Dexamethasone for the treatment of established postoperative nausea and vomiting: A randomised dose finding trial.

Dexamethasone is widely used for the prevention of postoperative nausea and vomiting (PONV) but little is known about its efficacy for the treatment of established PONV. To test the antiemetic efficacy of intravenous dexamethasone for the treatment of established PONV in adults undergoing surgery under general anaesthesia and to determine whether there is dose-responsiveness. The DexPonv trial is a multicentre, placebo-controlled, randomised, double-blind, dose-finding study. Inclusion of patients was between September 2012 and November 2017. Follow-up for PONV symptoms was for 24 h. Thirty days postoperatively, patients were contacted by study nurses for any information on postoperative bleeding and infection. Four public hospitals in Switzerland. A total of 803 adults scheduled for elective surgery without any antiemetic prophylaxis signed the consent form; 714 were included. Among those, 319 had PONV and 281 patients were eventually randomised (intention to treat population and safety set). The per protocol set consisted of 260 patients. Patients with PONV symptoms (including retching) were randomised to a single intravenous dose of dexamethasone 3, 6 or 12 mg or matching placebo. The primary endpoint was the absence of further nausea or vomiting (including retching), within 24 h after administration of the study drug. Dexamethasone was ineffective during the first 24 h, whatever the dosage, compared to placebo, even when the model was adjusted for known risk factors (P = 0.170). There were no differences in the time to treatment failure or the quality of sleep during the first night. There was a positive correlation between the dose of dexamethasone and blood glucose concentrations (P < 0.001), but not with bleeding risk, wound infections or other adverse effects. This randomised trial failed to show anti-emetic efficacy of any of the tested intravenous regimens of dexamethasone for the treatment of established PONV in adults undergoing surgery under general anaesthesia. clinicaltrials.gov (NCT01975727)

Laparoscopic aortic surgery: Techniques and results.

OBJECTIVE: This review describes and evaluates the results of laparoscopic aortic surgery. METHODS: We describe the different laparoscopic techniques used to treat aortic disease, including (1) total laparoscopic aortic surgery (TLS), (2) laparoscopy-assisted procedures including hand-assisted laparoscopic surgery (HALS), and (3) robot-assisted laparoscopic surgery, with their current indications. Results of these techniques are analyzed in a systematic review of the clinical series published between 1998 and 2008, each containing >10 patients with complete information concerning operative time, clamping time, conversion rate, length of hospital stay, morbidity, and mortality. RESULTS: We selected and reviewed 29 studies that included 1073 patients. Heterogeneity of the studies and selection of the patients made comparison with current open or endovascular surgery difficult. Median operative time varied widely in TLS, from 240 to 391 minutes. HALS had the shortest operating time. Median clamping time varied from 60 to 146 minutes in TLS and was shorter in HALS. Median hospital stay varied from 4 to 10 days regardless of the laparoscopic technique. The postoperative mortality rate was 2.1% (95% confidence interval, 1.4-3.0), with no significant difference between patients treated for occlusive disease or for aneurysmal disease. Conversion to open surgery was necessary in 8.1% of patients and was slightly higher with TLS than with laparoscopy-assisted techniques (P = .07). CONCLUSIONS: Analysis of these series shows that laparoscopic aortic surgery can be performed safely provided that patient selection is adjusted to the surgeon's experience and conversion is liberally performed. The future of this technique in comparison with endovascular surgery is still unknown, and it is now time for multicenter randomized trials to demonstrate the potential benefit of this type of surgery

Hydrogen sulfide-releasing peptide hydrogel limits the development of intimal hyperplasia in human vein segments.

Currently available interventions for vascular occlusive diseases suffer from high failure rates due to re-occlusive vascular wall adaptations, a process called intimal hyperplasia (IH). Naturally occurring hydrogen sulfide (H <sub>2</sub> S) works as a vasculoprotective gasotransmitter in vivo. However, given its reactive and hazardous nature, H <sub>2</sub> S is difficult to administer systemically. Here, we developed a hydrogel capable of localized slow release of precise amounts of H <sub>2</sub> S and tested its benefits on IH. The H <sub>2</sub> S-releasing hydrogel was prepared from a short peptide attached to an S-aroylthiooxime H <sub>2</sub> S donor. Upon dissolution in aqueous buffer, the peptide self-assembled into nanofibers, which formed a gel in the presence of calcium. This new hydrogel delivered H <sub>2</sub> S over the course of several hours, in contrast with fast-releasing NaHS. The H <sub>2</sub> S-releasing peptide/gel inhibited proliferation and migration of primary human vascular smooth muscle cells (VSMCs), while promoting proliferation and migration of human umbilical endothelial cells (ECs). Both NaHS and the H <sub>2</sub> S-releasing gel limited IH in human great saphenous vein segments obtained from vascular patients undergoing bypass surgery, with the H <sub>2</sub> S-releasing gel showing efficacy at a 5x lower dose than NaHS. These results suggest local perivascular H <sub>2</sub> S release as a new strategy to limit VSMC proliferation and IH while promoting EC proliferation, hence re-endothelialization. STATEMENT OF SIGNIFICANCE: Arterial occlusive disease is the leading cause of death in Western countries, yet current therapies suffer from high failure rates due to intimal hyperplasia (IH), a thickening of the vascular wall leading to secondary vessel occlusion. Hydrogen sulfide (H <sub>2</sub> S) is a gasotransmitter with vasculoprotective properties. Here we designed and synthesized a peptide-based H <sub>2</sub> S-releasing hydrogel and found that local application of the gel reduced IH in human vein segments obtained from patients undergoing bypass surgery. This work provides the first evidence of H <sub>2</sub> S efficacy against IH in human tissue, and the results show that the gel is more effective than NaHS, a common instantaneous H <sub>2</sub> S donor

Laparoscopic surgery for coeliac artery compression syndrome: current management and technical aspects.

Objectives: The study aims to assess the feasibility and midterm outcome of trans-peritoneal laparoscopy for coeliac artery compression syndrome (CACS).Design: Retrospective chart review involving four European vascular surgery departments and two surgical teams.Materials and methods: charts for patients who underwent laparoscopy for symptomatic CACS between December 2003 and November 2009 were reviewed. Preoperative computed tomography (CT) angiography and postoperative duplex scan and/or CT angiography were performed.Results: Eleven consecutive patients (nine women) with a median age of 52 years (interquartile range: 42.5-59 years) underwent trans-peritoneal laparoscopy for CACS. All patients had a history of postprandial abdominal pain; weight loss exceeded 10% of the body mass in eight cases. Preoperative CT angiography revealed coeliac trunk stenosis >70% in all cases. One patient had additional aortitis and inferior mesenteric artery occlusion, while another patient presented with an occluded superior mesenteric artery. Two conversions occurred (one difficult dissection and one aorto-hepatic bypass needed for incomplete release of CACS). The median blood loss was 195 ml (range: 50-900 ml) and median operative time was 80 min (interquartile range: 65-162.5 years). Symptoms improved immediately in 10/11 patients (no residual stenosis) while one remained unchanged despite a residual stenosis treated by a percutaneous angioplasty. Symptoms reappeared in one patient due to coeliac axis occlusion. The mean follow-up period was 35 +/- 23 months (range: 12-78 months).Conclusion: Our study demonstrates that trans-peritoneal laparoscopy for treating median arcuate ligament syndrome is safe and feasible. Additional patients and a longer follow-up are needed for long-term assessment of this laparoscopic technique. (C) 2011 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved