Realizing Textbook Outcomes Following Liver Resection for Hepatic Neoplasms with Development and Validation of a Predictive Nomogram.

BACKGROUND: 'Textbook Outcome' (TO) represents an effort to define a standardized, composite quality benchmark based on intraoperative and postoperative endpoints. This study aimed to assess the applicability of TO as an outcome measure following liver resection for hepatic neoplasms from a low- to middle-income economy and determine its impact on long-term survival. Based on identified perioperative predictors, we developed and validated a nomogram-based scoring and risk stratification system. METHODS: We retrospectively analyzed patients undergoing curative resections for hepatic neoplasms between 2012 and 2023. Rates of TO were assessed over time and factors associated with achieving a TO were evaluated. Using stepwise regression, a prediction nomogram for achieving TO was established based on perioperative risk factors. RESULTS: Of the 1018 consecutive patients who underwent liver resections, a TO was achieved in 64.9% (661/1018). The factor most responsible for not achieving TO was significant post-hepatectomy liver failure (22%). Realization of TO was independently associated with improved overall and disease-free survival. On logistic regression, American Society of Anesthesiologists score of 2 (p = 0.0002), perihilar cholangiocarcinoma (p = 0.011), major hepatectomy (p = 0.0006), blood loss >1500 mL (p = 0.007), and presence of lymphovascular emboli on pathology (p = 0.026) were associated with the non-realization of TO. These independent risk factors were integrated into a nomogram prediction model with the predictive efficiency for TO (area under the curve 75.21%, 95% confidence interval 70.69-79.72%). CONCLUSION: TO is a realizable outcome measure and should be adopted. We recommend the use of the nomogram proposed as a convenient tool for patient selection and prognosticating outcomes following hepatectomy.

Postoperative Hyperbilirubinemia and Acute Liver Dysfunction after Cytoreductive Surgery and HIPEC.

How to cite this article: Kannancheeri A, Solanki SL, Kazi M, Saklani A. Postoperative Hyperbilirubinemia and Acute Liver Dysfunction after Cytoreductive Surgery and HIPEC. Indian J Crit Care Med 2024;28(1):80-81.

Hyperammonemia after Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy: A Report of Three Cases with Unusual Presentation.

Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is a treatment modality for peritoneal surface malignancies. A variety of metabolic derangements have been reported in the perioperative period in these patients, most of which are a result of the complex interaction of peritoneal denudation, chemotherapy bath, and fluid imbalance. We report three cases of hyperammonemia-related neurological dysfunction seen in HIPEC patients. To the best of our knowledge, this is the first report of this presentation. Timely recognition of this condition needs a high degree of suspicion, and unless aggressively treated, is likely to be associated with poor outcome. How to cite this article: Sharma V, Solanki SL, Saklani AP. Hyperammonemia after Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy: A Report of Three Cases with Unusual Presentation. Indian J Crit Care Med 2021;25(5):590-593.

Impact of the COVID-19 pandemic on anesthesiologists in India: A cross-sectional online survey of the practices, preparedness, and mind-set.

BACKGROUND AND AIMS: India is one of the five worst hit countries in the world due to COVID-19, by the fourth week of June 2020. The impact of COVID-19 on the health practices is well-documented but there are no studies assessing its impact on anesthesiologists in India. This study aims at assessment of the impact of COVID-19 on the practices followed, the preparedness, and mindset of anesthesiologists in India. MATERIAL AND METHODS: Using Google forms, a cross-sectional, questionnaire-based survey was conducted between the 5th and 22nd of May, 2020, among trainees and practicing anesthesiologists, in India. The anesthesiologists were invited to participate, using their e-mail addresses and through the social media platforms such as Facebook and WhatsApp. The responses that were generated, were analyzed using SPSS version 23 (IBM, Armonk, NY). RESULTS: Of the 707 anesthesiologists who participated, 68.3% had already worked in a COVID-19 specialty unit. Only 41.7% of the anesthesiologists felt confident that they had sufficient knowledge to deal with COVID-19 infected patients. Fear of catching the infection and infecting loved ones were important causes of anxiety, which was seen in 95% of the participants. Majority of the participants, (64.5%) did not think that elective surgical procedures could be restarted at this point. CONCLUSION: COVID-19 has had grave impact on anesthesiologists, on the professional and personal front, and will possibly cause near-permanent changes in the work culture. Restarting elective surgical procedures, will require meticulous planning. In spite of their self-perceived under-preparedness to combat COVID-19, an overwhelming majority of participating anesthesiologists were prepared to contribute to the management of COVID-19.

Study of risk factors and psychological impact in physicians diagnosed with COVID-19: An online, postexposure, cross-sectional survey.

BACKGROUND AND AIMS: Healthcare workers (HCW's) who have contracted the disease while working in the hospital may have a deep psychological impact in the form of depression and anxiety, along with the stress of passing the infection to their family members. This study attempts to highlight the risk factors and psychological impact on doctors who have tested positive for coronavirus disease-2019 (COVID-19). MATERIAL AND METHODS: This online cross-sectional survey-based study enrolled all level doctors of all specialities of in Mumbai, India, who had tested positive for novel coronavirus. The survey questionnaire was a 26-item self-administered anonymous set of questions in English language only. This validated questionnaire was distributed by a link via Google forms for 1 week. RESULTS: We received 51 completed responses. Most of them were (67%) postgraduate students. Forty-three (85%) respondents were working in a COVID-19 center. Twenty-three (45%) had a history of contact with these patients without proper personal protective equipment (PPE) with unknown COVID-19 status of the patient at the time of contact. Ten percent regretted their decision of becoming a doctor. Only half (51%) had family support during their illness and 45% relied on friends and colleagues in the hospital. Twenty-six percent mentioned having a low mood throughout the illness. A major portion of people (32%) having fear of severe illness and death. CONCLUSION: Medical doctors working in direct contact with confirmed cases of COVID-19 are at increased risk of contracting the infection and it has a major impact on physical and mental health of medical doctors.

What you see and what you don't - Utility and pitfalls during fluorescence guided resections of gliomas using 5-aminolevulinic acid.

BACKGROUND: Fluorescence guided resections have been increasingly used for malignant gliomas. Despite the high reliability of the technique, there remain some practical limitations. METHODS: We retrospectively reviewed our experience with 50 consecutive cases of 5-aminolevulinic acid (ALA)-guided resections. Clinico-radiological features and intraoperative variables (pattern and type of fluorescence) were recorded. In a subset (12 cases), we performed annotated biopsies to calculate the diagnostic accuracy of the technique. We recorded and analysed the patterns of excision and residual fluorescence and correlated this with postoperative magnetic resonance imaging (MRI). RESULTS: Majority of the tumours (92%) were resectable and predominantly enhancing. Though strong fluorescence was seen in most of them, there were 2 cases with a non-enhancing tumor which showed fluorescence. Visualized strong fluorescence had a very high predictive value (100%) for detecting the pathological tissue. However, it was not always possible to resect all the fluorescing tissue. Proximity to critical neuro-vascular structures was the commonest reason for failure to achieve a gross total excision (16 cases). Additionally, there were some cases (5 of 8) where the non-fluorescing residue was resected intraoperatively with the help of ultrasound. Despite the presence of residual fluorescence, overall radiological gross total resection was achieved in 66% cases. CONCLUSIONS: ALA guided resections are very useful in malignant gliomas, even if these lesions do not enhance signi cantly. Although ALA reliably depicts the tumour intraoperatively, it may not be possible to resect all this tissue completely. Additionally, non-fluorescing tumor may be completely missed out and may require additional imaging tools. Working within the limitations of the technique and using complementary modalities (ultrasound or brain mapping) may be ideal for achieving a radical resection of malignant gliomas.

Artificial Intelligence in Perioperative Planning and Management of Liver Resection.

Artificial intelligence (AI) is a speciality within computer science that deals with creating systems that can replicate the intelligence of a human mind and has problem-solving abilities. AI includes a diverse array of techniques and approaches such as machine learning, neural networks, natural language processing, robotics, and expert systems. An electronic literature search was conducted using the databases of "PubMed" and "Google Scholar". The period for the search was from 2000 to June 2023. The search terms included "artificial intelligence", "machine learning", "liver cancers", "liver tumors", "hepatectomy", "perioperative" and their synonyms in various combinations. The search also included all MeSH terms. The extracted articles were further reviewed in a step-wise manner for identification of relevant studies. A total of 148 articles were identified after the initial literature search. Initial review included screening of article titles for relevance and identifying duplicates. Finally, 65 articles were reviewed for this review article. The future of AI in liver cancer planning and management holds immense promise. AI-driven advancements will increasingly enable precise tumour detection, location, and characterisation through enhanced image analysis. ML algorithms will predict patient-specific treatment responses and complications, allowing for tailored therapies. Surgical robots and AI-guided procedures will enhance the precision of liver resections, reducing risks and improving outcomes. AI will also streamline patient monitoring, better hemodynamic management, enabling early detection of recurrence or complications. Moreover, AI will facilitate data-driven research, accelerating the development of novel treatments and therapies. Ultimately, AI's integration will revolutionise liver cancer care, offering personalised, efficient and effective solutions, improving patients' quality of life and survival rates.

Postoperative Complications Result in Poor Oncological Outcomes: What Is the Evidence?

The majority of patients with solid tumors undergo a curative resection of their tumor burden. However, the reported rate of postoperative complications varies widely, ranging from 10% to 70%. This narrative review aims to determine the impact of postoperative complications on recurrence and overall survival rates following elective cancer surgeries, thereby providing valuable insights into perioperative cancer care. A systematic electronic search of published studies and meta-analyses from January 2000 to August 2023 was conducted to examine the effect of postoperative complications on long-term survival after cancer surgeries. This comprehensive search identified fifty-one eligible studies and nine meta-analyses for review. Recurrence-free survival (RFS) and overall survival (OS) rates were extracted from the selected studies. Additionally, other oncological outcomes, such as recurrence and cancer-specific survival rates, were noted when RFS and OS were not reported as primary outcomes. Pooled hazard ratios and 95% confidence intervals were recorded from the meta-analyses, ensuring the robustness of the data. The analysis revealed that long-term cancer outcomes progressively worsen, from patients with no postoperative complications to those with minor postoperative complications (Clavien-Dindo grade ≤ II) and further to those with major postoperative complications (Clavien-Dindo grade III-IV), irrespective of cancer type. This study underscores the detrimental effect of postoperative complications on long-term oncological outcomes, particularly after thoracoabdominal surgeries. Importantly, we found a significant gap in the data regarding postoperative complications in surface and soft tissue surgical procedures, highlighting the need for further research in this area.

Acute postoperative pain management techniques, their efficacy and complications after major gastrointestinal and hepato-pancreato-biliary cancer surgeries: An observational study.

BACKGROUND: Patients undergoing major gastrointestinal (GI) surgery including hepato-pancreato-biliary (HPB) surgeries have large incisions, which cause severe acute postoperative pain that, if untreated, is associated with a higher incidence of postoperative morbidity and delayed recovery. METHODOLOGY: Our study included all patients who underwent elective major upper GI and HPB surgeries from 1 January 2018 to 31 December 2018. The patients were divided into two groups: the epidural and the non-epidural group. The average and worst pain scores at rest and movement were compared between both groups. We also studied the effect of pain relief in the two groups and associated postoperative outcomes, resumption of feeding, ambulation, hospital stay and intensive care unit stay. RESULTS: A total of 566 patients were included in the study, out of which 490 received epidurals, and the rest, 76, belonged to the non-epidural group (transversus abdominis plane, rectus sheath block or no regional analgesia technique). The median average pain score at rest and movement was 2.0 and 3.0, respectively, in the epidural and non-epidural groups. The postoperative outcomes showed no statistical difference. CONCLUSION: The epidural group and the non-epidural group had similar pain scores, and the postoperative outcomes were also comparable.

Acute kidney injury after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy - A systematic review.

The use of nephrotoxic chemotherapeutic agents during hyperthermic intraperitoneal chemotherapy (HIPEC), carries the risk of postoperative acute kidney injury (AKI). The available evidence on this subject is sparse with variability in the reported incidence of AKI. In this systematic review, the aim was to analyse the incidence, risk factors, and preventive measures for AKI after cytoreductive surgery and HIPEC. A systematic literature search was conducted using the terms 'Acute kidney injury', 'Acute kidney failure', 'Acute renal failure', 'Acute renal impairment', 'HIPEC Surgery', 'Cytoreductive Surgery', 'Heated Chemotherapy' on PubMed, Scopus, clinical trial.gov, POPLINE and Google Scholar. Randomized controlled trials, cohort studies and observational studies published from January 2000-December 2020 were included. The systematic review was registered in the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42021247781). Data from 16 articles, which included 1622 patients, was included. The incidence AKI by any definition, was 23.36 %. The highest incidence of AKI (45.45 %) was reported after paclitaxel-HIPEC. The incidence of AKI after cisplatin-HIPEC was 34.7 %. Cisplatin HIPEC was the most common factor associated with AKI in 7/16 studies followed by pre-existing comorbidities and low intraoperative diuresis in 4 and 3 studies respectively. The perioperative use of sodium thiosulfate and amifostine led to a significant reduction in the incidence of AKI. The reported incidence of AKI after CRS-HIPEC is high. Identifying preoperative risk factors, optimising comorbidities, maintaining perioperative haemodynamic stability, perioperative use of sodium thiosulfate, maintaining adequate diuresis could reduce the incidence of AKI.

Impact of fluid and haemodynamic management in cytoreductive surgery with hyperthermic intraperitoneal chemotherapy on postoperative outcomes - A systematic review.

Background and Aims: Cytoreduction surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is an extensive surgery associated with significant fluid shift and blood loss. The haemodynamic management and fluid therapy protocol may impact postoperative outcomes. This systematic review was conducted to find the effect of haemodynamic monitoring and perioperative fluid therapy in CRS-HIPEC on postoperative outcomes. Methods: We searched PubMed, Scopus and Google Scholar. All studies published between 2010 and 2022 involving CRS-HIPEC surgeries that compared the effect of fluid therapy and haemodynamic monitoring on postoperative outcomes were included. Keywords for database searches included a combination of Medical Subject Headings terms and plain text related to the CRS-HIPEC procedure. The risk of bias and the certainty assessment were done by Risk of Bias-2 and the methodological index for non-randomised studies. Results: The review included 16 published studies out of 388 articles. The studies were heterogeneous concerning the design type and parameter measures. The studies with goal-directed fluid therapy protocol had a duration of intensive care unit (ICU) stay that varied from 1 to 20 days, while mortality varied from 0% to 9.5%. The choice of fluid, crystalloid versus colloid, remains inconclusive. The studies that compared crystalloids and colloids for perioperative fluid management did not show a difference in clinical outcomes. Conclusion: The interpretation of the available literature is challenging because the definitions of various fluid regimens and haemodynamic goals are not uniform among studies. An individualised approach to perioperative fluid therapy and a justified dynamic index cut-off for haemodynamic monitoring seem reasonable for CRS-HIPEC procedures.

Evaluation of perioperative routine coagulation testing versus thromboelastography for major liver resection - A single-arm, prospective, interventional trial (PORTAL trial).

Background and Aims: The International Normalised Ratio (INR), which assesses the loss of procoagulant factors in the extrinsic pathway, fails to evaluate the coagulation abnormalities comprehensively after a major liver resection, which often leads to reduced synthesis of procoagulant and anticoagulant-factors. This study was conducted with an aim to study the trend and compare the results of routine coagulation tests and thromboelastography (TEG) during the perioperative period in patients undergoing major liver resections (≥3 segments). Methods: Twenty-five patients who underwent a major liver resection were enrolled. This prospective, single-arm, interventional study was performed with the primary objective of determining the serial changes in conventional coagulation tests and TEG during the perioperative period in patients undergoing major liver resections, at the preincision period, intraoperative period, postoperatively, at 48 h and on the fifth postoperative day. Transfusion requirements of blood components were also assessed with a TEG-guided replacement strategy. Spearman rank-order correlation was used to study the relationships of coagulation tests (both TEG and conventional tests) at each time point. Results: The prothrombin time (PT)-INR was elevated in 14 patients (56%) at the intraoperative, immediate postoperative and 48-h time points in contrast to the TEG parameters, which remained normal in all patients. Blood component transfusion was avoided in 4, 11 and 10 patients at the intraoperative, immediate postoperative and 48-h time points, respectively. Conclusion: International Normalised Ratio overestimates the coagulopathy in patients undergoing major liver resection, and a thromboelastography-guided transfusion strategy reduces overall transfusion requirements.

Postoperative complications and critical care management after cytoreduction surgery and hyperthermic intraperitoneal chemotherapy: A systematic review of the literature.

BACKGROUND: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is a comprehensive treatment option performed for peritoneal surface malignancies. Postoperatively almost all patients are transferred to the intensive care unit electively. AIM: To describe the common and rare postoperative complications, postoperative mortality and their critical care management after CRS-HIPEC. METHODS: The authors assessed 54 articles for eligibility. Full text assessment identified 14 original articles regarding postoperative complications and critical care management for inclusion into the final review article. RESULTS: There is an exaggerated metabolic and inflammatory response after surgery which may be termed as physiological in view of the nature of surgery combined with the use of heated intraperitoneal chemotherapy with/out early postoperative intravenous chemotherapy. The expected postoperative course is further discussed. CRS-HIPEC is a complex procedure with some life-threatening complications in the immediate postoperative period, reported morbidity rates between 12%-60% and a mortality rate of 0.9%-5.8%. Over the years, since its inception in the 1980s, postoperative morbidity and survival have significantly improved. The commonest postoperative surgical complications and systemic toxicity due to chemotherapy as reported in the last decade are discussed. CONCLUSION: CRS-HIPEC is associated with a varying rate of postoperative complications including postoperative deaths and needs early suspicion and intensive care monitoring.

Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy in a 2-YearOld Child with Abdominopelvic Rhabdomyosarcoma: A Case Report of Anaesthetic Concerns.

Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is a well-established multimodal treatment in patients with peritoneal surface malignancies in adults. Children younger than 3 years rarely undergo such extensive surgeries with heated chemotherapy infusion intraoperatively. Only one such case is reported in the literature for CRS-HIPEC for an abdominopelvic rhabdomyosarcoma in a child of 2 years or less. We present the case of a 2-year-old child with abdominopelvic rhabdomyosarcoma undergoing CRS-HIPEC and discuss the perioperative concerns and challenges.

Role of prophylactic HIPEC in non-metastatic, serosa-invasive gastric cancer: a literature review.

The role of prophylactic hyperthermic intraperitoneal chemotherapy (p-HIPEC) in serosa invasive gastric cancers without gross or microscopic peritoneal disease, to reduce the rate of peritoneal relapse is an area of ongoing research. Although p-HIPEC is effective in reducing the rate of peritoneal relapse and improving disease free and overall survival with or without adjuvant chemotherapy, when added to curative surgery in locally advanced, non-metastatic gastric cancers, the available literature is at best, heterogeneous, centre-specific and skewed. Apart from that, variations in the systemic therapy used, and the presence of the associated nodal disease further complicate this picture. To evaluate the role of p-HIPEC the PubMed, Cochrane central register of clinical trials, and the American Society of Clinical Oncology (ASCO) meeting library were searched with the search terms, "gastric", "cancer", "hyperthermic", "intraperitoneal", "chemotherapy", prophylactic", "HIPEC" in various combinations, and a critical review of the available evidence was done. Although p-HIPEC is a promising therapy in the management of locally advanced gastric cancers, the current evidence is insufficient to recommend its inclusion into routine clinical practice. Future research should be directed towards identification of the appropriate patient subset and towards redefining its role with current peri-operative systemic therapies.

Severe stridor and marked respiratory difficulty after right-sided supraclavicular brachial plexus block.

Brachial plexus block is commonly used for upper limb surgery. Although the procedure is safe, it may be associated with some life-threatening complications. We performed right-sided supraclavicular brachial plexus block for below-elbow amputation in a 45-year-old female. At completion of the block the patient developed marked respiratory difficulty with audible inspiratory stridor. Although SpO(2) decreased to 82% initially, it was increased to 100% by continuous positive airway pressure with a face mask. On conventional direct laryngoscopy, the left vocal cord was found to be in the midline position and the right vocal cord was in the paramedian position. The trachea was intubated and surgery proceeded without any other complication. Postoperative indirect laryngoscopy revealed that the left vocal cord was fixed, whereas the right vocal cord was mobile, and diagnosis of pre-existing incomplete left vocal cord paralysis was made. This clinical report is to emphasize the importance of thorough pre-operative evaluation of the vocal cord in patients who have undergone any surgical procedure or radiation treatment of the neck before planning for brachial plexus block. If such an evaluation cannot be obtained, an alternative technique, for example axillary approach, should be preferred.