Evaluation of Hemodynamics During Posture Change to Knee-Chest Position by FloTracTM

In order to evaluate changes in hemodynamics, a FloTracTM system was used during posture change from supine to knee-chest position. Thirty-five patients undergoing lumbar surgery participated in this study. Anesthesia was performed with total intravenous anesthesia using propofol and remifentanil. Cardiac index (CI), stroke volume index (SVI), and stroke volume variation (SVV) were measured by using FloTracTM in addition with heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP) and mean blood pressure (MBP). The values before and after postural change were compared. SVV increased immediately after posture change and remained high. With posture change to the knee-chest position, HR, DBP and SVV increased and SBP, CI and SVI decreased. An increase in SVV from immediately after postural change indicated that SVV did not reflect circulating blood volume

Comparison of Prone Position and Knee-Chest Position in Hemodynamics During Postural Change

全静脈麻酔下で腹臥位または膝胸位へ体位変換した際の循環動態を両体位で比較するため，腰部脊椎手術を受けた患者を後方視的に調査した。体位変換の直前，体位変換直後， ３分後， ５分後の心拍数（HR）および収縮期血圧（SBP），拡張期血圧（DBP），平均血圧（MBP）を測定した。各パラメーターを体位変換前の値を基準とし体位変換後の変化率を算出し膝胸位（Knee-chest群）と腹臥位（Prone群）で比較した。統計はt検定を用いた。対象患者はKnee-chest群３０名，Prone群３０名であった。SBPは体位変換直後から５分後までKnee-chest群で有意に低く，MBPは５分後でKnee-chest群で有意に低く，HRは体位変換直後から５分後までKnee-chest群で有意に高かった。このため，全静脈麻酔管理下で膝胸位への体位変換は，腹臥位への体位変換よりも血圧の低下に注意する必要があると結論した。We compared the hemodynamics of posture change under general anesthesia between prone position and knee chest position. Patients who underwent lumbar spinal surgery were retrospectively investigated.　Heart rate (HR) and systolic blood pressure (SBP), diastolic blood pressure (DBP), mean blood pressure (MBP) were measured before and after postural change, 3 minutes and 5 minutes after postural change.　The rate of change of each parameter was calculated and compared in both groups of knee-chest and prone position.　Student’s t-test was used as statistical methods. We analyzed 60 patients (30 Knee-chest, 30 Prone).　SBP was significantly lower in the Knee-chest group from immediately after postural change to 5 minutes after postural change. MBP was significantly lower in the Knee-chest group 5 minutes after postural change. HR was significantly higher in the Knee-chest group from immediately after body change to 5 minutes after postural change.　In conclusion, SBP and MBP were significantly lower in the knee-chest position than in the prone position during postural change. Postural change to the kneechest position requires attention to lowering of blood pressure than postural change to the prone position

Delphi Method Consensus-Based Identification of Primary Trauma Care Skills Required for General Surgeons in Japan

Purpose General surgeons at regional hospitals should have the primary trauma care skills necessary to treat critically ill trauma patients to withstand transfer. This study was conducted to identify a consensus on primary trauma care skills for general surgeons. Methods An initial list of acute care surgical skills was compiled, and revised by six trauma experts (acute care surgeons); 33 skills were nominated for inclusion in the Delphi consensus survey. Participants (councilors of the Japanese Society for Acute Care Surgery) were presented with the list of 33 trauma care skills and were asked (using web-based software) to rate how strongly they agreed or disagreed (using a 5-point Likert scale) with the necessity of each skill for a general surgeon. The reliability of consensus was predefined as Cronbach’s α ≥ 0.8, and trauma care skills were considered as primarily required when rated 4 (agree) or 5 (strongly agree) by ≥ 80% participants. Results There were 117 trauma care specialists contacted to participate in the Delphi consensus survey panel. In the 1st round, 85 specialists participated (response rate: 72.6%). In the 2nd round, 66 specialists participated (response rate: 77.6%). Consensus was achieved after two rounds, reliability using Cronbach’s α was 0.94, and 34 items were identified as primary trauma care skills needed by general surgeons. Conclusion A consensus-based list of trauma care skills required by general surgeons was developed. This list can facilitate the development of a new trauma training course which has been optimized for general surgeons

大腸癌におけるSurgical site infection のリスク因子予測

2017(平成29)年

Survival benefit of conversion surgery for patients with initially unresectable pancreatic cancer who responded favorably to nonsurgical treatment

Background: Conversion surgery (CS) is expected as a new therapeutic strategy for patients with unresectable pancreatic cancer (UR-PC). We analyzed outcomes of CS for patients with UR-PC and evaluated the survival benefit of CS. Methods: Thirty-four patients diagnosed with UR-PC according to the National Comprehensive Cancer Network guideline underwent CS in our hospital. Resectability was considered by multimodal images in patients who underwent nonsurgical treatment (NST) for more than 6 months. CS was performed only in patients who were judged to be able to undergo R0 resection. Results: Twenty-six patients had locally advanced PC, and eight had distant metastases. The median duration of NST was 9 (range 5-44) months. R0 resection was achieved in 30 patients (88.2%). Six patients (17.6%) showed Evans grade ≥III. Three- and 5-year overall survival (OS) rates from initial treatment were 74% and 56.9%, respectively, with median survival time (MST) of 5.3 years. The actual 5-year OS rate in 19 patients was 47.4% with an MST of 4.0 years. Patients with Evans grade ≥III had a better prognosis than those with Evans grade <III (P = 0.0092, log-rank test). Conclusions: Conversion surgery might have survival benefits to patients with UR-PC who responded favorably to NST

Factors Affecting the Baseline and Post-Treatment Scores on the Hopkins Verbal Learning Test-Revised Japanese Version before and after Whole-Brain Radiation Therapy

Our objectives were to (1) investigate the feasibility of the use of the Japanese version of the Hopkins Verbal Learning Test-Revised (HVLT-R); (2) identify the clinical factors influencing the HVLT-R scores of patients undergoing whole-brain radiation therapy (WBRT); and (3) compare the neurocognitive function (NCF) after WBRT in different dose fractionation schedules. We administered the HVLT-R (Japanese version) before (baseline) and at four and eight months after WBRT in 45 patients who received either therapeutic (35Gy-in-14, n = 16; 30Gy-in-10, n = 18) or prophylactic (25Gy-in-10, n = 11) WBRT. Sixteen patients dropped out before the eight-month examination, due mostly to death from cancer. The Karnofsky Performance Status (KPS) 80–100 group had significantly higher baseline total recall (TR) scores (p = 0.0053), delayed recall (DR) scores (p = 0.012), and delayed recognition (DRecog) scores (p = 0.0078). The patients aged ≤65 years also had significantly higher TR scores (p = 0.030) and DRecog scores (p = 0.031). The patients who underwent two examinations (worse-prognosis group) had significantly decreased DR scores four months after WBRT compared to the baseline (p = 0.0073), and they were significantly more likely to have declined individual TR scores (p = 0.0017) and DR scores (p = 0.035) at four months. The eight-month HVLT-R scores did not significantly decline regardless of the WBRT dose fractionation. The baseline NCF was determined by age and KPS, and the early decline in NCF is characteristic of the worse-prognosis group

A Preoperative Prognostic Scoring System to Predict Prognosis for Resectable Pancreatic Cancer : Who Will Benefit from Upfront Surgery?

Background: Upfront surgery is recommended in patients with potentially resectable pancreatic ductal adenocarcinoma (R-PDAC) by National Comprehensive Center Network (NCCN) guidelines. However, even among R-PDACs, there is a subset that demonstrates extremely poor prognosis. The purpose of this study was to identify preoperative prognostic factors for upfront surgical resection of R-PDACs. Methods: The records of 278 consecutive patients with PDAC who underwent curative resection between 2001 and 2015 in a single institution were retrospectively reviewed. Preoperative factors to predict prognosis in patients with R-PDAC according to the NCCN guidelines were analyzed. Results: Of the 278 patients who underwent resection, 153 R-PDACs received upfront surgery with a median survival time (MST) of 26.4months. Tumor location (pancreatic head) (odds ratio [OR] 1.97, 95% confidence interval [CI] 1.14-3.40; P=0.015), preoperative cancer antigen 19-9 (CA19-9) >100U/mL (OR 1.92, 1.31-2.80; P=0.0009), and tumor size >20mm (OR 1.50, 1.02-2.19; P=0.038) were identified as preoperative independent predictive risk factors for poor prognosis in patients with R-PDACs. In the patients with R-PDAC, 5-year survival was 60.7%, 21.5%, and 0% in patients with 0, 1 or 2, and 3 risk factors, respectively. There were significant differences in overall survival between the three groups (P<.0001). Conclusions: A preoperative prognostic scoring system using preoperative tumor location, tumor size, and CA19-9 enables preoperative prediction of prognosis and facilitates selection of appropriate treatment for resectable pancreatic cancer