Long-term quality of life after surgery of head and neck cancer with microvascular reconstruction: a prospective study with 4.9-years follow-up.

PURPOSE: The aim of this study was to evaluate the long-term health-related quality of life (HRQoL) of head and neck cancer patients with microvascular surgery. Surgical treatment causes great changes in patient HRQoL. Studies focusing on long-term HRQoL after microvascular reconstruction for head and neck cancer patients are scarce. METHODS: We conducted a prospective study of 93 patients with head and neck cancer and microvascular reconstruction in Helsinki University Hospital Finland. HRQoL was measured using the 15D instrument at baseline and after a mean 4.9-years follow up. Results were compared with those of an age-standardized general population. RESULTS: Of the 93 patients, 61 (66%) were alive after follow-up; of these, 42 (69%) answered the follow-up questionnaire. The median time between surgery and HRQoL assessment was 4.9 years (range 3.7-7.8 years). The mean 15D score of all patients (n = 42) at the 4.9-years follow up was statistically significantly (p = 0.010) and clinically importantly lower than at baseline. The dimensions of "speech" and "usual activities" were significantly impaired at the end of follow up. There was a significant difference at the 4.9-years follow-up in the mean 15D score between patients and the general population (p = 0.014). After follow up, patients were significantly (p < 0.05) worse off on the dimensions of "speech," "eating," and "usual activities." CONCLUSIONS: Long-term HRQoL was significantly reduced in the whole patient cohort. Speech and usual activities were the most affected dimensions in head and neck cancer patients with microvascular reconstruction at the end of the 4.9-years follow up.

Dexamethasone in head and neck cancer patients with microvascular reconstruction: No benefit, more complications.

OBJECTIVES: Glucocorticoids are widely used in association with major surgery of the head and neck to improve postoperative rehabilitation, shorten intensive care unit and hospital stay, and reduce neck swelling. This study aimed to clarify whether peri- and postoperative use of dexamethasone in reconstructive head and neck cancer surgery is associated with any advantages or disadvantages. MATERIALS AND METHODS: This prospective double-blind randomized controlled trial comprised 93 patients. A total dose of 60mg of dexamethasone was administered to 51 patients over three days peri- and postoperatively. The remaining 42 patients served as controls. The main primary outcome variables were neck swelling, length of intensive care unit and hospital stay, duration of intubation or tracheostomy, and delay to start of possible radiotherapy. Complications were also recorded. RESULTS: No statistical differences emerged between the two groups in any of the main primary outcome variables. However, there were more major complications, especially infections, needing secondary surgery within three weeks of the operation in patients receiving dexamethasone than in control patients (27% vs. 7%, p=0.012). CONCLUSIONS: The use of dexamethasone in oral cancer patients with microvascular reconstruction did not provide a benefit. More major complications, especially infections, occurred in patients receiving dexamethasone. Our data thus do not support the use of peri- and postoperative dexamethasone in oropharyngeal cancer patients undergoing microvascular reconstruction.

Lost potential of kidney and liver donors amongst deceased intracerebral hemorrhage patients.

BACKGROUND AND PURPOSE: Intracerebral hemorrhage (ICH) has high acute mortality. The number of potential kidney and liver donors amongst deceased ICH patients was estimated to improve our institutional guidelines on acute care of neurocritical patients to increase organ donation. METHODS: A chart review was carried out by a multi-professional team for consecutive ICH patients admitted to the emergency department at Helsinki University Central Hospital and dying within 14 days between 2005 and 2010. RESULTS: In all, 955 patients had follow-up data, of whom 254 (27%) died within 14 days and eight ended up as organ donors. An additional 51 potentially suitable donors not different from actual donors were identified: nine suitable for kidney donation, 11 for liver and 31 for both. In 49/51 (96%) cases prognosis seemed non-existent and do-not-resuscitate orders were issued early, which led to refrainment from intensive care in 76.5%. These potential donors differed from those ICH patients surviving a whole year (n = 529) by male preponderance, more severe symptoms (median National Institutes of Health Stroke Scale 25 vs. 6 and Glasgow Coma Scale 7 vs. 15), larger hematoma volumes of 24.8 cm(3) (vs. 6.7), and frequent finding of midline shift and intraventricular rupture of the hemorrhage in admission brain CT. Based on the results, our guidelines were revised towards more active treatment including mechanical ventilation for neurocritical patients at the emergency department for at least 48 h, resulting in an increase in organ donations in 2012. CONCLUSIONS: A considerable number of ICH patients are potential organ donors if the evaluation takes place on arrival and organ donation is considered as part of usual end-of-life care.

Bridging therapies and liver transplantation in acute liver failure, 10 years of MARS experience from Finland.

Acute liver failure is a life-threatening condition in the absence of liver transplantation option. The aetiology of liver failure is the most important factor determining the probability of native liver recovery and prognosis of the patient. Extracorporeal liver assist devices like MARS (Molecular Adsorbent Recirculating System) may buy time for native liver recovery or serve as bridging therapy to liver transplantation, with reduced risk of cerebral complications. MARS treatment may alleviate hepatic encephalopathy even in patients with a completely necrotic liver. Taking this into account, better prognostic markers than hepatic encephalopathy should be used to assess the need for liver transplantation in acute liver failure.

Surgical stress index as a measure of nociception/antinociception balance during general anesthesia.

BACKGROUND: No validated monitoring method is available for evaluating the nociception/antinociception balance. We assessed the surgical stress index (SSI), computed from finger photoplethysmographic waveform amplitudes and pulse-to-pulse intervals, in patients undergoing shoulder surgery under general anesthesia (GA) and interscalene plexus block and in patients with GA only. METHODS: In this prospective, randomized study in 26 patients, increased blood pressure (BP) or heart rate, movement, and coughing were considered to be signs of intraoperative nociception and were treated with alfentanil. GA was maintained with desflurane aiming at a State Entropy level of 50. Photoplethysmographic waveforms were collected from the contra-lateral arm to the surgery and SSI values from 0 (no surgical stress) to 100 (maximal surgical stress) were calculated off-line. RESULTS: Two minutes after skin incision, SSI had not increased in the plexus group and was lower in the plexus group (38 +/- 13) compared with the controls (58 +/- 13, P<0.005). Among the controls, 1 min before alfentanil administration, the SSI value was higher than during periods of adequate antinociception, 59 +/- 11 vs. 39 +/- 12 (P<0.01). The total cumulative need for alfentanil was higher in controls (2.7 +/- 1.2 mg) compared with the plexus group (1.6 +/- 0.5 mg; P=0.008). Tetanic stimulation to the ulnar region of the hand increased SSI significantly only among the patients with plexus block not covering the site of the stimulation. CONCLUSION: SSI values were lower in patients with plexus block covering the sites of nociceptive stimuli. In detecting nociceptive stimuli, SSI had better performance than heart rate, BP, or response entropy.

Laparoscopic cholecystectomy with carbon dioxide pneumoperitoneum is safe even for high-risk patients.

BACKGROUND: Because of absorbed carbon dioxide (CO(2)) and elevated intraabdominal pressure (IAP), CO(2) pneumoperitoneum (CO(2)PP) has potentially harmful intraoperative circulatory and ventilatory effects. Although not clinically significant for healthy patients, these effects are assumed to be deleterious for patients with a high risk for anesthesia (American Society of Anesthesiology [ASA] 3 and 4) and significant cardiopulmonary, renal, or hepatic diseases. The authors assessed CO(2)PP-related adverse effects by comparing ASA 3 and 4 patients who underwent laparoscopic cholecystectomy (LC) with or without CO(2)PP. METHODS: A total of 20 successive ASA 3 and 4 patients who underwent LC were randomized into CO(2)PP (n = 10) and abdominal wall elevator (Laparolift) (n = 10) groups. The parameters for perioperative hemodynamics, ventilation, perfusion of intraabdominal organs, and blood chemistry were recorded periodically from before the induction of the anesthesia until postoperative day 2 and compared between the groups. RESULTS: Mean age, height, weight, the proportional number of ASA 3 vs ASA 4 patients, the volume of perioperative fluid loading, and the dose of analgesics did not differ significantly between the groups. The length of the operation was 49.9 +/- 10.6 min for the CO(2)PP group and 50.6 +/- 17.2 min for Laparolift group (nonsignificant difference). The mean central venous pressure (CVP) 30 min after insufflation was higher (12.3 +/- 4.8 vs 7.9 +/- 3.7 mmHg) and the (Gastric Mucosal pH) pHi at the end of the operation was lower (7.29 +/- 0.07 vs 7.35 +/- 0.04) in the CO(2)PP group than in the Laparolift group (p < 0.05). Later, CVP and pHi did not differ significantly. Other parameters of hemodynamics including oxygenation, perfusion, and blood chemistry did not differ significantly. CONCLUSIONS: For LC for patients with an ASA 3 and 4 risk for anesthesia, no significant adverse effects could be attributed to CO(2 )pneumoperitoneum. For high-risk patients, preoperative preparation and active perioperative monitoring are essential for safe anesthesia for LC with or without CO(2)PP.

Albumin dialysis has no clear effect on cytokine levels in patients with life-threatening liver insufficiency.

Cytokines play a important role in life-threatening liver insufficiency. They are released within the liver in response to hepatic injury and inflammation. To study cytokine clearance during albumin dialysis treatment (Molecular Adsorbent Recirculating System [MARS]), we monitored proinflammatory (tumor necrosis factor alpha [TNF-alpha] and interleukin-8 [IL-8]) and anti-inflammatory (IL-10 and IL-6) cytokines and the lymphocyte activation marker IL-2sRalpha in 81 consecutive ICU patients displaying serious hepatic decompensation. Cytokine levels were measured before treatment and after the last MARS treatment in 49 acute liver failure (ALF) and 32 acute decompensation of chronic liver disease (AcOChr) patients who were mainly considered for liver transplantation. No significant change in cytokines was observed before versus after the last MARS treatment in the AcOChr group, and only IL-10 decreased significantly in the ALF group. Baseline levels of IL-8 and IL-6 were significantly lower and IL-10 was higher in the ALF group compared with those in the AcOChr group. TNF-alpha and IL-2sRalpha levels did not differ between the groups. After treatment, IL-8 was also significantly lower in ALF patients compared with the levels in AcOChr patients. In this study, MARS therapy did not show a clearly identifiable efficacy at removing circulating cytokines. However, the results revealed that ALF and AcOChr patients displayed different profiles of circulating cytokines.

Experience of Mars therapy with and without transplantation in 101 patients with liver insufficiency.

Liver support devices are used to treat life-threatening organ dysfunction until a hepatic graft is available or recovery of the native liver. We used a blood purification system--molecular adsorbent recycling system (MARS)--that is based on removal of both protein-bound and water-soluble substances and toxins. Within 2.5 years we treated 101 patients, who were stratified to three subgroups: acute liver failure (ALF; n = 56), acute decompensation in chronic liver failure (AcOCh; n = 35) and liver graft failure (n = 10). MARS seems to be a promising therapy for ALF, allowing the patient's own liver to recover or to gain enough time to find a liver graft. The most promising results, namely the highest number of livers to recovery were observed among acute patients with liver failure due to a toxic etiology. However, we did not discover much benefit of MARS for patients with AcOCh without liver transplantation.

The effect of albumin dialysis on cytokine levels in acute liver failure and need for liver transplantation.

In acute liver failure (ALF), detoxification capacity of liver cells is reduced and a variety of cytokines, immune modulators, and toxic substances are accumulating. Multiple organ failure in ALF has been associated with increased blood cytokine levels. We have used a blood purification system, molecular adsorbent recirculating system (MARS), which is based on removal of both protein bound and water-soluble substances and toxins in liver failure. In this study, we measured the effect of MARS therapy on plasma cytokine levels in 49 patients with ALF. Interleukin 6 (IL-6), IL-8, IL-10 and tumor necrosis factor (TNF)alfa were determined immediately before and after the first MARS therapy and after the last session using enzyme-linked immunosorbent assays. The overall survival of these ALF patients was 82% at 6 months; the native liver recovered in 26 cases, and 14 were successfully transplanted. All three interleukins were increased before the MARS treatment but only anti-inflammatory IL-10 was reduced significantly during therapy, which in this setting could be interpreted as a positive effect. We were not able to show constant decreases in proinflammatory cytokines, but only transient effects on IL-8 and IL-6. Surprisingly TNFalfa level was normal and did not change during therapy. In theory, MARS albumin dialysis may remove toxic substances from the blood circulation and thereby improve the possibilities of the liver to recover; however, of the measured cytokines only IL-10 decreased significantly.

Experience with albumin dialysis in five patients with severe overdoses of paracetamol.

Five patients in whom the serum paracetamol levels or the amount of ingested paracetamol was high enough to cause severe liver injury were treated with N-acetyl-cysteine (NAC) and a molecular absorbant recirculating system (MARS). MARS treatment was started as early as possible in order to prevent or retard the development of hepatocyte necrosis. Four of our five patients survived without liver transplantation, and one died due to brain oedema. The early commencement with NAC and MARS treatments in paracetamol intoxication might give enough time for the liver to regenerate and thus avoid liver transplantation.

The European Association for Endoscopic Surgery clinical practice guideline on the pneumoperitoneum for laparoscopic surgery.

BACKGROUND: The pneumoperitoneum is the crucial element in laparoscopic surgery. Different clinical problems are associated with this procedure, which has led to various modifications of the technique. The aim of this guideline is to define the scientifically proven standards of the pneumoperitoneum. METHODS: Based on systematic literature searches (Medline, Embase, and Cochrane), an expert panel consensually formulated clinical recommendations, which were graded according to the strength of available literature evidence. RECOMMENDATIONS: Preoperatively, all patients should be assessed for the presence of cardiac, pulmonary, hepatic, renal, or vascular comorbidity. Presupposing appropriate perioperative measures and surgical technique, there is no reason to contraindicate pneumoperitoneum in patients with peritonitis or intraabdominal malignancy. During laparoscopy, monitoring of end tidal CO2 concentration is mandatory. The available data on closed- (Veress needle) and open-access techniques do not allow us to principally favor the use of either technique. Using 2 to 5-mm instead of 5 to 10-mm trocars improves cosmetic result and postoperative pain marginally. It is recommended to use the lowest intraabdominal pressure allowing adequate exposure of the operative field, rather than using a routine pressure. In patients with limited cardiac, pulmonary, or renal function, abdominal wall lifting combined with low-pressure pneumoperitoneum might be an alternative. Abdominal wall lifting devices have no clinically relevant advantages compared to low-pressure (5-7 mmHg) pneumoperitoneum. In patients with cardiopulmonary diseases, intra- and postoperative arterial blood gas monitoring is recommended. The clinical benefits of warmed, humidified insufflation gas are minor and contradictory. Intraoperative sequential intermittent pneumatic compression of the lower extremities is recommended for all prolonged laparoscopic procedures. For the prevention of postoperative pain a wide range of treatment options exists. Although all these options seem to reduce pain, the data currently do not justify a general recommendation.

Sentinel node mapping affects intraoperative pulse oximetric recordings during breast cancer surgery.

BACKGROUND: In invasive breast cancer lymphatic mapping with patent blue vital dye (PBV) is used intraoperatively to identify the sentinel lymph nodes: the first axillary node draining the mammary lymphatic basin and first involved by the metastatic growth in breast cancer. Patent blue vital dye spreads to tissues giving a bluish tinge to patients. We have noted the possibility that intraoperative peripheral pulse oximetric (SpO2) values are artificially low when intradermal PBV is used. METHODS: Twenty patients with normal pulmonary function undergoing breast cancer surgery in standardized anesthesia either did or did not receive intradermal PBV sentinel node marking. The radial artery was cannulated for blood-gas-analysis; arterial oxygen tension (PaO2); and arterial oxygen saturation (SaO2). Peripheral oxygen saturation was measured using the light absorption technique. Red and infrared light (660 and 900 nm), used by pulseoxymetry, is partially absorbed when passing through the tissue. The amount of light absorbed is sensed and saturation calculated. The color of the skin was evaluated. RESULTS: Peripheral oxygen saturation decreased only immediately after the injection of PBV, and remained at a significantly lower level (P<0.001) throughout the operation and up to 90 min postoperatively. Arterial oxygen tension and SaO2 values did not decrease after intradermal PBV. Patent blue vital dye made patients' skin more bluish (P<0.001). No changes in SpO2, PaO2 and SaO2 were found in control patients. CONCLUSION: The spectrum of PBV has a peak absorption at 640 nm, thus making the SpO2 values incorrect. Peripheral oxygen saturation values are falsely low and true arterial oxygenation is not impaired when PBV is used during sentinel node mapping.

Clonidine provides opioid-sparing effect, stable hemodynamics, and renal integrity during laparoscopic cholecystectomy.

BACKGROUND: Carbon dioxide pneumoperitoneum causes a hemodynamic stress response and decreases urine output because of an activated renin-angiotensin-aldosterone system (RAAS). Clonidine is a potent antihypertensive drug that suppresses RAAS. METHODS: The effects of clonidine 4.5 mg/kg or saline on hemodynamics, neuroendocrine response, and renal parameters were compared in 30 healthy patients undergoing laparoscopic cholecystectomy. RESULTS: Heart rate, arterial blood pressures, and plasma renin activity were lower during and after pneumoperitoneum in patients with clonidine. There were no differences in urine output, urine oxygen tension (reflecting medullary perfusion), or antidiuretic hormone between the groups. N-acetyl-b-D-glucosaminidase, a marker of proximal tubular damage, was minimally elevated after clonidine. CONCLUSIONS: Clonidine enabled stable hemodynamics and prevented activation of RAAS seen as unchanged plasma renin activity. Clonidine may be beneficial during laparoscopy in patients with hypertension, cardiovascular, and/or renal diseases.

The effect of ketorolac and sevoflurane anesthesia on renal glomerular and tubular function.

UNLABELLED: We assessed the renal effects of the combination of ketorolac and sevoflurane anesthesia by using sensitive and specific markers of renal proximal and distal tubular and glomerular function. Thirty women (ASA physical status I and II) undergoing breast surgery received either ketorolac 30 mg IM or saline at premedication, at the end, and 6 h after anesthesia maintained with sevoflurane. Peak levels of serum fluoride at 2 h after the end of anesthesia were 30.1 micromol/L (21.0-50.0 micromol/L) in the Ketorolac group and 33.3 micromol/L (13.0-38.0 micromol/L) in the Control group (mean and range, not significant). Urine alpha1-microglobulin indexed to urine creatinine was increased from 2 h after the start of anesthesia until the first postoperative day in the Ketorolac group (peak level, 0.8 +/- 0.4 mg/mmol; upper limit of normal, 0.7 mg/mmol) but did not change in the Control group. Urine glutathione-S-transferase (GST)-alpha indexed to urine creatinine (GST-alpha/creatinine) and GST-pi/creatinine were increased 2 h after anesthesia and returned to baseline values thereafter in both groups. There were no changes in serum cystatin C and urine kallikrein or urine output per hour between groups. The perioperative administration of ketorolac to healthy, well hydrated patients anesthetized with sevoflurane did not produce renal glomerular or tubular dysfunction. IMPLICATIONS: Ketorolac 90 mg IM, given in divided doses over approximately 10 h to patients anesthetized with sevoflurane with a fresh gas flow rate of 4-6 L/min, did not result in clinically significant changes in renal glomerular or tubular function.

Ketorolac is not nephrotoxic in connection with sevoflurane anesthesia in patients undergoing breast surgery.

UNLABELLED: Ketorolac, which may cause renal vasoconstriction by cyclooxygenase inhibition, is often administered to patients anesthetized with sevoflurane that is metabolized to inorganic fluoride (F(-)), another potential nephrotoxin. We assessed this possible interaction using urine N-acetyl-beta-D-glucosaminidase indexed to urinary creatinine (U-NAG/crea) as a marker of proximal tubular, beta2-microglobulin as a tubular, urine oxygen tension (P(u)O(2)) as a medullary, and erythropoietin as a marker of tubulointerstitial damage. Thirty women (ASA physical status I-II) undergoing breast surgery were included in our double-blinded study. They were allocated into two groups receiving either ketorolac 30 mg IM (Group K) or saline (Group C) at the time of premedication, at the end of, and 6 h after anesthesia maintained with sevoflurane. Urine output, U-NAG/crea, P(u)O(2,) serum creatinine, urea, and F(-) were assessed. Blood loss was larger in Group K (465 +/- 286 mL vs 240 +/- 149 mL, mean +/- SD, P < 0.05). The MAC-doses of sevoflurane were similar. U-NAG/crea increased during the first 2 h of anesthesia and serum F(-) peaked 2 h after the anesthesia without differences between the groups. There were no statistically significant changes in P(u)O(2), erythropoietin, beta2-microglobulin, serum creatinine, urea, or urine output during anesthesia or the recovery period in either group. Our results indicate that the kidneys are not affected by ketorolac administered in connection with sevoflurane anesthesia. IMPLICATIONS: The different kinetics of N-acetyl-beta-D-glucosaminidase indexed to urinary creatinine and serum inorganic fluoride during and after sevoflurane anesthesia suggest that the observed mild renal tubular function deterioration is not caused by inorganic fluoride. Administration of ketorolac IM is therefore considered safe in adequately hydrated healthy adult patients given sevoflurane anesthesia.

Effects of esmolol on haemodynamic response to CO2 pneumoperitoneum for laparoscopic surgery.

BACKGROUND: Carbon dioxide (CO2) pneumoperitoneum for laparoscopic surgery increases arterial pressures, systemic vascular resistance and heart rate and decreases urine output. METHODS: In this double-blind randomized study esmolol, an ultrashort-acting beta1-adrenoceptor antagonist was compared with physiological saline (control) in 28 patients undergoing laparoscopic surgery in standardized 1 MAC isoflurane anaesthesia. Alfentanil infusion was used to prevent the increase of mean arterial pressure more than 25% from baseline. RESULTS: Esmolol effectively prevented the pressor response to induction and maintenance of CO2 pneumoperitoneum. Significantly (P<0.001) less alfentanil was needed in the esmolol group than in the control group. Urine output was higher (P<0.05) and plasma renin activity (P<0.01) and urine N-acetyl-beta-D-glucosaminidase levels lower in the esmolol group when compared with the control group. CONCLUSIONS: Esmolol blunts the pressor response to induction and maintenance of pneumoperitoneum and may protect against renal ischaemia during pneumoperitoneum.