Li et al.1  have demonstrated that limb remote ischemic preconditioning (RIPC) attenuates lung injury after lung resection in patients without severe pulmonary disease under propofol–remifentanil anesthesia. The authors concluded that lung reexpansion from the one-lung ventilation provoked severe oxidative injuries, which was shown by increased serum levels of an oxidative product malondialdehyde,2  and that RIPC reduced the oxidative stress, resulting in improvement of pulmonary function after the lung resection.1  However, I would like to suggest another role of RIPC in the decreased oxidative stress in the study. When I looked at figure 3C of the article, patients receiving RIPC showed a higher serum malondialdehyde level from the time point 2, which was before resuming two-lung ventilation, and the level did not further increase 30 min after reexpansion (the time point 3).1  These results indicate that the mechanism other than reperfusion should have caused oxidative stress, resulting in increased levels of malondialdehyde. It is interesting to note that patients with lung cancer have a higher production of reactive oxygen species than that in the normal population and that manipulated lung tissue is a source of reactive oxygen species.3–5  In the study by Li et al.,1  the postoperative morbidity rate for acute lung injury and adult respiratory distress syndrome was too high (8.2 to 17.5%) compared with that reported in previous studies (2.45%),6  indicating that their study population contained severe lung cancer patients, who were exposed to increased oxidative stress. Therefore, it is likely that RIPC can reduce oxidative stress induced by advanced lung cancer during the operation. I would await additional data regarding this issue from their further studies.

The author declares no competing interests.

1.
Li
C
,
Xu
M
,
Wu
Y
,
Li
YS
,
Huang
WQ
,
Liu
KX
:
Limb remote ischemic preconditioning attenuates lung injury after pulmonary resection under propofol-remifentanil anesthesia: A randomized controlled study.
Anesthesiology
2014
;
121
:
249
59
2.
Niedernhofer
LJ
,
Daniels
JS
,
Rouzer
CA
,
Greene
RE
,
Marnett
LJ
:
Malondialdehyde, a product of lipid peroxidation, is mutagenic in human cells.
J Biol Chem
2003
;
278
:
31426
33
3.
Misthos
P
,
Katsaragakis
S
,
Milingos
N
,
Kakaris
S
,
Sepsas
E
,
Athanassiadi
K
,
Theodorou
D
,
Skottis
I
:
Postresectional pulmonary oxidative stress in lung cancer patients. The role of one-lung ventilation.
Eur J Cardiothorac Surg
2005
;
27
:
379
82; discussion 382–3
4.
Peddireddy
V
,
Siva Prasad
B
,
Gundimeda
SD
,
Penagaluru
PR
,
Mundluru
HP
:
Assessment of 8-oxo-7, 8-dihydro-2’- deoxyguanosine and malondialdehyde levels as oxidative stress markers and antioxidant status in non-small cell lung cancer.
Biomarkers
2012
;
17
:
261
8
5.
Esme
H
,
Cemek
M
,
Sezer
M
,
Saglam
H
,
Demir
A
,
Melek
H
,
Unlu
M
:
High levels of oxidative stress in patients with advanced lung cancer.
Respirology
2008
;
13
:
112
6
6.
Dulu
A
,
Pastores
SM
,
Park
B
,
Riedel
E
,
Rusch
V
,
Halpern
NA
:
Prevalence and mortality of acute lung injury and ARDS after lung resection.
Chest
2006
;
130
:
73
8