Influence of Deep Neuromuscular Blockade on Perioperative Stress Response in Patients Undergoing Robot-Assisted Gastrectomy: A Prospective Double-Blinded Randomized-Controlled Trial

Attenuating the intraoperative stress response is crucial; however, the effect of neuromuscular blockade (NMB) on surgical stress is not completely understood. We aimed to investigate the effects of NMB on the perioperative stress response during robot-assisted gastrectomy. Patients were assigned to the deep or moderate NMB group. Serum cortisol, prolactin, and interleukin-6 (IL-6) levels and natural killer (NK) cell percentage were measured before anesthesia induction, 90 min after pneumoperitoneum, operation end (OPEnd), and postoperative day 1. Additionally, C-reactive protein (CRP) and albumin levels were estimated. Additionally, intraoperative heart rate variability was evaluated. The deep NMB group showed significantly lower levels of low-frequency/high-frequency (HF) ratio at OPEnd compared to the moderate NMB group (1.4 ± 0.2 vs. 2.2 ± 0.3, respectively; Bonferroni corrected p = 0.039). Furthermore, HF power in the deep NMB group was significantly higher at OPEnd than that in the moderate NMB group (45.2 ± 3.6 vs. 33.8 ± 4.0, respectively; Bonferroni corrected p = 0.044). However, no significant differences in cortisol, prolactin, IL-6, CRP, and albumin levels and NK cell percentage were found between the two groups. The degree of NMB may have similar effects on stress-related biological markers in patients undergoing robot-assisted gastrectomy.

Modulation of Peripheral CD4+CD25+Foxp3+ Regulatory T Cells Ameliorates Surgical Stress-Induced Atherosclerotic Plaque Progression in ApoE-Deficient Mice

Systemic inflammation associated with major surgery rapidly accelerates atherosclerotic plaque progression in mice. Regulatory T cells (Tregs) have emerged as important modulators of atherogenesis. In coronary artery disease patients, low frequency of Tregs constitutes an independent risk factor for cardiovascular complications after non-cardiac surgery. In this exploratory analysis, we investigate whether preoperative Treg levels affect surgery-induced atherosclerotic lesion destabilization in a murine model of perioperative stress. After 9 weeks of high-cholesterol diet, atherosclerotic apolipoprotein E-deficient mice with modulated Treg levels were subjected to a 30-minute surgical procedure consisting of general isoflurane anesthesia, laparotomy and moderate blood loss. Controls underwent general anesthesia only. Brachiocephalic arteries were harvested 3 days after the intervention for histomorphological analyses of atherosclerotic plaques. Tregs were depleted by a single dose of anti-CD25 monoclonal antibody (mAb) administered 6 days prior to the intervention. Expansion of Tregs was induced by daily injections of IL-2/anti-IL-2 complex (IL-2C) on three consecutive days starting 3 days before surgery. Isotype-matched antibodies and PBS served as controls. Antibody-mediated modulation was Treg-specific. IL-2C treatment resulted in an eight-fold elevation of peripheral CD4+CD25+Foxp3+ Tregs compared to mice administered with anti-CD25 mAb. In mice treated with PBS and anti-CD25 mAb, surgical stress response caused a significant increase of atherosclerotic plaque necrosis (PBS: p < 0.001; anti-CD25 mAb: p = 0.037). Preoperative Treg expansion abrogated perioperative necrotic core formation (p = 0.556) and significantly enhanced postoperative atherosclerotic plaque stability compared to PBS-treated mice (p = 0.036). Postoperative plaque volume (p = 0.960), stenosis (p = 0.693), lesional collagen (p = 0.258), as well as the relative macrophage (p = 0.625) and smooth muscle cell content (p = 0.178) remained largely unaffected by preoperative Treg levels. In atherosclerotic mice, therapeutic expansion of Tregs prior to major surgery mitigates rapid effects on perioperative stress-driven atherosclerotic plaque destabilization. Future studies will show, whether short-term interventions modulating perioperative inflammation qualify for prevention of cardiovascular events associated with major non-cardiac surgery.

Die Hybridstabilisierung und geriatrische Komplexbehandlung in der Therapie von A-Frakturen der Wirbelsäule

Zusammenfassung In Deutschland ereignen sich ca. 200.000 geriatrische Wirbelfrakturen pro Jahr. Die dezimierte Stabilität des Wirbelkörpers führt häufig zu A‑Frakturen mit einem wesentlichen Einfluss bei der begleitenden Osteoporose. Eine mobilitätserhaltende und schonende Therapie hat gegenüber der konservativen Behandlung deutliche Vorteile. Dabei hat sich die Hybridstabilisierung als Kombination der minimal-invasiven dorsalen Stabilisierung und einer Wirbelkörperaugmentation etabliert. Im Zeitraum vom 01.07.2014 bis 30.06.2015 wurden 205 Wirbelsäulenoperationen erfasst. In der Gruppe der hochbetagten Patienten wurden über 80 % aufgrund einer geriatrischen Wirbelkörperfraktur Typ A behandelt und 24 mittels Hybridstabilisierung (77,1 Jahre, ±6,8), 5 perkutan-bisegmental (75,9 Jahre), 22 per Kyphoplastiestabilisierung (75,7 Jahre) und 13 perkutan-polysegmental versorgt (72,4 Jahre). Diese vier Gruppen wurden ferner auch bezüglich der Behandlung im alterstraumatologischen Zentrum (ATZ) betrachtet. Die operative und perioperative Versorgung bei der Hybridstabilisierung war 36 min länger. Die vier Versorgungsformen erzielten eine durchschnittliche Vergütung von 11.238,77 €. Für die Versorgungsform Kyphoplastie zeigt sich bei ähnlichem Patientengut eine Steigerung in der Vergütung von 4276,54 €, wenn die Patienten der geriatrischen Komplexbehandlung zugeführt werden und dabei die DRG „I34Z“ abgerechnet wird. Im Bereich der operativen Versorgung geriatrischer Wirbelkörperfrakturen gelten die augmentiven Verfahren der Kypho- oder Vertebroplastie als etabliert, aber es zeigt sich häufig eine verletzungsbedingte Mitbeteiligung benachbarter Wirbelsäulensegmente und Anschlussfrakturen, sodass eine bisegmentale Hybridstabilisierung Vorteile zeigt. Da diese Wirbelsäulenpatienten durchschnittlich 15 Jahre älter sind, wird in der geriatrischen Wirbelsäulenchirurgie der goldene Weg zwischen schonender Operationsmethode und frühzeitigster Mobilisierung verfolgt. Zudem ist der perioperative Stress bei der Hybridstabilisierung nur unwesentlich länger, sodass die Hybridstabilisierung und die geriatrische Komplexbehandlung als neuer wirbelsäulenchirurgischer Versorgungsstandard für die Versorgung der A‑Frakturen hochbetagter Patienten empfohlen werden können.

Effect of Dexmedetomidine on Perioperative Stress Response and Immune Function in Patients With Tumors

Objective: This study aims to investigate the effect of dexmedetomidine on perioperative stress response and immune function in patients with tumors. Methods: Sixty patients who underwent selective radical gastrectomy for cancer were randomly divided into 3 groups: remifentanil group (group R), dexmedetomidine group (group D), and sufentanil group (group S). Remifentanil, dexmedetomidine, and sufentanil were used as general anesthetics. Endotracheal intubation and mechanical ventilation were performed after the spontaneous respiration disappeared. Then, the data were recorded, and blood samples were collected at all time points. Results: The heart rate significantly increased ( P < 0.05) at T1 in group S, and both heart rate and mean arterial pressure significantly increased ( P < 0.05) in group R when compared to group D. The heart rate significantly increased ( P < 0.05) at T2 in group S and group R. Furthermore, the heart rate significantly increased ( P < 0.05) at T3 and T4 in group S and group R. Intra-group comparison: The heart rate at T1–T4 and mean arterial pressure at T1–T4 significantly increased ( P < 0.05) in group S, and the heart rate at T1 and T4, and mean arterial pressure at T2–T4 significantly increased ( P < 0.05) in group R when compared to T0. The serum IL-6, IFN-γ, and β-EP significantly increased ( P < 0.05) at T0’ in group S and group R when compared to group D. Blood glucose, and serum IL-10, IFN-γ, and β-EP significantly increased ( P < 0.05), while IL-18 significantly decreased ( P < 0.05) at T1’ in group S and group R. Conclusion: Continuous infusion of dexmedetomidine in combination with the inhalation of sevoflurane is superior to sevoflurane + remifentanil or sufentanil in patients undergoing tumor surgery.