In 2015, we experienced the largest in-hospital Middle East respiratory syndrome (MERS) outbreak outside the Arabian Peninsula. We share the infection prevention measures for surgical procedures during the unexpected outbreak at our hospital. We reviewed all forms of related documents and collected information through interviews with healthcare workers of our hospital. After the onset of outbreak, a multidisciplinary team devised institutional MERS-control guidelines. Two standard operating rooms were converted to temporary negative-pressure rooms by physically decreasing the inflow air volume (−4.7 Pa in the main room and −1.2 Pa in the anteroom). Healthcare workers were equipped with standard or enhanced personal protective equipment according to the MERS-related patient's profile and symptoms. Six MERS-related patients underwent emergency surgery, including four MERS-exposed and two MERS-confirmed patients. Negative conversion of MERS-CoV polymerase chain reaction tests was noticed for MERS-confirmed patients before surgery. MERS-exposed patients were also tested twice preoperatively, all of which were negative. All operative procedures in MERSrelated patients were performed without specific adverse events or perioperative MERS transmission. Our experience with setting up a temporary negative-pressure operation room and our conservative approach for managing MERS-related patients can be referred in cases of future unexpected MERS outbreaks in non-endemic countries.The Middle East respiratory syndrome (MERS) is a serious acute respiratory disease caused by the MERS coronavirus (MERS-CoV), and the mortality rates in infected patients are estimated at 20-40% 1 . Since the first case report in Saudi Arabia in 2012 2 , MERS outbreaks have occurred mainly in Middle Eastern countries and a small number of imported cases arose in Europe, Asia, United States, and Africa 3-7 . From May to July 2015, South Korea experienced the largest MERS outbreak outside the Arabian Peninsula 8,9 . The South Korean outbreak resulted in 186 laboratory-confirmed MERS cases, 92 of which were associated with our tertiary care hospital 10,11 . According to our institutional policy during the MERS outbreak, all elective surgeries for MERS-related patients were postponed when possible. However, several MERS-related patients inevitably required emergency operations under anesthesia. Two of the 92-MERS confirmed cases and four MERS-exposed patients underwent surgery. Although there is some literature regarding infection prevention during operative procedures for severe acute respiratory syndrome (SARS) coronavirus 12,13 , guidelines or references for MERS prevention during perioperative patient care were very limited. Therefore, we developed institutional guidelines for perioperative MERS infection prevention and we set up a temporary negative-pressure operating room.In this globalized era, along with small and large outbreaks that persist in the Arabian Peninsula, MERS outbreaks may recur in any other regions, especially if a super spreader i...

Pure laparoscopic donor right hepatectomy (PLDRH) is not a standard procedure for living donor liver transplantation but is safe and reproducible in the hands of experienced surgeons. However, the perioperative outcomes of PLDRH have not been fully evaluated yet. We used propensity score matching to compare the perioperative complications and postoperative short-term outcomes of donors undergoing PLDRH and open donor right hepatectomy (ODRH). A total of 325 consecutive donors who underwent elective, adult-to-adult right hepatectomy were initially screened. After propensity score matching, all patients were divided into two groups: PLDRH (n = 123) and ODRH (n = 123) groups. Perioperative complications and postoperative outcomes were compared between the two groups. Postoperative pulmonary complications were significantly more common in the ODRH than in the PLDRH group (54.5 vs. 31.7%, P < 0.001). The biliary complications (leak and stricture) were higher in PLDRH group than in the ODRH group (8% vs. 3%), but it failed to reach statistical significance (P = 0.167). Overall, surgical complication rates were similar between the two groups (P = 0.730). The opioid requirement during the first 7 postoperative days was higher in the ODRH group (686 vs. 568 mg, P < 0.001). The hospital stay and time to the first meal were shorter in the PLDRH than in the ODRH group (P = 0.003 and P < 0.001, respectively). PLDRH reduced the incidence of postoperative pulmonary complications and afforded better short-term postoperative outcomes compared to ODRH. However, surgical complication rates were similar in both groups.Laparoscopic liver surgery has become widely accepted, affording many benefits including fewer overall complications, less blood loss, lower pain scores, better donor quality-of-life during the early postoperative period, and a shorter hospital stay, compared to open surgery 1-3 . As surgical techniques advanced over time, laparoscopic surgery for living donor liver transplantation (LDLT) became possible 2 . After the first successful reports of laparoscopic left lateral sectionectomy during adult-to-child LDLT in 2002 4 , many centers adopted the laparoscopic approach as the standard for living liver donors undergoing small graft resections 5,6 . However, the use of laparoscopic procedures to perform larger graft resections (such as right hepatectomies) was initially limited by technical complexities and the steep learning curve associated with the procedures. However, a series of laparoscopic right hepatectomies performed by experienced surgeons at living donor centers showed that the results open Scientific RepoRtS | (2020) 10:5314 | https://doi.

Background: Shoulder surgery in the beach chair position frequently causes hypotensive bradycardic events (HBEs), which are potentially associated with an increased risk of cerebral hypoperfusion. Here, we aimed to investigate the incidence and characteristics of symptomatic HBEs that require pharmacological interventions, and to identify specific risk factors associated with symptomatic HBEs. Methods: We retrospectively examined the records of all patients aged ≥ 18 years who underwent shoulder arthrotomy in the beach chair position between January 2011 and December 2018 at a tertiary hospital. For patients who experienced HBEs while in the beach chair position, the minimum heart rate and systolic blood pressure were noted, as was the total dose of ephedrine or atropine. Results: Symptomatic HBEs occurred in 61.0% of all cases (256/420). Two patients with symptomatic HBEs experienced postoperative neurological complications. Multivariable logistic regression analysis showed that preoperative interscalene brachial plexus block (ISB) and advanced age were risk factors associated with symptomatic HBEs

Corticosteroids have been empirically administered to reduce the rate of acute respiratory distress syndrome (ARDS) after esophagectomy. However, their efficacy remains controversial, and corticosteroids may increase the risk of graft dehiscence and infection, which are major concerns after esophagectomy. Therefore, we compared the incidence of composite complications (ARDS, graft dehiscence and infection) after esophagectomy between patients who received a preventive administration of corticosteroids and those who did not. All patients who underwent esophagectomy from 2010 to 2015 at a tertiary care university hospital were reviewed retrospectively ( n = 980). Patients were divided into Steroid ( n = 120) and Control ( n = 860) groups based on the preventive administration of 100 mg hydrocortisone during surgery. The primary endpoint was the incidence of composite complications. The incidence of composite complications was not different between the Control and Steroid groups (17.4% vs. 21.7% respectively; P = 0.26). The incidence rates of complications in each category were not different between the Control and Steroid groups: ARDS (3.8% vs. 5.0%; P = 0.46), graft dehiscence (4.8% vs. 6.7%; P = 0.37), and infection (12.8% vs. 15.8%; P = 0.36). Propensity score matching revealed that composite complications (20.0% vs. 21.7%; P = 0.75), ARDS (4.3% vs. 5.2%; P = 0.76) and infection (16.5% vs. 15.7%; P = 0.86) were not different between the Control and Steroid group, but the incidence of graft dehiscence was higher in the Steroid group than in the Control group (0.9% vs. 7.0%; P = 0.0175). In conclusions, the preventive use of corticosteroids did not reduce the incidence of ARDS, but may be related to an increased incidence of graft dehiscence. Therefore, routine administration of corticosteroids to prevent ARDS is not recommended in esophagectomy.

During emergence from general anesthesia, coughing caused by the endotracheal tube frequently occurs and is associated with various adverse complications. In patients undergoing endovascular neurointervention, achieving smooth emergence from general anesthesia without coughing is emphasized since coughing is associated with intracranial hypertension. Therefore, the up-and-down method was introduced to determine the effective effect-site concentration (Ce) of remifentanil to prevent coughing in 50% and 95% (EC 50 and EC 95 ) of patients during emergence from sevoflurane anesthesia for endovascular neurointervention. A total of 43 participants, American Society of Anesthesiologists class I or II participants, aged from 20 to 70 years who were undergoing endovascular neurointervention through transfemoral catheter for cerebrovascular disease were enrolled. Using the up-and-down method with isotonic regression, the EC 50 and EC 95 of remifentanil to prevent coughing during emergence from sevoflurane anesthesia were determined. We also investigated differences of hemodynamic and recovery profiles between the cough suppression group and the cough group. In total, 38 of 43 patients were included for estimation of EC 50 and EC 95 . The EC 50 and EC 95 of remifentanil to prevent coughing were 1.42 ng/mL (95% confidence interval [CI], 1.28–1.56 ng/mL) and 1.70 ng/mL (95% CI, 1.67–2.60 ng/mL), respectively. There was comparable emergence and recovery data between the cough suppression group (n = 22) and the cough group (n = 16). However, the Ce of remifentanil and total dose of remifentanil were significantly higher in the cough suppression group (P = 0.002 and P = 0.004, respectively). Target-controlled infusion of remifentanil at 1.70 ng/mL could effectively prevent extubation-related coughing in 95% of neurointervention patients, which could ensure smooth emergence.

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Background: Although corticosteroids were known to reduce acute respiratory distress syndrome (ARDS) after esophagectomy, the efficacy of corticosteroid remains debatable. Moreover, the risk of anastomosis leakage or infection, which relates to the administration of corticosteroid is another concern. Therefore, we compared the incidence of composite complications between patients who received or not the preventive administration of corticosteroid in esophagectomy. Methods: All patients who underwent esophagectomy from 2010 to 2015 at a tertiary care university hospital, were reviewed in this retrospective study (n=1,041). Patients were divided into Steroid (n=120) and Control (n=860) groups based on the preventive administration of corticosteroid during surgery. The primary endpoint was the incidence of composite complications (acute respiratory distress syndrome, wound dehiscence, and infection). Comparison between the two groups was performed after adjustment of co-variables. Results: The incidence of composite complications was not different between Steroid and Control group (21.7% vs 17.4%, respectively; P=0.26). Incidence of complications in each category between Steroid and Control groups were not significantly different: acute respiratory distress syndrome (5.0% vs 3.8%; P=0.46), graft dehiscence (6.7% vs 4.8%; P=0.37), and infection (15.8% vs 12.8%; P=0.36). After propensity score matching, the difference between the groups was also not significant. In multivariable analysis, age, lower body mass index, diabetes mellitus and duration of operation were independent risk factors of composite complications. Additionally, intraoperative vasopressor was a risk factor of graft dehiscence (odds ratio, 2.06; 95% confidence interval, 1.03-4.12; P=0.0407). Conclusions: The preventive use of corticosteroid was not related to the incidence of composite complications after esophagectomy. Application of corticosteroid for prevention of acute respiratory distress syndrome is not recommended due to its lack of apparent benefit. Keywords: Acute respiratory distress syndrome, corticosteroid, esophagectomy.