Use of low dose dopamine, gabexate mesilate and ulinastatin reduces the water balance and pulmonary complication in thoracic esophagectomy patients

Continuous infusion of high-dose ulinastatin during surgery does not improve early postoperative clinical outcomes in patients undergoing radical lung cancer surgery: A pilot study

Background

Ulinastatin can prevent the perioperative increase in proinflammatory cytokines for lung resection surgery; however, its impact on early clinical outcomes remains unknown.

Methods

The study enrolled 108 non‐small cell lung cancer (NSCLC) patients who were randomly allocated into two groups: ulinastatin (group U) and control (group C). Patients in group U (n = 52) were continuously intravenously infused with ulinastatin at a rate of 20 000 U/kg/hour for the first hour after anesthesia induction, and then at a rate of 5000 U/kg/hour until the conclusion of surgery. Patients in group C (n = 56) received an equivalent volume of normal saline. The primary outcome was to record the postoperative pulmonary complications that occurred during hospital stay. Other clinical courses, such as hospital mortality, blood loss, respiratory parameters, postoperative chest drainage, and duration of intensive care unit and postoperative hospital stay, were also observed and analyzed.

Results

There were no significant differences between the two groups in early postoperative pulmonary complications, hospital mortality, blood loss, or other perioperative laboratory values, except for the duration of postoperative chest drainage and serum creatinine level. The frequency of pulmonary complications was lower in patients treated with ulinastatin compared with the control (38.46% in group U vs. 48.21% in group C).

Conclusion

Administration of high‐dose ulinastatin during surgery did not reduce postoperative pulmonary complications, hospital mortality, or hospital stay for patients undergoing lung radical thoracotomy. However, a protective trend of ulinastatin was observed.

Randomized Phase II Study of the Anti-inflammatory Effect of Ghrelin During the Postoperative Period of Esophagectomy

OBJECTIVE

A prospective randomized phase II trial was conducted to evaluate the efficacy of ghrelin administration in reducing systemic inflammatory response syndrome (SIRS) duration after esophagectomy.

BACKGROUND

Esophagectomy for esophageal cancer is highly invasive and leads to prolonged SIRS duration and postoperative complications. Ghrelin has multiple effects, including anti-inflammatory effects.

METHODS

Forty patients undergoing esophagectomy were randomly assigned to either the ghrelin group (n = 20), which received continuous infusion of ghrelin (0.5 μg/kg/h) for 5 days, or the placebo group (n = 20), which received pure saline for 5 days. The primary endpoint was SIRS duration. The secondary endpoints were the incidence of postoperative complications, time of a negative nitrogen balance, changes in body weight and composition, and levels of inflammatory markers, including C-reactive protein (CRP) and interleukin-6 (IL-6).

RESULTS

The ghrelin group had a shorter SIRS duration and lower CRP and IL-6 levels than did the placebo group. The incidence of pulmonary complications was lower in the ghrelin group than in the placebo group, whereas other complications did not differ between the groups. Although time of the negative nitrogen balance was shorter in the ghrelin group than in the placebo group, changes in total body weight and lean body weight did not differ significantly.

CONCLUSIONS

Postoperative ghrelin administration was effective for inhibiting inflammatory mediators and improving the postoperative clinical course of patients with esophageal cancer.

Does intraoperative ulinastatin improve postoperative clinical outcomes in patients undergoing cardiac surgery: a meta-analysis of randomized controlled trials

INTRODUCTION

The systematic meta-analysis of randomized controlled trials (RCTs) evaluated the effects of intraoperative ulinastatin on early-postoperative recovery in patients undergoing cardiac surgery.

METHODS

RCTs comparing intraoperative ulinastatin with placebo in cardiac surgery were searched through PubMed, Cochrane databases, Medline, SinoMed, and the China National Knowledge Infrastructure (1966 to May 20th, 2013). The primary endpoints included hospital mortality, postoperative complication rate, length of stay in intensive care unit, and extubation time. The physiological and biochemical parameters illustrating postoperative cardiac and pulmonary function as well as inflammation response were considered as secondary endpoints.

RESULTS

Fifteen RCTs (509 patients) met the inclusion criteria. Ulinastatin did not affect hospital mortality, postoperative complication rate, or ICU length of stay but reduced extubation time. Ulinastatin also increased the oxygenation index on postoperative day 1 and reduced the plasma level of cardiac troponin-I. Additionally, ulinastatin inhibited the increased level of tumor necrosis factor-alpha, polymorphonuclear neutrophil elastase, interleukin-6, and interleukin-8 associated with cardiac surgery.

CONCLUSION

Ulinastatin may be of value for the inhibition of postoperative increased inflammatory agents and most likely provided pulmonary protective effects in cardiac surgery. However, larger adequately powered RCTs are required to define the clinical effect of ulinastatin on postoperative outcomes in cardiac surgery.

Preventive effect of ulinastatin on postoperative complications, immunosuppression, and recurrence in esophagectomy patients

Background

To evaluate the potential efficacy of preventive effect of ulinastatin in esophagectomy patients.

Methods

Eighty patients with esophageal cancer were preoperatively allocated at random into two equal groups. Ulinastatin was administered to the treatment group (U) whereas the control group (C) received a placebo. The arterial oxygen tension and carbon dioxide tension were measured and the respiratory index (RI) was calculated. Plasma levels of circulating T lymphocyte subsets and interleukin 6 (IL-6) were measured and clinical courses of patients in the two groups were compared.

Results

RI in the U group was significantly lower than that in the C group. The rate of postoperative complications and the duration of ICU stay were significantly lower in the U group. Ulinastatin significantly increased the rate of CD3⁺ and CD4⁺ cells, and ratio of CD4⁺/CD8⁺, but decreased the rate of CD8⁺ cells and release of IL-6 compared to the C group on postoperative days 1 and 3. Patients within the C group showed worse recurrence free survival. Multivariate analysis revealed that ulinastatin administration significantly decreased the incidence of recurrence.

Conclusions

Ulinastatin had a preventive effect on postoperative complications and immunosuppression in esophagectomy patients, thereby prolongingrecurrence free survival.

Urinary trypsin inhibitor as a therapeutic option for endotoxin-related inflammatory disorders

IMPORTANCE OF THE FIELD

Urinary trypsin inhibitor (UTI), a serine protease inhibitor, has been widely used as a drug for patients with inflammatory disorders such as pancreatitis, shock and disseminated intravascular coagulation (DIC). Previous in vitro studies have demonstrated that serine protease inhibitors may have anti-inflammatory properties at sites of inflammation. However, the therapeutic effects of UTI in vivo remain unclarified, as commercial UTI has been developed to act against humans, with the activity and selectivity toward the relevant animal UTI being less characterized.

AREAS COVERED IN THIS REVIEW

In this review, we introduce the roles of UTI in experimental endotoxin (lipopolysaccharide; LPS)-related inflammatory disorders using UTI-deficient (-/-) and corresponding wild-type mice.

WHAT THE READER WILL GAIN

Our experiments using genetic approach suggest that endogenous UTI can protect against the systemic inflammatory response and subsequent organ injury induced by LPS, at least partly, through the inhibition of pro-inflammatory cytokine and chemokine expression, which provide important in vivo evidence and understanding about a protective role of UTI in inflammatory conditions.

TAKE HOME MESSAGE

Using genetically targeted mice selectively lacking UTI, UTI has been evidenced to provide an attractive 'rescue' therapeutic option for endotoxin-related inflammatory disorders such as DIC, acute lung injury and acute liver injury.

Postoperative management using intensive patient-controlled epidural analgesia and early rehabilitation after an esophagectomy

PURPOSE

Patient-controlled epidural analgesia (PCEA) was developed for use after surgery for thoracic esophageal cancer to relieve wound pain, introduce early rehabilitation, and provide an uneventful postoperative recovery.

METHODS

This retrospective study investigated 22 patients who underwent esophageal surgery to determine the efficacy of postoperative management with PCEA. In the PCEA group (n = 12), patients had two epidural catheters inserted to cover both the thoracic and abdominal incision with a patient-controlled bolus capability.

RESULTS

Postoperative mechanical ventilation was administered in all cases in the control group (n = 10). On the other hand, this was only necessary in two patients in the PCEA group. The amount of time the patients stayed in the intensive care unit and the hospital was significantly shorter in the PCEA group than in the control group (P < 0.001 and P < 0.01, respectively). Respiratory complications occurred in four patients in the control group, and none in the PCEA group. The mean number of supplemental analgesics administered for breakthrough pain until the 7th postoperative day was 5.5 in the control group, and 1.3 in the PCEA group (P < 0.001).

CONCLUSIONS

Early rehabilitation is facilitated with intensive PCEA, while it also improves postoperative management and reduces hospitalization after esophageal surgery.