[Muscle relaxant and reversal practices and impact of reversal modalities on operating room and postoperative room duration - results of a Delphi study]. / Pratiques de curarisation/décurarisation et impact des modalités de décurarisation sur les durées en salle opératoire et SSPI ­ résultats d'une enquête Delphi.

OBJECTIVE: The objectives of this Delphi study are to describe muscle relaxant and reversal practices in France and to seek a consensus on the impact of the reversal method on the time spent in the OR and PACU. METHOD: A two-round Delphi survey was conducted on a panel of French anesthetists involved in colectomies, hysterectomies or bariatric surgery. The questionnaire was designed in collaboration with a scientific committee and was intended to assess neuromuscular blockade reversal techniques and their impact on time spent in the OR and PACU. The first round gathered data on practices and the second round sought a consensus for the time aspect. RESULTS: Overall, all participants (99%) monitored neuromuscular blockade, with a majority (82%) doing so continuously. Of the participants, 22% routinely used a reversal drug. The time saved in the OR or PACU with sugammadex varied between 1 and 43 minutes depending on the surgery and the neuromuscular blockade reversal method it was compared to. CONCLUSION: Although SFAR recommendations (French Society of Anesthesia & Intensive Care Medicine) were generally well followed, the use of neuromuscular blockade reversal drugs was observed to be not fully integrated into regular practice, despite the fact that more than half of patients were reported to have residual neuromuscular blockade post-surgery and that sugammadex is known to reduce time spent in the OR and PACU compared to other neuromuscular blockade reversal methods.

Management of epithelial cancer of the ovary, fallopian tube, primary peritoneum. Long text of the joint French clinical practice guidelines issued by FRANCOGYN, CNGOF, SFOG, GINECO-ARCAGY, endorsed by INCa. (Part 2: systemic, intraperitoneal treatment, elderly patients, fertility preservation, follow-up).

Adjuvant chemotherapy by carboplatin and paclitaxel is recommended for all high-grade ovarian and tubal cancers (FIGO stages I-IIA) (grade A). After primary surgery is complete, 6 cycles of intravenous chemotherapy (grade A) are recommended, or a discussion with the patient about intraperitoneal chemotherapy, according to her risk-benefit ratio. After complete interval surgery for FIGO stage III, hyperthermic intraperitoneal chemotherapy (HIPEC) can be proposed, in accordance with the modalities of the OV-HIPEC trial (grade B). In cases of postoperative tumor residue or in FIGO stage IV tumors, chemotherapy associated with bevacizumab is recommended (grade A).

Management of epithelial cancer of the ovary, fallopian tube, and primary peritoneum. Long text of the Joint French Clinical Practice Guidelines issued by FRANCOGYN, CNGOF, SFOG, and GINECO-ARCAGY, and endorsed by INCa. Part 1: Diagnostic exploration and staging, surgery, perioperative care, and pathology.

An MRI is recommended for an ovarian mass that is indeterminate on ultrasound. The ROMA score (combining CA125 and HE4) can also be calculated (grade A). In presumed early-stage ovarian or tubal cancers, the following procedures should be performed: an omentectomy (at a minimum, infracolic), an appendectomy, multiple peritoneal biopsies, peritoneal cytology (grade C), and pelvic and para-aortic lymphadenectomies (grade B) for all histologic types, except the expansile mucinous subtypes, for which lymphadenectomies can be omitted (grade C). Minimally invasive surgery is recommended for early-stage ovarian cancer, when there is no risk of tumor rupture (grade B). For FIGO stages III or IV ovarian, tubal, and primary peritoneal cancers, a contrast-enhanced computed tomography (CT) scan of the thorax/abdomen/pelvis is recommended (grade B), as well as laparoscopic exploration to take multiple biopsies (grade A) and a carcinomatosis score (Fagotti score at a minimum) (grade C) to assess the possibility of complete surgery (i.e., leaving no macroscopic tumor residue). Complete surgery by a midline laparotomy is recommended for advanced ovarian, tubal, or primary peritoneal cancer (grade B). For advanced cancers, para-aortic and pelvic lymphadenectomies are recommended when metastatic adenopathy is clinically or radiologically suspected (grade B). When adenopathy is not suspected and when complete peritoneal surgery is performed as the initial surgery for advanced cancer, the lymphadenectomies can be omitted because they do not modify either the medical treatment or overall survival (grade B). Primary surgery (before other treatment) is recommended whenever it appears possible to leave no tumor residue (grade B).

Management of epithelial cancer of the ovary, fallopian tube, and primary peritoneum. Short text of the French Clinical Practice Guidelines issued by FRANCOGYN, CNGOF, SFOG, and GINECO-ARCAGY, and endorsed by INCa.

An MRI is recommended for an ovarian mass that is indeterminate on ultrasound. The ROMA score (combining CA125 and HE4) can also be calculated (Grade A). In presumed early-stage ovarian or tubal cancers, the following procedures should be performed: an omentectomy (at a minimum, infracolic), an appendectomy, multiple peritoneal biopsies, peritoneal cytology (grade C), and pelvic and para-aortic lymphadenectomies (Grade B) for all histologic types, except the expansile mucinous subtypes, for which lymphadenectomies can be omitted (grade C). Minimally invasive surgery is recommended for early-stage ovarian cancer, when there is no risk of tumor rupture (grade B). Adjuvant chemotherapy by carboplatin and paclitaxel is recommended for all high-grade ovarian and tubal cancers (FIGO stages I-IIA) (grade A). For FIGO stage III or IV ovarian, tubal, and primary peritoneal cancers, a contrast-enhanced computed tomography (CT) scan of the thorax/abdomen/pelvis is recommended (Grade B), as well as laparoscopic exploration to take multiple biopsies (grade A) and a carcinomatosis score (Fagotti score at a minimum) (grade C) to assess the possibility of complete surgery (i.e., leaving no macroscopic tumor residue). Complete surgery by a midline laparotomy is recommended for advanced ovarian, tubal, or primary peritoneal cancers (grade B). For advanced cancers, para-aortic and pelvic lymphadenectomies are recommended when metastatic adenopathy is clinically or radiologically suspected (grade B). When adenopathy is not suspected and when complete peritoneal surgery is performed as the initial surgery for advanced cancer, the lymphadenectomies can be omitted because they do not modify either the medical treatment or overall survival (grade B). Primary surgery (before other treatment) is recommended whenever it appears possible to leave no tumor residue (grade B). After primary surgery is complete, 6 cycles of intravenous chemotherapy (grade A) are recommended, or a discussion with the patient about intraperitoneal chemotherapy, according to her risk-benefit ratio. After complete interval surgery for FIGO stage III disease, hyperthermic intraperitoneal chemotherapy (HIPEC) can be proposed, in accordance with the modalities of the OV-HIPEC trial (grade B). In cases of postoperative tumor residue or in FIGO stage IV tumors, chemotherapy associated with bevacizumab is recommended (grade A).

[Part II drafted from the short text of the French guidelines entitled "Initial management of patients with epithelial ovarian cancer" developed by FRANCOGYN, CNGOF, SFOG, GINECO-ARCAGY and endorsed by INCa. (Systemic and intraperitoneal treatment, elderly, fertility preservation, follow-up)]. / Partie 2 rédigée à partir de la synthèse de la recommandation nationale de bonnes pratiques cliniques intitulée « Conduites à tenir initiales devant des patientes atteintes d'un cancer épithélial de l'ovaire ¼ élaborée par FRANCOGYN, CNGOF, SFOG, GINECO-ARCAGY et labélisée par l'INCa. (Traitement systémique et intrapéritonéal, personnes âgées, préservation de la fertilité et suivi).

Adjuvant chemotherapy with carboplatin and paclitaxel is recommended for all high-grade ovarian or Fallopian tube cancers, stage FIGO I-IIA (grade A). After a complete first surgery, it is recommended to deliver 6 cycles of intravenous (grade A) or to propose intraperitoneal (grade B) chemotherapy, to be discussed with patient, according to the benefit/risk ratio. After a complete interval surgery for a FIGO III stage, the hyperthermic intra peritoneal chemotherapy (HIPEC) can be proposed in the same conditions of the OV-HIPEC trial (grade B). In case of tumor residue after surgery or FIGO stage IV, chemotherapy associated with bevacizumab is recommended (grade A). For BRCA mutated patient, Olaparib is recommended (grade B).

[Part I drafted from the short text of the French Guidelines entitled "Initial management of patients with epithelial ovarian cancer" developed by FRANCOGYN, CNGOF, SFOG, GINECO-ARCAGY and endorsed by INCa. (Diagnosis management, surgery, perioperative care, and pathological analysis)]. / Partie 1 rédigée sur la base de la recommandation nationale de bonnes pratiques cliniques en cancérologie intitulée « Conduites à tenir initiales devant des patientes atteintes d'un cancer épithélial de l'ovaire ¼ élaborée par FRANCOGYN, CNGOF, SFOG, GINECO-ARCAGY et labélisée par l'INCa. (Explorations diagnostiques et bilan d'extension, chirurgie, soins périopératoires et anatomopathologie).

Faced to an undetermined ovarian mass on ultrasound, an MRI is recommended and the ROMA score (combining CA125 and HE4) can be proposed (grade A). In case of suspected early stage ovarian or fallopian tube cancer, omentectomy (at least infracolonic), appendectomy, multiple peritoneal biopsies, peritoneal cytology (grade C) and pelvic and para-aortic lymphadenectomy are recommended (grade B) for all histological types, except for the expansive mucinous subtype where lymphadenectomy may be omitted (grade C). Minimally invasive surgery is recommended for early stage ovarian cancer, if there is no risk of tumor rupture (grade B). Laparoscopic exploration for multiple biopsies (grade A) and to evaluate carcinomatosis score (at least using the Fagotti score) (grade C) are recommended to estimate the possibility of a complete surgery (i.e. no macroscopic residue). Complete medial laparotomy surgery is recommended for advanced cancers (grade B). It is recommended in advanced cancers to perform para-aortic and pelvic lymphadenectomy in case of clinical or radiological suspicion of metastatic lymph node (grade B). In the absence of clinical or radiological lymphadenopathy and in case of complete peritoneal surgery during an initial surgery for advanced cancer, it is possible not to perform a lymphadenectomy because it does not modify the medical treatment and the overall survival (grade B). Primary surgery is recommended when no tumor residue is possible (grade B).

[Perioperative care of epithelial ovarian cancer: Article drafted from the French Guidelines in oncology entitled "Initial management of patients with epithelial ovarian cancer" developed by FRANCOGYN, CNGOF, SFOG, GINECO-ARCAGY under the aegis of CNGOF and endorsed by INCa]. / Soins périopératoires dans le cancer de l'ovaire. Article rédigé sur la base de la recommandation nationale de bonnes pratiques cliniques en cancérologie intitulée « Conduites à tenir initiales devant des patientes atteintes d'un cancer épithélial de l'ovaire ¼ élaborée par FRANCOGYN, CNGOF, SFOG, GINECO-ARCAGY sous l'égide du CNGOF et labellisée par l'INCa.

The following recommendations cover the perioperative management of ovarian, Fallopian tube and primary peritoneal cancers. Five questions related to pre-habilitation and enhanced recovery after surgery were evaluated. The conclusions and recommendations are based on an analysis of the level of evidence available in the literature. These recommendations are part of the overall recommendations for improving the management of ovarian, fallopian or primary peritoneal cancer, made with the support of INCa (Institut National du Cancer). The main preoperative measures are screening for nutritional deficiencies (Grade B) and for anaemia (GradeC) in patients with ovarian cancer. It is not possible to make recommendations on the correction of malnutrition and/or anemia or on the contribution of pre-operative immuno-nutrition due to the absence of data in ovarian cancer, tube cancer or primary peritoneum cancer. For the same reasons, no recommendation can be made on the value of preoperative digestive preparation in ovarian, fallopian tube or primary peritoneum cancer. During surgery, goal-directed fluid therapy for patients with advanced ovarian cancer is recommended (Grade B). A single dose infusion of tranexamic acid is recommended for patients with ovarian, fallopian tube or primary peritoneal cancer (GradeC). For postoperative analgesia, epidural analgesia is recommended for patients undergoing cyto-reduction surgery by laparotomy (Grade B). In the absence of epidural analgesia, patient controlled analgesia with morphine without continuous infusion (Grade B) is recommended. No recommendation can be given regarding intravenous administration of lidocaine and/or ketamine during surgery, or, regarding peri-operatively prescription of gabapentin or pregabalin. In the absence of studies on the impact of different non-opiate analgesic combinations for ovarian cancer surgery, no recommendations can be made. Early oral feeding is recommended, including in cases of digestive resection (Grade B). The implementation of enhanced recovery programs, including early mobilization, is recommended (GradeC).

[Short version of recommendations for enhanced recovery program (ERP) for cystectomy: Technical measures]. / Version courte des recommandations de la récupération ameliorée après chirurgie (RAAC) pour la cystectomie : mesures techniques.

INTRODUCTION: The enhanced recovery program (ERP) is a management mode whose objective is to reduce the risk of complications and allow the patient to recover more quickly all its functional capacities and to reintegrate at most quickly and safely in his usual environment. This intentionally synthetic document aims to disseminate in the urological community the main points of the ERP recommendations for cystectomy. This work, coordinated by AFU, involves several other partners. The full document is available on the "Urofrance" website. Another article will follow on organizational measures. METHOD: The development of the recommendations is based on the method "formalized consensus of experts" proposed by the HAS. The report is based on a systematic review of the literature (January 2006-May 2017), two rounds of iterative quotations and a national proofreading. Levels of proof of conclusions and gradation of recommendations are based on the HAS grid. RESULTS: The bibliographic strategy made it possible to retain 298 articles. Only the recommendations that obtained a strong agreement after the two rounds of iterative listing were retained. The recommendations presented here are in chronological form (before, during, after hospitalization). Twenty-six key points on the technical and organizational measures of ERP have been identified. CONCLUSION: The result of the literature review, supplemented by expert opinion, suggests a significant clinical interest in the application and dissemination of ERP for cystectomy, despite the limited data available for this indication.

Combining long-acting bronchodilators with different mechanisms of action: A pharmacological approach to optimize bronchodilation of equine airways.

The ultra long-acting ß2 -adrenoceptor agonist olodaterol plus the ultra long-acting muscarinic antagonist tiotropium bromide are known to relax equine airways. In human bronchi combining these drugs elicits a positive interaction, thus we aimed to characterize this information further in equine isolated airways stimulated by electrical field stimulation (EFS) and using the Concentration-Reduction Index (CRI) and Combination Index (CI) equations. The drugs were administered alone and together by reproducing ex vivo the concentration-ratio delivered by the currently available fixed-dose combination (1:1). The single agents elicited a significant (p < .05) concentration-dependent reduction in the EFS-induced contractility, that was synergistically improved (CI 0.18) when administered in combination (0.9 logarithms more potent, 24% more effective than the monocomponents). The drugs mixture allowed a reduction in the concentration of olodaterol from ≃1 to ≃2.3 logarithms. A favorable CRI was detected also for tiotropium bromide, whose concentration can be reduced ≃1 logarithm at medium effect levels, remaining positive up to submaximal relaxant effect in the presence of olodaterol. The combination of tiotropium bromide/olodaterol allows the reduction in the concentration of the monocomponents to achieve airway smooth muscle relaxation, thus potentially decreases the risk of adverse events when these drugs are used to treat severe asthmatic horses.

Thermoregulation and pain perception: Evidence for a homoeostatic (interoceptive) dimension of pain.

BACKGROUND: Experimental and clinical observations of interactions between the nociceptive and thermoceptive systems have suggested that they could be part of the homoeostatic system relating to the condition of the body, described as 'interoception'. Homoeostatic physiological systems are extensively interconnected. Thus, consistent with this hypothesis, we would expect thermoregulatory challenges to be associated with changes in pain perception. METHODS: The effects of whole-body warming or cooling inducing significant changes in mean body temperature were tested in 15 healthy volunteers (29 ± 6 years old) on: (i) the paradoxical burning pain induced by the application of simultaneous non-noxious thermal stimuli with a 'thermal grill' and (ii) the 'normal' pain evoked by noxious thermal stimuli. RESULTS: Whole-body warming and cooling induced changes in opposite direction of the threshold of the paradoxical pain induced by the thermal grill, consisting of an increase by 1.2 ± 1.7 °C (p = 0.02) during the warming session and a nonsignificant decrease by 0.7 ± 2.7 °C (p = 0.15) during the cooling session. In addition, there was a correlation (r = 0.54; p = 0.002) between the magnitude of the change in mean body temperature and the magnitude of the change in the threshold of the paradoxical pain induced by the thermal grill. By contrast, the thermal challenges induced no significant change in pain evoked by noxious hot or cold stimuli. CONCLUSIONS: Our results are consistent with the notion that pain has a homoeostatic (interoceptive) dimension and showed that the thermal grill-induced pain is a unique experimental model to investigate this differentiable pain dimension.

[Guidelines for enhanced recovery after elective colorectal surgery]. / Réhabilitation rapide après une chirurgie colorectale programmée.

Early recovery after surgery provides patients with all means to counteract or minimize the deleterious effects of surgery. This concept is suitable for a surgical procedure (e.g., colorectal surgery) and comes in the form of a clinical pathway that covers three periods (pre-, intra- and postoperative). The purpose of this Expert panel guideline is firstly to assess the impact of each parameter usually included in the rehabilitation programs on 6 foreseeable consequences of colorectal surgery: surgical stress, postoperative ileus, water and energy imbalance, postoperative immobility, sleep alterations and postoperative complications; secondly, to validate the usefulness of each as criteria of efficiency criteria for success of rehabilitation programs. Two main criteria were selected to evaluate the impact of each parameter: the length of stay and frequency of postoperative complications. Lack of information in the literature forced experts to assess some parameters with criteria (duration of postoperative ileus or quality of analgesia) that mainly surrogate a positive impact for the implementation of an early recovery program. After literature analysis, 19 parameters were identified as potentially interfering with at least one of the foreseeable consequences of colorectal surgery. GRADE® methodology was applied to determine a level of evidence and strength of recommendation. After synthesis of the work of experts using GRADE® method on 19 parameters, 35 recommendations were produced by the organizing committee. The recommendations were submitted and amended by a group of reviewers. After three rounds of Delphi quotes, strong agreement was obtained for 28 recommendations (80%) and weak agreement for seven recommendations. A consensus was reached among anesthesiologists and surgeons on a number of approaches that are likely not sufficiently applied for rehabilitation programs in colorectal surgery such as: preoperative intake of carbohydrates; intraoperative hemodynamic optimization; oral feeding resume before ha24; gum chewing after surgery; patient out of bed and walking at D1. The panel also clarified the value and place of such approaches such as: patient information; preoperative immunonutrition; laparoscopic surgery; antibiotic prophylaxis; prevention of hypothermia; systematic prevention of nausea and vomiting; morphine-sparing analgesic techniques; indications and techniques for bladder catheterization. The panel also confirmed the futility of approaches such as: bowel preparation for colon surgery; maintain of the nasogastric tube; surgical drainage for colonic surgery.

Guidelines for enhanced recovery after elective colorectal surgery

Early recovery after surgery provides patients with all means to counteract or minimize the deleterious effects of surgery. This concept is suitable for a surgical procedure (e.g., colorectal surgery) and comes in the form of a clinical pathway that covers three periods (pre-, intra- and postoperative). The purpose of this Expert panel guideline is firstly to assess the impact of each parameter usually included in the rehabilitation programs on 6 foreseeable consequences of colorectal surgery: surgical stress, postoperative ileus, water and energy imbalance, postoperative immobility, sleep alterations and postoperative complications; secondly, to validate the usefulness of each as criteria of efficiency criteria for success of rehabilitation programs. Two main criteria were selected to evaluate the impact of each parameter: the length of stay and frequency of postoperative complications. Lack of information in the literature forced experts to assess some parameters with criteria (duration of postoperative ileus or quality of analgesia) that mainly surrogate a positive impact for the implementation of an early recovery program. After literature analysis, 19 parameters were identified as potentially interfering with at least one of the foreseeable consequences of colorectal surgery. GRADE® methodology was applied to determine a level of evidence and strength of recommendation. After synthesis of the work of experts using GRADE® method on 19 parameters, 35 recommendations were produced by the organizing committee. The recommendations were submitted and amended by a group of reviewers. After three rounds of Delphi quotes, strong agreement was obtained for 28 recommendations (80%) and weak agreement for seven recommendations. A consensus was reached among anesthesiologists and surgeons on a number of approaches that are likely not sufficiently applied for rehabilitation programs in colorectal surgery such as: preoperative intake of carbohydrates; intraoperative hemodynamic optimization; oral feeding resume before ha24; gum chewing after surgery; patient out of bed and walking at D1. The panel also clarified the value and place of such approaches such as: patient information; preoperative immunonutrition; laparoscopic surgery; antibiotic prophylaxis; prevention of hypothermia; systematic prevention of nausea and vomiting; morphine-sparing analgesic techniques; indications and techniques for bladder catheterization. The panel also confirmed the futility of approaches such as: bowel preparation for colon surgery; maintain of the nasogastric tube; surgical drainage for colonic surgery.

French guidelines for enhanced recovery after elective colorectal surgery

Enhanced recovery after surgery provides patients with optimal means to counteract or minimize the deleterious effects of surgery. This concept can be adapted to suit a specific surgical procedure (i.e., colorectal surgery) and comes in the form of a program or a clinical pathway covering the pre-, intra- and postoperative periods. The purpose of these Expert Panel Guidelines was firstly to assess the impact of each parameter typically included in the fast-track programs on six foreseeable consequences of colorectal surgery: surgical stress, postoperative ileus, fluid and electrolyte imbalances, decreased postoperative mobility, sleep disorders and postoperative complications; secondly, to validate the value of each parameter in terms of efficacy criteria for success of rapid rehabilitation programs. Two primary endpoints were selected to evaluate the impact of each parameter: the duration of hospital stay and rate of postoperative complications. For some of the parameters, the lack of information in the literature forced the experts to assess the parameter using different criteria (i.e., the duration of postoperative ileus or quality of analgesia); improvement in endpoints favored the implementation of a rapid rehabilitation program. After analysis of the literature, 19 parameters were identified as potentially impacting at least one of the foreseeable consequences of colorectal surgery. GRADE(®) methodology was applied to determine a level of evidence and the strength of recommendation regarding each parameter. After synthesis of the work of experts on the 19 parameters using GRADE(®) methodology, the organizing committee reached 35 formal recommendations. The recommendations were submitted and amended by a group of reviewers. After three rounds of Delphi quotes, strong agreement was obtained for 28 recommendations (80%) and weak agreement for seven recommendations. Consensus was reached among anesthesiologists and surgeons on a number of tactics that are insufficiently applied in current rehabilitation programs in colorectal surgery such as: pre-operative intake of carbohydrates; optimization of intra-operative volume control; resumption of oral feeding within 24 hours; gum chewing after surgery; getting the patient out of bed and walking on D1. The panel also clarified the value and place of such approaches as: patient information; pre-operative immunonutrition; laparoscopic surgery; antibiotic prophylaxis; prevention of hypothermia; systematic medication to prevent nausea and vomiting; morphine-sparing analgesia techniques; indications and techniques for bladder catheterization. The panel also confirmed the futility of other methods such as: bowel preparation for colon surgery; maintaining a nasogastric tube; surgical drainage for colorectal surgery.

French guidelines for enhanced recovery after elective colorectal surgery.

Enhanced recovery after surgery provides patients with optimal means to counteract or minimize the deleterious effects of surgery. This concept can be adapted to suit a specific surgical procedure (i.e., colorectal surgery) and comes in the form of a program or a clinical pathway covering the pre-, intra- and postoperative periods. The purpose of these Expert Panel Guidelines was firstly to assess the impact of each parameter typically included in the fast-track programs on six foreseeable consequences of colorectal surgery: surgical stress, postoperative ileus, fluid and electrolyte imbalances, decreased postoperative mobility, sleep disorders and postoperative complications; secondly, to validate the value of each parameter in terms of efficacy criteria for success of rapid rehabilitation programs. Two primary endpoints were selected to evaluate the impact of each parameter: the duration of hospital stay and rate of postoperative complications. For some of the parameters, the lack of information in the literature forced the experts to assess the parameter using different criteria (i.e., the duration of postoperative ileus or quality of analgesia); improvement in endpoints favored the implementation of a rapid rehabilitation program. After analysis of the literature, 19 parameters were identified as potentially impacting at least one of the foreseeable consequences of colorectal surgery. GRADE(®) methodology was applied to determine a level of evidence and the strength of recommendation regarding each parameter. After synthesis of the work of experts on the 19 parameters using GRADE(®) methodology, the organizing committee reached 35 formal recommendations. The recommendations were submitted and amended by a group of reviewers. After three rounds of Delphi quotes, strong agreement was obtained for 28 recommendations (80%) and weak agreement for seven recommendations. Consensus was reached among anesthesiologists and surgeons on a number of tactics that are insufficiently applied in current rehabilitation programs in colorectal surgery such as: pre-operative intake of carbohydrates; optimization of intra-operative volume control; resumption of oral feeding within 24 hours; gum chewing after surgery; getting the patient out of bed and walking on D1. The panel also clarified the value and place of such approaches as: patient information; pre-operative immunonutrition; laparoscopic surgery; antibiotic prophylaxis; prevention of hypothermia; systematic medication to prevent nausea and vomiting; morphine-sparing analgesia techniques; indications and techniques for bladder catheterization. The panel also confirmed the futility of other methods such as: bowel preparation for colon surgery; maintaining a nasogastric tube; surgical drainage for colorectal surgery.

[Accelerated postoperative recovery after colorectal surgery]. / Programme de réhabilitation précoce en chirurgie colorectale.

Accelerated recovery programs are clinical pathways which outline the stages, and streamline the means, and techniques aiming toward the desired end a rapid return of the patient to his pre-operative physical and psychological status. Recovery from colo-rectal surgery may be slowed by the patient's general health, surgical stress, post-surgical pain, and post-operative ileus. Both surgeons and anesthesiologists participate throughout the peri-operative period in a clinical pathway aimed at minimizing these delaying factors. Key elements of this pathway include avoidance of pre-operative colonic cleansing, early enteral feeding, and effective post-operative pain management permitting early ambulation (usually via thoracic epidural anesthesia). Pre-operative information and motivation of the patient is also a key to the success of this accelerated recovery program. Studies of such programs have shown decreased duration of post-operative ileus and hospital stay without an increase in complications or re-admissions. The elements of the clinical pathway must be regularly re-evaluated and updated according to local experience and published data.

Totally laparoscopic tube graft bypass for infrarenal aortic aneurysm: a well-established surgical technique.

Abdominal aortic aneurysm (AAA) repair enters the field of laparoscopic surgery. Main advantage of laparoscopic AAA repair is to perform the gold standard endoaneurysmorraphy with a reduced surgical trauma. Since 2001, the technique has evolved and is now well-established. We describe the standard technique of totally laparoscopic endoaneurysmorraphy with tube graft interposition through a transperitoneal left retrorenal approach. Main technical points are discussed.

Undiagnosed aorto-caval fistula during total laparoscopic abdominal aortic aneurysm repair: a cause of conversion.

Total laparoscopic aortic repair is evolving and is now the technique of choice for the treatment of infrarenal abdominal aortic aneurysms (AAA) in our department. With growing experience, surgeons will be confronted with the same peroperative situations than open surgery. We report a case of total laparoscopic AAA repair with peroperative diagnosis of aorto-caval fistula (ACF).

Total laparoscopic abdominal aortic aneurysms repair.

AIM: The aim of the study was to describe our experience of total laparoscopic abdominal aortic aneurysm (AAA) repair. METHODS: Between February 2002 and September 2004, we performed 49 total laparoscopic AAA repair in 45 men and 4 women. Median age was 73 years (range, 46-85 years). Median aneurysm size was 52 mm (range, 30-95 mm). ASA class of patients was II, III and IV in 16, 32 and 1 cases, respectively. We used the laparoscopic transperitoneal left retrocolic approach in 47 patients. Seven patients were operated via a tranperitoneal left retrorenal approach and one patient via a retroperitoneoscopic approach. RESULTS: We implanted tube grafts and bifurcated grafts in 19 and 30 patients, respectively. Median operative time was 290 min (range, 160-420 min). Median clamping time was 81.5 min (range, 35-230 min). Median blood loss was 1800 cc (range, 300-6900 cc). Mortality was 6.1% (3 patients). In our early experience, two patients died of myocardial infarction. The 3rd death was due to a multiple organ failure. Thirteen major non lethal postoperative complications were observed in 9 patients (18%). Four patients had local/vascular complications, which required reintervention (8%). Nasogastric tube is now removed at the end of procedure. Median duration of ileus, return to general diet, ambulation and hospital stay were 2, 3, 3 and 10 days. With a median follow-up of 19 months (range, 8-39 months), complete recovery with patent graft was observed in 44 patients. Two patients needed a crossover femoral graft for one iliac dissection and one graft limb occlusion. CONCLUSIONS: These results show that total laparoscopic AAA repair is feasible and worthwhile for patients once the learning curve is overcome. It remains technically demanding and a previous training in videoscopic sutures is essential. Initial learning curve in laparoscopic aortic surgery with aortoiliac occlusive lesions is preferable before to begin laparoscopic AAA repair.

Postanaesthetic shivering. Epidemiology, pathophysiology and approaches to prevention and management.

Postanaesthetic shivering is one of the leading causes of discomfort for patients recovering from general anesthesia. During EMG records, the distinguishing factor from shivering in fully awake patients is the existence of clonus similar to that recorded in patients with spinal cord transection. They coexist with the classic waxing and waning signals associated with cutaneous vasoconstriction (thermoregulatory shivering). The causes responsible for their appearance primarily include hypothermia, which sets in due to thermoregulation inhibition by anesthetics. However, we also note the existence of shivering associated with cutaneous vasodilatation (non-thermoregulatory shivering) one of the origins of which is postoperative pain. Apart from the discomfort and aggravated pain, postanaesthetic shivering raises metabolic demand proportionally to the solicited muscle mass and the patient's cardiac capacities. No link has been demonstrated between their occurrence and an increase in cardiac morbidity but it is preferable to avoid postanaesthetic shivering since it is oxygen draining. Prevention mainly entails preventing hypothermia by actively rewarming the patient. Postoperative skin surface rewarming is a way of obtaining the threshold shivering temperature while raising the skin temperature and improving the patient's comfort. However, it is less efficient than certain drugs such as meperidine, nefopam or tramadol, which act by reducing the shivering threshold temperature.

Effect of postoperative skin-surface warming on oxygen consumption and the shivering threshold.

Cutaneous warming is reportedly an effective treatment for shivering during epidural and after general anaesthesia. We quantified the efficacy of cutaneous warming as a treatment for shivering. Unwarmed surgical patients (final intra-operative core temperatures approximately 35 degrees C) were randomly assigned to be covered with a blanket (n = 9) or full-body forced-air cover (n = 9). Shivering was evaluated clinically and by oxygen consumption. Forced-air heating increased mean-skin temperature (mean (SD) 35.7 degrees C (0.4) vs. 33.2 degrees C (0.8); p < 0.0001) and lowered core temperature at the shivering threshold (35.7 degrees C (0.2) vs. 36.4 degrees C(0.2); p < 0.0001). Active warming improved thermal comfort and significantly reduced oxygen consumption from 9.7 (4.4) ml x min(-1) x kg(-1) to 5.6 (1.9) ml x min(-1) x kg(-1) (p = 0.038). However, the duration of shivering was similar in the unwarmed (37 min (11)) and active warming (36 min (10)) groups. Core temperature contributed about four times as much as skin temperature to control of shivering. Cutaneous warming improved thermal comfort and reduced metabolic stress in postoperative patients, but did not quickly obliterate shivering.