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Background: Preoperative telemonitoring of vital signs, physical activity, and well-being might be able to optimize prehabilitation of the patient's physical and mental condition prior to surgery, support setting alarms during in-hospital monitoring, and allow personalization of the postoperative recovery process., Objective: The primary aim of this study was to evaluate when and how long patients awaiting major abdominal surgery should be monitored to get reliable preoperative individual baseline values of heart rate (HR), daily step count, and patient-reported outcome measures (PROMs). The secondary aim was to describe the perioperative course of these measurements at home., Methods: In this observational single-center cohort study, patients used a wearable sensor during waking hours and reported PROMs (pain, anxiety, fatigue, nausea) on a tablet twice a day. Intraclass correlation coefficients (ICCs) were used to evaluate the reliability of mean values on 2 specific preoperative days (the first day of telemonitoring and the day before hospital admission) and randomly selected preoperative periods compared to individual reference values. Mean values of HR, step count, and PROMs per day were visualized in a boxplot from 14 days before hospital admission until 30 days after surgery., Results: A total of 16 patients were included in the data analyses. The ICCs of mean values on the first day of telemonitoring were 0.91 for HR, 0.71 for steps, and at least 0.86 for PROMs. The day before hospital admission showed reliability coefficients of 0.76 for HR, 0.71 for steps, and 0.92-0.99 for PROMs. ICC values of randomly selected measurement periods increased over the continuous period of time from 0.68 to 0.99 for HR and daily step counts. A lower bound of the 95% CI of at least 0.75 was determined after 3 days of measurements. The ICCs of randomly selected PROM measurements were 0.89-0.94. Visualization of mean values per day mainly showed variable preoperative daily step counts (median 2409, IQR 1735-4661 steps/day) and lower postoperative daily step counts (median 884, IQR 474-1605 steps/day). In addition, pain was visually reduced until 30 days after surgery at home., Conclusions: In this prospective pilot study, for patients awaiting major abdominal surgery, baseline values for HR and daily step count could be measured reliably by a wearable sensor worn for at least 3 consecutive days and PROMs during any preoperative day. No clear conclusions were drawn from the description of the perioperative course by showing mean values of HR, daily step count, and PROM values over time in the home situation., (©Marjolein E Haveman, Rianne van Melzen, Mostafa El Moumni, Richte C L Schuurmann, Hermie J Hermens, Monique Tabak, Jean-Paul P M de Vries. Originally published in JMIR Perioperative Medicine (http://periop.jmir.org), 28.11.2022.)

Radical cystectomy with pelvic lymphadenectomy and urinary diversion is the standard treatment for patients diagnosed with localized muscle-invasive bladder cancer. Enhanced recovery after surgery (ERAS) is a multimodal perioperative care pathway comprising recommendations on different items with variable evidence that are aimed at improving outcomes. This review provides an overview of the application of specific elements of the ERAS guidelines. Forty-eight series were identified through our literature search. The studies reported a median of 16 out of the 22 ERAS steps (72.7%). The elements were applied in 79.3% of cases (interquartile range 61.1-85%) if mentioned in the studies, decreasing to 73.5% in the postoperative period. PATIENT SUMMARY: Guidelines on enhanced recovery after surgery recommend steps to follow and cover all areas of the patient's journey through the surgical process. We looked at the application of the elements for patients with bladder cancer. We found inconsistent reporting and use., (Copyright © 2022 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Background: Duodenal cancer presents an elusive therapeutic challenge for clinicians to treat because of its highly malignant behavior and anatomical complexity. Endoscopic excision has been administered to treat early-stage cancers of upper gastrointestinal tract, especially esophagus and stomach cancer. There is currently a scarcity of data regarding the application and efficacy of endoscopic resection for early duodenal cancer due to its rarity. This study aimed at exploring the prevalence and efficacy of endoscopic excision in treatment for early duodenal cancer in comparison with major surgery.Methods: This cohort study retrospectively collected patients with primary Tis/T1-N0-M0 duodenal cancer in the Surveillance, Epidemiology, and End Results database from 2004 to 2017. Prevalence of endoscopic excision in duodenal cancer treatment, overall survival (OS) and disease-specific survival (DSS) of patients who received different tumor-resection procedures were estimated.Results: A total of 1354 patients with Tis/T1-stage duodenal cancer were identified. Most patients (69.4%) underwent tumor resection as initial treatments. Among them, 65.7% underwent endoscopic excision, while 34.3% underwent major surgery. The multivariable Cox analyses revealed that endoscopic excision was associated with a significantly favorable OS (HR: 0.70; 95% CI: 0.52-0.95, p = 0.02) and DSS (HR: 0.32; 95% CI: 0.17-0.60, p < 0.001), compared to major surgery, for Tis/T1-stage cancer patients. In addition to cancer-related deaths (p < 0.001), endoscopic resection manifested significantly lower cumulative mortality rate of post-operative infectious diseases (p = 0.03).Conclusion: Endoscopic resection currently accounted for approximately two-thirds of all procedures to resect Tis/T1-stage duodenal tumor. Endoscopic resection represents a viable therapeutic option in the management of Tis/T1-stage duodenal cancer for its oncological superiorities to major surgery and its capacity to reduce operative traumas and morbidities. [ABSTRACT FROM AUTHOR]

Major surgery is usually invasive and associated with significant tissue trauma; therefore, adequate analgesia using a combination of analgesic drugs and techniques is paramount. Opioids remain the backbone of peri-operative analgesic regimens for major surgery and also contribute significantly to a balanced anaesthesia technique. Ideally, full Mu agonist opioids should be used peri-operatively for major surgery because they provide superior analgesia to partial Mu agonists and butorphanol for management of moderate-to-severe pain. Where possible, consider the use of loco-regional anaesthesia and analgesia techniques in order to contribute to a reduction in required volatile agent concentration and thus provide balanced anaesthesia and contribute to a multi-modal analgesia approach. Analgesic adjuncts such as ketamine and lidocaine should be used in combination with opioids and are best administered by continuous-rate infusion using controlled infusion apparatus, such as a syringe driver. [ABSTRACT FROM AUTHOR]

Background: Patients presenting for major surgery with low cardiorespiratory fitness (deconditioning) and other modifiable risk factors are at increased risk of postoperative complications. This study investigated the feasibility of delivering prehabilitation in high-risk patients scheduled for major abdominal cancer surgery., Methods: Eligible patients in this single-center cohort study included patients with poor fitness (objectively assessed by cardiopulmonary exercise testing, CPET) scheduled for elective major abdominal cancer surgery. Patients were recruited to participate in a prehabilitation program that spanned up to 6 weeks pre-operatively and comprised aerobic and resistance exercise training, breathing exercise, and nutritional support. The primary outcome assessed pre-specified feasibility targets: recruitment >70%, retention >85%, and intervention adherence >70%. Secondary outcomes were assessed for improved pre-operative functional status and health-related quality of life and for postoperative complications., Results: Eighty-two (34%) out of 238 patients screened between April 2018 and December 2019 were eligible for recruitment. Fifty (61%) patients (52% males) with a median age of 71 (IQR, 63-77) years participated in the study. Baseline oxygen consumption the at anaerobic threshold and at peak exercise (mean±SD: 9.8±1.8 and 14.0±2.9 mL/kg/min, respectively) confirmed the deconditioned state of the study cohort. The retention rate within the prehabilitation program was 84%, with 42 participants returning for repeat CPET testing. While >60% of participants preferred to do home-based prehabilitation, adherence to the intervention was low-with only 12 (28%) and 15 (35%) of patients having self-reported compliance >70% with their exercise prescriptions., Conclusion: Our prehabilitation program in high-risk cancer surgery patients did not achieve pre-specified targets for recruitment, retention, and self-reported program adherence. These findings underpin the importance of implementation research and strategies for the prehabilitation programs in major surgery., Trial Registration: Australian New Zealand Clinical Trials Registry ( ACTRN12620000073909 ) retrospectively registered., (© 2022. The Author(s).)

The difference between arterial and central venous carbon dioxide partial pressure (PCO 2 gap), a marker of oxygen delivery (DO 2) and oxygen consumption (VO 2) adequacy, has been evaluated as a promising prognostic tool in intensive care unit (ICU) patients. We therefore sought to study the association between intraoperative PCO 2 gap and postoperative complications (POC) in the perioperative setting of elective major abdominal surgery. We conducted a single-centre prospective observational study. All adult patients who underwent major planned abdominal surgery were eligible. PCO 2 gap was measured every 2 h during surgery, at ICU admission and repeated 12 h and 24 h later. Severe POC within 28 days after surgery were defined as complications graded 3 or more according to Clavien-Dindo classification. Following a univariate analysis, a multivariable analysis using a logistic regression model was performed. Ninety patients were included and divided into two groups according to the occurrence of POC. No significant difference was found between groups regarding baseline characteristics at inclusion. Thirty-nine (43%) patients developed postoperative complications. The median [IQR] intraoperative PCO 2 gap was significantly higher in patients who had complications (6.5 [5.5−7.3] mmHg) compared to those who did not (5.0 [3.9–5.8] mmHg; p < 0.001). The area under the receiver operating characteristic curve for occurrence of POC was 0.78 for the PCO 2 gap. After multivariable analysis, PCO 2 gap was found independently associated with POC (OR: 14.9, 95% CI [4.68–60.1], p < 0.001) with a threshold value of 6.2 mmHg. The duration of surgery (OR: 1.01, 95% CI [1.00; 1.01], p = 0.04) and the need for vasoactive support during surgery (OR: 5.76, 95% CI [1.72; 24.1], p = 0.006) were also independently associated with POC. Intraoperative PCO 2 gap is a relevant predictive factor of severe postoperative complications in high-risk elective surgery patients. ClinicalTrials.gov , NCT03914976. [ABSTRACT FROM AUTHOR]

Purpose: To analyze different factors affecting the outcome of patients undergoing Two Stage Esophagectomy (TSE) for the treatment of esophageal carcinoma (EC) while relating these factors to the length of stay on Intensive Care Unit (ILOS), mortality, and morbidity. Methods: Retrospective study of case-notes of 45 patients who underwent a TSE for resection of EC at a general district hospital in the United Kingdom (UK). These procedures were performed by the same surgical team and followed same approach, known as the Ivor-Lewis procedure. Results: The duration of One Lung Ventilation (OLV) during TSE was found to be critical for patient's outcome. Statistical analysis suggested a potentially strong effect of the duration of OLV (range: 90-320 minutes) on the ILOS (P=0.001). The ratio OLV: Total duration of surgery (TOT) was significantly different in early post-operative (PO) deaths (within 3 months) and late deaths after the third month (P=0.032). The POSSUM value (Physiological and Operative Severity Score for Enumeration of Mortality) correlated well with ILOS (P=0.05). Regression analysis showed a strong relationship between the two variables (P=0.03). An excellent to good quality of PO analgesia allowed for shorter ILOS (P=0.023). Conclusions: Duration of the OLV appears as an important factor in the outcome of patients. POSSUM value could help in planning the post-operative critical care need of patients undergoing TSE. A well managed post-operative pain allowed to reduce the ILOS. [ABSTRACT FROM AUTHOR]

Abstract: To determine predictability of serial estimations of blood lactate levels for postoperative outcome of head and neck cancer patients and determine validity of single versus serial estimations for accurate prediction of outcome. The study included 322 cancer patients assigned for major head and neck surgeries and admitted to ICU. Data collection included age, sex, and associated comorbidities, and clinical status was determined using APACHE II score. Arterial lactate was measured at time of admission (T0), and 8-hourly (T8, T16, T24), and percentage of change of blood lactate level was calculated versus T0 level. Patients were categorized as survivor and non-survivors, and among each group, patients were categorized according to estimated level of blood lactate into four categories. The mean of APACHE score at ICU admission was 16.6±3.1, and mean duration of ICU and hospital stay was 3.2±1.2 and 19.3±5.5 days, respectively. Fifty-two patients died for postoperative mortality rate 16.1%. Non-survivors were significantly older and had significantly higher APACHE score and significantly longer ICU and hospital stay. At admission blood lactate level was significantly higher in non-survivors compared to survivors. All patients showed progressive increase of blood lactate level, but non-survivors showed significantly higher frequency of elevated blood lactate strata compared to survivors with significantly higher difference between both groups at T8, T16, and T24. There was positive significant correlation between high at admission blood lactate level and APACHE score. Regression analysis defined % of change of blood lactate at T16, high APACHE score, high at admission blood lactate and old age as specific predictors for postoperative mortality in descending order of specificity. Serial estimations of blood lactate are conclusive test for follow-up of patients undergoing major surgical procedures requiring ICU admission. Combined high APACHE score and percentage of change of blood lactate could discriminate survivors from non-survivors especially 16-h after ICU admission. [Copyright &y& Elsevier]

Background: Surgery plays a key role in HIV palliative care, specifically in the diagnosis and treatment of HIV related and non-related conditions. Yet major surgery depresses the immune system. Whereas the surgical consequences of HIV infection are well described, there is a paucity of published data, in resource-limited settings, on the effects of major surgery on the immune system. The purpose of this study was to determine the effect of major abdominal surgery on CD4 count in HIV positive and HIV negative patients after emergency major surgery. Methods: A prospective cohort study was done for patients who underwent emergency major abdominal surgery. Their peri-operative CD4 counts were done for both HIV- and HIV + patients. Median CD4s were used in analysis. Mann Whitney test of significance was used for continuous data and Fisher' exact test used for categorical data. IRB approval was obtained. Results: A total of 101 patients were recruited, 25 HIV positive and 76 HIV negative. The median CD4 cell reduction was higher in the HIV negative group (-68 cells) than HIV positive group (-29 cells) (p = 0.480). There was a general increase in the median CD4 change by 72 cells for the HIV positives and 95 cells for the HIV negatives (p = 0.44). CD4 change rose in both the HIV positive and negative groups by 27 cells for the HIV positives and 28 cells for the HIV negatives (p = 0.94). Relative Risk was 0.96, {CI 0.60 - 1.53}. Conclusion: Major emergency abdominal surgery had no significant effect on CD4 cell count among HIV positive patients. [ABSTRACT FROM AUTHOR]

Background: In planned major surgery the duration of inpatient hospital care during the last decade has decreased because of a combination of different perioperative interventions. It is expected that patients can manage the needed pre- and postoperative self-care to a large extent on their own. This entails challenges to healthcare system to deliver appropriate information to patients in a safe and efficient manner. The aim of this study was therefore to describe healthcare workers' perceptions of how eHealth applications can support patients' self-care in relation to planned major surgery., Methods: Semi-structured interviews were performed with sixteen healthcare workers from different disciplines. The interviews were transcribed and analysed using the phenomenography approach., Results: Healthcare workers perceived both positive aspects and challenges with eHealth applications for self-care. eHealth applications can work as an information source, affect patients' understanding of self-care, improve patients' participation in self-care, streamline communication with healthcare professionals and improve patient safety during the pre- and postoperative period. The challenges included perceptions of that eHealth applications may have negative impact on personal interaction in care. eHealth applications may not be useful to all patients because of lack of equipment or knowledge and may increase patients' suffering if physical visits are replaced by digital solutions., Conclusions: This study improves our understanding of healthcare workers' perceptions of how the use of self-care eHealth applications can support patients in performing pre- and postoperative self-care for major surgery. Access to appropriate and personalized information and instructions can improve patients' understanding of self-care and enhance the participation and safety of those who can afford and handle digital tools. All these aspects must be considered in future digital development of eHealth applications to guarantee a person-centered care., (© 2022. The Author(s).)

We carried out a retrospective exploratory study on 173 patients who underwent major surgery and developed septic shock after surgery. Our findings suggest that CEACAM7 rs1001578, rs10409040, and rs889365 polymorphisms could influence septic shock-related death in individuals who underwent major surgery., Competing Interests: Declaration of competing interest The authors declare that they have no competing interests., (Copyright © 2021. Published by Elsevier B.V.)

Background: There is scant clinical research on neuraxial analgesia in dogs undergoing major surgery. With this study we compared the perioperative analgesic effects of thoracic epidural anaesthesia (TEA) and intrathecal morphine (ITM) in dogs scheduled for thoracic or cranial abdominal surgery. The dogs received methadone and dexmedetomidine, were anaesthetized with propofol maintained with sevoflurane, and randomly assigned to receive either TEA (ropivacaine 0.5% at 0.2 mg/kg and morphine 0.1 mg/kg administered at T 12 -T 13 ) or ITM (morphine 30 μg/kg administered at L 6 -L 7 ). Intraoperative rescue analgesia (iRA) was fentanyl 1 μg/kg administered if heart rate or mean arterial pressure increased by 30% above the pre-stimulation level. Glasgow Pain Composite Scale score (GPCS) dictated the use of postoperative rescue analgesia (pRA) with methadone 0.2 mg/kg., Results: There was a statistically significant difference in iRA, median time to first fentanyl bolus, median fentanyl dose after surgical opening, and median GPCS score at 30 minutes (min), 1 ,2, 4, 6, and 8 hours (h) between the two groups (p<0.001; p<0.001; p<0.001; p<0.01; p<0.01; p<0.001; p<0.01; p=0.01; p=0.01, respectively). Fewer TEA than ITM group dogs required iRA during surgical opening and pRA: 5% (1/18) and 2/18 (11%), respectively, in the TEA and 83% (16/18) and 10/18 (55%), respectively, in the ITM group. Side effects were urinary retention in 3/18 (16%) TEA group dogs and 2/18 (11%) ITM group dogs and prolonged sedation in 2/18 (11%) in ITM group dogs. TEA and ITM were effective in managing perioperative pain in dogs undergoing thoracic or cranial abdominal surgery., (© 2022. The Author(s).)

Perioperative acute kidney injury (AKI) occurrence is probably increased in recent years due to the increased level of complexity of surgical procedures and severity of illness of surgical patients. Perioperative AKI has a multifactorial aetiology (preoperative co-morbidities such as diabetes, heart failure and chronic kidney disease, emergent surgery, exposure to nephrotoxic drugs, haemodynamic instability, hypothermia, inflammatory response to surgery, hospital-acquired infections and abdominal compartment syndrome). However, fluid choice for perioperative volume replacement might have a major role in perioperative AKI, as administration of crystalloid solutions, colloids or haemoderivates has the potential for kidney injury. This review focusses on the issue of fluid replacement quality and quantity and their association with renal dysfunction. [ABSTRACT FROM AUTHOR]

Purpose: Although the relationship between preoperative risk factors and outcomes has been extensively studied, the effect of intraoperative hemodynamic changes in a patient's postoperative course has been less well defined. Methods: We designed a prospective observational study to assess the impact of several variables, and especially hypotension, on postoperative outcome. Patients considered eligible for the study, all more than 18 years old, were mentally stable patients scheduled for major abdominal surgery with an expected duration of more than 2 h. Total hypotension time (THT), with other variables that possibly influence the outcome, was analyzed using multivariate logistic regression analysis in 100 consecutive patients. Results: Total hypotension time was isolated as a factor significantly associated with morbidity [odds ratio, 5.1 (1.95-13.35)] and significantly prolonged hospital stay [odds ratio, 4.56 (1.85-10.96)]. Patients who had prolonged THT presented more complications (50 vs. 30), especially of the cardiovascular, pulmonary, and gastrointestinal systems. These complications led to delayed hospital discharge in a significant number of patients (36 with THT vs. 17 others). Finally, duration of surgery was associated with postoperative complications [odds ratio, 3.1 (1.2-8.0)]. Conclusion: Persistent hypotension during elective major abdominal surgery is a significant risk factor for postoperative complications and may prolong hospitalization and affect patient outcomes. Anesthetic management for the avoidance of hypotension, as much as possible, during major abdominal surgery may positively affect outcomes. [ABSTRACT FROM AUTHOR]

Purpose. Acute renal failure is a serious complication of surgery causing morbidity and mortality. The aim of this study was to evaluate the efficacy of fenoldopam, a selective dopamine-1 receptor agonist, in patients at high risk of perioperative renal dysfunction. Methods. In this prospective single-center randomized double-blind trial we enrolled 64 patients undergoing major surgery. Patients received either fenoldopam at a dosage of 0.05 mcg/kg/min or dopamine at a dosage of 2.5 mcg/kg/min after anesthesia induction for a 12-hour period. The primary endpoint was defined as 25% serum creatinine increase from baseline after surgery. Results. All the patients included were at high risk of perioperative renal dysfunction and underwent major surgery. The two groups (fenoldopam versus dopamine) were homogenous cohorts and no difference in outcome was observed. The incidence of acute renal failure was similar: 11/32 (34%) in the fenoldopam group and 14/32 (44%) in the dopamine group (p=0.6). The postoperative serum creatinine peak was also similar in the two groups. No in-hospital death was observed. Conclusion. Despite an increasing number of reports suggesting renal protective properties of fenoldopam, we observed no difference in clinical outcome compared to dopamine in a high-risk population undergoing major surgery. [ABSTRACT FROM AUTHOR]

Background Prolonged surgical procedures involving stress, extended general anaesthesia and a long pre-surgical fasting period may have systemic effects such as alterations in saliva flow rate and composition. These may compromise the patient’s electrolytes and fluid balance and cause dehydration, systemic stress and oxidative changes. Patients and methods Saliva was collected prior and following surgery from 20 patients and 20 control subjects. The saliva samples were analyzed for flow rates and levels of the following: calcium (Ca), magnesium (Mg), total protein, albumin and lactate dehydrogenase (LDH), total antioxidant status (TAS), uric acid (UA), superoxide dismutase (SOD), carbonyls, matrix metalloproteinases (MMPs) -2, -3 and -9 and heat shock proteins (HSPs) 70 and 90. Results Salivary levels of Ca, Mg, protein, albumin and LDH were higher in post-surgical patients by 70% (P = 0Æ002), 88% (P = 0Æ0001), 120% (P = 0Æ13), 111% (P = 0Æ039) and 492% (P = 0Æ006) respectively than that in healthy controls. Salivary antioxidants in the surgical patients were higher while salivary carbonyls remained unchanged. Salivary TAS levels in pre- and post-surgical patients were higher by 63% (P = 0Æ001) and 85% (P = 0Æ0001) respectively, UA concentrations by 92% (P = 0Æ014) and 81% (P = 0Æ036) respectively and SOD values by 47% (P = 0Æ61) and 112% (P = 0Æ049) respectively. Salivary concentrations of MMP3 were higher in pre- and post-surgical patients by 23% (P = 0Æ067) and 30% (P = 0Æ044) respectively. Conclusions Local salivary, oral and systemic-induced alterations should be prevented. Moreover, salivary collection and analysis may be a new, efficient tool in the monitoring of patients undergoing major surgery. Further related research is necessary. [ABSTRACT FROM AUTHOR]

Background: This study assessed the analgesic efficacy, side effects, and time to extubation of intravenous paracetamol when administered as an adjuvant to intravenous meperidine after major surgery in intensive care unit (ICU). Material: Patients were randomized postoperatively into 2 groups in ICU. Patients received either 100 mL of serum saline intravenous (IV) every 6 hours and IV meperidine (n = 20 group M) or IV paracetamol 1 g every 6 hours and IV meperidine (n = 20, group MP) into a peripheral vein for 24 hours. Behavioral Pain Scale (BPS) is used until extubation, and visual analog score (VAS) is used after extubation. When BPS and VAS values were more than 4, meperidine, 1 mg/kg IV, was administered and noted in 2 groups. Pain scores, total meperidine consumption, time to extubation, sedation scores, and side effects are 24-hour postoperatively noted. Results: Behavioral Pain Scale and VAS scores are significantly lower in group paracetamol-meperidine at 24 hours (P < .05). In group MP, postoperative meperidine consumption (76.75 ± 18.2 mg vs. 198 ± 66.4 mg) and extubation time (64.3 ± 40.6 min vs. 204.5 ± 112.7 min) were lower than in group M (P < .01). In addition to, postoperative nausea-vomiting and sedation scores were significantly lower in group MP when compared with group M (P < .05). Conclusion: We have demonstrated important clinical benefits by the addition of 4 g/d of paracetamol to meperidine after major surgery. This benefit has been shown in a range of patients under routine clinical conditions and therefore has important practical consequences in ICU. These data suggest that intravenous paracetamol is a useful component of the multimodal analgesia model, especially after major surgery. [Copyright &y& Elsevier]

Summary: Targeted Fluid Adminstration (TFA) is a technique using less invasive cardiac output monitors to guide individualised intra-operative fluid therapy. Typically, the anaesthetist administers boluses of approximately 200–250 ml of colloid solution whilst measuring changes in stroke volume or another measure of fluid responsiveness, such as stroke volume variation. When the stroke volume measurements indicate that the cardiovascular system is no longer fluid responsive, the patient is assumed to be close to the upper flat phase of the Frank–Starling Curve. Research using TFA suggests that post-operative complications such as ileus and length of hospital stay are reduced when fluid therapy is managed in this way. Most of the positive evidence for TFA has been achieved using the oesophageal Doppler (CardioQ, Deltex Medical, Chichester UK), although other cardiac output monitors are available, there are few clinical outcome studies that justify their use in routine practice. Widespread adoption of TFA for patients undergoing major surgery will help achieve the goals of enhanced recovery. [Copyright &y& Elsevier]

The development of inhibitors following factor VIII replacement therapy is a serious complication in severe inherited haemophilia. Whereas significant experience, notably in orthopaedic surgery, is now obtained with the use of bypassing agents in haemophilia with high-titre inhibitor, new surgical challenges might occur due to patients’ increasing life expectancy. A 56-year-old severe haemophilia A patient with a high-titre inhibitor was diagnosed for probable right temporoparietal malignant glioneuronal tumour on cerebral magnetic resonance imaging (MRI) (4 cm x 3 cm cerebromeningeal tumour with perilesional oedema and transfalcial herniation) requiring total resection. Then recombinant activated FVII (rFVIIa) was chosen as the haemostatic agent: bolus of 270 μg kg−1 every 2 h during the first 24 h, 180 μg kg−1 every 3, 4 and 6 h, respectively, at days 2–3, from days 4–10 and finally from days 11–15. Tranexamic acid was associated. Pre- and postoperative courses were uneventful, the surgical procedure being assessed at optimal haemostatic condition without any unusual haemorrhage on MRI controls, diffuse intravascular coagulation criteria or thromboembolic event. Intensive rFVIIa therapy has shown to be safe and effective in this first reported neurosurgery about a malignant tumour exhibiting to a high-bleeding risk notably in haemophilia with high-titre inhibitor. The use of lower doses of rFVIIa might have been possible; however, in the absence of accurate test for monitoring rFVIIa therapy, the potentially life-threatening complications of this procedure required maximum haemostasis with high rFVIIa doses. [ABSTRACT FROM AUTHOR]

Abstract: Hepato-pancreatico-biliary (HPB) surgery encompasses major hepatic resection and pancreatic surgery, both procedures of high complexity with a potentially high complication rate. The establishment of centres of excellence with a high patient volume has lowered the complication and increased the resection rate. Besides this, increased life expectancy and improved general health status have increased the number of elderly patients eligible for major surgery. Because elderly patients have more co-morbidities and decreased life expectancy, the benefit of these procedures must be critically evaluated in such patients. Analysis of the literature on this subject demonstrated that pancreatico-duodenectomy can be performed safely in selected elderly patients (80 years of age or older), with morbidity and mortality rates approaching those observed in younger patients. This aspect was also confirmed by cost analysis studies that reported similar data in both groups. Similar findings are also reported for major hepatic resection in elderly patients with either hepatocellular carcinoma (HCC), Klatskin tumour or gallbladder carcinoma. Nevertheless, those elderly patients who will benefit from surgery must be critically selected. [Copyright &y& Elsevier]

Abstract: A wide variety of patients present for urological surgery, from young fit patients to the elderly with multiple co-morbidities. Urological surgery ranges from minor, minimally invasive procedures to major surgery with significant physiological disturbance. It presents several specific challenges to anaesthetists. In day-case urology, a rapid turnover of patients, many of whom are elderly with significant co-morbidity, is required. General anaesthesia, with the patient breathing spontaneously through a laryngeal mask, is often used. Transurethral resection of prostate (TURP) has a specific complication, TURP syndrome, which occurs when excess irrigation fluid is absorbed, causing hypervolaemia and hyponatraemia. Spinal anaesthesia is often chosen because it allows early identification of the neurological deterioration seen in this condition. For major urological procedures careful preoperative assessment is essential as the incidence of cardiorespiratory co-morbidity is high. This assessment, in conjunction with the nature of the surgery, will guide preoperative investigations. Cardiopulmonary exercise testing has been shown to identify high-risk patients and may be helpful. General anaesthesia, with intermittent positive pressure ventilation, and an epidural is the technique of choice. There is a risk of major blood loss, so blood must be cross-matched and available. Large-bore access and invasive monitoring are needed. A careful assessment and appropriate management of fluid balance, using a goal-directed system, is important. Temperature should be monitored and normothermia maintained. Meticulous patient positioning and protection of pressure areas is essential to prevent nerve damage and compartment syndrome in prolonged procedures. Postoperative high-dependency care is beneficial. [Copyright &y& Elsevier]

Background: The facilitation of early recovery of acute kidney injury (AKI) is an important step to improve outcome, particularly because of the limited therapeutic interventions currently available for AKI. The combination of an electronic alert and biomarker-guided kidney-protection strategy implemented in the routine care may have an impact on the incidence of early complete reversal of AKI after major non-cardiac surgery. Methods: We studied 294 patients in two cohorts before (n = 151) and after protocol implementation (n = 143). Data collection required 6 months for each cohort. The kidney-protection protocol included an electronic alert to detect patients who were eligible for urinary biomarker [TIMP2 × IGFBP7]-guided kidney-protection intervention. Intervention was stratified according to three levels of immediate AKI risk: low, moderate, and high. After intervention, postoperative changes in the glomerular filtration rate (eGFR) were identified with a tracking software that included an alert for nephrology consultation if the eGFR had declined by >25% from the preoperative reference value. Primary outcome was early AKI recovery, i.e., the complete reversal of any AKI stage to absence of AKI within the first 7 postoperative days. Results: Protocol implementation significantly increased the recovery of AKI (36/46, 78% compared to control 27/48, 56%, (p = 0.025)) and reduced the length of the ICU stay (p < 0.001). There was no significant difference in the overall incidence of all AKI and moderate and severe AKI in the first 7 postoperative days: 46/143 (32%) and 12/151 (8%) in the protocol implementation group compared to 48/151 (32%) and 18/151 (12%) in the historical control group. Patients with AKI reversal within the first 7 postoperative days had lower in-hospital mortality than patients without AKI reversal. Conclusions: Implementing a combined electronic alert and biomarker-guided kidney-protection strategy in routine care improved early recovery of AKI after major surgery. [ABSTRACT FROM AUTHOR]

Background. This study was designed to evaluate the quality of life (QOL) of patients older than 75 years undergoing major head and neck surgery. Methods. Three groups of patients were included: elderly patients (>75, n = 35) and younger patients (65 to 75 years, n = 30) undergoing major head and neck surgery and healthy controls (>75, n = 40). Measurements were made using the SF-12 health survey, the University of Washington QOL questionnaire, and measurements of the “sense of burden” on the caregiver. Results. With the SF-12, the role physical, role emotional, and bodily pain were decreased by the surgical intervention, while physical function was affected by age alone. With the UW-QOL Questionnaire, overall QOL was preserved. “Appearance” and “Leisure” subscales were affected by the surgical intervention and old age. “Chewing” and “Activity” were decreased by the surgical intervention in the older patients, and “Speech” was affected by the surgical intervention alone. The “sense of burden” was alleviated by surgery in the elderly patients. Conclusions. Several QOL domains are decreased in elderly patients undergoing major head and neck surgery. © 2007 Wiley Periodicals, Inc. Head Neck 2007 [ABSTRACT FROM AUTHOR]

Prior to the introduction of virally inactivated clotting factor concentrates, the majority of patients with haemophilia became infected with the hepatitis C virus. Although transjugular liver biopsy can be safely performed in these patients, the procedure is associated with a significant financial burden mainly related to replacement therapy with clotting factor. The purpose of this study was to evaluate the feasibility and safety of transjugular liver biopsy in patients with haemophilia substituted with clotting factor concentrates for major surgical procedures. Over the last 5 years, transjugular liver biopsy was performed in nine patients with haemophilia within 1–10 days after orthopaedic (7), thoracic (1) or abdominal surgery (1). All patients had abnormal liver function tests and persistent hepatitis C viraemia. At the time of the biopsy, patients received recombinant factor VIII delivered by dose-adjusted continuous infusion through a central catheter inserted preoperatively in the left internal jugular ( n = 8) or in an ante-cubital vein ( n = 1). Before the biopsy, basal FVIII levels were raised to 80–100% by a bolus infusion and maintained above 80% for 24 h. The biopsy was informative in all cases. Only one patient developed an episode of supraventricular dysrhythmia. No bleeding or infectious complications were observed. When compared with elective liver biopsy performed outside the postsurgical period, the cost-savings per biopsy were 19 875 ± 2660 €. This study shows that intensive replacement therapy required by surgical procedures provides a safe and cost-effective opportunity for transjugular liver biopsy in patients with haemophilia and active hepatitis C. [ABSTRACT FROM AUTHOR]

Sleep and circadian disturbances may underlie cognitive dysfunction after major surgery. The aim of this study was to examine the association between sleep and circadian disturbances (as assessed by changes in the melatonin rhythm) and postoperative cognitive dysfunction (POCD). We measured subjective and objective sleep quality, excretion of the major metabolite of melatonin, 6-sulphatoxymelatonin (aMT6s) in urine and cognitive function before and 4 days after major abdominal surgery in 36 patients. Subjective sleep quality was measured by visual analogue scale, objective sleep quality was measured by actigraphy, and cognitive function was assessed by neuropsychological testing. Eighteen patients (50%) had POCD on day 4 after surgery. At that time, the excretion of aMT6s was disturbed with significantly higher daytime excretion and a reduced night/day ratio compared with the preoperative measure ( P = 0.05). Patients with POCD had significantly worse sleep quality and more night awakenings ( P < 0.05) but we found no significant differences in day time (06:00–22:00 hr), night-time (22:00–06:00 hr) or total aMT6s excretion ( μg/24 hr). A significant correlation was found between the total excretion of aMT6s and actigraphically measured sleep efficiency ( r s = 0.45, P = 0.03) and wakefulness after sleep onset ( r s = −0.44, P = 0.04). In conclusion, POCD was associated with worse subjective sleep quality and more awakenings. Circadian rhythmicity as assessed by aMT6s excretion was disturbed after surgery but we were unable to show an association with POCD. Strategies to improve postoperative sleep quality should be investigated in the future. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the quality of the consent forms for major surgery used in different services of hospitals of III - IV level of Lima and Callao. Material and methods: Descriptive, qualitative and transversal study. Once obtained consent forms for major surgery in III and IV level hospitals of Lima and Callao, quality was evaluated according to the requirements established from a research in medical literature. Results: From 28 consent forms of 20 hospitals of III-IV level of Lima and Callao analyzed, 14.2% fulfilled more than 75% of the requirements; 57.2%, between 75-50%; and 28.6%, less than 50%. The requirements about the procedure and its characteristics were absent in more than 75% of the forms. The consent forms from the hospitals of Ministerio de Salud fulfilled an average of 12 requirements (in a range of 4-21); the ones from Military Forces, 17 (range 14-18); and the ones from EsSALUD, 18 (range 16-22). Conclusions: Consent forms for major surgery used at the different services of hospitals of level III - IV of Lima and Callao are not harmonized and do not guarantee that the patient has been informed completely, nor respected his autonomy at adopting his decision. The consent forms from the hospitals of Ministerio de Salud were the most deficient and the ones with more quality variability. We propose a consent form model for future consent forms. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: We retrospectively reviewed the records of the octogenarian patients who underwent major surgery for urologic cancer at two institutions. The aims of our study were to assess intra- and postoperative morbidity and mortality rates, and to identify potential risk factors that can predict postoperative complications and, as a consequence, surgical outcome. Methods: Fifty-five patients (median age: 83 yr) underwent major surgery for urologic cancer. Radical nephrectomy was performed in 27 patients, radical cystectomy with urinary diversion was done in 20 patients, and nephroureterectomy was performed in the remainder. Significant comorbidity was present in 51 patients. Results: The perioperative mortality rate was 9%. The overall mortality rate was 69%; cancer-specific mortality was 28%. Intraoperative complications occurred in 11% of patients. Postoperative intensive care monitoring was required in 29% of patients. The early postoperative complication rate was 33%. Only the presence of more than two comorbidities (p <0.05) and chronic obstructive lung disease (COLD) (p =0.017) resulted in independent prognostic factors for morbidity. Sixteen percent of patients developed a late postoperative complication within the first 6 mo. Median hospital stay was 14 d (range: 6–55), and hospital stays were significantly longer among patients with complications (p <0.05). The 3-yr and 5-yr overall survival rates were 36% and 26%, respectively; these rates were significantly lower in patients with COLD (p <0.01). There was no significant difference between cancer-specific and non-cancer-specific survival rates. Conclusions: Major surgery for urologic malignancies can be safely performed in selected octogenarian patients. [Copyright &y& Elsevier]

Objectives: Vascular endothelial growth factor (VEGF) plays an important role in angiogenesis. We evaluated the changes in serum levels of VEGF following major surgical trauma postoperative inflammatory complications. Materials and Methods: The serum concentration of VEGF was measured with enzyme-linked immunosorbent assay in 41 patients with esophageal cancer who underwent right transthoracic esophagectomy with extensive lymphadenectomy and in 13 patients with gallstones who underwent less-invasive laparoscopic cholecystectomy for comparison. Serum and plasma samples were obtained before the operation and on postoperative days (PODs) 1,7,14,21, and 28. The changes in serum VEGF levels were compared among groups categorized by age, sex, blood loss volume during operation, amount of transfusion, pathological stage of the tumor, and postoperative inflammatory complications. The correlation between serum VEGF levels and inflammatory factors, such as peripheral blood cell count, interleukin-6 (IL-6), C-reactive protein (CPR), and severity of postoperative inflammatory complications, was also investigated. Furthermore, because platelets are a potential source of serum VEGF, platelet-poor plasma (PPP) was prepared from plasma samples, and the VEGF concentration in PPP was measured to compare with those in sera. Results: Serum VEGF levels increased significantly postoperatively. After reaching maximal levels on POD 14, VEGF levels gradually decreased until POD 28. The increase in the tranthoracic esophagectomy group was approximately twice that in laparoscopic chlolecystectomy group on POD 14. Serum VEGF levels were not correlated with sex, age, blood loss, amount of transfusion, or tumor stage. However, serum VEGF levels were significantly higher in patients with postoperative inflammatory lung complications than in patients without such complications, and the maximal level of serum VEGF correlated with the severity of postoperative lung complications. However, there were no significant correlations between the increase in the level of serum VEGF and that of serum IL-6 or CRP. The increase of platelet counts in the peripheral blood correlated with that of the serum VEGF level, and VEGF levels in PPP were significantly lower than those in sera. Conclusion: Serum VEGF levels increased in the angiogenesis phase of wound healing following major surgical injury. Platelets are a potential source of increased serum VEGF levels, whereas inflammatory lung complications might also be related to increased serum VEGF levels. [ABSTRACT FROM AUTHOR]

Objective Life expectancy and incidence of rectal cancer have been increasing. The purpose of this study was to evaluate rectal cancer treatment among very old patients. Methods This prospective national cohort study includes all 4875 rectal cancer patients in Norway aged over 65 years treated between November 1993 and December 2001. Patients aged 65–74, 75–79, 80–84 and over 85 years were compared for patient-, tumour- and treatment-characteristics and relative survival. Two thousand eight hundred and forty patients treated for cure with major surgery and TME technique were further evaluated for postoperative mortality, five-year local recurrence, distant metastasis and disease-free survival. Results There were more palliative surgery and local procedures and less surgery for cure (47% vs 77%, P < 0.001) for patients over 85 years compared to younger patients. Five-year relative survival was 36% for patients aged over 85 years compared to 49% for patients 80–84 years and 60% for patients 65–74 years. Among patients treated for cure with major surgery the rate of anterior resection decreased by age (67% vs 46%, P < 0.001). Postoperative mortality increased from 3% to 8% ( P < 0.001). There were no significant differences in the rates of five-year local recurrence, distant metastasis or relative survival. Conclusion Although a slight increase in postoperative mortality, major rectal cancer surgery can be performed in very old patients. These patients had similar rates of local recurrence, distant metastasis and relative survival as younger patients. [ABSTRACT FROM AUTHOR]

Abstract: Objective: Costs related to postoperative complications continue to be a major burden on any health care system. The aim of the present study was to calculate hospital costs for postoperative complications and to evaluate whether preoperative supplementation with ω-3 fatty acids and arginine (specialized diet) might lead to cost savings in patient care. Methods: Blind analysis of costs performed on data gathered from a randomized clinical trial carried out on 305 patients with gastrointestinal cancer showed that an oral preoperative specialized diet decreased postoperative morbidity compared with conventional treatment (no supplementation). Estimates of complication costs were based on resources used for treatment and on additional length of hospital stay. Cost-comparison and cost-effectiveness analyses were then carried out. Results: The mean cost of postoperative complications was €4492. The greatest amount of resources was consumed by 19 anastomotic leaks (€159803), 18 abdominal abscesses (€112921), and 18 pancreatic fistulae (€106516). The mean costs per complication were €6178 in the conventional group and €4639 in the preoperative group (P = 0.05). The mean total costs of patients with complications were €10494 in the conventional group and €8793 in the preoperative group. The mean cost per randomized patient was €3122 in the conventional group versus €1872 in the preoperative group (P = 0.04). Effectiveness values were 50.0% in the conventional group and 62.8% in the preoperative group (P = 0.03). Total costs consumed 93% of the diagnosis-related group reimbursement rate in the conventional group and 78% in the preoperative group. Conclusions: The costs of postoperative morbidity consumed a large amount of the diagnosis-related group reimbursement rate. Preoperative supplementation with the specialized diet appears to be a cost-effective treatment. [Copyright &y& Elsevier]

We experienced a case with complex regional pain syndrome that showed a tendency toward alleviation of the symptoms after thoracotomy. The patient was a 27-year-old woman. Following surgery for cubital tunnel syndrome, complex regional pain syndrome occurred in the upper limb. Subsequently, she suffered from ankle fracture. Despite surgery, complex regional pain syndrome occurred also in the right lower limb. Five months after surgery, she had onset of pulmonary embolism, and was therefore subjected to thoracic thrombectomy. Post-surgically, the dose of analgesics required decreased, probably due to alleviation of symptoms. It has been reported that stress and pain occasionally contribute to increase in thalamic blood flow. Given the fact that she showed decreased blood flow in the contralateral thalamus before onset of pulmonary embolism, it is postulated that an extreme stress, like thoracotomy, might be responsible for reversing the pre-existing limited blood flow to increased levels, resulting in alleviation of symptoms. [ABSTRACT FROM AUTHOR]