku H, Svendsen LB, Achiam MP. Mesenteric traction syndrome - Incidence, impact, and treatment: A systematic scoping review of the literature. Anaesth Crit Care Pain Med 2023; 42:101162. [PMID: 36162787 DOI: 10.1016/j.accpm.2022.101162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 07/14/2022] [Accepted: 09/01/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Mesenteric traction syndrome (MTS) is commonly seen during major abdominal surgery and is characterised by facial flushing, hypotension, and tachycardia 15 min into surgery. MTS also impacts the postoperative course, as severe MTS has been associated with increased postoperative morbidity. However, despite MTS being common and severe MTS causing increased postoperative morbidity, the gaps in the literature are not clearly defined. We aimed to examine the diagnostic criteria, incidence, intraoperative and postoperative impact, and potential preventative measures of MTS while highlighting potential gaps in the literature. METHODS We followed the Prisma guidelines and performed a systematic literature search. We included only human studies examining MTS. All hits were screened for title and abstract, followed by a full-text review by at least two authors for determining eligibility for inclusion. Data were extracted and risk of bias was assessed by two independent reviewers. RESULTS A total of 37 studies, comprising 1102 patients were included in the review. The combined incidence of MTS during open abdominal surgery was found to be 76%, with 35% developing severe MTS. It was found that the development of MTS was associated with marked haemodynamic changes. It was also found that several different subjective diagnostic criteria exist and that severe MTS was associated with increased postoperative morbidity. Furthermore, several preventative measures for protecting against MTS have been examined, but only on the incidence of MTS and not on the postoperative course. CONCLUSION MTS occurs in 76% of patients undergoing major abdominal surgery and is associated with deleterious haemodynamic effects, which are more pronounced in patients developing severe MTS. Severe MTS is also associated with a worse postoperative outcome. However, gaps are still present in the current literature on MTS.
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Affiliation(s)
- August A Olsen
- Department of Surgery and Transplantation, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
| | - Laser A Bazancir
- Department of Surgery and Transplantation, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Stig Dahl
- Department of Surgery and Transplantation, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Daisuke Fukumori
- Department of Surgery and Transplantation, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Hironari Shiwaku
- Department of Gastroenterological Surgery, Fukuoka University Faculty of Medicine, Fukuoka, Japan
| | - Lars Bo Svendsen
- Department of Surgery and Transplantation, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Michael P Achiam
- Department of Surgery and Transplantation, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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Olsen AA, Svendsen LB, Achiam MP. Mesenteric traction syndrome – It is not just benign flushing. J Clin Anesth 2022; 80:110822. [DOI: 10.1016/j.jclinane.2022.110822] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 03/31/2022] [Accepted: 04/03/2022] [Indexed: 01/23/2023]
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Evaluation of the systemic inflammatory response, endothelial cell dysfunction, and postoperative morbidity in patients, receiving perioperative corticosteroid, developing severe mesenteric traction syndrome — an exploratory study. Langenbecks Arch Surg 2022; 407:2095-2103. [DOI: 10.1007/s00423-022-02507-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 04/01/2022] [Indexed: 01/01/2023]
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Zheng C, Luo C, Xie K, Li JS, Zhou H, Hu LW, Wang GM, Shen Y. OUP accepted manuscript. Interact Cardiovasc Thorac Surg 2022; 35:6549451. [PMID: 35293571 DOI: 10.1093/icvts/ivac045] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 01/24/2022] [Accepted: 02/02/2022] [Indexed: 11/14/2022] Open
Affiliation(s)
- Chao Zheng
- Department of Cardiothoracic Surgery, Jinling Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Chao Luo
- Department of Cardiothoracic Surgery, Jinling Hospital, Southern Medical University, Guangzhou, China
| | - Kai Xie
- Department of Cardiothoracic Surgery, Jinling Hospital, Jinling School of Clinical Medicine, Nanjing Medical University, Nanjing, China
| | - Jiang-Shan Li
- University of Science and Technology Beijing, Beijing, China
| | - Hai Zhou
- Department of Cardiothoracic Surgery, Nanjing second Hospital, Medical School of Southeast University, Nanjing, China
| | - Li-Wen Hu
- Department of Cardiothoracic Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Gao-Ming Wang
- Department of Thoracic Surgery, Xuzhou Clinical School of Xuzhou Medical University, Xuzhou, China
- Department of Thoracic Surgery, Xuzhou Central Hospital, Xuzhou, China
| | - Yi Shen
- Department of Cardiothoracic Surgery, Jinling Hospital, School of Medicine, Southeast University, Nanjing, China
- Department of Cardiothoracic Surgery, Jinling Hospital, Southern Medical University, Guangzhou, China
- Department of Cardiothoracic Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
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Strandby RB, Osterkamp JTF, Ambrus R, Henriksen A, Goetze JP, Secher NH, Achiam MP, Svendsen L. Mesenteric traction syndrome in pigs: A single-blinded, randomized controlled trial. Animal Model Exp Med 2021; 4:162-168. [PMID: 34179723 PMCID: PMC8212818 DOI: 10.1002/ame2.12160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 02/01/2021] [Indexed: 12/03/2022] Open
Abstract
Background Mesenteric traction syndrome is commonly observed in patients undergoing upper abdominal surgery and is associated with severe postoperative complications. A triad of hypotension, tachycardia, and facial flushing seems provoked by prostacyclin (PGI2) release from the gut in response to mesenteric traction. The administration of nonsteroidal anti-inflammatory drugs (NSAID) inhibits PGI2 release, stabilizing the hemodynamic response. Here, we examined the effect of mesenteric traction on splanchnic blood flow in pigs randomized to NSAID or placebo treatment. Materials and Methods Twenty pigs were allocated to either ketorolac or placebo treatment. Five minutes of manual mesenteric traction was applied. Plasma 6-keto-PGF1α, a stable metabolite of PGI2, hemodynamic variables, and regional blood flow (laser speckle contrast imaging) to the liver, stomach, small intestine, upper lip, and snout (laser Doppler flowmetry) were recorded prior to traction and 5 and 30 minutes thereafter. Results Both groups of pigs presented a decrease in systemic vascular resistance (P = .01), mean arterial blood pressure (P = .001), and blood flow in the gastric antrum (P = .002). Plasma 6-keto-PGF1α did not increase in either group (P = .195), and cardiac output, heart rate, central venous pressure, and blood flow to the liver, small intestine, upper lip, and snout remained unchanged. Conclusion Mesenteric traction resulted in cardiovascular depression, including reduced blood flow in the gastric antrum. Plasma 6-keto-PGF1α did not increase, and ketorolac administration did not alter the response to mesenteric traction. Furthers studies are needed to identify which substance is responsible for eliciting the cardiovascular response to mesenteric traction in pigs.
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Affiliation(s)
- Rune B. Strandby
- Department of Surgical Gastroenterology, RigshospitaletUniversity of CopenhagenCopenhagen ØDenmark
| | - Jens T. F. Osterkamp
- Department of Surgical Gastroenterology, RigshospitaletUniversity of CopenhagenCopenhagen ØDenmark
| | - Rikard Ambrus
- Department of Surgical Gastroenterology, RigshospitaletUniversity of CopenhagenCopenhagen ØDenmark
| | - Amelie Henriksen
- Department of Surgical Gastroenterology, RigshospitaletUniversity of CopenhagenCopenhagen ØDenmark
| | - Jens P. Goetze
- Department of Clinical Biochemistry, RigshospitaletUniversity of CopenhagenCopenhagen ØDenmark
| | - Niels H. Secher
- Department of Anaesthesia, RigshospitaletUniversity of CopenhagenCopenhagen ØDenmark
| | - Michael P. Achiam
- Department of Surgical Gastroenterology, RigshospitaletUniversity of CopenhagenCopenhagen ØDenmark
| | - Lars‐Bo Svendsen
- Department of Surgical Gastroenterology, RigshospitaletUniversity of CopenhagenCopenhagen ØDenmark
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Severe mesenteric traction syndrome is associated with increased systemic inflammatory response, endothelial dysfunction, and major postoperative morbidity. Langenbecks Arch Surg 2021; 406:2457-2467. [PMID: 33686490 DOI: 10.1007/s00423-021-02111-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 02/01/2021] [Indexed: 01/01/2023]
Abstract
This study aimed to determine if mesenteric traction syndrome (MTS) triggers increased systemic inflammation and endothelial cell dysfunction. Patients developing severe MTS had pronounced early IL6 elevations followed by endothelial cell damage. Furthermore, these processes were associated with increased postoperative morbidity. OBJECTIVE To determine whether mesenteric traction syndrome (MTS) leads to increased systemic inflammation and dysfunction of the glycocalyx and endothelial cell and whether this correlates with the degree of postoperative morbidity. INTRODUCTION Severe MTS is associated with increased postoperative morbidity following major gastrointestinal surgery, but the pathophysiological mechanism has not been previously explored. Systemic inflammatory response and impaired glycocalyx and endothelial cells may be responsible for the development of symptoms. METHODS The study analyzed prospectively collected data from two cohorts (n = 67). The severity of the MTS response was graded intraoperatively and blood samples for PGI2, catecholamines, IL6, and endothelial biomarkers obtained at predefined time points. RESULTS Patients undergoing either esophagectomy (n = 45) or gastrectomy (n = 22) were included. Surgery led to significantly increased plasma concentrations of all biomarkers. Yet, patients who developed severe MTS had higher baseline epinephrine levels (p < 0.05) and higher levels of PGI2 (p < 0.05), Syndecan-1 (p < 0.001), and sVEGFR1 (p < 0.001). Peak values of IL6, Syndecan-1, sVEGFR1, and sTM all correlated to peak PGI2. Lastly, patients with high postoperative morbidity had higher baseline epinephrine (p = 0.009) and developed higher plasma IL6 (p = 0.007) and sTM (p = 0.022). CONCLUSION The development of severe MTS during upper gastrointestinal surgery is associated with preoperative elevated plasma epinephrine and further a more pronounced proinflammatory response and damage to the vascular endothelium. The increased postoperative morbidity seen in patients with severe MTS may thus, in part, be explained by an inherent susceptibility towards an inappropriate secretion of PGI2, which leads to an increased surgical stress response and endothelial damage. These findings must be confirmed in a new prospective cohort.
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Strandby RB, Ambrus R, Ring LL, Nerup N, Secher NH, Goetze JP, Achiam MP, Svendsen LB. Hypotension Associated with MTS is Aggravated by Early Activation of TEA During Open Esophagectomy. Local Reg Anesth 2021; 14:33-42. [PMID: 33688249 PMCID: PMC7936689 DOI: 10.2147/lra.s294556] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Accepted: 02/04/2021] [Indexed: 12/13/2022] Open
Abstract
Objective A mesenteric traction syndrome (MTS) is elicited by prostacyclin (PGI2)-induced vasodilation and identified by facial flushing, tachycardia, and hypotension during abdominal surgery. We evaluated whether thoracic epidural anesthesia (TEA) influences the incidence of MTS. Design Randomized, blinded controlled trial. Setting Single-center university hospital. Participants Fifty patients undergoing open esophagectomy. Interventions Patients were randomized to either early (EA, after induction of general anesthesia) or late activation of TEA (LA, after re-established gastric continuity). Plasma 6-keto-PGF1α, a stable metabolite of PGI2 and interleukine-6 (IL6) were measured in plasma during surgery along with hemodynamic variables and MTS graded according to facial flushing together with plasma C-reactive protein on the third post-operative day. Results Forty-five patients met the inclusion criteria. Development of MTS tended to be more prevalent with EA (n=13/25 [52%]) than with LA TEA (n=5/20 [25%], p=0.08). For patients who developed MTS, there was a transient increase in plasma 6-keto-PGF1α by 15 min of surgery and plasma IL6 (p<0.001) as C-reactive protein (P<0.009) increased. EA TEA influenced the amount of phenylephrine needed to maintain mean arterial pressure >60 mmHg in patients who developed MTS (0.16 [0.016–0.019] mg/min vs MTS and LA TEA 0.000 [0.000–0.005] mg/min, p<0.001). Conclusion The incidence of MTS is not prevented by TEA in patients undergoing open esophagectomy. On the contrary, the risk of hypotension is increased in patients exposed to TEA during surgery, and the results suggest that it is advantageous to delay activation of TEA. Also, MTS seems to be associated with a systemic inflammatory response, maybe explaining the aggravated post-operative outcome.
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Affiliation(s)
- Rune B Strandby
- Department of Surgical Gastroenterology, Rigshospitalet, Institute for Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Rikard Ambrus
- Department of Surgical Gastroenterology, Rigshospitalet, Institute for Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Linea L Ring
- Department of Surgical Gastroenterology, Rigshospitalet, Institute for Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Nikolaj Nerup
- Department of Surgical Gastroenterology, Rigshospitalet, Institute for Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Niels H Secher
- Department of Anesthesia, Rigshospitalet, Institute for Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jens P Goetze
- Department of Clinical Biochemistry, Rigshospitalet, Institute for Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Michael P Achiam
- Department of Surgical Gastroenterology, Rigshospitalet, Institute for Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Lars B Svendsen
- Department of Surgical Gastroenterology, Rigshospitalet, Institute for Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Osterkamp J, Strandby R, Nerup N, Svendsen M, Svendsen L, Achiam M. Quantitative fluorescence angiography detects dynamic changes in gastric perfusion. Surg Endosc 2020; 35:6786-6795. [PMID: 33258036 DOI: 10.1007/s00464-020-08183-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 11/17/2020] [Indexed: 02/06/2023]
Abstract
INTRODUCTION The use of Indocyanine green (ICG) fluorescence angiography (ICG-FA) is an applied method to assess visceral perfusion during surgical procedures worldwide. Further development has entailed quantification of the fluorescence signal; however, whether quantified ICG-FA can detect intraoperative changes in perfusion after hemorrhage has not been investigated previously. In this study, we investigated whether a quantification method, developed and validated in our department (q-ICG), could detect changes in gastric perfusion induced by hemorrhage and resuscitation. METHODS Ten pigs were included in the study. Specific regions of interest of the stomach were chosen, and three q-ICG measurements of gastric perfusion obtained: 20 min after completion of the laparoscopic setup (baseline), after reducing the circulating blood volume by 30%, and after reinfusion of the withdrawn blood volume. Hemodynamic variables were recorded, and blood samples were collected every 10 min during the procedure. RESULTS The reduction in blood volume generated decreased gastric perfusion (q-ICG) from baseline (p = 0.023), and gastric perfusion subsequently increased (p < 0.001) after the reintroduction of the withdrawn blood volume. Cardiac output (CO) and mean arterial blood pressure (MAP) shifted correspondingly and the gastric perfusion correlated to CO (r = 0.575, p = 0.001) and MAP (r = 0.436, p = 0.018). CONCLUSION We present a novel study showing that the q-ICG method can detect dynamic changes in local tissue perfusion induced by hemorrhage and resuscitation. As regional gastrointestinal perfusion may be significantly reduced, while hemodynamic variables such as MAP or heart rate remain stable, q-ICG may provide an objective, non-invasive method for detecting regional early ischemia, strengthening surgical decision making.
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Affiliation(s)
- Jens Osterkamp
- Department of Surgical Gastroenterology, Rigshospitalet, University Hospital of Copenhagen, Inge Lehmanns Vej 7, 2100, Copenhagen, Denmark.
| | - Rune Strandby
- Department of Surgical Gastroenterology, Rigshospitalet, University Hospital of Copenhagen, Inge Lehmanns Vej 7, 2100, Copenhagen, Denmark
| | - Nikolaj Nerup
- Department of Surgical Gastroenterology, Rigshospitalet, University Hospital of Copenhagen, Inge Lehmanns Vej 7, 2100, Copenhagen, Denmark
| | - Morten Svendsen
- Copenhagen Academy of Medical Education and Simulation, Rigshospitalet, University Hospital of Copenhagen, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Lars Svendsen
- Department of Surgical Gastroenterology, Rigshospitalet, University Hospital of Copenhagen, Inge Lehmanns Vej 7, 2100, Copenhagen, Denmark
| | - Michael Achiam
- Department of Surgical Gastroenterology, Rigshospitalet, University Hospital of Copenhagen, Inge Lehmanns Vej 7, 2100, Copenhagen, Denmark
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Chen Z, Shao DH, Ma XD, Mao ZM. Dexmedetomidine aggravates hypotension following mesenteric traction during total gastrectomy: a randomized controlled trial. Ann Saudi Med 2020; 40:183-190. [PMID: 32493029 PMCID: PMC7270615 DOI: 10.5144/0256-4947.2020.183] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 02/13/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Mesenteric traction syndrome (MTS), which is characterized by arterial hypotension and tachycardia following mesenteric traction (MT), frequently occurs during abdominal surgery. Dexmedetomidine, commonly used in general anesthesia during major surgery, has a sympatholytic effect and attenuates the compensatory response to hypotension. OBJECTIVE Assess the effect of dexmedetomidine on hypotension following mesenteric traction. DESIGN Prospective, randomized, controlled clinical trial. SETTING Department of Anesthesiology, Zhenjiang First People's Hospital in China. PATIENTS AND METHODS Patients were randomly divided into three groups. Dexmedetomidine, 0.5 or 1.0 µg/kg, was intravenously administered over 15 minutes before skin incision followed by a maintenance rate of 0.5 µg/kg/h in groups D1 and D2, respectively; saline was administered in group C. MAIN OUTCOME MEASURE(S) The duration of hypotension, heart rate and plasma norepinephrine level in patients with MTS were recorded within 60 minutes following MT. SAMPLE SIZE 75 patients. RESULTS The duration of hypotension in the MTS patients in group D1 and D2 was significantly longer than that in groups C (D1 vs. C, P<.05; D2 vs. C, P<.01). Significantly more phenylephrine was required to treat hypotension in group D1 and D2 than was required for patients in group C (P<.05). The increase in heart rate during the first 15 minutes of MT in group D2 was significantly attenuated compared to that in group C (P<.0083). The increases in norepinephrine levels during the first 15 minutes of MT in group C were significantly higher than those in groups D1 and D2 (P<.0167). CONCLUSION Adjunctive dexmedetomidine in general anesthesia aggravates hypotension during MTS in open total gastrectomy. LIMITATIONS Postoperative complications were not evaluated. CONFLICT OF INTEREST None.
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Affiliation(s)
- Zheng Chen
- From the Department of Anesthesiology, Zhenjiang First People's Hospital, Zhenjiang, Jiangsu, China
| | - Dong-Hua Shao
- From the Department of Anesthesiology, Zhenjiang First People's Hospital, Zhenjiang, Jiangsu, China
| | - Xiao-Dong Ma
- From the Department of Anesthesiology, Zhenjiang First People's Hospital, Zhenjiang, Jiangsu, China
| | - Zu-Min Mao
- From the Department of Anesthesiology, Zhenjiang First People's Hospital, Zhenjiang, Jiangsu, China
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