Laparoscopic surgery in 3D improves results and surgeon convenience in sleeve gastrectomy for morbid obesity.

PURPOSE: Advanced laparoscopic procedures are still challenging. One critical issue is the lack of stereoscopic vision. The aim of this surgical study is to evaluate whether 3D vision offers any advantages for surgical performance over 2D vision during sleeve gastrectomy for morbid obesity using a laparoscopic system that allows changing between 2D and 3D optics. METHODS: A total of 78 patients were analyzed, with 37 in the 2D group and 41 in the 3D group. Performance time, hospital stay, complications, and early outcomes were collected. To assess the quality of the 2D and 3D techniques, visual analog scales from 0 to 10 were designed, and image quality, depth of field, precision in performing tasks, and general ergonomics were measured. RESULTS: According to the vision system used, the mean duration of surgery was 85 ± 16.8 min for patients operated on with the 2D system and 69 ± 16.9 min for those operated on with the 3D system. There were no significant differences between the overall percentages of complications according to the type of vision used. However, postoperative complications were more severe in the 2D laparoscopy group. The average length of stay was shorter for patients in the 3D group. Regarding the differences perceived by the surgeon, the depth of field and the precision of tasks were better in the 3D vision group. CONCLUSION: The 3D system provided greater depth perception and precision in more complex tasks, enabling safer surgery. This led to a reduction in the operative time and hospital stay. Moreover, the severity of complications was less.

The EUropean PErioperative MEdical networking (EUPEMEN) project: recommendations for perioperative care in colorectal surgery. a quality improvement study.

BACKGROUND: Despite consensus supporting enhanced recovery programs, their full implementation in such a context is difficult due to conventional practices within various groups of professionals. The goal of the EUropean PErioperative MEdical Networking (EUPEMEN) project was to bring together the expertise and experience of national clinical professionals who have previously helped deliver major change programs in their countries and to use them to spread enhanced recovery after surgery protocols (ERAS) in Europe. The specific aim of this study is to present and discuss the key points of the proposed recommendations for colorectal surgery. MATERIALS AND METHODS: Five partners from university hospitals in four European countries developed the project as partners. Following a non-systematic review of the literature, the European consensus panel generated a list of recommendations for perioperative care in colorectal surgery. A list of recommendations was formulated and distributed to collaborators at each center to allow modifications or additional statements. These recommendations were then discussed in three consecutive meetings to share uniform ERAS protocols to be disseminated. RESULT: The working group developed (1) the EUPEMEN online platform to offer, free of charge, evidence-based standardized perioperative care protocols, learning activities, and assistance to health professionals interested in enhancing the recovery of their patients; (2) the preparation of the EUPEMEN Multimodal Rehabilitation manuals; (3) the training of the trainers to teach future teachers; and (4) the dissemination of the results in five multiplier events, one for each partner, to promote and disseminate the protocols. CONCLUSION: The EUPEMEN project allowed the sharing of the expertise of many professionals from four different European countries with the objective of training the new generations in the dissemination of ERAS protocols in daily clinical practice through a new learning system. This project was proposed as an additional training tool for all the enhanced recovery program teams.

Model for predicting early and late-onset postoperative pulmonary complications in perioperative patients receiving neuromuscular blockade: a secondary analysis.

Pulmonary complications continue to be the most common adverse event after surgery. The main objective was to carry out two independent predictive models, both for early pulmonary complications in the Post-Anesthesia Care Unit and late-onset pulmonary complications after 30 postoperative days. The secondary objective was to determine whether presenting early complications subsequently causes patients to have other late-onset events. This is a secondary analysis of a cohort study. 714 patients were divided into four groups depending on the neuromuscular blocking agent, and spontaneous or pharmacological reversal. Incidence of late-onset complications if we have not previously had any early complications was 4.96%. If the patient has previously had early complications the incidence of late-onset complications was 22.02%. If airway obstruction occurs, the risk of atelectasis increased from 6.88 to 22.58% (p = 0.002). If hypoxemia occurs, the incidence increased from 5.82 to 21.79% (p < 0.001). Based on our predictive models, we conclude that diabetes mellitus and preoperative anemia are two risk factors for early and late-onset postoperative pulmonary complications, respectively. Hypoxemia and airway obstruction in Post-Anesthesia Care Unit increased four times the risk of the development of pneumonia and atelectasis at 30 postoperative days.

Predictive study of pharmacological reversal for residual neuromuscular blockade and postoperative pulmonary complications: a prospective, observational, cohort study.

In recent years, some studies have generated controversy since they conclude that intraoperatively pharmacological reversal of neuromuscular blockade does not contribute to the reduction of postoperative residual neuromuscular blockade or pulmonary complications. Therefore, the main objective of this study was to assess the incidence of residual neuromuscular blockade and postoperative pulmonary complications according to spontaneous or pharmacological neuromuscular reversal. The secondary aim was to present a prognostic model to predict the probability of having postoperative residual neuromuscular blockade depending on a patient's comorbidities and intraoperative neuromuscular blocking agents management. A single-center, prospective, observational cohort study including patients undergoing surgical procedures with general anesthesia was designed. A total of 714 patients were analyzed. Patients were divided into four groups: cisatracurium with spontaneous reversal, cisatracurium with neostigmine antagonism, rocuronium with spontaneous reversal, and rocuronium with sugammadex antagonism. According to our binomial generalized linear model, none of the studied comorbidities was a predisposing factor for an increase in the residual neuromuscular blockade. However, in our study, pharmacological reversal of rocuronium with sugammadex and, particularly, neuromuscular monitoring during surgery were the factors that most effectively reduced the risk of residual neuromuscular blockade as well as early and late postoperative pulmonary complications.

Neuromonitoring depth of anesthesia and its association with postoperative delirium.

Delirium after surgery or Postoperative delirium (POD) is an underdiagnosed entity, despite its severity and high incidence. Patients with delirium require a longer hospital stay and present more postoperative complications, which also increases hospital costs. Given its importance and the lack of specific treatment, multifactorial preventive strategies are evidenced based. Our hypothesis is that using general anaesthesia and avoiding the maximum time in excessively deep anaesthetic planes through BIS neuromonitoring device will reduce the incidence of postoperative delirium in patients over the age of 65 and their hospitalization stay. Patients were randomly assigned to two groups: The visible BIS group and the hidden BIS neuromonitoring group. In the visible BIS group, the depth of anaesthesia was sustained between 40 and 60, while in the other group the depth of anaesthesia was guided by hemodynamic parameters and the Minimum Alveolar Concentration value. Patients were assessed three times a day by research staff fully trained during the 72 h after the surgery to determine the presence of POD, and there was follow-up at 30 days. Patients who developed delirium (n = 69) was significantly lower in the visible BIS group (n = 27; 39.1%) than in the hidden BIS group (n = 42, 60.9%; p = 0.043). There were no differences between the subtypes of delirium in the two groups. Patients in the hidden BIS group were kept for 26.6 ± 14.0 min in BIS values < 40 versus 11.6 ± 10.9 min (p < 0.001) for the patients in the visible BIS group. The hospital stay was lower in the visible BIS group 6.56 ± 6.14 days versus the 9.30 ± 7.11 days (p < 0.001) for the hidden BIS group, as well as mortality; hidden BIS 5.80% versus visible BIS 0% (p = 0.01). A BIS-guided depth of anaesthesia is associated with a lower incidence of delirium. Patients with intraoperative neuromonitoring stayed for a shorter time in excessively deep anaesthetic planes and presented a reduction in hospital stay and mortality.

Higher Adherence to ERAS Society® Recommendations is Associated with Shorter Hospital Stay Without an Increase in Postoperative Complications or Readmissions in Bariatric Surgery: the Association Between Use of Enhanced Recovery After Surgery Protocols and Postoperative Complications after Bariatric Surgery (POWER 3) Multicenter Observational Study.

PURPOSE: The effectiveness of enhanced recovery after surgery (ERAS) pathways in patients undergoing bariatric surgery remains unclear. Our objective was to determine the effect of the ERAS elements on patient outcomes following elective bariatric surgery. MATERIALS AND METHODS: Prospective cohort study in adult patients undergoing elective bariatric surgery. Each participating center selected a single 3-month data collection period between October 2019 and September 2020. We assessed the 24 individual components of the ERAS pathways in all patients. We used a multivariable and multilevel logistic regression model to adjust for baseline risk factors, ERAS elements, and center differences RESULTS: We included 1419 patients. One hundred and fourteen patients (8%) developed postoperative complications. There were no differences in the incidence of overall postoperative complications between the self-designated ERAS and non-ERAS groups (54 (8.7%) vs. 60 (7.6%); OR, 1.14; 95% CI, 0.73-1.79; P = .56), neither for moderate-to-severe complications, readmissions, re-interventions, mortality, or hospital stay (2 [IQR 2-3] vs. 3 [IQR 2-4] days, 0.85; 95% CI, 0.62-1.17; P = .33) Adherence to the ERAS elements in the highest adherence quartile (Q1) was greater than 72.2%, while in the lowest adherence quartile (Q4) it was less than 55%. Patients with the highest adherence rates had shorter hospital stay (2 [IQR 2-3] vs. 3 [IQR 2-4] days, 1.54; 95% CI, 1.09-2.17; P = .015), while there were no differences in the other outcomes CONCLUSIONS: Higher adherence to ERAS Society® recommendations was associated with a shorter hospital stay without an increase in postoperative complications or readmissions. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03864861.

Study of Rocuronium-Sugammadex as an Alternative to Succinylcholine-Cisatracurium in Microlaryngeal Surgery.

Microlaryngeal surgery (ML) is a short procedure that requires a deep neuromuscular blockade to provide optimum surgical conditions. Succinylcholine is a relaxant widely used but involves numerous complications. One valid alternative is rocuronium, with a specific antagonist, sugammadex. The primary objective was to assess the surgical conditions in ML according to the relaxant. The secondary objectives were to assess intubation conditions and intraoperative and immediate postoperative adverse events. STUDY DESIGN: Prospective randomized study. METHODS: This was a prospective study of patients scheduled for ML randomized into two groups according to relaxant. Neuromuscular blockade was recorded after administration and during ML surgery. Surgical conditions were assessed using the ML Rating Scale, intubation conditions, remifentanil doses, intraoperative complications, surgery time, emergence time, and complications in the postanesthesia care unit. RESULTS: Two hundred five patients were included (rocuronium = 103, succinylcholine = 102). Train-of-four values were higher for rocuronium, though the otorhinolaryngology surgical conditions were significantly better in that group (rocuronium = 5.54 ± 1.39 points; succinylcholine = 9.13 ± 1.99 points). Intubation conditions were similar in both groups. Remifentanil doses were higher for succinylcholine (P < .001) (rocuronium = 0.102 ± 0.05 µg/kg/min; succinylcholine = 0.201 ± 0.05 µg/kg/min). There were no differences in the duration of surgery, but the time to awakening was significantly longer for succinylcholine (rocuronium = 3.82 ± 1.38 minutes, succinylcholine = 9.18 ± 2.04 minutes, P < .001). CONCLUSIONS: Rocuronium provides better surgical conditions and allows for the use of lower doses of remifentanil as compared to succinylcholine and cisatracurium in ML. This makes it possible to decrease the time to awakening and the complications associated with high doses of remifentanil. LEVEL OF EVIDENCE: 1b Laryngoscope, 131:E212-E218, 2021.

Surgical treatment for colorectal cancer: analysis of the influence of an enhanced recovery programme on long-term oncological outcomes-a study protocol for a prospective, multicentre, observational cohort study.

INTRODUCTION: The evidence currently available from enhanced recovery after surgery (ERAS) programmes concerns their benefits in the immediate postoperative period, but there is still very little evidence as to whether their correct implementation benefits patients in the long term. The working hypothesis here is that, due to the lower response to surgical aggression and lower rates of postoperative complications, ERAS protocols can reduce colorectal cancer-related mortality. The main objective of this study is to analyse the impact of an ERAS programme for colorectal cancer on 5-year survival. As secondary objectives, we propose to analyse the weight of each of the predefined items in the oncological results as well as the quality of life. METHODS AND ANALYSIS: A multicentre prospective cohort study was conducted in patients older than 18 years of age who are scheduled to undergo surgery for colorectal cancer. The study involved 12 hospitals with an implemented enhanced recovery protocol according to the guidelines published by the Spanish National Health Service. The intervention group includes patients with a minimum implementation level of 70%, and the control group includes those who fail to reach this level. Compliance will be studied using 18 key performance indicators, and the results will be analysed using cancer survival indicators, including overall survival, cancer-specific survival and relapse-free survival. The time to recurrence, perioperative morbidity and mortality, hospital stay and quality of life will also be studied, the latter using the validated EuroQol Five questionnaire. The propensity index method will be used to create comparable treatment and control groups, and a multivariate regression will be used to study each variable. The Kaplan-Meier estimator will be used to estimate survival and the log-rank test to make comparisons. A p value of less than 0.05 (two-tailed) will be considered to be significant. ETHICS AND DISSEMINATION: Ethical approval for this study was obtained from the Aragon Ethical Committee (C.P.-C.I. PI20/086) on 4 March 2020. The findings of this study will be submitted to peer-reviewed journals (BMJ Open, JAMA Surgery, Annals of Surgery, British Journal of Surgery). Abstracts will be submitted to relevant national and international meetings. TRIAL REGISTRATION NUMBER: NCT04305314.

Analysis of the postoperative hemostatic profile of colorectal cancer patients subjected to liver metastasis resection surgery.

BACKGROUND: Liver resection surgery has advanced greatly in recent years, and the adoption of fasttrack programs has yielded good results. Combination anesthesia (general anesthesia associated to epidural analgesia) is an anesthetic-analgesic strategy commonly used for the perioperative management of patients undergoing surgery of this kind, though there is controversy regarding the coagulation alterations it may cause and which can favor the development of spinal hematomas. AIM: To study the postoperative course of liver resection surgery, an analysis was made of the outcomes of liver resection surgery due to colorectal cancer metastases in our centre in terms of morbiditymortality and hospital stay according to the anesthetic technique used (general vs combination anesthesia). METHODS: A prospective study was made of 61 colorectal cancer patients undergoing surgery due to liver metastases under general and combination anesthesia between January 2014 and October 2015. The patient characteristics, intraoperative variables, postoperative complications, evolution of hemostatic parameters, and stay in intensive care and in hospital were analyzed. RESULTS: A total of 61 patients were included in two homogeneous groups: general anesthesia (n = 30) and combination anesthesia (general anesthesia associated to epidural analgesia) (n = 31). All patients had normal coagulation values before surgery. The international normalized ratio (INR) in both the general and combination anesthesia groups reached maximum values at 2448 h (mean 1.37 and 1.45 vs 1.39 and 1.41, respectively), followed by a gradual decrease. There was less intraoperative bleeding in the combination anesthesia group (769 mL) than in the general anesthesia group (1200 mL) (P < 0.05). Of the 61 patients, 38.8% in the general anesthesia group experienced some respiratory complication vs 6.6% in the combination anesthesia group (P < 0.001). The time to gastrointestinal tolerance was significantly correlated to the type of anesthesia, though not so the stay in critical care or the time to hospital discharge. CONCLUSION: Epidural analgesia in liver resection surgery was seen to be safe, with good results in terms of pain control and respiratory complications, and with no associated increase in complications secondary to altered hemostasis.

Prospective study of residual neuromuscular block and postoperative respiratory complications in patients reversed with neostigmine versus sugammadex.

BACKGROUND: Postoperative residual curarization (PORC) is an important complication of neuromuscular blocking drug (NMBD) use. This study evaluates the incidence of PORC in the Postanesthesia Care Unit (PACU), its relation to the type of muscle relaxant and reversal agent used, and its implication in the development of postoperative respiratory complications. METHODS: A prospective observational study of cohorts was made with 558 patients operated under general anesthesia. Data regarding patient history, muscle relaxation (train-of-four [TOF]) monitoring, type of relaxants and reversal agents used, and TOF upon admission to the PACU was collected. Four groups were established: cisatracurium, cisatracurium-neostigmine, rocuronium, and rocuronium-sugammadex. An evaluation was made on the incidence of PORC (TOF ratio [TOFr] <0.9) in PACU, and its relation to the relaxants and reversal agents used and to the development of postoperative respiratory complications - minor and major (pneumonia, atelectasis). RESULTS: From a total of 558 patients, 27.9% presented with PORC. According to the NMBD used and the administration or not of a reversal agent, the incidence of PORC in the four groups was: cisatracurium 34%, cisatracurium-neostigmine 28.6%, rocuronium 34%, and rocuronium-sugammadex 1.15%. The global incidence of minor critical respiratory events (CREs) was 14.5%: cisatracurium 27.5%, cisatracurium-neostigmine 17.4%, rocuronium 10.5%, and rocuronium-sugammadex 2.3%, with statistically significant differences. The global incidence of major CREs was 7.5%, and was significantly higher in patients with TOFr<0.9 upon admission to the PACU. CONCLUSIONS: PORC in the PACU is associated to a greater incidence of major and minor respiratory complications. The use of rocuronium-sugammadex significantly reduces the incidence of PORC in the PACU.

Recurrent intestinal intussusception in an adult due to intestinal pseudopolyps not associated with inflammatory bowel disease: a case report.

INTRODUCTION: Intestinal intussusception is very rare in adults and, unlike in children, it is due to an organic cause, mainly benign or malignant tumors, in 90 % of cases. Recurrent intussusception in an adult is even more exceptional, and in the case reported it was due to repeated occurrence of intestinal pseudopolyps, which is exceptional according to the literature. Preoperative diagnosis is difficult, and surgery is always indicated because a tumor is usually present. The surgical procedure may be controversial, as some would prefer desintussusception before resection, while others would advocate initial resection because of the risk of dissemination if a malignant lesion exists. CASE PRESENTATION: We report the case of a 34-year-old Caucasian man who underwent emergency laparoscopic surgery for intestinal obstruction and was found to have a jejunal intussusception. Polyps or pseudopolyps, some of them large and causing the intussusception, were seen in the surgical specimen. Our patient had also undergone surgery for intussusception 10 years before, after which the pathological report also noted the presence of these formations. CONCLUSIONS: Recurrent intussusception in adults due to the presence of intestinal pseudopolyps is exceptional and, to the best of our knowledge, this is the first such case reported.

Three-Dimensional Laparoscopic Sleeve Gastrectomy: Improved Patient Safety and Surgeon Convenience.

One of the aims of laparoscopic surgery is to improve upon the results obtained by open surgery. This clearly appears to have been achieved in bariatric surgery. Two-dimensional (2-D) systems have been used to date, though new 3-dimensional (3-D) technologies have been introduced in an attempt to improve surgeon vision and thus increase the safety of the surgical techniques. Sixty obese patients underwent sleeve gastrectomy using a device equipped with 3-D optics allowing surgery to be viewed by the surgeon in 3 dimensions by using a specific monitor and wearing appropriate glasses. The mean patient age was 48.1 years. The mean weight was 114 kg (range, 92-172), with a mean body mass index (BMI) of 44 ± 5.21 kg/m(2). All surgeries were performed using the 3-D system, with a mean surgical time of 71 ± 49.6 minutes and a mean hospital stay of 3.0 ± 1.2 days. Only 1 intraoperative complication was recorded: retroperitoneal bleeding on insertion of the optical trocar. Over a mean follow-up period of 12 months, the mean body weight of the patients was 88 kg (range, 71-121), with a BMI of 30.56 ± 3.98 kg/m(2) and a percentage excess weight loss of 68.14% ± 7.89%. There was clear improvement of both the blood pressure and glucose levels. Three-dimensional sleeve gastrectomy is safe, viable, and fully reproducible compared with 2-D surgery, improving visualization of the surgical field, safety, and surgeon convenience. Randomized studies involving larger patient samples are needed for the comparison of results.