Search

Consent exists to have the indication for cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in patients with appropriate general and nutritional status. Preoperative risk assessment using validated tools and patient compliance are key issues with impact on postoperative morbidity and outcome. Preoperative strategies should be directed towards conditioning the patient to be fit for an Enhanced Recovery after Surgery (ERAS) protocol. In case of functional impairment, the potential of individualized prehabilitation should be explored. Next to functional assessment serum albumin level mostly associated with nutritional status is a prognostic predictor for postoperative complications. In case of serum albumin

Most of ovarian masses in children and adolescents are benign. The preservation of ovarian tissue is one of the main goals to facilitate future hormonal health and fertility. However, malignant ovarian tumors are encountered in a significant percentage of surgical procedures. Due to this circumstance a thorough preoperative risk stratification to identify those being at highest risk for malignancy is mandatory, as this affects the surgical approach, and the type of resection. The current chapter discusses preoperative diagnostic workup including preoperative tumor markers and imaging modalities. The enclosed video highlights the complete removal of a symptomatic cyst while preserving normal ovarian tissue. Furthermore it emphasizes the required surgical steps to fulfil current staging protocols for ovarian masses.

Delayed surgical resection for non-small-cell lung cancer is associated with decreased survival. For patients who smoke, tobacco use at the time of surgery is a risk factor for pulmonary and overall surgical complications. While smoking cessation decreases the risk of postoperative pulmonary complications, there is no ideal time cut-off past which the risk of morbidity significantly decreases. Therefore, smoking cessation should be encouraged as early as possible for all patients, but delaying surgery for active smokers to extend preoperative smoking cessation is unnecessary.

Over the past 80 years, various risk models have been published attempting to aid clinical decision-making in the perioperative period. The primary goal of such models is to objectively classify risks numerically or into categories that can be readily understood by clinicians and patients. Some models have been extrapolated from nonsurgical patient populations, whereas others have been derived and validated solely in surgical cohorts. The scope of perioperative medicine is broad, and a discussion of risks surrounding the surgical period can vary from general statements noting whether patients are acceptable candidates, to detailed problem-specific discussions. We present here an outline of key preoperative models developed over time. These models relay general risk assessments as well as problem- and specialty-specific assessments.

Since its first description in 1991, the use of laparoscopy for colorectal surgery has increased from 22.7% in 2005 to 49.8% in 2014. Increased adoption of laparoscopy is multifactorial and largely due to improved instrumentation and training and supported by demonstration of clinical benefits as well as level I evidence in support of oncologic safety when applied to colon cancer. Conversion rates have remained variable based on case volume but can be reduced with training and increased familiarity with surgical techniques described throughout this colorectal textbook. This chapter will review risk factors for conversion and discuss tips and tricks on how to avoid conversion during laparoscopic colorectal resections.

Thoughtful preoperative preparation is necessary prior to performing transanal total mesorectal excision (TaTME) whether it be for benign or malignant disease. Evaluation begins with a careful history and thorough physical examination. Additionally, the patient’s entire past medical and surgical history should be reviewed along with a detailed assessment of the patient’s current medications. Several preoperative tests are necessary regardless of etiology, and stringent oncologic principles must be followed in the preoperative staging of patients with malignant disease. Irrespective of the indication for surgery, a careful preoperative risk assessment must be performed and may warrant additional testing for cardiopulmonary fitness. Routine laboratory workup and imaging should be individualized for each patient. An enhanced recovery after surgery (ERAS) protocol should be implemented in the preoperative, intraoperative, and postoperative care of the patient. Care must be taken to ensure individual patient factors are taken into consideration with utilization of each element of the pathway.

Over the past two decades, endovascular embolization has become a fundamental part of a multidisciplinary approach for the treatment of intracranial arteriovenous malformations (AVMs). Several embolic agents are now an intrinsic part of the neurointerventional armamentarium. However, none has represented as remarkable an improvement as the introduction of ethylene vinyl alcohol copolymer (EVOH). In conjunction with n-butyl cyanoacrylate (NBCA), EVOH has revolutionized the endovascular management of intracranial AVMs because of its ability to systematically deliver a sufficient volume of the embolic agent to the nidus and pedicles without extension into the venous drainage. The clinical decision to treat an AVM is facilitated by preoperative risk stratification; the first question to be addressed is whether to treat the AVM; and, if so, the second question is how to treat it. Endovascular EVOH embolization is primarily applied as an adjunct treatment to microsurgical resection or radiosurgery. Few cases are amenable to angiographic cure by embolization alone. The goal of this chapter is to describe the pertinent properties, endovascular techniques, and pitfalls for the endovascular management of intracranial AVMs using EVOH.

Staging is an essential component of cancer care. It is necessary to estimate prognosis, develop treatment plans, facilitate communication, and establish a bases for research efforts. Various clinicopathologic features of papillary thyroid cancer have been used to create a large number of staging systems. These systems incorporate preoperative risk factors, intraoperative findings, and postoperative results to estimate mortality and to a lesser degree recurrence. Preoperatively environmental exposures, age, gender, and genetics contribute to risk assessment in addition to physical exam and ultrasonographic findings. Intraoperative thyroid gland and lymph node assessment is important for guiding management both intraoperatively and postoperatively. Finally, postoperative response to therapy is becoming a guiding principle in the dynamic staging of patients with papillary thyroid cancer. This chapter discusses the evolution of staging systems for papillary thyroid cancer as well as patient and tumor characteristics that are evaluated at different time intervals as part of the staging process.

Noncardiac surgery is associated with an average overall complication rate of about 11 % and a mortality rate of 1.5 %. Despite benefits associated with the introduction of safety procedures and improved surgical techniques, major perioperative complications continue to occur. As a consequence, there is a major interest in an efficient preoperative risk stratification that uses available clinical information to stratify the risk of perioperative cardiac complications in order to tailor potential protective strategies. Unfortunately, the currently available preoperative risk prediction models have limitations and do not allow for an accurate individual patient risk stratification. Measurements of sensitive biomarkers have been shown to be of additional help in identifying the patient at risk for adverse postoperative outcome, and preliminary data suggest that intensification of therapy in those patients improves outcome. Taking into account the major implications of perioperative cardiac events and the fact that occurrence of these events can be modulated, maximal efforts should be directed toward the prevention and treatment of perioperative myocardial ischemia. The present chapter summarizes available perioperative cardioprotective strategies that may help to improve outcome of patients with increased cardiac risk undergoing noncardiac surgery.

Ventral and incisional hernias are commonly encountered in general surgical practice today. These range in complexity and acuity with the incarcerated or strangulated hernia presenting a challenge in management. The true rate of the hernia “accident” with bowel obstruction or ischemia is difficult to ascertain, yet this must be discussed with the patient presenting with a reducible or chronically incarcerated ventral/incisional hernia. The decision making encompasses the timing of repair for the reducible or largely asymptomatic chronically incarcerated ventral hernia, preoperative risk modification, potential for mesh contamination, and the risk of hernia recurrence. The impact of these surgical decisions is amplified in the emergent setting with an acutely ill patient. There are many options for repair at the surgeon’s disposal. Thoughtful consideration of the advantages and disadvantages of each and the patient’s desires and expectations are central to the success of repair.

Background The rapidly aging population affects Japan’s health system, which is characterized by equity and full health insurance coverage for the entire population. However, the current outcomes after surgery in tertiary hospitals in Japan are not known. We aimed to gain an overview of postoperative mortality and death in a tertiary university hospital. Methods Using the administrative database of Kawasaki Medical School Hospital, we investigated the pattern of in-hospital mortality and death for patients who underwent surgery under general or regional anesthesia between January 2010 and December 2011. We used a logistic regression model to find pre-operative risk factors associated with in-hospital mortality in this derivation cohort and tested its results in the validation cohort obtained from surgical patients between January 2012 and April 2014. Results Among 8414 admissions for surgery patients aged ≥65 years was 41.0 %, reflecting aged population in Japan. There were 170 deaths in the derivation cohort, resulting in in-hospital mortality of 2.0 %, and in 30-day mortality of 1.0 %, because a half of the death occurred later than 30 days. We identified four independent preoperative risk factors for in-hospital mortality: high-risk surgery [odds ratio (OR) 18.64], moderate-risk surgery (OR 5.00), ASA-PS ≥3 (OR 5.55), and emergency (OR 2.35). A good correlation between actual and calculated mortality based on the derivation cohort was confirmed in the validation cohort. Conclusions This retrospective study of a single university hospital in Japan shows that aged patients in their 70 s is the largest group undergoing surgery, and that the overall in-hospital mortality is similar to that of other countries, but the 30-day mortality is less than that. Risk stratification for in-hospital mortality using preoperative factors was validated.

The knowledge about quality control and the development of quality initiatives provide techniques for the optimal performance of SPECT imaging and therefore maximize the clinical value of this important non-invasive technique. Given the increasing volume in cardiac imaging and its related expense, it is critical to provide clinically relevant data and do so in a cost-effective manner. This section will focus on the clinical implications of SPECT myocardial perfusion imaging. We will review the evaluation of multiple patient populations including those with suspected coronary artery disease, risk stratification, preoperative risk assessment, evaluation of therapy in patients with known coronary disease, risk stratification of the diabetic patient, assessment of women and additional unique patient cohorts. The body of evidence supporting each of these indications is very strong and will be reviewed.

Surgery on the morbidly obese patient can carry a high risk of peri-operative morbidity and mortality due to the unusual stress placed on the physiology of such patients. This risk is often increased because of pre-existing medical cardiorespiratory and metabolic comorbidities. This chapter discusses the preoperative risk scoring systems that are currently used in bariatric surgery, in order to identify and evaluate the morbidity and mortality risks for each patient. These risk scoring systems include the Obesity Surgery Mortality Risk Score (OSMRS), the Bariatric Mortality Risk (BMR), the Edmonton Obesity Staging System (EOSS), the Metabolic Acuity Score (MAS) and the Nomogram for predicting surgical complications. Other useful scoring or classification systems used include the Cardiac Risk Assessment for non-cardiac surgery system and the American Society of Anesthesiologists (ASA) physical status classification system. While there is no single ideal risk scoring system that caters to every patient, preoperative risk scoring systems are useful tools in planning a customized approach for each patient.

Futility in healthcare is an area of significant debate. Generally, a futile treatment is one that is incapable of producing a beneficial result. The degree of benefit required has been contentious in the ethics literature. Different definitions of futility have been proposed to arrive at a consensus regarding which treatments would be provided and to agree on futile interventions that could be withheld. However, each of these definitions has flaws. Some hospitals, healthcare organizations, and states have implemented policies to create a procedural approach to futility disputes. Several authors have advocated discarding the language of futility as it often is an expression of physician frustration and impedes communication between care providers, patients and their surrogates. Many resources are available to assist in difficult cases involving futility including preoperative risk calculators and institutional ethics committees, but, ultimately, the best tool in approaching these challenging situations is open and honest communication between the patient, or surrogate, and the physician.

More than 230 million major surgical procedures are undertaken worldwide each year [1]. Data from the USA and Europe suggests that approximately 18 % of patients undergoing surgery will develop a major postoperative complication and 3–5 % will die before hospital discharge [1–4]. If this rate is applicable worldwide approximately 40 million patients undergoing surgery each year will die or develop a major postoperative complication. Those patients who develop a postoperative complication and survive to hospital discharge have diminished functional independence and reduced long-term survival. In a landmark study Khuri and coworkers demonstrated that survival up to 8 years after major surgery was strongly related to the development within 30 days of surgery of a major postoperative complication [4]. In this study, independent of preoperative risk, the occurrence of a 30-day complication reduced median patient survival by 69 %. In both the USA and Europe there are large variations in postoperative morbidity and mortality within healthcare systems [2, 3, 5]. Interventions that reduce the risks of postoperative death and complications, particularly in high risk patients have become a priority in perioperative medicine [6]. Interventions such as the use of perioperative beta-blockers, statins and tight glycemic control have proved disappointing [7, 8]. Pre-emptive goal-directed hemodynamic therapy (GDT) appears to be a promising approach to reduce postoperative complications and deaths.