Breast-conserving surgery for non-palpable breast cancer: relationship of lumpectomy resection margins measurements between remote perioperative ultrasound and postoperative histopathology

Purpose: Tumour-free resection margins (RMs) are mandatory in breast-conserving surgery. On-site intraoperative ultrasound (US)-guided tumour resection with extemporaneous histopathological assessment of RMs has been described. Remote intraoperative US assessment of RMs is an alternative. The purpose of this study was to evaluate the relationship of lumpectomy RMs measurements between remote intraoperative US and postoperative histopathology.Methods and Materials: In a retrospective IRB-approved review of 100 consecutive lumpectomies performed between October 2009 and April 2011 for presumed non-palpable breast cancer, 71 women (mean age 63.8years) were included. Twenty-nine patients were excluded because of absence of cancer at histopathology and/or incomplete data. Measurements of lumpectomy minimal RMs and tumour maximal diameter obtained on remote intraoperative US and postoperative histopathology were compared.Results: Minimal RMs were 0.35±0.32 (mean±SD) and 0.35±0.32cm on remote intraoperative US and postoperative histopathology, respectively. No significant difference was found between these measurements (p=0.37). Tumour maximal diameter was 1.02±0.51 (mean±SD) and 1.33±0.74cm on remote intraoperative US and postoperative histopathology, respectively. US measurements were significantly smaller (p<0.001). The 71 breast carcinoma (CA) consisted of: invasive canalar (n=49), invasive lobular (n=11), in situ (n=3) and other types of CA (n=8). Twenty-nine patients had intraoperative re-excision (24 without residual CA), while 16 patients were re-operated due to insufficient histopathological RMs (12 without residual CA).Conclusion: Good correlation of minimal RMs between remote intraoperative US and postoperative histopathology warrants use of both techniques in a complementary manner. Remote intraoperative US is helpful in taking rapid decision of re-excision and maintaining low re-operation rate after breast-conserving surgery for non-palpable cancer.

Guidelines for perioperative care for pancreaticoduodenectomy: Enhanced Recovery After Surgery (ERAS®) Society recommendations.

BACKGROUND & AIMS: Protocols for enhanced recovery provide comprehensive and evidence-based guidelines for best perioperative care. Protocol implementation may reduce complication rates and enhance functional recovery and, as a result of this, also reduce length-of-stay in hospital. There is no comprehensive framework available for pancreaticoduodenectomy. METHODS: An international working group constructed within the Enhanced Recovery After Surgery (ERAS®) Society constructed a comprehensive and evidence-based framework for best perioperative care for pancreaticoduodenectomy patients. Data were retrieved from standard databases and personal archives. Evidence and recommendations were classified according to the GRADE system and reached through consensus in the group. The quality of evidence was rated "high", "moderate", "low" or "very low". Recommendations were graded as "strong" or "weak". RESULTS: Comprehensive guidelines are presented. Available evidence is summarised and recommendations given for 27 care items. The quality of evidence varies substantially and further research is needed for many issues to improve the strength of evidence and grade of recommendations. CONCLUSIONS: The present evidence-based guidelines provide the necessary platform upon which to base a unified protocol for perioperative care for pancreaticoduodenectomy. A unified protocol allows for comparison between centres and across national borders. It facilitates multi-institutional prospective cohort registries and adequately powered randomised trials.

Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations.

BACKGROUND: This review aims to present a consensus for optimal perioperative care in colonic surgery and to provide graded recommendations for items for an evidenced-based enhanced perioperative protocol. METHODS: Studies were selected with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohorts. For each item of the perioperative treatment pathway, available English-language literature was examined, reviewed and graded. A consensus recommendation was reached after critical appraisal of the literature by the group. RESULTS: For most of the protocol items, recommendations are based on good-quality trials or meta-analyses of good-quality trials (quality of evidence and recommendations according to the GRADE system). CONCLUSIONS: Based on the evidence available for each item of the multimodal perioperative-care pathway, the Enhanced Recovery After Surgery (ERAS) Society, International Association for Surgical Metabolism and Nutrition (IASMEN) and European Society for Clinical Nutrition and Metabolism (ESPEN) present a comprehensive evidence-based consensus review of perioperative care for colonic surgery.

Three short perioperative infusions of n-3 PUFAs reduce systemic inflammation induced by cardiopulmonary bypass surgery: a randomized controlled trial.

BACKGROUND: Fish oil (FO) has antiinflammatory effects, which might reduce systemic inflammation induced by a cardiopulmonary bypass (CPB). OBJECTIVE: We tested whether perioperative infusions of FO modify the cell membrane composition, inflammatory responses, and clinical course of patients undergoing elective coronary artery bypass surgery. DESIGN: A prospective randomized controlled trial was conducted in cardiac surgery patients who received 3 infusions of 0.2 g/kg FO emulsion or saline (control) 12 and 2 h before and immediately after surgery. Blood samples (7 time points) and an atrial biopsy (during surgery) were obtained to assess the membrane incorporation of PUFAs. Hemodynamic data, catecholamine requirements, and core temperatures were recorded at 10-min intervals; blood triglycerides, nonesterified fatty acids, glucose, lactate, inflammatory cytokines, and carboxyhemoglobin concentrations were measured at selected time points. RESULTS: Twenty-eight patients, with a mean ± SD age of 65.5 ± 9.9 y, were enrolled with no baseline differences between groups. Significant increases in platelet EPA (+0.86%; P = 0.0001) and DHA (+0.87%; P = 0.019) were observed after FO consumption compared with at baseline. Atrial tissue EPA concentrations were higher after FO than after control treatments (+0.5%; P < 0.0001). FO did not significantly alter core temperature but decreased the postoperative rise in IL-6 (P = 0.018). Plasma triglycerides increased transiently after each FO infusion. Plasma concentrations of glucose, lactate, and blood carboxyhemoglobin were lower in the FO than in the control group on the day after surgery. Arrhythmia incidence was low with no significant difference between groups. No adverse effect of FO was detected. CONCLUSIONS: Perioperative FO infusions significantly increased PUFA concentrations in platelet and atrial tissue membranes within 12 h of the first FO administration and decreased biological and clinical signs of inflammation. These results suggest that perioperative FO may be beneficial in elective cardiac surgery with CPB. This trial was registered at clinicaltrials.gov as NCT00516178.

Peri-operative management of antiplatelet therapy in patients with coronary artery disease. Joint position paper by members of the working group on Perioperative Haemostasis of the Society on Thrombosis and Haemostasis Research (GTH), the working group on Perioperative Coagulation of the Austrian Society for Anesthesiology, Resuscitation and Intensive Care (ÖGARI) and the Working Group Thrombosis of the European Society for Cardiology (ESC).

An increasing number of patients suffering from cardiovascular disease, especially coronary artery disease (CAD), are treated with aspirin and/or clopidogrel for the prevention of major adverse events. Unfortunately, there are no specific, widely accepted recommendations for the perioperative management of patients receiving antiplatelet therapy. Therefore, members of the Perioperative Haemostasis Group of the Society on Thrombosis and Haemostasis Research (GTH), the Perioperative Coagulation Group of the Austrian Society for Anesthesiology, Reanimation and Intensive Care (ÖGARI) and the Working Group Thrombosis of the European Society of Cardiology (ESC) have created this consensus position paper to provide clear recommendations on the perioperative use of anti-platelet agents (specifically with semi-urgent and urgent surgery), strongly supporting a multidisciplinary approach to optimize the treatment of individual patients with coronary artery disease who need major cardiac and non-cardiac surgery. With planned surgery, drug eluting stents (DES) should not be used unless surgery can be delayed for ≥12 months after DES implantation. If surgery cannot be delayed, surgical revascularisation, bare-metal stents or pure balloon angioplasty should be considered. During ongoing antiplatelet therapy, elective surgery should be delayed for the recommended duration of treatment. In patients with semi-urgent surgery, the decision to prematurely stop one or both antiplatelet agents (at least 5 days pre-operatively) has to be taken after multidisciplinary consultation, evaluating the individual thrombotic and bleeding risk. Urgently needed surgery has to take place under full antiplatelet therapy despite the increased bleeding risk. A multidisciplinary approach for optimal antithrombotic and haemostatic patient management is thus mandatory.

Guidelines for Perioperative Care for Pancreaticoduodenectomy: Enhanced Recovery After Surgery (ERAS(®)) Society Recommendations.

BACKGROUND: Protocols for enhanced recovery provide comprehensive and evidence-based guidelines for best perioperative care. Protocol implementation may reduce complication rates and enhance functional recovery and, as a result of this, also reduce length-of-stay in hospital. There is no comprehensive framework available for pancreaticoduodenectomy. METHODS: An international working group constructed within the Enhanced Recovery After Surgery (ERAS(®)) Society constructed a comprehensive and evidence-based framework for best perioperative care for pancreaticoduodenectomy patients. Data were retrieved from standard databases and personal archives. Evidence and recommendations were classified according to the GRADE system and reached through consensus in the group. The quality of evidence was rated "high", "moderate", "low" or "very low". Recommendations were graded as "strong" or "weak". RESULTS: Comprehensive guidelines are presented. Available evidence is summarised and recommendations given for 27 care items. The quality of evidence varies substantially and further research is needed for many issues to improve the strength of evidence and grade of recommendations. CONCLUSIONS: The present evidence-based guidelines provide the necessary platform upon which to base a unified protocol for perioperative care for pancreaticoduodenectomy. A unified protocol allows for comparison between centres and across national borders. It facilitates multi-institutional prospective cohort registries and adequately powered randomised trials.

Impact of restrictive intravenous fluid replacement and combined epidural analgesia on perioperative volume balance and renal function within a Fast Track program.

BACKGROUND AND OBJECTIVE: Key factors of Fast Track (FT) programs are fluid restriction and epidural analgesia (EDA). We aimed to challenge the preconception that the combination of fluid restriction and EDA might induce hypotension and renal dysfunction. METHODS: A recent randomized trial (NCT00556790) showed reduced complications after colectomy in FT patients compared with standard care (SC). Patients with an effective EDA were compared with regard to hemodynamics and renal function. RESULTS: 61/76 FT patients and 59/75 patients in the SC group had an effective EDA. Both groups were comparable regarding demographics and surgery-related characteristics. FT patients received significantly less i.v. fluids intraoperatively (1900 mL [range 1100-4100] versus 2900 mL [1600-5900], P < 0.0001) and postoperatively (700 mL [400-1500] versus 2300 mL [1800-3800], P < 0.0001). Intraoperatively, 30 FT compared with 19 SC patients needed colloids or vasopressors, but this was statistically not significant (P = 0.066). Postoperative requirements were low in both groups (3 versus 5 patients; P = 0.487). Pre- and postoperative values for creatinine, hematocrit, sodium, and potassium were similar, and no patient developed renal dysfunction in either group. Only one of 82 patients having an EDA without a bladder catheter had urinary retention. Overall, FT patients had fewer postoperative complications (6 versus 20 patients; P = 0.002) and a shorter median hospital stay (5 [2-30] versus 9 d [6-30]; P< 0.0001) compared with the SC group. CONCLUSIONS: Fluid restriction and EDA in FT programs are not associated with clinically relevant hemodynamic instability or renal dysfunction.

Aspects opératoires et péri-opératoires de la stimulation cérébrale profonde [Operative and perioperative aspects of deep brain stimulation].

La stimulation cérébrale profonde (SCP) nécessite l'implantation chirurgicale d'un système comprenant électrodes cérébrales et boîtier(s) de stimulation. Les noyaux cérébraux visés par la méthodologie stéréotaxique d'implantation doivent être visualisés au mieux par une imagerie à haute résolution. La procédure chirurgicale d'implantation des électrodes se fait si possible en anesthésie locale pour faire des mesures électro-physiologiques et tester en peropératoire l'effet de la stimulation, afin d'optimiser la position de l'électrode définitive. Dans un deuxième temps, le ou les générateur(s) d'impulsions sont implantés en anesthésie générale. La SCP pour les mouvements anormaux a une très bonne efficacité et un risque de complications graves faible quoique non nul. Les complications liées au matériel sont les plus fréquentes. Deep brain stimulation (DBS) requires the surgical implantation of a system including brain electrodes and impulsion generator(s). The nuclei targeted by the stereotaxic implantation methodology have to be visualized at best by high resolution imaging. The surgical procedure for implanting the electrodes is performed if possible under local anaesthesia to make electro-physiological measurements and to test intra-operatively the effect of the stimulation, in order to optimize the position of the definitive electrode. In a second step, the impulsion generator(s) are implanted under general anaesthesia. DBS for movement disorders has a very good efficacy and a low albeit non-zero risk of serious complications. Complications related to the material are the most common.

Updates in the perioperative and emergency management of non-vitamin K antagonist oral anticoagulants.

Perioperative management of patients treated with the non-vitamin K antagonist oral anticoagulants is an ongoing challenge. Due to the lack of good clinical studies involving adequate monitoring and reversal therapies, management requires knowledge and understanding of pharmacokinetics, renal function, drug interactions, and evaluation of the surgical bleeding risk. Consideration of the benefit of reversal of anticoagulation is important and, for some low risk bleeding procedures, it may be in the patient's interest to continue anticoagulation. In case of major intra-operative bleeding in patients likely to have therapeutic or supra-therapeutic levels of anticoagulation, specific reversal agents/antidotes would be of value but are currently lacking. As a consequence, a multimodal approach should be taken which includes the administration of 25 to 50 U/kg 4-factor prothrombin complex concentrates or 30 to 50 U/kg activated prothrombin complex concentrate (FEIBA®) in some life-threatening situations. Finally, further studies are needed to clarify the ideal therapeutic intervention.

Implementation of a perioperative management protocol for patients undergoing orthopedic surgery

OBJECTIVE: To evaluate the initial results after the implementation of perioperative protocol in patients over 60 years of age undergoing surgical treatment for femur fractures.METHODS: We conducted a prospective study of patients older than 60 years who were hospitalized with femur fracture. They were operated under spinal anesthesia and analgesia by lumbar plexus blockade. Data evaluation was performed before arrival in the operating room during surgery, in the post-anesthesia recovery room and in the ward the next morning of the operation.RESULTS: 105 patients underwent various types of surgical corrections of the femur. The hospital stay ranged from three to 86 days. Fasting ranged from 9h15min to 19h30mn. Hypotension occurred in 5.7%. The duration of motor blockade ranged from 1h45min to 5h30imn. Maltodextrin feeding ranged from 50min to 3h45min and the time spent in the post-anesthetic care unit ranged from 50 minutes to 4 hours. Onset of oral intake in the ward ranged from 4hto 8h15min. The duration of anesthesia ranged from 14 to 33 hours. No patient required a urinary catheter, nor was transferred to the ICU. All patients were able to be discharged on the first postoperative day.CONCLUSION: The use of a protocol to accelerate the postoperative period may reduce the fasting time, length of hospital stay and provide faster i discharge n elderly patients with femur fractures.

A detailed assessment of adverse perioperative outcomes of the elderly treated with radical cystectomy for bladder cancer

Objectifs: Les données provenant des centres de soins tertiaires suggèrent que le taux de mortalité péri-opératoire (MPO) après cystectomie notés pour les patients âgés (septuagénaires et octogénaires) n’excède pas celle des patients plus jeunes. Toutefois, les données provenant de la communauté démontrent un phénomène inverse. Spécifiquement, la MPO est plus élevés chez les ainés. Dans cette thèse nous allons présenter une réévaluation contemporaine du taux de MPO après cystectomie. Méthodes: Entre 1988 et 2006, 12722 cystectomies radicales pour le carcinome urothéliale de la vessie ont été enregistrées dans la banque de données SEER. Le taux de MPO a été évalué dans les analyses de régression logistique univariées et multivariées à 90 jours après cystectomie radicale. Les covariables incluaient: le sexe, l’ethnie, l’année de chirurgie, la région d’origine du patient ainsi que le grade et le stade de la tumeur. Résultats: Parmi tous les patients, 4480 étaient des septuagénaires (35.2%) et 1439 étaient des octogénaires (11.3%). Le taux de MPO à 90 jours était de 4% pour la cohorte entière vs. 2% pour les patients moins de 69 ans vs. 5.4% pour les septuagénaires vs. 9.2% pour les octogénaires. Dans les analyses de régression logistiques multivariées, les septuagénaires (OR=2.80; <0.001) et les octogénaires (OR=5.02; <0.001) avaient reçu un taux de MPO plus augmenté que les patients moins de 70 ans après une cystectomie radicale. Conclusion: Cette analyse épidémiologique basée sur les donnés le plus contemporaines démontre que l’âge avancée représente un facteur de risque pour un taux de MPO plus élevé.

Perioperative cardiac arrest and its mortality in children. A 9-year survey in a Brazilian tertiary teaching hospital

Background: the incidence of perioperative cardiac arrest and mortality in children is higher than in adults. This survey evaluated the incidence, causes, and outcome of perioperative cardiac arrests in a pediatric surgical population in a tertiary teaching hospital between 1996 and 2004.Methods: the incidence of cardiac arrest during anesthesia was identified from an anesthesia database. During the study period, 15 253 anesthetics were performed in children. Data collected included patient demographics, surgical procedures (elective, urgent, or emergency), ASA physical status classification, anesthesia provider information, type of surgery, surgical areas, and outcome. All cardiac arrests were reviewed and grouped by the cause of arrest and death into one of four groups: totally anesthesia-related, partially anesthesia-related, totally surgery-related, or totally child disease or condition-related.Results: There were 35 cardiac arrests (22.9 : 10 000) and 15 deaths (9.8 : 10 000). Major risk factors for cardiac arrest were neonates and children under 1 year of age (P < 0.05) with ASA III or poorer physical status (P < 0.05), in emergency surgery (P < 0.05), and general anesthesia (P < 0.05). Child disease/condition was the major cause of cardiac arrest or death (P < 0.05). There were seven cardiac arrests because of anesthesia (4.58 : 10 000) - four totally (2.62 : 10 000) and three partially related to anesthesia (1.96 : 10 000). There were no anesthesia attributable deaths reported. The main causes of anesthesia attributable cardiac arrest were respiratory events (71.5%) and medication-related events (28.5%).Conclusions: Perioperative cardiac arrests were relatively higher in neonates and infants than in older children with severe underlying disease and during emergency surgery. The fact that all anesthesia attributable cardiac arrests were related to airway management and medication administration is important in prevention strategies.

Perioperative cardiac arrest: a study of 53718 anaesthetics over 9 yr from a Brazilian teaching hospital

Background. Little information exists regarding factors influencing perioperative cardiac arrests and their outcome. This survey evaluated the incidence, causes and outcome of perioperative cardiac arrests in a Brazilian tertiary general teaching hospital between April 1996 and March 2005.Methods. The incidence of cardiac arrest during anaesthesia was prospectively identified from an anaesthesia database. There were 53 718 anaesthetics during the study period. Data collected included patient characteristics, surgical procedures (elective, urgent or emergency), ASA physical status classification, anaesthesia provider information, type of surgery, surgical areas and outcome. All cardiac arrests were retrospectively reviewed and grouped by cause of arrest and death into one of four groups: totally anaesthesia related, partially anaesthesia related, totally surgery related or totally patient disease or condition related.Results. One hundred and eighty-six cardiac arrests (34.6:10 000) and 118 deaths (21.97:10 000) were found. Major risk factors for cardiac arrest were neonates, children under 1 yr and the elderly (P < 0.05), male patients with ASA III or poorer physical status (P < 0.05), in emergency surgery (P < 0.05) and under general anaesthesia (P < 0.05). Patient disease/condition was the major cause of cardiac arrest or death (P < 0.05). There were 18 anaesthesia-related cardiac arrests (3.35:10 000)-10 totally attributed (1.86:10 000) and 8 partially related to anaesthesia (1.49:10 000). There were 6 anaesthesia-related deaths (1.12:10 000)-3 totally attributable and 3 partially related to anaesthesia (0.56:10 000 in both cases). The main causes of anaesthesia-related cardiac arrest were respiratory events (55.5%) and medication-related events (44.5%).Conclusions. Perioperative cardiac arrests were relatively higher in neonates, infants, the elderly and in males with severe underlying disease and under emergency surgery. All anaesthesia-related cardiac arrests were related to airway management and medication administration which is important for prevention strategies.