Epidural analgesia combined with a comprehensive physiotherapy program after Cytoreductive Surgery and HIPEC is associated with enhanced post-operative recovery and reduces intensive care unit stay: A retrospective study of 124 patients.

BACKGROUND: Although Cytoreductive Surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) confers health benefits in peritoneal carcinomatosis (PC) treatment, it is associated with significant postoperative morbidity and mortality rate with increased length of hospital stay. The goal of this study is to determine whether a new comprehensive physiotherapy program including epidural loco-regional analgesia can improve the quality of care and patients recovery. METHODS: Between 2009 and 2013, 124 patients with PC were operated for CRS and HIPEC procedures. These patients were analyzed and divided in 2 groups by means of time. No Physio group included patients operated from 2009 to 2011 (n = 57) having a thoracic patient controlled epidural analgesia (PCEA) but no preoperative physiotherapy program. The Physio group included patients operated from 2012 to 2013 (n = 67) having both a PCEA with a preoperative physiotherapy program. RESULTS: The mortality rate was 1.6% (n = 2). The median length of stay in the intensive care unit (ICU) was lower in the Physio group, 2 days vs. 0 for No Physio group (p < 0.0001). The first time of mobilization after surgery was shorter in the Physio group (day 3 vs. 2, p = 0.0043). The overall satisfaction in the Physio group was achieved in 93% of patients, helping in decreasing fear of surgery and mobilization in 70% and 84% of cases respectively. CONCLUSION: Our study demonstrates that a clear pre-operative information and education by a physiotherapist, associated with a PCEA-pain management significantly benefits the patient's post-operative recovery and reduces the length of stay in the ICU.

Colorectal anastomotic leakage can be predicted by abdominal aortic calcification on preoperative CT scans: A pilot study.

BACKGROUND: There have been no solid data regarding whether patients with aortic calcification (AC) who have undergone colorectal surgery are at increased risk for anastomotic leakage. Our study aim to investigate the impact of AC on anastomotic leakage (AL) and postoperative morbidity after colorectal resection. METHODS: This was a cohort study of 60 patients who were prospectively registered in a database. We evaluated the relationship between an aortic calcification score (ACS), measured on preoperative computed tomography (CT) imaging, and surgical complications in patients undergoing colorectal surgery. RESULTS: ACS was strongly correlated with mortality rate. All three of the deceased patients were in the ACS-2 group (5%; P=0.021). The rate of AL was positively correlated with ACS; no leakage was found cases of ACS-0, with a rate of 18% in cases of ACS-1 and 44% in cases of ACS-2 (P=0.022). The consequences of AL were more serious according to the grade of ACS. DISCUSSION: This study suggested that aortic calcification score is correlated with surgical outcomes, particularly anastomosis leakage, after colorectal surgery. These findings could provide useful tools for adapting surgical strategies by delaying colorectal anastomosis in high-risk patients.

Comparison of cardiac output measured by oesophageal Doppler ultrasonography or pulse pressure contour wave analysis.

BACKGROUND: Maintaining adequate organ perfusion during high-risk surgery requires continuous monitoring of cardiac output to optimise haemodynamics. Oesophageal Doppler Cardiac Output monitoring (DCO) is commonly used in this context, but has some limitations. Recently, the cardiac output estimated by pulse pressure analysis- (PPCO) was developed. This study evaluated the agreement of cardiac output variations estimated with 9 non-commercial algorithms of PPCO compared with those obtained with DCO. METHODS: High-risk patients undergoing neurosurgery were monitored with invasive blood pressure and DCO. For each patient, 9 PPCO algorithms and DCO were recorded before and at the peak effect for every haemodynamic challenge. RESULTS: Sixty-two subjects were enrolled; 284 events were recorded, including 134 volume expansions and 150 vasopressor boluses. Among the 9 algorithms tested, the Liljestrand-Zander model led to the smallest bias (0.03 litre min(-1) [-1.31, +1.38] (0.21 litre min(-1) [-1.13; 1.54] after volume expansion and -0.13 litre min(-1) [-1.41, 1.15] after vasopressor use). The corresponding percentage of the concordance was 91% (86% after volume expansion and 94% after vasopressor use). The other algorithms, especially those using the Winkessel concept and the area under the pressure wave, were profoundly affected by the vasopressor. CONCLUSIONS: Among the 9 PPCO algorithms examined, the Liljestrand-Zander model demonstrated the least bias and best limits of agreement, especially after vasopressor use. Using this particular algorithm in association with DCO calibration could represent a valuable option for continuous cardiac output monitoring of high risk patients. CLINICAL TRIAL REGISTRATION: Comité d'éthique de la Société de Réanimation de Langue Française No. 11-356.

[Chordoma]. / Les chordomes.

PURPOSES: To review in the literature, all the epidemiological, clinical, radiological, histological and therapeutic data regarding chordomas as well as various notochordal entities: ecchordosis physaliphora, intradural and intraparenchymatous chordomas, benign notochordal cell tumors, parachordomas and extra-axial chordomas. To identify different types of chordomas, including familial forms, associations with tuberous sclerosis, Ollier's disease and Maffucci's syndrome, forms with metastasis and seeding. To assess the recent data regarding molecular biology and progress in targeted therapy. To compare the different types of radiotherapy, especially protontherapy and their therapeutic effects. To review the largest series of chordomas in their different localizations (skull base, sacrum and mobile spine) from the literature. MATERIALS: The series of 136 chordomas treated and followed up over 20 years (1972-2012) in the department of neurosurgery at Lariboisière hospital is reviewed. It includes: 58 chordomas of the skull base, 47 of the craniocervical junction, 23 of the cervical spine and 8 from the lombosacral region. Similarly, 31 chordomas in children (less than 18 years of age), observed in the departments of neurosurgery of les Enfants-Malades and Lariboisière hospitals, are presented. They were observed between 1976 and 2010 and were located intracranially (n=22 including 13 with cervical extension), 4 at the craniocervical junction level and 5 in the cervical spine. METHODS: In the entire Lariboisière series and in the different groups of localization, different parameters were analyzed: the delay of diagnosis, of follow-up, of occurrence of metastasis, recurrence and death, the number of primary patients and patients referred to us after progression or recurrence and the number of deaths, recurrences and metastases. The influence of the quality of resection (total, subtotal and partial) on the prognosis is also presented. Kaplan-Meier actuarial curves of overall survival and disease free survival were performed in the entire series, including the different groups of localization based on the following 4 parameters: age, primary and secondary patients, quality of resection and protontherapy. In the pediatric series, a similar analysis was carried-out but was limited by the small number of patients in the subgroups. RESULTS: In the Lariboisière series, the mean delay of diagnosis is 10 months and the mean follow-up is 80 months in each group. The delay before recurrence, metastasis and death is always better for the skull base chordomas and worse for those of the craniocervical junction, which have similar results to those of the cervical spine. Similar figures were observed as regards the number of deaths, metastases and recurrences. Quality of resection is the major factor of prognosis with 20.5 % of deaths and 28 % of recurrences after total resection as compared to 52.5 % and 47.5 % after subtotal resection. This is still more obvious in the group of skull base chordomas. Adding protontherapy to a total resection can still improve the results but there is no change after subtotal resection. The actuarial curve of overall survival shows a clear cut in the slope with some chordomas having a fast evolution towards recurrence and death in less than 4 years and others having a long survival of sometimes more than 20 years. Also, age has no influence on the prognosis. In primary patients, disease free survival is better than in secondary patients but not in overall survival. Protontherapy only improves the overall survival in the entire series and in the skull base group. Total resection improves both the overall and disease free survival in each group. Finally, the adjunct of protontherapy after total resection is clearly demonstrated. In the pediatric series, the median follow-up is 5.7 years. Overall survival and disease free survival are respectively 63 % and 54.3 %. Factors of prognosis are the histological type (atypical forms), localization (worse for the cervical spine and better for the clivus) and again it will depend on the quality of resection. CONCLUSIONS: Many different pathologies derived from the notochord can be observed: some are remnants, some may be precursors of chordomas and some have similar features but are probably not genuine chordomas. To-day, immuno-histological studies should permit to differentiate them from real chordomas. Improving knowledge of molecular biology raises hopes for complementary treatments but to date the quality of surgical resection is still the main factor of prognosis. Complementary protontherapy seems useful, especially in skull base chordomas, which have better overall results than those of the craniocervical junction and of the cervical spine. However, we are still lacking an intrinsic marker of evolution to differentiate the slow growing chordomas with an indolent evolution from aggressive types leading rapidly to recurrence and death on which more aggressive treatments should be applied.

Use of the Nexfin™ device to detect acute arterial pressure variations during anaesthesia induction.

BACKGROUND: Standard non-invasive arterial pressure (AP) measurements are discontinuous. By providing non-invasive beat-to-beat AP measurements, Nexfin™ might limit duration of intraoperative hypotension and hypertension. We assessed the ability of Nexfin™ to detect AP variations by comparing its trending ability with invasive AP monitoring. METHODS: Thirty-one subjects undergoing elective surgery under general anaesthesia were included. During induction, simultaneous pairs of AP measurements were collected every 5 s from the Nexfin™ finger sensor and a homolateral radial artery catheter. Magnitude and time lags of AP variations from baseline to nadir and peak were calculated for both methods. Concordance analysis was performed by the Bland-Altman method (for comparison of repeated measures when appropriate). RESULTS: Nexfin™ detected 100% of AP changes with the median delays of 0 s (-13 to 7) and 0 s (-5 to 12) for nadir and peak, respectively. Bias [limits of agreement (LOA)] of systolic AP (SAP) variations was -0.5 mm Hg (-31.2 to 30.2) and -9.4 mm Hg (-31.3 to 12.6) from baseline to nadir and from baseline to peak, respectively. For 3479 analysed paired measurements, bias was -3.8 and -8.8 mm Hg for SAP and diastolic AP, with LOA of (-36.0 to 28.5) and (-29.8 to 12.3), respectively. CONCLUSIONS: Nexfin™ detects AP variations accurately and can be a useful warning device during anaesthesia. However, it is not interchangeable with invasive monitoring, given the large LOA between the two measurements. CLINICAL TRIAL REGISTRATION: NCT01658631.

[Objective severity markers in women with severe postpartum haemorrhage: a 310-case series]. / Critères objectifs de gravité en cas d'hémorragie grave du post-partum: à propos de 310 cas.

OBJECTIVES: Postpartum haemorrhage (PPH) is a major contributor to maternal morbidity and mortality in France. The objective of our study was to reveal predictive factors of severity or cure, allowing an adapted management as less invasive as possible, in case of severe PPH. PATIENTS AND METHODS: This retrospective study included 310 patients, who had been treated for a severe PPH in Lariboisière university hospital from April 2007 to April 2009. RESULTS: The predictive factors found for an invasive management (surgery or embolization) are: at clinical examination, heart rate (88 versus 100 pulses per minute), importance of bleeding and the tonicity of the uterine globe. At biological examination, they are haemoglobin level (9 versus 8.2g/dL) and clotting factors, especially fibrinogen (3 versus 2g/L) and prothrombin time (PT) (76 versus 63%). The identified cure factors are the same ones as severity factors. With multivariate analysis, initial independent predictive factors about an invasive management were: the tonicity of the uterine globe (OR=0.14), heart frequency (OR=1.3) and PT (OR=0.76). DISCUSSION AND CONCLUSION: In case of severe haemorrhage, there may be the question of transfer of the patient. The difficulty is to avoid unnecessary transport, without delay for the future care. Very few studies searched predictive factors of severity or cure. Our study found, as predictive factors of invasive treatment, elements of physical examination (heart rate and the tonicity of the uterine globe) and biological factors (hemoglobin level and clotting factors).

CNAP(®) does not reliably detect minimal or maximal arterial blood pressures during induction of anaesthesia and tracheal intubation.

BACKGROUND: CNAP(®) provides continuous non-invasive arterial pressure (AP) monitoring. We assessed its ability to detect minimal and maximal APs during induction of general anaesthesia and tracheal intubation. METHODS: Fifty-two patients undergoing surgery under general anaesthesia were enrolled. Invasive pressure monitoring was established at the radial artery, and CNAP monitoring using a finger sensor recording was begun before induction. Statistical analysis was conducted with the Bland-Altman method for comparison of repeated measures and intraclass correlation coefficient (ICC). RESULTS: Patients' median age was 67 years [interquartile range (59-76)], median American Society of Anesthesiologists score was 3 [interquartile range (2-3)]. Bias was 5 and -7 mmHg for peak and nadir systolic AP (SAP), with upper and lower limits of agreement of (42:-32) and (27;-42), respectively. The corresponding ICC values were 0.74 [95% confidence interval (CI) = 0.57-0.84] and 0.60 (95% CI = 0.44-0.73). Time lags to reach these values were 7.5 s (95% CI = -10.0 to 60.0) for the highest SAP and 10 s (95% CI = -12.5 to 72.5) for the lowest SAP. Bias, lower and upper limits of agreement for diastolic, and mean AP were -14 (-36 to 9) and -12 (-37 to 13) for the nadir value and -7 (-29 to 15) and -2 (-28 to 25) for the peak value. CONCLUSIONS: The CNAP monitor could detect acute change in AP within a reasonable time lag. Precision of its measurements is not satisfactory, and therefore, it could only serve as a clue to the occurrence of changes in AP.

Pelvic arterial ligations for severe post-partum hemorrhage. Indications and techniques.

In cases of serious bleeding postpartum, resuscitation and surgical techniques are complementary and should be adapted to both the etiology and severity of bleeding. In extremely severe cases, the performance of a hysterectomy should not be delayed. For women with stable hemodynamic status, so-called "conservative" surgical techniques can instead be used. In this study, we describe and discuss the indications and feasibility of various techniques of vascular ligation. Uterine mattress suture compression techniques and abdomino-pelvic packing are also described. When conservative management is feasible, the first line approach should be bilateral distal ligation of the uterine arteries: this simple and low-risk technique is immediately effective in 80% of cases. If bleeding persists, uterine devascularization can be completed by a triple ligation as described by Tsirulnikov, with or without supplemental proximal ligation of the uterine arteries. This procedure should be performed in preference to the so-called "stepwise ligation sequence", which involves ligation of the ovarian pedicles and poses a risk of subsequent ovarian failure. Bilateral hypogastric artery ligation is also an effective and widely used first-line technique for experienced surgeons. This approach is technically challenging for less-experienced surgeons and is reserved for cases of failed triple ligation.

Radiofrequency ablation of retained placenta accreta after conservative management: preliminary evaluation in the pregnant ewe and in normal human placenta in vitro.

OBJECTIVE: To evaluate radiofrequency (RF) efficiency and safety for the ablation of retained placenta in humans, using a pregnant sheep model. DESIGN: Experimental study. SETTING: Laboratory of Surgery School, Nancy, France. POPULATION/SAMPLE: Three pregnant ewes/ten human placentas. METHODS: Various RF procedures were tested in pregnant ewes on 50 placentomes (individual placental units). Reproducibility of the best procedure was then evaluated in a further 20 placentomes and on ten human term placentas in vitro after delivery. MAIN OUTCOME MEASURES: Placental tissues destruction, lesions' size, myometrial lesions. RESULTS: Low power (100 W) and low target temperatures (60 degrees C) lead to homogenous tissue destruction, without myometrial lesion. No significant difference was observed in terms of lesion size and procedure duration for in the placentomes of pregnant ewe in vivo and in human placentas in vitro. The diameter of the ablation could be correlated with the tines deployment. CONCLUSION: The placental tissue structure is very permissive to RF energy, which suggests that RF could be used for the ablation of retained placenta, providing optimal control of tissue destruction. These results call for further experimental evaluations.

[Complete cost of surgery for postpartum haemorrhage]. / Coût total des actes chirurgicaux dans la prise en charge des hémorragies de la délivrance.

OBJECTIVE: Reduction of maternal mortality is a major priority in the public health domain. One of the main causes of maternal mortality is postpartum haemorrhage. Because economic pressures favour the use of less expensive strategies, it is becoming now critical to know exactly the cost of the surgical procedures involved in the treatment of postpartum haemorrhage, in order to provide future guidelines in Implementing reforms in hospital. MATERIALS AND METHODS: Evaluation was made on multiple data collected in the Gynecology-Obstetrics and Central Sterile Supplies departments of a tertiary care Hospital. Analysis of the production costs was made based on the actual costs. The receipts were figured on the basis of applicable reimbursement in France in 2005, taking into account the financial decisions of the producers. RESULTS: From January 2004 to December 2005, 262 patients were treated for postpartum hemorrhage and patients files were available for review in 255 cases. Of these, surgery was performed in 52 cases. The costs of surgery in the postpartum care ranged from 275.04 euro per manual exploration of the uterine cavity (n=8), 302.48 euro per exploration with valve (n=26), 601.55 euro per vascular ligation (n=3), 725.53 euro per vaginal packing or unpacking (n=10) to 875.06 euro per hysterectomy (n=5). Cleaning and sterilizing of surgical instruments represented a substantial burden, ranging from 7.5% to 11.4% of the total cost of surgery. DISCUSSION AND CONCLUSION: The costs of surgery for postpartum haemorrhage have been calculated to provide future guidelines for the directions and follow-up of these activities in light of the T2A-EPRD and poles of activity. The actual costs could be used to determine the bases of one or more French DRGs (PMSI) "postpartum hemorrhage" evolution.