Abstract Background: It is the basic duty of all healthcare professionals to relieve pain, and the most important indication for treating pain after surgery is humanitarian. Objectives: Comparing the effects of intravenous morphine, tramadol and ketorolac on post operative pain in patients undergoing modified radical mastectomy Study design: A randomized, double blind trial. Methods: Sixty patients randomly were assigned to receive either IV morphine 5mg (Group I, n = 20), tramadol 100 mg (Group II, n = 20), or ketorolac 60 mg (Group III, n = 20) at the end of surgery. Assessment parameters included hemodynamics, respiratory rate, oxygen saturation, sedation score, VAS score, time of first analgesic request, total amount of analgesics consumption, and side effects in the first 24 hours. Results: The mean time to the first request for rescue analgesia was significantly prolonged in group II (11.00± 2.49 hrs ranged from 8- 15 hrs) and group III (8± 1.89 hrs ranged from 6.0 -10.0 hrs) in comparison to group I (3.75± 0.89 hrs ranged from 3 – 5 hrs) (P 0.001). Total post-operative amount of analgesics consumption over 24 hrs in the three studied groups was (7.00 ± 2.51 mg ranged from 5- 10 mg of morphine) in group I;(160.00± 68.06 mg ranged from 100-300 mg of tramadol) in group II;(80.00± 19.47 mg ranged from 60– 120 mg of ketorolac) in group III. The mean (VAS) score in studied groups, showed no significant difference between the three studied groups at all time periods(P >0.05), but there was a significant decrease in the (VAS) in each group separately over the course of 24 hrs in comparison to base line values (P 0.007). No significant differences were observed in the mean systolic and diastolic blood pressure values, respiratory rate and oxygen saturation between groups. Conclusion: intravenous morphine, tramadol and ketorolac had similar analgesic efficacy on the post-operative pain in patients undergoing modified radical mastectomy. Key words: Breast Cancer Surgery; Postoperative Pain; morphine, tramadol, ketorolac

Abstract Background: It is the basic duty of all healthcare professionals to relieve pain, and the most important indication for treating pain after surgery is humanitarian. Objectives: Comparing the effects of intravenous morphine, tramadol and ketorolac on post operative pain in patients undergoing modified radical mastectomy Study design: A randomized, double blind trial. Methods: Sixty patients randomly were assigned to receive either IV morphine 5mg (Group I, n = 20), tramadol 100 mg (Group II, n = 20), or ketorolac 60 mg (Group III, n = 20) at the end of surgery. Assessment parameters included hemodynamics, respiratory rate, oxygen saturation, sedation score, VAS score, time of first analgesic request, total amount of analgesics consumption, and side effects in the first 24 hours. Results: The mean time to the first request for rescue analgesia was significantly prolonged in group II (11.00± 2.49 hrs ranged from 8- 15 hrs) and group III (8± 1.89 hrs ranged from 6.0 -10.0 hrs) in comparison to group I (3.75± 0.89 hrs ranged from 3 – 5 hrs) (P 0.001). Total post-operative amount of analgesics consumption over 24 hrs in the three studied groups was (7.00 ± 2.51 mg ranged from 5- 10 mg of morphine) in group I;(160.00± 68.06 mg ranged from 100-300 mg of tramadol) in group II;(80.00± 19.47 mg ranged from 60– 120 mg of ketorolac) in group III. The mean (VAS) score in studied groups, showed no significant difference between the three studied groups at all time periods(P >0.05), but there was a significant decrease in the (VAS) in each group separately over the course of 24 hrs in comparison to base line values (P 0.007). No significant differences were observed in the mean systolic and diastolic blood pressure values, respiratory rate and oxygen saturation between groups. Conclusion: intravenous morphine, tramadol and ketorolac had similar analgesic efficacy on the post-operative pain in patients undergoing modified radical mastectomy. Key words: Breast Cancer Surgery; Postoperative Pain; morphine, tramadol, ketorolac

Abstract Background: It is the basic duty of all healthcare professionals to relieve pain, and the most important indication for treating pain after surgery is humanitarian. Objectives: Comparing the effects of intravenous morphine, tramadol and ketorolac on post operative pain in patients undergoing modified radical mastectomy Study design: A randomized, double blind trial. Methods: Sixty patients randomly were assigned to receive either IV morphine 5mg (Group I, n = 20), tramadol 100 mg (Group II, n = 20), or ketorolac 60 mg (Group III, n = 20) at the end of surgery. Assessment parameters included hemodynamics, respiratory rate, oxygen saturation, sedation score, VAS score, time of first analgesic request, total amount of analgesics consumption, and side effects in the first 24 hours. Results: The mean time to the first request for rescue analgesia was significantly prolonged in group II (11.00± 2.49 hrs ranged from 8- 15 hrs) and group III (8± 1.89 hrs ranged from 6.0 -10.0 hrs) in comparison to group I (3.75± 0.89 hrs ranged from 3 – 5 hrs) (P 0.001). Total post-operative amount of analgesics consumption over 24 hrs in the three studied groups was (7.00 ± 2.51 mg ranged from 5- 10 mg of morphine) in group I;(160.00± 68.06 mg ranged from 100-300 mg of tramadol) in group II;(80.00± 19.47 mg ranged from 60– 120 mg of ketorolac) in group III. The mean (VAS) score in studied groups, showed no significant difference between the three studied groups at all time periods(P >0.05), but there was a significant decrease in the (VAS) in each group separately over the course of 24 hrs in comparison to base line values (P 0.007). No significant differences were observed in the mean systolic and diastolic blood pressure values, respiratory rate and oxygen saturation between groups. Conclusion: intravenous morphine, tramadol and ketorolac had similar analgesic efficacy on the post-operative pain in patients undergoing modified radical mastectomy. Key words: Breast Cancer Surgery; Postoperative Pain; morphine, tramadol, ketorolac

BACKGROUND: Surgery remains the mainstay of therapy for pancreatic head (PH) and periampullary carcinoma (PC) and provides the only chance of cure. Improvements of surgical technique, increased surgical experience and advances in anesthesia, intensive care and parenteral nutrition have substantially decreased surgical complications and increased survival. We evaluate the effects of reconstruction type, complications and pathological factors on survival and quality of life. MATERIALS AND METHODS: This is a prospective study to evaluate the impact of various reconstruction methods of the pancreatic remnant after pancreaticoduodenectomy and the pathological characteristics of PC patients over 3.5 years. Patient characteristics and descriptive analysis in the three variable methods either with or without stent were compared with Chi-square test. Multivariate analysis was performed with the logistic regression analysis test and multinomial logistic regression analysis test. Survival rate was analyzed by use Kaplan-Meier test. RESULTS: Forty-one consecutive patients with PC were enrolled. There were 23 men (56.1%) and 18 women (43.9%), with a median age of 56 years (16 to 70 years). There were 24 cases of PH cancer, eight cases of PC, four cases of distal CBD cancer and five cases of duodenal carcinoma. Nine patients underwent duct-to-mucosa pancreatico jejunostomy (PJ), 17 patients underwent telescoping pancreatico jejunostomy (PJ) and 15 patients pancreaticogastrostomy (PG). The pancreatic duct was stented in 30 patients while in 11 patients, the duct was not stented. The PJ duct-to-mucosa caused significantly less leakage, but longer operative and reconstructive times. Telescoping PJ was associated with the shortest hospital stay. There were 5 postoperative mortalities, while postoperative morbidities included pancreatic fistula-6 patients, delayed gastric emptying in-11, GI fistula-3, wound infection-12, burst abdomen-6 and pulmonary infection-2. Factors that predisposed to development of pancreatic leakage included male gender, preoperative albumin 30g/dl, pre-operative hemoglobin 10g/dl and non PJ-duct to mucosa type of reconstruction. The ampullary cancers presented at an earlier stage and had a better prognosis than pancreatic cancer and cholangiocarcinoma. Early stage (I and II), negative surgical margin, well and moderate differentiation and absence of lymph node involvement significantly predicted for longer survival. CONCLUSIONS: PJ duct-to-mucosa anastomosis was safe, caused least pancreatic leakage and least blood loss compared with the other methods of reconstruction and was associated with early return back to home and prolonged disease free and overall survival.

Abstract Background: Esophagectomy is associated with increase in pro-inflammatory cytokine whose extent has been claimed as a causative agent of postoperative acute lung injury. Objectives: The aim of this study was to determine whether a ventilatory strategy based on the reduction of tidal volume (VT) and a moderate level of positive end-expiratory pressure (PEEP) during one lung ventilation (OLV) could reduce the pro-inflammatory cytokine response associated with esophagectomy. Also, its impact on oxygenation and postoperative outcome were evaluated. Patients and methods: Thirty patients were randomly allocated into two groups: Group (CV), Patients (n = 15) received a conventional ventilation strategy (tidal volume of 9 ml/kg during two-lung and OLV); no PEEP was applied and group (PV), Patients (n = 15) received a protective ventilation strategy (tidal volume of 9 ml/kg during two-lung ventilation, reduced to 5 ml/kg during OLV and PEEP 5 cm H20 was applied. Serum level of interleukins (IL-6 and IL-8) were measured at baseline time after anesthetic induction (TBaseline,); at the end of abdominal stage of the operation (TAbdo,); at the end of OLV (TOLV end, ); 1 hour and 20 hour after The end of the surgical procedure respectively (TPostop1) and (TPostop20,). Also, peri-operative oxygenation and post-operative outcome were evaluated. Results: There were significant increases in blood level of IL-6 and IL-8 all over the time in both groups in comparison to their baseline values (p= 0.001). However there were significant reduction in blood level of IL-6 and IL-8 in group PV compared to CV group all over the study period (p0.05). The oxygenation index was significantly higher in PV group during the period of OLV (p 0.001) and during the first day postoperatively (p 0.001). There was no significant difference in post-operative outcome between groups. Conclusion: The use of VT 5 ml /kg and PEEP of 5 cm H2O during OLV reduced the systemic pro-inflammatory cytokine response, improved peri-operative oxygenation, but there were no significant differences in occurrence of ARDS or postoperative outcome in patients undergoing esophagectomy

Abstract Background: Esophagectomy is associated with increase in pro-inflammatory cytokine whose extent has been claimed as a causative agent of postoperative acute lung injury. Objectives: The aim of this study was to determine whether a ventilatory strategy based on the reduction of tidal volume (VT) and a moderate level of positive end-expiratory pressure (PEEP) during one lung ventilation (OLV) could reduce the pro-inflammatory cytokine response associated with esophagectomy. Also, its impact on oxygenation and postoperative outcome were evaluated. Patients and methods: Thirty patients were randomly allocated into two groups: Group (CV), Patients (n = 15) received a conventional ventilation strategy (tidal volume of 9 ml/kg during two-lung and OLV); no PEEP was applied and group (PV), Patients (n = 15) received a protective ventilation strategy (tidal volume of 9 ml/kg during two-lung ventilation, reduced to 5 ml/kg during OLV and PEEP 5 cm H20 was applied. Serum level of interleukins (IL-6 and IL-8) were measured at baseline time after anesthetic induction (TBaseline,); at the end of abdominal stage of the operation (TAbdo,); at the end of OLV (TOLV end, ); 1 hour and 20 hour after The end of the surgical procedure respectively (TPostop1) and (TPostop20,). Also, peri-operative oxygenation and post-operative outcome were evaluated. Results: There were significant increases in blood level of IL-6 and IL-8 all over the time in both groups in comparison to their baseline values (p= 0.001). However there were significant reduction in blood level of IL-6 and IL-8 in group PV compared to CV group all over the study period (p0.05). The oxygenation index was significantly higher in PV group during the period of OLV (p 0.001) and during the first day postoperatively (p 0.001). There was no significant difference in post-operative outcome between groups. Conclusion: The use of VT 5 ml /kg and PEEP of 5 cm H2O during OLV reduced the systemic pro-inflammatory cytokine response, improved peri-operative oxygenation, but there were no significant differences in occurrence of ARDS or postoperative outcome in patients undergoing esophagectomy

Abstract Background: Esophagectomy is associated with increase in pro-inflammatory cytokine whose extent has been claimed as a causative agent of postoperative acute lung injury. Objectives: The aim of this study was to determine whether a ventilatory strategy based on the reduction of tidal volume (VT) and a moderate level of positive end-expiratory pressure (PEEP) during one lung ventilation (OLV) could reduce the pro-inflammatory cytokine response associated with esophagectomy. Also, its impact on oxygenation and postoperative outcome were evaluated. Patients and methods: Thirty patients were randomly allocated into two groups: Group (CV), Patients (n = 15) received a conventional ventilation strategy (tidal volume of 9 ml/kg during two-lung and OLV); no PEEP was applied and group (PV), Patients (n = 15) received a protective ventilation strategy (tidal volume of 9 ml/kg during two-lung ventilation, reduced to 5 ml/kg during OLV and PEEP 5 cm H20 was applied. Serum level of interleukins (IL-6 and IL-8) were measured at baseline time after anesthetic induction (TBaseline,); at the end of abdominal stage of the operation (TAbdo,); at the end of OLV (TOLV end, ); 1 hour and 20 hour after The end of the surgical procedure respectively (TPostop1) and (TPostop20,). Also, peri-operative oxygenation and post-operative outcome were evaluated. Results: There were significant increases in blood level of IL-6 and IL-8 all over the time in both groups in comparison to their baseline values (p= 0.001). However there were significant reduction in blood level of IL-6 and IL-8 in group PV compared to CV group all over the study period (p0.05). The oxygenation index was significantly higher in PV group during the period of OLV (p 0.001) and during the first day postoperatively (p 0.001). There was no significant difference in post-operative outcome between groups. Conclusion: The use of VT 5 ml /kg and PEEP of 5 cm H2O during OLV reduced the systemic pro-inflammatory cytokine response, improved peri-operative oxygenation, but there were no significant differences in occurrence of ARDS or postoperative outcome in patients undergoing esophagectomy

Abstract Background: Esophagectomy is associated with increase in pro-inflammatory cytokine whose extent has been claimed as a causative agent of postoperative acute lung injury. Objectives: The aim of this study was to determine whether a ventilatory strategy based on the reduction of tidal volume (VT) and a moderate level of positive end-expiratory pressure (PEEP) during one lung ventilation (OLV) could reduce the pro-inflammatory cytokine response associated with esophagectomy. Also, its impact on oxygenation and postoperative outcome were evaluated. Patients and methods: Thirty patients were randomly allocated into two groups: Group (CV), Patients (n = 15) received a conventional ventilation strategy (tidal volume of 9 ml/kg during two-lung and OLV); no PEEP was applied and group (PV), Patients (n = 15) received a protective ventilation strategy (tidal volume of 9 ml/kg during two-lung ventilation, reduced to 5 ml/kg during OLV and PEEP 5 cm H20 was applied. Serum level of interleukins (IL-6 and IL-8) were measured at baseline time after anesthetic induction (TBaseline,); at the end of abdominal stage of the operation (TAbdo,); at the end of OLV (TOLV end, ); 1 hour and 20 hour after The end of the surgical procedure respectively (TPostop1) and (TPostop20,). Also, peri-operative oxygenation and post-operative outcome were evaluated. Results: There were significant increases in blood level of IL-6 and IL-8 all over the time in both groups in comparison to their baseline values (p= 0.001). However there were significant reduction in blood level of IL-6 and IL-8 in group PV compared to CV group all over the study period (p0.05). The oxygenation index was significantly higher in PV group during the period of OLV (p 0.001) and during the first day postoperatively (p 0.001). There was no significant difference in post-operative outcome between groups. Conclusion: The use of VT 5 ml /kg and PEEP of 5 cm H2O during OLV reduced the systemic pro-inflammatory cytokine response, improved peri-operative oxygenation, but there were no significant differences in occurrence of ARDS or postoperative outcome in patients undergoing esophagectomy