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Zheng X, Gao Z, Li Y, Wang Y, Guo C, Du X, Shen Q, Zhang X, Yang H, Yin X, Sun J, Wang H, Wan M, Zheng L. Impact and effect of preoperative short-term preoperative pulmonary-related training on patients with gastric cancer: a randomized controlled single center trial. J Gastrointest Surg 2024:S1091-255X(24)00589-4. [PMID: 39181232 DOI: 10.1016/j.gassur.2024.08.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2024] [Revised: 07/28/2024] [Accepted: 08/18/2024] [Indexed: 08/27/2024]
Abstract
PURPOSE This study aimed is to evaluate the impact of pre- and postoperative pulmonary-related training, including respiratory and aerobic training, on postoperative pulmonary complications (PPCs) after radical resection of gastric cancer (GC). METHODS We conducted a randomized controlled trial of 121 participants who received a systematic, comprehensive, high-intensity pulmonary exercise regimen for 5 days preoperatively and at least 5 days postoperatively. The control group received standard preoperative care. We analyzed the occurrence of PPCs in both groups as the primary outcome RESULTS: A total of 43 of 121 participants (35.5%) were diagnosed as having PPCs, and the incidence of PPCs was markedly lower in the training group than in the control group (26.2% [16 of 61] vs 45.0% [27 of 60]; P = .031). Moreover, the duration of the postoperative hospital stay was shorter in the training group (8.69 ± 1.92 days) than the control group (9.57 ± 2.16 days; P = .020) and reduced hospitalization costs, amounting to €9605.1 ± €2556.26 in the training group and €10,594.6 ± €2560.7 in the control group (P = .035). CONCLUSION Our study established that a perioperative pulmonary-related training notably diminishes the incidence of PPCs, curtails the duration of hospitalization, and mitigates hospitalization expenses for patients undergoing GC surgery.
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Affiliation(s)
- Xuefeng Zheng
- Department of Gastrointestinal Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Zehao Gao
- Department of Gastrointestinal Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yinling Li
- Department of Gastrointestinal Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yuyang Wang
- Department of Rehabilitation Medicine, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Caihong Guo
- Department of Respiratory Medicine, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xiaoyan Du
- Department of Gastrointestinal Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Qiuxia Shen
- Department of Gastrointestinal Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xue Zhang
- Department of Gastrointestinal Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Hongjun Yang
- Department of Gastrointestinal Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xiaoying Yin
- Department of Gastrointestinal Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Jing Sun
- Department of Gastrointestinal Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Hong Wang
- Department of Gastrointestinal Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Minmin Wan
- Department of Gastrointestinal Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Longbo Zheng
- Department of Gastrointestinal Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China.
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Qin PP, Jin JY, Wang WJ, Min S. Perioperative breathing training to prevent postoperative pulmonary complications in patients undergoing laparoscopic colorectal surgery: A randomized controlled trial. Clin Rehabil 2020; 35:692-702. [PMID: 33283533 DOI: 10.1177/0269215520972648] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE The aim of this study was to determine whether perioperative breathing training reduces the incidence of postoperative pulmonary complications in patients undergoing laparoscopic colorectal surgery. DESIGN A randomized controlled trial. SETTING University hospital. SUBJECTS A total of 240 patients undergoing laparoscopic colorectal surgery participated in this study. INTERVENTION The enrolled patients were randomized into an intervention or control group. Patients in the intervention group received perioperative breathing training, including deep breathing and coughing exercise, balloon-blowing exercise, and pursed lip breathing exercise. The control group received standard perioperative care without any breathing training. MAIN MEASURES The primary endpoint was the incidence of postoperative pulmonary complications. The secondary objectives were to evaluate the effect of perioperative breathing training on arterial oxygenation, incidence of other postoperative complications, patient satisfaction, length of stay, and hospital charges. RESULTS The incidence of postoperative pulmonary complications in the breathing training group was lower than that in the control group (5/120 [4%] vs 14/120 [12%]; RR 0.357, 95%CI 0.133-0.960; P = 0.031). In addition, PaO2 and arterial oxygenation index on the first and fourth days after surgery were significantly higher in the breathing training group than in the control group (P < 0.001). In addition, patients with breathing training had shorter length of stay (6d [IQR 5-7] vs 8d [IQR 7-9]), lower hospital charges (7761 ± 1679 vs 8212 ± 1326), and higher patient satisfaction (9.46 ± 0.65 vs 9.21 ± 0.47) than those without. CONCLUSION Perioperative breathing training may reduce the incidence of postoperative pulmonary complications and preserve of arterial oxygenation after laparoscopic colorectal surgery.
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Affiliation(s)
- Pei-Pei Qin
- The Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Ju-Ying Jin
- The Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wen-Jian Wang
- The Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Su Min
- The Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Quintero OI, Chavarro PA, Martínez W, García C, Castro AM, Manzano-Nunez R, Ospina GA. Improvement in Lung Insufflation in Spontaneously Breathing Tracheostomized Patients by Using a New Pulmonary Expansion Device: A Pilot Study. J Med Device 2020. [DOI: 10.1115/1.4048801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Abstract
Lung expansion techniques (LETs) are a key component of pulmonary rehabilitation. Nevertheless, these can be limited in tracheostomized patients because of the infraglottic position of tracheostomy cannulas. We propose a novel pulmonary expansion device (PED) that allows deep inspiration with a postinspiratory pause for a few seconds by means of a unidirectional valve and an occlusion/flow release cap. It is equipped with a relief valve that opens at 60 cm H2O in cases in which this threshold is attained. We aimed to evaluate the impact on lung volume and pressure in spontaneously breathing tracheostomized patients subjected to LETs. A single-arm pilot interventional study was conducted in an adult intensive care unit (ICU), including spontaneously breathing tracheostomized patients. 80 treatments were performed on 10 patients with tracheostomies with PED over a period of 3 months. The maximal inspiratory volume (MIV) was significantly increased by using PED (MIV-PED) at both day 1 (725 (600–820) mL versus 1550 (1250–1700) mL, P < 0.001) and day 3 (870 (750–950) mL versus 1662 (1550–1900) mL, P < 0.001). Inspiratory pause pressure (PIP-PED) did not significantly change from day 1 to day 3 (18 (14–20) cm H2O versus 14 (12–22) cm H2O, P = 0.36). The use of the PED in tracheostomy patients acted as an artificial glottis by performing a novel pulmonary re-expansion maneuver, and increased volumes and intrapulmonary pressure with prolongation of maximum inspiration were achieved.
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Affiliation(s)
- Oscar I. Quintero
- Centro de Investigaciones Clínicas, Fundación Valle del Lili, Cali 760026, Colombia
| | - Paola A. Chavarro
- Facultad de Salud, Escuela de Rehabilitación Humana, Universidad del Valle, Cali 760043, Colombia
| | - William Martínez
- Departamento de Neumología, Fundación Valle del Lili, Cali 760026, Colombia; Facultad de ciencias de la salud, Universidad Icesi, Cali 760031, Colombia
| | - Carlos García
- Departamento de Radiología, Fundación Valle del Lili, Cali 760026, Colombia
| | - Andrés M. Castro
- Centro de Investigaciones Clínicas, Fundación Valle del Lili, Cali 760026, Colombia
| | - Ramiro Manzano-Nunez
- Centro de Investigaciones Clínicas, Fundación Valle del Lili, Cali 760026, Colombia
| | - Gustavo A. Ospina
- Departamento de Cuidado Intensivo Adulto, Fundación Valle del Lili, Cali 760026, Colombia
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Tosta ADM, Borges MDC, Silva ÉMCD, Silva AAD, Crema E. Pre- and postoperative respiratory muscle strength, body mass index and fasting glucose profile of patients with type 2 diabetes mellitus submitted to metabolic surgery. FISIOTERAPIA EM MOVIMENTO 2020. [DOI: 10.1590/1980-5918.033.ao51] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Abstract Introduction: The lung is considered a target organ in diabetes mellitus as a consequence of alterations secondary to chronic hyperglycemia that compromise respiratory muscle strength. Metabolic surgery for improving diabetes mellitus has beneficial effects on weight loss and glucose metabolism. Objective: The objective of this study was to evaluate the respiratory muscle strength, assessed by MIP and MEP, body mass index (BMI) and fasting glucose profile of patients with type 2 diabetes mellitus before and after metabolic surgery without gastric resection. Method: Seventeen patients with type 2 diabetes mellitus participated in the study. The participants had a mean age of 44.8 ± 11.81 years. Results: The results showed a significant decrease of MEP values in the immediate postoperative period when compared to the preoperative period (p=0.001), while no significant results were obtained for MIP. Regarding BMI and fasting glucose, significant weight loss and a significant reduction in fasting glucose levels were observed in the late postoperative period (p=0.006 and p=0.007, respectively). Conclusion: The MIP and MEP were reestablished and satisfactory results were obtained for BMI and fasting glucose in the late postoperative period. Further studies are needed to monitor patients in the pre- and postoperative period of metabolic surgery, identifying complications and acting on the care and recovery of these patients.
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Laveneziana P, Albuquerque A, Aliverti A, Babb T, Barreiro E, Dres M, Dubé BP, Fauroux B, Gea J, Guenette JA, Hudson AL, Kabitz HJ, Laghi F, Langer D, Luo YM, Neder JA, O'Donnell D, Polkey MI, Rabinovich R, Rossi A, Series F, Similowski T, Spengler C, Vogiatzis I, Verges S. ERS statement on respiratory muscle testing at rest and during exercise. Eur Respir J 2019; 53:13993003.01214-2018. [DOI: 10.1183/13993003.01214-2018] [Citation(s) in RCA: 227] [Impact Index Per Article: 45.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 02/18/2019] [Indexed: 12/12/2022]
Abstract
Assessing respiratory mechanics and muscle function is critical for both clinical practice and research purposes. Several methodological developments over the past two decades have enhanced our understanding of respiratory muscle function and responses to interventions across the spectrum of health and disease. They are especially useful in diagnosing, phenotyping and assessing treatment efficacy in patients with respiratory symptoms and neuromuscular diseases. Considerable research has been undertaken over the past 17 years, since the publication of the previous American Thoracic Society (ATS)/European Respiratory Society (ERS) statement on respiratory muscle testing in 2002. Key advances have been made in the field of mechanics of breathing, respiratory muscle neurophysiology (electromyography, electroencephalography and transcranial magnetic stimulation) and on respiratory muscle imaging (ultrasound, optoelectronic plethysmography and structured light plethysmography). Accordingly, this ERS task force reviewed the field of respiratory muscle testing in health and disease, with particular reference to data obtained since the previous ATS/ERS statement. It summarises the most recent scientific and methodological developments regarding respiratory mechanics and respiratory muscle assessment by addressing the validity, precision, reproducibility, prognostic value and responsiveness to interventions of various methods. A particular emphasis is placed on assessment during exercise, which is a useful condition to stress the respiratory system.
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Dos Reis IMM, Ohara DG, Januário LB, Basso-Vanelli RP, Oliveira AB, Jamami M. Surface electromyography in inspiratory muscles in adults and elderly individuals: A systematic review. J Electromyogr Kinesiol 2019; 44:139-155. [PMID: 30658230 DOI: 10.1016/j.jelekin.2019.01.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 07/21/2018] [Accepted: 01/09/2019] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Electromyography (EMG) helps to evaluate disorders and pulmonary behavior, as impairments in respiratory muscle function are associated with the development of diseases. There is a wide range of methods and protocols used to record and analyze EMG obtained from respiratory muscles, demonstrating a lack of standardization. OBJECTIVE To identify the most common procedures used to record surface EMG (sEMG) of inspiratory muscles in adults and elderly individuals through a systematic review (primary), and to evaluate the quality of the report presented by the studies (secondary). METHOD Studies published from January 1995 until June 2018 were searched for in the Web of Science, PubMed, LILACS, EBSCO and Embase databases. Only studies evaluating sEMG of inspiratory muscles were included. RESULTS The electronic search retrieved a total of 6697 titles and 92 of them were included. A great variability on the methods applied to both recording and processing/analyzing data was found. Therefore, the synthesis of practical/clinical evidence to support immediate recommendations was impaired. In general, the descriptions presented by the studies are poor. CONCLUSION The most common procedures used for sEMG were identified. Methodological studies with objective comparisons were fundamental for improving standardization, given the impossibility of recommendations from this review.
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Affiliation(s)
- Ivanize Mariana Masselli Dos Reis
- Department of Physical Therapy, Biological and Health Sciences Center, Federal University of São Carlos (UFSCar), São Carlos/SP, Brazil; Spirometry and Respiratory Physiotherapy Laboratory (LEFiR) at UFSCar, São Carlos/SP, Brazil.
| | - Daniela Gonçalves Ohara
- Department of Physical Therapy, Biological and Health Sciences Center, Federal University of São Carlos (UFSCar), São Carlos/SP, Brazil; Federal University of Amapá (UNIFAP), Macapá/AP, Brazil
| | - Letícia Bergamin Januário
- Department of Physical Therapy, Biological and Health Sciences Center, Federal University of São Carlos (UFSCar), São Carlos/SP, Brazil; Laboratory of Clinical and Occupational Kinesiology (LACO) at UFSCar, São Carlos/SP, Brazil
| | - Renata Pedrolongo Basso-Vanelli
- Department of Physical Therapy, Biological and Health Sciences Center, Federal University of São Carlos (UFSCar), São Carlos/SP, Brazil; University Hospital of UFSCar, São Carlos/SP, Brazil
| | - Ana Beatriz Oliveira
- Department of Physical Therapy, Biological and Health Sciences Center, Federal University of São Carlos (UFSCar), São Carlos/SP, Brazil; Laboratory of Clinical and Occupational Kinesiology (LACO) at UFSCar, São Carlos/SP, Brazil
| | - Mauricio Jamami
- Department of Physical Therapy, Biological and Health Sciences Center, Federal University of São Carlos (UFSCar), São Carlos/SP, Brazil; Spirometry and Respiratory Physiotherapy Laboratory (LEFiR) at UFSCar, São Carlos/SP, Brazil
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Comparison of Diaphragmatic Breathing Exercise, Volume and Flow Incentive Spirometry, on Diaphragm Excursion and Pulmonary Function in Patients Undergoing Laparoscopic Surgery: A Randomized Controlled Trial. Minim Invasive Surg 2016; 2016:1967532. [PMID: 27525116 PMCID: PMC4972934 DOI: 10.1155/2016/1967532] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Revised: 04/21/2016] [Accepted: 05/08/2016] [Indexed: 12/22/2022] Open
Abstract
Objective. To evaluate the effects of diaphragmatic breathing exercises and flow and volume-oriented incentive spirometry on pulmonary function and diaphragm excursion in patients undergoing laparoscopic abdominal surgery. Methodology. We selected 260 patients posted for laparoscopic abdominal surgery and they were block randomization as follows: 65 patients performed diaphragmatic breathing exercises, 65 patients performed flow incentive spirometry, 65 patients performed volume incentive spirometry, and 65 patients participated as a control group. All of them underwent evaluation of pulmonary function with measurement of Forced Vital Capacity (FVC), Forced Expiratory Volume in the first second (FEV1), Peak Expiratory Flow Rate (PEFR), and diaphragm excursion measurement by ultrasonography before the operation and on the first and second postoperative days. With the level of significance set at p < 0.05. Results. Pulmonary function and diaphragm excursion showed a significant decrease on the first postoperative day in all four groups (p < 0.001) but was evident more in the control group than in the experimental groups. On the second postoperative day pulmonary function (Forced Vital Capacity) and diaphragm excursion were found to be better preserved in volume incentive spirometry and diaphragmatic breathing exercise group than in the flow incentive spirometry group and the control group. Pulmonary function (Forced Vital Capacity) and diaphragm excursion showed statistically significant differences between volume incentive spirometry and diaphragmatic breathing exercise group (p < 0.05) as compared to that flow incentive spirometry group and the control group. Conclusion. Volume incentive spirometry and diaphragmatic breathing exercise can be recommended as an intervention for all patients pre- and postoperatively, over flow-oriented incentive spirometry for the generation and sustenance of pulmonary function and diaphragm excursion in the management of laparoscopic abdominal surgery.
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Moraes K, Paisani DM, Pacheco NCT, Chiavegato LD. Effects of nephrectomy on respiratory function and quality of life of living donors: a longitudinal study. Braz J Phys Ther 2015; 19:264-70. [PMID: 26443973 PMCID: PMC4620974 DOI: 10.1590/bjpt-rbf.2014.0105] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND: A living donor transplant improves the survival and quality of life of a
transplant patient. However, the impact of transplantation on postoperative lung
function and respiratory muscular strength in kidney donors remains unknown. OBJECTIVE: To evaluate pulmonary function, respiratory muscle strength, quality of life and
the incidence of postoperative pulmonary complications (PPCs) in kidney donors
undergoing nephrectomy. METHOD: This prospective cohort enrolled 110 consecutive kidney donors undergoing
nephrectomy. Subjects underwent pulmonary function (using spirometry) and
respiratory muscular strength (using manovacuometry) assessments on the day prior
to surgery and 1, 2, 3 and 5 days postoperatively. Quality of life (measured by
the SF-36) was evaluated preoperatively and 30 days postoperatively. PPCs were
assessed daily by a blinded assessor. RESULTS: Donors exhibited a decrease of 27% in forced vital capacity, 58% in maximum
inspiratory capacity and 51% in maximum expiratory pressure on the
1stpostoperative day (p<0.001) but this improved over days 2, 3 and
5 but had not returned to preoperative levels. Patient quality of life was still
impaired at 30 days with regards to functional capacity, physical role, pain,
vitality and social functioning (p<0.05) but these parameters improved slowly.
None of the patients developed PPCs. CONCLUSION: Kidney donors submitted to nephrectomy exhibited a reduction in pulmonary
function, respiratory muscular strength and quality of life, most of which were
improving toward pre-surgical levels.
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Affiliation(s)
- Karen Moraes
- Universidade Cidade de São Paulo, São Paulo, SP, BR
| | - Denise M Paisani
- Departamento de Fisioterapia, Escola de Medicina, Universidade de São Paulo, São Paulo, SP, BR
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Lunardi AC, Paisani DM, Silva CCBMD, Cano DP, Tanaka C, Carvalho CR. Comparison of Lung Expansion Techniques on Thoracoabdominal Mechanics and Incidence of Pulmonary Complications After Upper Abdominal Surgery. Chest 2015; 148:1003-1010. [DOI: 10.1378/chest.14-2696] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Mohamed ZK, Law WL. Outcome of tumor-specific mesorectal excision for rectal cancer: the impact of laparoscopic resection. World J Surg 2015; 38:2168-74. [PMID: 24671302 DOI: 10.1007/s00268-014-2533-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE The study aimed to compare the outcomes of laparoscopic and open resection for rectal cancer in 1,063 consecutive cases in a single center. METHODS We performed an analysis of 11 years of experience in rectal cancer surgery and compared the outcome of laparoscopic and open surgery. Multivariate and subgroup analysis was performed to look at the effect of the level of tumor and stage of disease on short-term outcomes like conversion rate, anastomotic leak rate, length of stay, complication rate, 30-day mortality, and long-term outcomes like local recurrence and survival. RESULTS A total of 1,063 patients underwent rectal resection with 470 (44.2%) patients undergoing the laparoscopic approach. Groups were comparable in terms of age, sex, or co-morbidities, and the operating time was longer in the laparoscopic group (210 vs. 150 min; p value < 0.001). A conversion rate of 6.8% was noted, with an anastomotic leak rate of 3.87% in the open group and 2.97% in the laparoscopic group. The laparoscopic group had a lower blood loss (100 vs. 350 ml; p < 0.001), lower complication rates, and shorter length of stay (6 vs. 9 days). The local recurrence rate was comparable, and the laparoscopic approach had better overall and cancer-specific survival, even after adjusting for stages. The laparoscopic approach was an independent factor associated with better overall and cancer-specific survival on multivariate analysis. CONCLUSION We confirmed the oncological safety of laparoscopic rectal cancer surgery. Laparoscopic surgery also showed superiority in the short-term and long-term outcomes of rectal cancer.
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Affiliation(s)
- Zakir K Mohamed
- Division of Colorectal Surgery, Department of Surgery, The University of Hong Kong, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong, China
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Fransson BA, Grubb TL, Perez TE, Flores K, Gay JM. Cardiorespiratory Changes and Pain Response of Lift Laparoscopy Compared to Capnoperitoneum Laparoscopy in Dogs. Vet Surg 2014; 44 Suppl 1:7-14. [DOI: 10.1111/j.1532-950x.2014.12198.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2013] [Accepted: 03/01/2014] [Indexed: 01/12/2023]
Affiliation(s)
- Boel A. Fransson
- Washington State University, Department of Veterinary Clinical Sciences; Pullman Washington
| | - Tamara L. Grubb
- Washington State University, Department of Veterinary Clinical Sciences; Pullman Washington
| | - Tania E. Perez
- Washington State University, Department of Veterinary Clinical Sciences; Pullman Washington
| | - Krystina Flores
- Washington State University, Department of Veterinary Clinical Sciences; Pullman Washington
| | - John M. Gay
- Washington State University, Department of Veterinary Clinical Sciences; Pullman Washington
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