A Simple Clinical Application for Locating the Frontotemporal Branch of the Facial Nerve Using the Zygomatic Arch and the Tragus.

BACKGROUND: The seventh cranial nerve (CN VII), also known as the facial nerve, is an anatomically intricate structure the branches of which serve several physiologic functions. CN VII innervates the muscles of facial expression which are crucial for eye protection, oral competence, and social interaction. The temporal branch, clinically referred to as the frontotemporal branch (FTB), is the most superior of the 5 branches and is at risk during cutaneous surgery of the parotid gland and in the temporal region. Several methods for delineating the FTB trajectory exist, the most widely known being Pitanguy's Line, which is defined as running from 0.5 cm below the tragus to 1.5 cm above the lateral eyebrow. However, variations in eyebrow location, often affected by modern-day cosmetic trends, complicate the accuracy of this approach. OBJECTIVES: The aim of this study was to develop a surgical landmark to identify FTB location without relying on soft tissue structures. METHODS: To minimize variation, we chose landmarks that were both consistent and easy to locate based on simple surface anatomy. Twenty-one cadaver hemifaces were dissected in order to locate the FTB in relation to the inferior border of the zygomatic arch and the apex of the tragus. RESULTS: We found that the mean ± SEM distance from the apex of the tragus to the point where the FTB crossed the inferior border of the zygomatic arch was 3.21 ± 0.05 cm. CONCLUSIONS: Through the use of this measurement, we aim to avoid the pitfalls of previous techniques by providing a widely applicable clinical tool based on landmarks easily found on any patient.

Opioids and tumour metastasis: does the choice of the anesthetic-analgesic technique influence outcome after cancer surgery?

PURPOSE OF REVIEW: Cancer is now one of the leading causes of death worldwide, and excisional surgery is an essential treatment for the four most common adult cancers. Opioids remain the most commonly prescribed analgesics in the perioperative period of cancer surgery, yet the question of whether opioids could influence recurrence or metastasis remains unanswered. RECENT FINDINGS: In-vitro cell culture, live animal models, and retrospective clinical reviews investigating the effects of opioids on outcomes after cancer surgery have yielded conflicting results, with findings ranging from deleterious, null to potentially protective effects. SUMMARY: Prospective randomized trials are required to investigate this important topic further. Several are currently ongoing. Until the results of these are available for scrutiny, there is currently insufficient evidence to recommend any changes to current clinical practice. Opioids continue to play an important role in the perioperative period.

Comparison of American Association for the Surgery of Trauma grading scale with modified Hinchey classification in acute colonic diverticulitis: A pilot study.

BACKGROUND: The American Association for the Surgery of Trauma (AAST) developed a severity scale for surgical conditions, including diverticulitis. The Hinchey classification requires operative intervention yet remains the established scoring system for acute diverticulitis. This is a pilot study to compare the AAST grading scale for acute colonic diverticulitis with the traditional Hinchey classification. We hypothesize that the AAST classification scale is equivalent to the Hinchey in predicting outcomes. METHODS: This is a retrospective cohort study at an academic medical center. A consecutive sample of patients with acute diverticulitis and computed tomography imaging was reviewed. Chart review identified demographic and physiologic data with interventional and clinical outcomes. Each computed tomography scan was assigned AAST and modified Hinchey classification scores by a radiologist. Multivariate regression and receiver operating characteristic curve analysis compared six outcomes: need for procedure, complication, intensive care unit (ICU) admission, length of stay, 30-day readmission, and mortality. RESULTS: One hundred twenty-nine patients were included. Of the total patients, 42.6% required procedural intervention, 21.7% required ICU admission, 18.6% were readmitted, and 6.2% died. Both AAST and Hinchey predicted the need for operation (AAST odds ratios, 1.55, 12.7, 18.09, and 77.24 for stages 2-5; Hinchey odds ratios, 8.85, 11.49, and 22.9 for stages 1b-3, stage 4 predicted perfectly). The need for operation c-statistics (area under the curve) for AAST and Hinchey was 0.80 and 0.83 for Hinchey and AAST, respectively (p = 0.35). The complication c-statistics curve for AAST and Hinchey was 0.83 and 0.80, respectively (p = 0.33). The AAST and Hinchey scores were less predictive for ICU admission, readmission, and mortality with c-statistics of less than 0.80. CONCLUSION: The AAST grading of acute diverticulitis is equivalent to the modified Hinchey classification in predicting procedural intervention and complications. The AAST system may be preferable to Hinchey because it can be applied preoperatively. Although this pilot study demonstrated that the AAST score predicts surgical need, a larger study is required to evaluate the AAST score for other outcomes. LEVEL OF EVIDENCE: Prognostic and epidemiological study, level III.

How Anesthetic, Analgesic and Other Non-Surgical Techniques During Cancer Surgery Might Affect Postoperative Oncologic Outcomes: A Summary of Current State of Evidence.

The question of whether anesthetic, analgesic or other perioperative intervention during cancer resection surgery might influence long-term oncologic outcomes has generated much attention over the past 13 years. A wealth of experimental and observational clinical data have been published, but the results of prospective, randomized clinical trials are awaited. The European Union supports a pan-European network of researchers, clinicians and industry partners engaged in this question (COST Action 15204: Euro-Periscope). In this narrative review, members of the Euro-Periscope network briefly summarize the current state of evidence pertaining to the potential effects of the most commonly deployed anesthetic and analgesic techniques and other non-surgical interventions during cancer resection surgery on tumor recurrence or metastasis.

Evaluation of hyperdynamic resuscitation in 60% TBSA burn-injured sheep.

It has been suggested that hyperdynamic (HD) resuscitation improves outcomes. We hypothesized that initial HD resuscitation of burn injury using fluid and inotropes would improve metabolic function as indicated by base excess. We used an anesthetized ovine model of 60% TBSA full-thickness flame burn with delayed resuscitation started at 90 min after burn and continued for 8 h. Three groups (n = 6 each) were included: 1) HD defined as cardiac index (CI) of 1.5x baseline achieved by using Ringer's lactate alone (HD-Fluid); 2) Ringer's lactate and dobutamine (HD-Drug); and 3) Parkland Formula (Parkland) as a control group. Statistical analysis performed using analysis of variance and Tukey's HSD test. Significance accepted at P < 0.05. Higher CI was achieved in both HD-Fluid and HD-Drug groups, e.g., at 8 h the CI was 4.6 +/- 0.4 and 4.7 +/- 0.6 L/min/m respectively, as compared with Parkland 3.6 +/- 0.5 L/min/m. The net fluid balance (fluid infused - urine output) was similar in both Parkland and HD-Drug groups, which were 2.5x more in HD-Fluid (P = 0.001). The mean postburn urinary outputs were similar in both Parkland and HD-Drug groups, e.g., Parkland (0.9 +/- 0.08 mL/kg/h), HD-Drug (1.0 +/- 0.2 mL/kg/h) and increased in HD-Fluid (3.7 +/- 1.0 mL/kg/h; P = 0.0005). Base excess remained positive in both HD-Drug (+2.5 +/- 1 mmol/L) and Parkland (+1.5 +/- 1.7 mmol/L), and declined to -4.0 +/- 3.6 mmol/L in HD-Fluid group (P = 0.036). We conclude that there may be no benefit to using hyperdynamic regimens for the initial resuscitation of burn injury.