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.

Enhanced recovery pathway in open and minimally invasive colorectal cancer surgery: a prospective study on feasibility, compliance, and outcomes in a high-volume resource limited tertiary cancer center.

BACKGROUND: Enhanced recovery program (ERP) has demonstrated improved postoperative outcomes with increased compliance to pathway. However, there is scarce data on feasibility and safety in resource limited setting. The objective was to assess compliance with ERP and its impact on postoperative outcomes and return to intended oncological treatment (RIOT). METHODS: A single center prospective observational audit was conducted from 2014 to 2019, in elective colorectal cancer surgery. Before implementation, multi-disciplinary team was educated regarding ERP. Compliance to ERP protocol and its elements was recorded. Impact of quantum of compliance (≥80% vs. <80%) to ERP on postoperative morbidity, mortality, readmission, stay, re-exploration, functional GI recovery, surgical-specific complications, and RIOT was evaluated for open and minimal invasive surgery (MIS). RESULTS: During study, 937 patients underwent elective colorectal cancer surgery. Overall compliance with ERP was 73.3%. More than 80% compliance was observed in 332 (35.4%) patients in the entire cohort. Patients with <80% compliance had significantly higher overall, minor and surgery-specific complications, longer postoperative stay, delayed functional GI recovery for both open and MIS procedures. RIOT was observed in 96.5% patients. Duration to RIOT was significantly shorter following open surgery with ≥80% compliance. Compliance <80% to ERP was identified as one of the independent predictors for developing postoperative complications. CONCLUSION: The study demonstrates beneficial impact of increased compliance to ERP on postoperative outcomes following open and minimally invasive surgery for colorectal cancer. Within a resource limited setting, ERP was found to feasible, safe, and effective in both open and minimally invasive colorectal cancer surgery.

Hemolytic Response of Iron Oxide Magnetic Nanoparticles at the Interface and in Bulk: Extraction of Blood Cells by Magnetic Nanoparticles.

Surface-active and water-soluble magnetic nanoparticles (NPs) were synthesized in the presence of a series of amphiphilic molecules of different functional groups to determine the hemolytic response and their ability to extract blood cells across the interface and aqueous bulk while maintaining minimum hemolysis. Amphiphilic molecules such as Gemini surfactants of strong hydrophobicity and low hydrophilic-lipophilic balance produced surface-active magnetic NPs, which were highly cytotoxic even when placed at the blood suspension (aqueous)-air interface. A similar behavior was shown by water-soluble magnetic NPs produced using monomeric ionic and nonionic surfactants and different amino acids. The NPs produced using mild biological surfactants and mono- and oligosaccharides of the same functional group proved to be excellent blood cell extractors with minimum hemolysis. α/ß-cyclodextrin and dextrose-stabilized magnetic NPs induced negligible hemolysis and extracted more than 50% of blood cells. The results showed that nontoxic magnetic NPs are excellent blood cell extractors from the blood suspension when tagged with amphiphilic molecules possessing good biocompatibility with cell membranes without inducing hemolysis. The work highlights the biological applicability of nontoxic magnetic NPs at biointerfaces and in blood suspensions.

Impact of enhanced recovery pathway in 408 gallbladder cancer resections.

BACKGROUND: Gallbladder cancer (GBC) is the sixth most common gastrointestinal malignancy with poor prognosis. Enhanced Recovery Pathway (ERP) is associated with improved outcomes following abdominal surgical procedures. Currently, there is no study evaluating ERP in patients undergoing GBC surgery. The objective was to assess compliance with ERP elements and evaluate its impact on postoperative outcomes. METHODS: Prospective study conducted from February 2014-2019, including elective GBC surgery. Team was educated prior to ERP implementation. Compliance with the protocol, functional gastrointestinal (GI) recovery, mobilisation, and postoperative outcomes were recorded. Impact of degree of compliance (more or less than 80%) with ERP and postoperative outcomes was evaluated. RESULTS: In 408 patients, compliance with ERP was 84.6% (53.8-100%). Compliance >80% with ERP elements was observed in 245 patients (60%). Patients with >80% compliance had lower rate of minor (18.8% vs. 27%, p = 0.050) and significantly less major (0.8% vs. 6.1%, p = 0.002) and postoperative stay (5.84 ± 4.86 vs. 7.55 ± 6.6 days, p < 0.001) and earlier functional GI recovery. Intraoperative blood loss more than 600 ml, lower compliance (<80%) with ERP and preoperative albumin independently predicted postoperative complications. CONCLUSION: This study demonstrates safety and efficacy of enhanced recovery pathway in gallbladder cancer. Higher compliance with the pathway was associated with significantly improved postoperative outcomes following gallbladder cancer surgery.

An Integrated Surgical Management for Giant Dermatofibrosarcoma Protuberans of Anterior Abdominal Wall.

Giant dermatofibrosarcoma protuberans (DFSP) is a very rare dermal sarcoma whose diagnosis and management are important because of the high local recurrence but low metastatic potential. Complete surgical excision of giant DFSP in a single stage is difficult but has a high cure rate. A 47-year-old man presented with a gradually increasing large (18 x 15 x 7 cm) DFSP in the epigastrium. A 3 cm circumferential wide local excision (WLE) with microscopic tumor-free margin confirmed by frozen section was performed. Immediate single staged tension-free primary closure of resultant defect was done on the principle of abdominal wall reconstruction (AWR) in ventral hernia repair. This technique of anterior component separation and bridge meshplasty is functional, avoids multiple surgeries, is cost-effective, and can be done in a resource-limited setting in developing countries. A multidisciplinary and integrated surgical approach to treat giant DFSP over epigastrium, by three-dimensional WLE and immediate AWR with anterior component separation technique (CST) and bridging meshplasty, can be of immense help in managing such rare cases in developing countries.

Postoperative Outcomes Following Elective Surgery in India.

INTRODUCTION: The incidence of complications and mortality in patients undergoing elective surgery in India are unknown. We contributed Indian data to ISOS. Since there were fewer than ten centers, Indian data were not included in the primary analysis. We report postoperative outcomes in the Indian data set of patients following elective surgery. MATERIALS AND METHODS: In this prospective 7-day observational study, after obtaining a waiver of informed consent, data were collected for 30 days from consecutive patients >18 years undergoing elective surgery. The primary outcome was in-hospital postoperative complications. The secondary outcomes were in-hospital all-cause mortality, the relationship between postoperative complications and admission to critical care, and the duration of hospital stay. Complications were graded as mild, moderate, and severe. Failure to rescue was defined as mortality in patients admitted to an intensive care unit (ICU) for the treatment of complications. RESULTS: Complications occurred in 57 (27.5%) patients, who were older (53 vs 47 years, p < 0.001) and had American Society of Anaesthesiologists grades III and IV physical status (p = 0.029). One hundred and thirty-eight (65.7%) patients underwent a major surgical procedure of which 132 (62.8%) procedures were done for malignancy. Postoperative complications were significantly higher (41.5% vs 22.7%) in patients electively admitted to ICU. The overall mortality rate was 2.4%, whereas the mortality rate was 8.8% in those who developed complications. CONCLUSION: We found that 28% of patients developed postoperative complications. The overall mortality was 2.4% but was higher (8.8%) in those who developed complications. Age and complex surgical procedures independently predicted complications, while lower preoperative hemoglobin appeared to be protective. STUDY REGISTRATION: ISRCTN51817007. HOW TO CITE THIS ARTICLE: Agarwal V, Muthuchellappan R, Shah BA,Rane PP, Kulkarni AP, et al. Postoperative Outcomes Following Elective Surgery in India. Indian J Crit Care Med 2021;25(5):528-534.

Preoperative Albumin-Globulin Ratio and Its Association with Perioperative and Long-Term Outcomes in Patients Undergoing Pancreatoduodenectomy.

BACKGROUND: Systemic inflammatory response is involved in natural progression of cancers by different pathways. Albumin-globulin ratio (AGR) has been reported to have impact on prognosis in various solid tumors. OBJECTIVE: To study the significance of AGR on perioperative and long-term outcomes in patients undergoing PD. METHODS: This is a post hoc analysis of the pancreatic surgery database from January 2012 to March 2017. Cutoff value for AGR was calculated by using the receiver operating curve, and the study cohort was divided into group I (AGR ≥1) and group II (AGR <1). Two groups were compared for perioperative and long-term survival outcomes. RESULTS: Two groups were comparable with respect to clinicodemographic variables. Groups I and II had similar perioperative outcomes (p > 0.05) like median hospital stay (14 vs. 15 days), clinically relevant postoperative pancreatic fistula (16.6 vs. 15.7%), hemorrhage (3.1 vs. 2.6%), bile leak (1.4 vs. 0.65%), overall morbidity (30.1 vs. 28.9%), and postoperative mortality (2.7 vs. 3.9%). With a median follow-up of 3 years, median survival, overall survival, and disease-free survival were similar in both groups. CONCLUSION: AGR at the cutoff value of ≥1 was not associated with adverse perioperative and long-term oncological outcomes after PD.

Pre-induction Ultrasonographic Evaluation of Gastric Residual Volume in Elective Gastrointestinal Cancer Surgeries.

Pulmonary aspiration of gastric contents during elective surgery remains a major cause of airway-related mortality and morbidity. The preoperative fasting times for solids and liquids have been standardized across various anesthesia society guidelines. Enhanced Recovery After Surgery (ERAS) guidelines now advocate liberal clear fluid intake with carbohydrate loading up to 2 h preoperatively. The aim of the study was to assess whether practicing both ASA fasting guidelines and ERAS protocol makes the patients prone to a full stomach. The supine position standard curvilinear ultrasound probe (2-5 MHz) with Sonosite M-Turbo ©system was used to obtain the images. Gastric residual volume (GRV) was derived from the cross-sectional area (CSA) using the Perlas and colleagues model. A total of 102 patients were recruited and analyzed. The mean age and BMI were 50.65 years ± 13.35 years and 22.23 kg/m2 ± 3.7 kg/m2, respectively. A total of four patients (3.92%) had gastric volume > 1.5 ml/kg; out of these four patients, three were female and one was male. We did not observe any case of pulmonary aspiration in any of our patients. In conclusion, even though for elective surgeries, the current fasting guidelines are adequate, these findings cannot be extrapolated to patients with risk factors for high gastric residual volume where further studies need to be performed.

Complications after Supramajor Gastrointestinal Surgery: Role of Enhanced Recovery after Surgery.

BACKGROUND: Enhanced recovery after surgery (ERAS) is currently the standard of care in perioperative medicine, but it is widely underutilized in our healthcare setting because of the lack of awareness of benefits exerted by ERAS and its components. ERAS is a multidisciplinary collaboration, where intensivists play an important role in the implementation of the protocol during the perioperative period. AIM: This review article aims to appraise the role of ERAS pathway on complications following supramajor gastrointestinal surgery. REVIEW: A summary and review of evidence was conducted on the role of ERAS and its elements on non-specific and surgery-specific complications. Enhanced recovery pathways (ERPs) and its elements were directly found to be associated with lower incidence of hospital-associated infections, postoperative ileus, and postoperative pulmonary complications. Although there are no specific elements of ERPs found to have beneficial effect in preventing major adverse cardiac and cerebrovascular events, and surgery-specific complications such as postoperative pancreatic fistula, delayed gastric emptying, post-pancreatectomy hemorrhage, post-hepatic liver failure, bile, and anastomotic leak, studies have demonstrated that implementation of an ERP bundle can decrease the incidence of these complications. Implementation of an ERP was associated with an increase in the incidence of acute kidney injury with minor elevations in creatinine that returned to baseline before discharge. CONCLUSION: Although there is ample evidence that ERAS is beneficial in reducing complications and hospital stay following supramajor gastrointestinal surgery, there is scope for further research to unravel the role of ERAS on patient-reported outcomes. HOW TO CITE THIS ARTICLE: Thomas M, Joshi R, Bhandare M, Agarwal V. Complications after Supramajor Gastrointestinal Surgery: Role of Enhanced Recovery after Surgery. Indian J Crit Care Med 2020;24(Suppl 4):S205-S210.

Correction to: Twelve Hundred Consecutive Pancreato-Duodenectomies from Single Centre: Impact of Centre of Excellence on Pancreatic Cancer Surgery Across India.

The authors' affiliations are updated as reflected here.

Twelve Hundred Consecutive Pancreato-Duodenectomies from Single Centre: Impact of Centre of Excellence on Pancreatic Cancer Surgery Across India.

BACKGROUND: Pancreato-duodenectomy (PD) is a technically challenging operation with significant morbidity and mortality. Over the period of time, Tata Memorial Centre has evolved into a high-volume centre for management of pancreatic cancer. Aim of this study is to report the short- and long-term outcomes of 1200 consecutive PDs performed at single tertiary cancer centre in India. METHODS: 1200 PDs were performed from 1992 to 2017. Prospectively maintained database was used to retrospectively assess the short- and long-term outcomes. RESULTS: Study cohort was divided into periods A and B (500 and 700 patients, respectively). Both groups were comparable for demographic variables. Overall morbidity and mortality in entire cohort were 31.2% and 3.9%, respectively. Period B documented significant reduction in post-operative mortality (5.4% vs 2.8%), post-pancreatectomy haemorrhage (5.8% vs 3%) and bile leaks (3.4% vs 1.3%). However, incidence of delayed gastric emptying and clinically relevant post-operative pancreatic fistula was higher in period B. With median follow-up of 25 months, 3-year overall survival and disease-free survival for patients with pancreatic cancer were 43.7% and 38.7%, respectively, and that for periampullary tumours were 65.9% and 59.4%, respectively. Period B also corresponded with dissemination of technical expertise across diverse regions of India with specialised training of 35 surgeons. CONCLUSION: Our study demonstrates the feasibility of delivering high-quality care in a dedicated high-volume centre even in a country with low incidence of pancreatic cancer with marked disparities in medical care and socio-economic conditions. Improved outcomes underscore the need to promote regionalisation via a dedicated training programme.

Society of Onco-Anaesthesia and Perioperative Care consensus guidelines for perioperative management of patients for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC).

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) for primary peritoneal malignancies or peritoneal spread of malignant neoplasm is being done at many centres worldwide. Perioperative management is challenging with varied haemodynamic and temperature instabilities, and the literature is scarce in many aspects of its perioperative management. There is a need to have coalition of the existing evidence and experts' consensus opinion for better perioperative management. The purpose of this consensus practice guideline is to provide consensus for best practice pattern based on the best available evidence by the expert committee of the Society of Onco-Anaesthesia and Perioperative Care comprising perioperative physicians for better perioperative management of patients of CRS-HIPEC.

Enhanced recovery after surgery in liver resection: current concepts and controversies.

Enhanced recovery after surgery (ERAS) attenuates the stress response to surgery in the perioperative period and hastens recovery. Liver resection is a complex surgical procedure where the enhanced recovery program has been shown to be safe and effective in terms of postoperative outcomes. ERAS programs have been shown to be associated with lower morbidity, shortened postoperative stay, and reduced cost with no difference in mortality and readmission rates. However, there are challenges that are unique to hepatic resection such as safety after epidural catheterization and postoperative coagulopathy, intraoperative fluids and postoperative organ dysfunction, need for low central venous pressure to reduce blood loss, and non-lactate containing intravenous fluids. This narrative review briefly discusses these concerns and controversies and suggests revisiting some of the strong recommendations made by the ERAS society in light of the recent evidence.

Pain after posterolateral versus nerve-sparing thoracotomy: A randomized trial.

OBJECTIVES: Post-thoracotomy pain leads to patient discomfort, pulmonary complications, and increased analgesic use. Intercostal nerve injury during thoracotomy or its entrapment during closure can contribute to post-thoracotomy pain. We hypothesized that a modified technique of posterolateral thoracotomy and closure, preserving the intercostal neurovascular bundle, would reduce acute and chronic post-thoracotomy pain. METHODS: We randomized 90 patients undergoing posterolateral thoracotomy for pulmonary resection at a tertiary level oncology center to standard posterolateral (control arm) or modified nerve-sparing thoracotomy. All patients received morphine via patient-controlled analgesia pumps. The primary outcome was the worst postoperative pain score in the first 3 postoperative days. Secondary outcomes included the average pain score and analgesic requirements in the first 3 postoperative days and the incidence of post-thoracotomy pain 6 months after surgery. RESULTS: No significant differences were seen between the groups in acute or chronic post-thoracotomy measured by the numeric rating scale. There was no difference seen in the worst (mean) postoperative pain scores (3.71 vs 3.83, difference 0.12; 99% confidence interval [CI], -0.7 to +0.9; P = .7), average (mean) pain scores in the first 3 postoperative days (1.77 vs 1.85, difference 0.08; 99% CI, -0.4 to +0.6; P = .69), mean consumption of morphine (mg/kg) (1.45 vs 1.40, difference -0.05; 99% CI, -0.4 to +0.3; P = .73), or incidence of chronic postoperative pain (37.8% vs 40%, difference 4.9%; 99% CI, -22.8 to +30.7%; P = .73). CONCLUSIONS: The modified nerve-sparing thoracotomy technique does not reduce post-thoracotomy pain compared with standard posterolateral thoracotomy.

Improved Outcomes in 394 Pancreatic Cancer Resections: the Impact of Enhanced Recovery Pathway.

BACKGROUND: Enhanced recovery (ER) pathway reduces morbidity and accelerates recovery. It is associated with reduced postoperative stay, morbidity, and costs. Feasibility and safety of ER programme has not been studied in developing countries. The objectives were to assess compliance with Enhanced Recovery After Surgery (ERAS) elements and to assess outcomes in pancreatic surgery. METHODS: Prospective study conducted from February 2014 to December 2016, following elective pancreatic cancer surgery. Team was educated prior to implementation of ERAS. Patients were followed up until 30 days postoperatively or discharge. Data was recorded regarding the compliance with the protocol, functional GI recovery, mobilisation, and postoperative morbidity and mortality. RESULTS: A total of 394 patients underwent surgery. Compliance with ER elements implemented was 84% (23-100%). Compliance > 80% with ER elements was observed in 278 patients (70.5%) and < 80% in 116 patients (29.5%). Patients with > 80% compliance have significantly lower major complications (28.7 vs. 44%, p = 0.001), mortality (2.1 vs. 6.8%, p = 0.021), and postoperative stay (11 (5-78) days vs. 15 (4-61) days, p < 0.001). CONCLUSION: ER programme is feasible and safe in resource and infrastructure limited lower middle-income country. Improved compliance was associated with reduced major complications, mortality, and shorter stay in patients undergoing pancreatic cancer surgery in high-volume centre. TRIAL REGISTRATION: CTRI/2015/01/005393 ( www.ctri.nic.in ).

Holt-Oram syndrome: Anesthetic challenges and safe outcome.

Holt-Oram syndrome (HOS) is an autosomal dominant disease with skeletal and cardiac manifestations. We here are presenting a 31-year-old man and a diagnosed case of HOS, with an ulceroproliferative lesion on lateral border of the tongue, was posted for wide excision of lesion with primary closure and left side radical neck dissection.

Awareness during general anesthesia: An Indian viewpoint.

BACKGROUND AND AIMS: The incidence of intra-operative awareness with explicit recall in the Western world has been reported to be between 0.1% and 0.2% in the general surgical population and up to 1-2% of patients at high risk for this complication. Awareness in the Indian population has never been studied; we therefore wanted to detect the incidence of awareness in patients who were at high risk of experiencing awareness during surgery in our population. MATERIAL AND METHODS: We conducted a prospective single-center observational study at a 600-bedded tertiary cancer care referral hospital. We recruited adult patients posted for major cancer surgery who were considered to be at high risk for awareness. These patients were interviewed at three time-points using the structured modified Brice interview questionnaire. The primary outcome studied was the incidence of definite intra-operative awareness. RESULTS: A total of 934 patients were included in the final analysis of which none reported awareness. Using the rule of three (Hanley and Lippman-Hand) we conclude that the upper 95% confidence interval for the incidence of awareness in this population is <1 in 300 (0.33%). CONCLUSION: Awareness under anesthesia is a distressing complication with a potential for long-term psychological consequences, and every effort should be undertaken to prevent it. It is reassuring though that our data in Indian cancer patients at high risk for intra-operative awareness suggests that it is an uncommon occurrence.

A Complicated Case of Acute Promyelocytic Leukemia in the Second Trimester of Pregnancy Successfully Treated with All-trans-Retinoic Acid.

A 40-year-old female at 26-week gestation was diagnosed with acute promyelocytic leukemia (APL) after an abnormal prenatal lab workup showed pancytopenia. She was treated with all-trans-retinoic acid (ATRA), idarubicin, and dexamethasone. After day one of treatment, she developed differentiation syndrome, which was treated with dexamethasone. At 30-week gestation, she had preterm premature rupture of membranes and delivered by cesarean section because of the fetus' breech presentation. Despite ATRA's potential for teratogenicity, a viable infant was born without apparent anomalies. Postpartum, she underwent consolidation treatment with ATRA and arsenic trioxide (ATO). The patient continued ATRA therapy after delivery and is currently in remission.