Background: Higher positive end-expiratory pressure (PEEP) during laparoscopic surgery may increase oxygenation and respiratory compliance. This meta-analysis aimed to compare the impact of different intraoperative PEEP strategies on arterial oxygenation, compliance, and hemodynamics during laparoscopic surgery in non-obese patients. Methods: We searched RCTs in PubMed, Cochrane Library, Web of Science, and Google Scholar from January 2012 to April 2022 comparing the different intraoperative PEEP (Low PEEP (LPEEP): 0–4 mbar; Moderate PEEP (MPEEP): 5–8 mbar; high PEEP (HPEEP): >8 mbar; individualized PEEP - iPEEP) on arterial oxygenation, respiratory compliance (Cdyn), mean arterial pressure (MAP), and heart rate (HR). We calculated mean differences (MD) with 95% confidence intervals (CI), and predictive intervals (PI) using random-effects models. The Cochrane Bias Risk Assessment Tool was applied. Results: 21 RCTs (n = 1554) met the inclusion criteria. HPEEP vs. LPEEP increased PaO₂ (+ 29.38 [16.20; 42.56] mmHg, p < 0.0001) or PaO₂/FiO₂ (+ 36.7 [+ 2.23; +71.70] mmHg, p = 0.04). HPEEP vs. MPEEP increased PaO₂ (+ 22.00 [+ 1.11; +42.88] mmHg, p = 0.04) or PaO₂/FiO₂ (+ 42.7 [+ 2.74; +82.67] mmHg, p = 0.04). iPEEP vs. MPEEP increased PaO₂/FiO₂ (+ 115.2 [+ 87.21; +143.20] mmHg, p < 0.001). MPEEP vs. LPEP, and HPEEP vs. MPEEP increased PaO₂ or PaO₂/FiO₂ significantly with different heterogeneity. HPEEP vs. LPEEP increased Cdyn (+ 7.87 [+ 1.49; +14.25] ml/mbar, p = 0.02). MPEEP vs. LPEEP, and HPEEP vs. MPEEP did not impact Cdyn (p = 0.14 and 0.38, respectively). iPEEP vs. LPEEP decreased driving pressure (-4.13 [-2.63; -5.63] mbar, p < 0.001). No significant differences in MAP or HR were found between any subgroups. Conclusion: HPEEP and iPEEP during PNP in non-obese patients could promote oxygenation and increase Cdyn without clinically significant changes in MAP and HR. MPEEP could be insufficient to increase respiratory compliance and improve oxygenation. LPEEP may lead to decreased respiratory compliance and worsened oxygenation. Prospero registration: CRD42022362379; registered October 09, 2022.

High and individual positive end-expiratory pressure (PEEP) during laparoscopic surgery may improve oxygenation and respiratory mechanics. We searched RCTs in PubMed, Cochrane Library, Web of Science, and Google Scholar from from from January 2000 to December 2023 comparing the different intraoperative PEEP (low PEEP (LPEEP): 0–5 mbar; moderate PEEP (MPEEP): 6–9 mbar; high PEEP (HPEEP): >=10 mbar; individualized PEEP (iPEEP): PEEP set by special physiological technique) on arterial oxygenation, respiratory compliance (Cdyn) or driving pressure, mean arterial pressure (MAP), and heart rate (HR) in patients during laparoscopic surgery in reverse Trendelenburg position. We calculated mean differences (MD) with 95% confidence intervals (CI), and predictive intervals (PI) using random-effects models. The Cochrane Bias Risk Assessment Tool was applied. 8 RCTs (n = 425) met the inclusion criteria. HPEEP vs. LPEEP increased PaO2/FiO2 (+ 129.93 [+ 75.20; +184.65] mmHg, p < 0.0001) with high variation of true effect (Chi2 34.92, p < 0.0001; I2 89%). iPEEP vs. LPEEP also increased PaO2/FiO2 + 130.23 [+ 57.18; +203.27] mmHg, p = 0.0005) with high variation of true effect (Chi2 26.95, p < 0.0001; I2 93%). HPEEP vs. LPEEP increased Cdyn (+ 15.06 [5.47; +24.65] ml/mbar, p = 0.002) with high variation of true effect (Chi2 93.16, p < 0.0001; I2 96%). iPEEP vs. LPEEP increased Cdyn (+ 22.46 [+ 8.56; +36.35] ml/mbar, p = 0.002) with high variability of the true effect (Chi2 53.92, p < 0.0001; I2 96%). HPEEP group had higher MAP as compared to LPEEP) + 4.36 [+ 0.36;+8.36], p = 0.03), variability of the true effect was nonsignificant. HR did nit differ between all comparisons. In patients with obesity undergoing surgery in the reverse Trendelenburg position HPEEP and iPEEP may improve oxygenation, decrease driving pressure, and increase dynamic compliance compared to LPEEP with high variation of true effect without relevant hemodynamic compromise. Data with MPEEP comparisons are inconclusive. CRD42023488971; registered December 14, 2023.

Cancers represent a significant global health burden, affecting millions of individuals each year

Background: Gastric cancer is a serious health issue both globally and in Kazakhstan. Worldwide, gastric cancer ranks fifth in incidence, with the highest rates reported in East Asia, the Andes of South America, and Eastern Europe, while the lowest rates are reported in North America, Northern Europe, Africa, and Southeast Asia. Over 70% of the cases occur in resource-limited countries. In Kazakhstan, gastric cancer ranks third in morbidity and second in mortality, representing a serious clinical and social problem. Annually, 1600 deaths from malignant gastric neoplasms are registered. Peritoneal metastasis is considered one of the most severe complications of gastric cancer and has long been regarded as its terminal stage. The average life expectancy of patients with peritoneal metastasis is only 3-6 months, reflecting a high mortality rate and the limited efficacy of current treatments. Objective: We hypothesize that the prophylactic use of pressurized intraperitoneal aerosol chemotherapy (PIPAC) may reduce the incidence of peritoneal metastasis. The aim of this study is to evaluate the incidence of peritoneal metastasis following prophylactic PIPAC in patients with gastric cancer. The primary goal of this research is to evaluate whether adding prophylactic PIPAC to standard treatment before neoadjuvant chemotherapy can reduce the incidence of peritoneal metastasis in patients with locally advanced gastric cancer. Methods: This study is a single-center nonrandomized controlled trial with a planned enrollment of 160 patients. All participants will be included in one of the 2 groups: intervention group (PIPAC + perioperative chemotherapy + gastrectomy with D2 lymphadenectomy) or control group (perioperative chemotherapy + gastrectomy with D2 lymphadenectomy). The primary end point is the incidence of peritoneal metastasis, and the secondary end points are overall survival, recurrence-free survival, treatment-related adverse events, and personal satisfaction. Results: As of September 2025, this study is funded and recruiting; 102 participants have already been enrolled. Recruitment is planned to be performed between January 2025 and December 2026. No interim analyses have been performed; primary results are planned for Q1 2027. The manuscript is expected to be published by Q4 2027. Conclusions: Compared to standard chemotherapy, PIPAC has been reported to significantly improve survival rates in patients with peritoneal metastasis of gastric origin. We suggest that the neoadjuvant use of PIPAC may reduce the incidence of peritoneal metastasis and improve long-term survival outcomes. The results of our study will provide key information on the practicality and viability of PIPAC as a prophylactic technique for preventing the progression of gastric cancer. Trial Registration: ClinicalTrials.gov NCT06784765; https://clinicaltrials.gov/study/NCT06784765 International Registered Report Identifier (IRRID): PRR1-10.2196/78053

Laparoscopic surgery, a cornerstone of contemporary surgical practice, revolutionizes traditional surgical techniques by employing minimally invasive procedures. However, this innovative approach poses intricate challenges, particularly in respiratory management, necessitating a comprehensive understanding of its physiological implications. Pneumoperitoneum involves insufflating the abdominal cavity with carbon dioxide (CO2) to create a suitable working space. The introduction of CO2 into the peritoneal cavity elevates intra-abdominal pressure, prompting physiological adaptations that compromise respiratory function. These alterations, including increased peak inspiratory pressure, decreased dynamic respiratory system compliance, and the promotion of intraoperative atelectasis, underscore the intricate interplay between pneumoperitoneum and respiratory physiology.Amidst these challenges, positive end-expiratory pressure emerges as a crucial intervention for mitigating the adverse effects of pneumoperitoneum on respiratory mechanics. By maintaining airway patency and preventing alveolar collapse during expiration, positive end-expiratory pressure helps counteract the reduction in functional residual capacity associated with elevated intra-abdominal pressure. Additionally, positive endexpiratory pressure serves to optimize lung recruitment, thereby improving ventilation-perfusion matching and enhancing oxygenation.Mechanical ventilation during laparoscopic procedures further complicates respiratory management, potentially exacerbating lung injury. The application of protective lung ventilation strategies, such as low tidal volume combined with judicious positive end-expiratory pressure titration, represents a cornerstone in mitigating ventilator-induced lung injury and reducing postoperative pulmonary complications. However, the optimal implementation of these strategies remains a subject of ongoing debate, highlighting the need for personalized approaches tailored to individual patient characteristics and surgical contexts.Understanding the pivotal role of positive end-expiratory pressure in mitigating the adverse respiratory effects of pneumoperitoneum underscores its importance as a cornerstone intervention in laparoscopic surgery. By optimizing positive end-expiratory pressure levels based on patient characteristics and procedural requirements, healthcare practitioners can effectively mitigate the risk of pulmonary complications and enhance surgical outcomes.

: Background: Klebsiella pneumoniae is a World Health Organization (WHO) critical priority pathogen, and carbapenem-resistant K. pneumoniae (CRKP) causes 50,000–100,000 attributable deaths annually worldwide. Systematic antimicrobial resistance (AMR) data from Central Asia are virtually absent from the global literature. Methods: Longitudinal surveillance study of routine microbiological data from the National Research Oncology Centre (NROC), Astana, Kazakhstan (January 2022–March 2026). Four data sources were integrated: monthly microbial landscape reports (October 2022–September 2024; n=596 K. pneumoniae isolates), a full-year patient-level clinical register (2025; n=91 isolates), monthly landscape reports for first quarter 2026 (Q1 2026 n=50 isolates), and biannual antibiograms (2022, 2026). Isolates were classified as CRKP (4MRGN), 3MRGN, ESBL-producing, or susceptible. Results: A total of 737 K. pneumoniae isolates were identified across the full study period. CRKP (4MRGN) was the dominant phenotype throughout, peaking at 76.4% in January–September 2024 and remaining at 62.0% in Q1 2026. The aggregate MDR rate (CRKP + 3MRGN + ESBL) was 76–87% across all periods, consistently 2–3 times above the global pooled mean of 28.7%. The highest resistance burden was observed in the bone marrow transplantation department (86–98% MDR) and intensive care units (67–100% MDR). Between 2022 and 2026, a profound shift in reserve antibiotic susceptibility was documented: amikacin resistance rose from 8.5% (2022) to 38.1% (Q1 2026, whole institution) and 60% (Q1 2026, intensive care sector), nearly eliminating the sole previously active antibiotic class. In contrast, polymyxins (colistin R 0%, polymyxin B R 2%) and tigecycline (R 52%) emerged as the only agents with retained activity in 2026. Carbapenem resistance showed a modest partial improvement (meropenem R 72%→64%) but remained critically high. Simultaneously, Escherichia coli (ESBL+/MDR) emerged as the dominant pathogen in haematological and surgical departments by 2025–2026, reflecting a broader Enterobacterales resistance crisis beyond K. pneumoniae alone. Conclusions: This study provides the first systematic published AMR surveillance evidence from Kazakhstan over a four-year period. CRKP dominates the institutional microbiological landscape, and the progressive loss of aminoglycoside activity now leaves polymyxins and tigecycline as the last remaining active agents — a development with profound implications for patient safety. These findings represent a critical call to action for antimicrobial stewardship implementation, carbapenemase genotyping, and integration into national and global AMR surveillance systems in Central Asia.