Prevalence and impact of incompetence of internal jugular valve on postoperative cognitive dysfunction in elderly patients undergoing robot-assisted laparoscopic radical prostatectomy

Assessing Stress Induced by Fluid Shifts and Reduced Cerebral Clearance during Robotic-Assisted Laparoscopic Radical Prostatectomy under Trendelenburg Positioning (UroTreND Study)

In addition to general anesthesia and mechanical ventilation, robotic-assisted laparoscopic radical prostatectomy (RALP) necessitates maintaining a capnoperitoneum and placing the patient in a pronounced downward tilt (Trendelenburg position). While the effects of the resulting fluid shift on the cardiovascular system seem to be modest and well tolerated, the effects on the brain and the blood-brain barrier have not been thoroughly investigated. Previous studies indicated that select patients showed an increase in the optic nerve sheath diameter (ONSD), detected by ultrasound during RALP, which suggests an elevation in intracranial pressure. We hypothesize that the intraoperative fluid shift results in endothelial dysfunction and reduced cerebral clearance, potentially leading to transient neuronal damage. This prospective, monocentric, non-randomized, controlled clinical trial will compare RALP to conventional open radical prostatectomy (control group) in a total of 50 subjects. The primary endpoint will be the perioperative concentration of neurofilament light chain (NfL) in blood using single-molecule array (SiMoA) as a measure for neuronal damage. As secondary endpoints, various other markers for endothelial function, inflammation, and neuronal damage as well as the ONSD will be assessed. Perioperative stress will be evaluated by questionnaires and stress hormone levels in saliva samples. Furthermore, the subjects will participate in functional tests to evaluate neurocognitive function. Each subject will be followed up until discharge. Conclusion: This trial aims to expand current knowledge as well as to develop strategies for improved monitoring and higher safety of patients undergoing RALP. The trial was registered with the German Clinical Trials Register DRKS00031041 on 11 January 2023.

Effect of internal jugular vein catheterization on intracranial pressure and postoperative cognitive function in patients undergoing robot-assisted laparoscopic surgery

Background

We aimed to evaluate the effects of internal jugular vein (IJV) catheterization on intracranial pressure (ICP) and postoperative delirium (POD) during robot-assisted laparoscopic surgery by measuring the optic nerve sheath diameter (ONSD).

Methods

Data from a prospective single-center cohort study, conducted from October 2021 to February 2022, were used. Forty out of 80 patients scheduled for laparoscopic radical hysterectomy or prostatectomy were assigned to the group receiving IJV catheterization (Group I), and the other 40 only received peripheral venous cannulation (Group C) according to clinical need of patients. Ultrasonography of ONSDs, the proportion of regurgitation time in a cardiac cycle, and hemodynamic parameters were measured at four time points: immediately after induction of anesthesia in the supine position (T0), 30 min (T1), 60 min (T2) after orienting to the Trendelenburg position, and before returning to the supine position at the end of surgery (T3). Time to eye opening and emergence stay, POD, and QoR-15 were compared.

Results

The ONSDs increase gradually as the surgery progressed. Group I showed a higher value of ONSD at T1 (4.72 ± 0.29 mm vs. 4.5 ± 0.33 mm, p = 0.0057) and T3 (5.65 ± 0.33 mm vs. 5.26 ± 0.31 mm, p < 0.0001). The proportions of the regurgitation time of IJVV were greater in Group I than those in Group C at T1 (14.95, 8.5%-18.9% vs. 9.6%, 0%-17.2%, p < 0.0001) and T3 (14.3, 10.6%-18.5% vs. 10.4%, 0%-16.5%, p = 0.0003). Group I had a delayed time to eye opening (10.7 ± 1.72 min vs. 13.3 ± 2.35 min, p < 0.0001) and emergence stay (32.2 ± 5.62 min vs. 39.9 ± 6.7 min, p < 0.0001). There were no significant differences in POD and QoR-15 between the two groups on day three.

Conclusion

IJV cannulation may not be the preferred approach in robot-assisted laparoscopic surgery as it was risk factor for IJVV regurgitation, ICP elevation, emergence delayed.

Changes in cerebral oxygen saturation with the Trendelenburg position and increased intraabdominal pressure in laparocopic rectal surgery

Objectives

Position changes and increased intra-abdominal pressure in laparoscopic interventions lead to some physiopathological changes. There is no definite information in the literature regarding cerebral oxygen saturation in patients undergoing colorectal surgery. Our aim was to investigate whether there is oxygen saturation change in the brain tissue in pneumoperitoneum and the Trendelenburg position during laparoscopic rectal surgery.

Material and Methods

Cerebral oxygen saturation was measured in 35 patients who underwent laparoscopic rectal surgery in the Trendelenburg position. Measurements were made under general anesthesia in the pneumoperitoneum and the Trendelenburg position.

Results

The values that are statistically affected by the position are systolic blood pressure, mean arterial blood pressure and cerebral oxygen saturation. The Trendelenburg position does not disturb the cerebral oxygen saturation and it causes an increase in saturation. After pneumoperitoneum occurred, changes in systolic blood pressure, mean arterial blood pressure and brain oxygen saturation were detected. Cerebral oxygen saturation increases with the formation of pneumoperitoneum.

Conclusion

The Trendelenburg position and increased intraabdominal pressure during laparoscopic rectal surgery do not impair brain oxygen saturation.

Intracranial venous reflux without the central venous occlusive disease in a patient receiving hemodialysis through brachio-brachial arteriovenous fistula: A case report

Background

Upper-limb arteriovenous fistula as a hemodialysis access among patients with end-stage renal disease (ESRD) has become a preferred type of vascular access. However, complications involving the central nervous system may occur. There have been no reported cases of internal jugular vein (IJV) regurgitation without central venous occlusive diseases (CVODs).We describe the case of a patient on HD who presented with symptomatic IJV regurgitation without CVODs.

Case Description

An 83-year-old man with ESRD receiving HD through a left upper-limb AVF presented with impaired consciousness and seizures. After recovery from unconsciousness, he became alert with cognitive impairment. The left subclavian arteriography revealed early filling of the left subclavian vein due to the AVF on the left brachium, with retrograde high-flow venous reflux to the left IJV, sigmoid and transverse sinuses, with the left central veins patent. All cerebral venous drainage procedures were dependent on the right IJV. The left internal carotid arteriography showed venous congestion of the left hemisphere. The flow of the left brachial artery was measured extremely high. Under compression of the left brachial artery to reduce the flow, the regurgitation persisted. With the findings that all cerebral venous return were in the right IJV, sacrificing the left IJV was thought to be acceptable. Left IJV ligation was performed, and the patient's cognitive function improved.

Conclusion

The short-term outcome after IJV ligation may be positive in the patient who was confirmed to have a normal cerebral venous return route independent of the refluxed IJV.

Effects of stage I hypertension on the recovery of early postoperative attention network function in elderly patients undergoing elective hip or knee arthroplasty surgery

Background/aim

Hypertension is an important risk factor for cognitive impairment. This study explored whether elderly patients with stage I hypertension (HPs) and normotensive patients (NPs) showed differences in the recovery of postoperative attention network function according to the attentional network test (ANT) performance.

Materials and methods

Of 110 patients screened, 25 HPs and 25 NPs completed this study. The Mini-Mental State Examination (MMSE) was applied to all participants before the operation and the ANT (on days 2 and 7) after the operation. All participants completed 1 day preoperatively and the ANT on postoperative days (PODs) 2 and 7.

Results

Compared with NPs, HPs had significantly lower alerting network effect scores and more difficulty resolving conflict on POD 7. However, no significant difference was observed between the groups on POD 2. Orienting network performance was similar between the groups at all time points. Significant differences in alerting and executive control network performances were observed between PODs 2 and 7 in each group.

Conclusion

HPs showed selective cognitive impairment at different time points following elective hip or knee arthroplasty. Compared with NPs, during the first postoperative week, HPs were more likely to experience delayed recovery of alerting and executive control network function, but not orienting network function.

Mechanical Function of Internal Jugular Vein Valve: Post-analysis of M-Mode Imaging under Cardiac Monitoring

Because the internal jugular vein (IJV) valve is the only protective valve between the brain and heart, recent studies have focused on the dynamic behaviour of the valve and its importance in regulating the cerebral blood outflow pathway. However, the mechanism underlying valve opening and closure, as well as the normal opening time, has not been investigated before. The aim of the study described here was to investigate IJV physiology in healthy young adults by means of ultrasound imaging. Twenty-four normal young adults (16 male, 8 female, 21.79 ± 0.79 y of age) were enrolled in this study. Each participant underwent IJV B- and M-mode ultrasound scans of the neck veins in supine position. Data on IJV leaflet movement and IJV blood velocity were extracted from images with the associated electrocardiogram traces to analyze the opening and closure cycles of IJV leaflets. The normal opening time calculated in this study includes 70% of the dynamic valve cycle. The normal opening time of the IJV valve could be a new physiologic metric and serves as a premise for further studies in the field of cerebral venous return.

Effects of pneumoperitoneum and steep Trendelenburg position on cerebral hemodynamics during robotic-assisted laparoscopic radical prostatectomy: A randomized controlled study

BACKGROUND

We evaluated the relationship between ultrasonographical acquired parameters and short-term postoperative cognitive function in patients undergoing robotic-assisted radical prostatectomy (RALP).

METHODS

Ninety elderly patients scheduled for RALP had their optic nerve sheath diameter (ONSD), the cross-sectional area (CSA) of the internal jugular vein (IJV) and the IJV valve (IJVV) competency assessed by ultrasound. The patients were analyzed in 2 groups based on whether displayed IJVV incompetency (IJVVI). The 3 parameters were measured before anesthesia (T0), immediately after induction of general anesthesia (T1), 5 minutes after establishing pneumoperitoneum (T2), 5 minutes after placing the patient in the Trendelenburg position (T3), and 5 minutes after the release of the pneumoperitoneum in the supine position (T4). Regional cerebral tissue oxygen saturation (rSO2) was also measured by near-infrared spectroscopy intraoperatively. The Mini-Mental State Examination (MMSE) and Confusion Assessment Method (CAM) were performed the day before surgery and on postoperative days 1, 3, and 7.

RESULTS

We found that 52% of patients had evidence of IJVVI after being placed in the Trendelenburg position after pneumoperitoneum was established (T4). Patient with IJVVI showed a significant increase of ONSD and CSA at T1, T2, T3, T4 but there was no associated decrease in rSO2. MMSE scores were reduced at postoperative day 1 and the 7 patients that developed postoperative delirium came from Group IJVVI.

CONCLUSIONS

Our observations suggest that elderly patients that show IJVVI after adequate positioning for RALP may develop elevated intracranial pressure as well as mildly compromised postoperative cognitive function in the short term.

Complications in robotic urological surgeries and how to avoid them: A systematic review

Objectives

To review the main complications related to the robot-assisted laparoscopic (RAL) approach in urology and to suggest measures to avoid such issues.

Methods

A systematic search for articles of the contemporary literature was performed in PubMed database for complications in RAL urological procedures focused on positioning, access, and operative technique considerations. Each complication topic is followed by recommendations about how to avoid it.

Results

In all, 40 of 253 articles were included in this analysis. Several complications in RAL procedures can be avoided if the surgical team follows some key steps. Adequate patient positioning must avoid skin, peripheral nerve, and muscles injuries, and ocular and cognitive complications mainly related to steep Trendelenburg positioning in pelvic procedures. Port-site access and closure should not be neglected during minimally invasive procedures as these complications although rare can be troublesome. Technique-related complications depend on surgeon experience and the early learning curve should be monitored.

Conclusions

Adequate patient selection, surgical positioning, mentorship training, and avoiding long-lasting procedures are essential to prevent RAL-related complications. The robotic surgical team must be careful and work together to avoid possible complications. This review offers several steps in surgical planning to reach this goal.