Enhanced recovery after elective colorectal resection outside a strict fast-track protocol. A single centre experience.

INTRODUCTION: Optimising the management of hospitalised patients is a major concern. In colorectal surgery, the concept of enhanced recovery has been popularised by means of "fast-track" protocols, aiming at patient's discharge on the second postoperative day. Nevertheless, a strict fast-track protocol has several limitations. It is very demanding for the patient and therefore applicable only to a limited number of patients. AIM: In order to optimise, in every aspect, the postoperative recovery of each patient undergoing an elective colorectal resection inside our institution, we set up a "soft" enhanced recovery programme. MATERIAL-METHODS: A retrospective analysis was conducted in 92 patients evaluating the respective impact of protocol application throughout the duration of the hospital stay. RESULTS: When all the required measures of our protocol were correctly implemented, the median discharge day was postoperative day 3 (range 3-5 days). On the contrary, when deviations occurred, they resulted in longer hospital stay (p < 0.001). Patients operated by laparoscopy were discharged earlier than patients operated by laparotomy (p < 0.001). The use of nasogastric tube and postoperative drainage prolonged significantly the length of stay (p = 0.001 and p < 0.001 respectively). When the urinary catheter was not removed or oral feeding not resumed on postoperative day 1, the patients were discharged later (p < 0.001). CONCLUSIONS: There are substantial possibilities of optimising the recovery process after an elective colorectal resection, outside a strict fast-track protocol.

[Rivaroxaban: Xarelto--recommendations for pharmacists]. / Le Rivaroxaban (Xarelto): guide de la pratique officinale.

Rivaroxaban is one of the new oral anticoagulants (NOACs). It has many potential advantages in comparison with Vitamin K Antagonists (VKA). It has a predictable anticoagulant effect and does not theoretically require biological monitoring. It is also characterized by less food and drug interactions. However, due to major risks associated with over- and under-dosage, its optimal use in patients should be carefully followed by health care professionals. The aim of this article is to provide recommendations for pharmacists on the practical use of Xarelto in its different approved indications. This document is adapted from the practical user guide of rivaroxaban which was developed by an independent group of Belgian experts in the field of thrombosis and haemostasis.

Ketamine has no effect on bispectral index during stable propofol-remifentanil anaesthesia.

BACKGROUND: Ketamine 0.15-1 mg kg(-1) decreases postoperative morphine consumption, but 0.5 mg kg(-1) is associated with an increase in the bispectral index (BIS) values that can lead to an overdose of hypnotic agents. The purpose of our investigation was to study the effect of ketamine 0.2 mg kg(-1) administered over a 5 min period on the BIS during stable target-controlled infusion (TCI) propofol-remifentanil general anaesthesia. METHODS: Thirty ASA I or II patients undergoing abdominal laparoscopic surgery were included in this double-blind, randomized study. Anaesthesia was induced and maintained with a TCI of propofol and remifentanil. After 5 min of steady-state anaesthesia (BIS at 40) without surgical stimulation, patients received either an infusion of ketamine 0.2 mg kg(-1) or normal saline. The test drug was infused over 5 min. Standard parameters and BIS values were recorded every minute until 15 min post-infusion. RESULTS: The baseline mean (sd) value for the BIS was 37 (6.5) for the ketamine group and 39 (8.2) for the placebo group. The highest mean BIS value during the recording period was 41.5 (8.7) for the ketamine group and 40.1 (8.9) for the placebo group. BIS values were not statistically different between the groups (P=0.62); there was no significant change over time (P=0.65) with no group-time interaction (P=0.55). CONCLUSIONS: Under stable propofol and remifentanil TCI anaesthesia, a slow bolus infusion of ketamine 0.2 mg kg(-1) administered over a 5 min period did not increase the BIS value over the next 15 min.

Management of antiplatelet therapy for non elective invasive procedures of bleeding complications: proposals from the French working group on perioperative haemostasis (GIHP), in collaboration with the French Society of Anaesthesia and Intensive Care Medicine (SFAR).

The French Working Group on Perioperative Haemostasis (GIHP) and the French Study Group on Haemostasis and Thrombosis (GFHT) in collaboration with the French Society of Anaesthesia and Intensive Care Medicine (SFAR) drafted up-to-date proposals on the management of antiplatelet therapy for non-elective invasive procedures or bleeding complications. The proposals were discussed and validated by a vote; all proposals could be assigned with a high strength. Emergency management of oral antiplatelet agents (APA) requires knowledge on their pharmacokinetic/pharmacodynamics parameters, evaluation of the degree of the alteration of haemostatic competence and the associated bleeding risk. Platelet function testing may be considered. When APA-induced bleeding risk may worsen the prognosis, measures should be taken to neutralise antiplatelet therapy by considering not only the efficacy of available means (which can be limited for prasugrel and even more for ticagrelor) but also the risks that these means expose the patient to. The measures include platelet transfusion at the appropriate dose and haemostatic agents (tranexamic acid; rFVIIa for ticagrelor). When possible, postponing non-elective invasive procedures at least for a few hours until the elimination of the active compound (which could compromise the effect of transfused platelets) or if possible a few days (reduction of the effect of APA) should be considered.

New anticoagulant drugs: monitoring and perioperative strategies.

Arterial and venous thromboses are major causes of mortality and morbidity. In Western countries, more than 1% of the population takes an antithrombotic agent. Many of these patients will need to undergo surgery and decisions need to be made regarding whether to continue their antithrombotic medication and risk increased bleeding or to stop it and potentially increase the risk of thrombosis. Anaesthesiologists, therefore, need to be aware of the basic pharmacology of the available agents as well as their individual indications, contraindications, and adverse effects. In this review we will discuss these aspects, and also discuss new antithrombotic agents that are currently being developed to improve efficacy and to increase safety in comparison with conventional agents. New coagulation monitoring devices will also be discussed.

Value of the MELD score for the assessment of pre- and post-liver transplantation survival.

The MELD score has now been implemented in the United States for liver allocation, but it has not been validated in Europe. Its association with posttransplant outcome is unclear. Optimal cutoff values of MELD and Child-Pugh scores to predict death on the liver waiting list were defined in a series of 137 cirrhotic patients listed for liver transplantation. Six-month actuarial survival while on the waiting list was 90% with a Child-Pugh <11 and MELD <17, whereas it decreased progressively to 40% at 6 months after listing for those having a Child-Pugh and MELD score >10 and >16. Analysis of a series of 112 patients (85 chronic liver disease and 27 hepatocellular carcinoma) revealed no change in MELD value at the time of transplantation compared to the score at the time of listing (mean +/- SD: 15.5 +/- 7.7 vs 15 +/- 5.8) with a mean waiting time of 118 days. Using either the optimal cutoff for MELD score (<17 or >16) or seven different strata (3 to 7, 8 to 10, 11 to 13, 14 to 16, 17 to 19, 20 to 22, 23 to 39), whether measured at listing or just before liver transplantation, there was no significant difference (chi(2) 4.97, P = .58) in survival: 82.7% and 63% at 6 and 60 months, overall. Our data confirm that the MELD score with only three parameters is as good as the Child-Pugh score to predict mortality on the Eurotransplant waiting list. The optimal cutoff to assess higher priority for the bad category is >16. There was no negative impact on short- or long-term prognosis of the bad categories of MELD.

Domino hepatic transplantation using the liver from a patient with primary hyperoxaluria.

BACKGROUND: We report a case of domino liver transplantation using the liver harvested from a patient who underwent a combined liver and kidney transplantation for primary hyperoxaluria (PH). METHOD: A cadaveric liver transplantation was performed in a 19-year-old man with PH. In a second step, the PH liver harvested from the first patient was transplanted in a 69-year-old man with hepatitis C-related cirrhosis, not a candidate for a classic liver graft owing to multifocal hepatocellular carcinoma. RESULTS: At 8 months after transplantation, the domino recipient has normal hepatic function and no signs of tumoral recurrence, but he progressively developed hyperoxalemia, hyperoxaluria, and renal insufficiency. CONCLUSION: Regarding the favorable postoperative clinical evolution, domino liver transplantations using livers from PH patients may represent a new opportunity for marginal candidates for liver transplantation. However, the progressive renal insufficiency expected in such domino recipients should limit this procedure to selected cases.

A pilot trial of recombinant human interleukin-10 in kidney transplant recipients receiving OKT3 induction therapy.

BACKGROUND: We conducted a randomized, double-blind, placebo-controlled, rising single-dose study to investigate the effects of recombinant human (rh) interleukin (IL) 10 in renal transplant patients who received OKT3 as induction therapy. METHODS: Patients received 0.1 (n=6), 1 (n=6), or 10 microg/kg (n=3) rhIL-10 or placebo (n=6) intravenously 30 min before the first injection of 5 mg of OKT3. We monitored IL-10 serum levels, the effect of rhIL-10 on OKT3-induced cytokine production, clinical toxicity, and the incidence of immunization against OKT3. RESULTS: Serum IL-10 levels in the three experimental groups reached 0.8+/-0.2, 7.9+/-1.3, and 118.6+/-7.3 ng/ml (mean+/-SEM), respectively, 30 min after rhIL-10 injection. Peak plasma levels of tumor necrosis factor-alpha (TNF-alpha) were reduced from 2953+/-1599 pg/ml in patients injected with OKT3 and placebo to 447+/-155, 703+/-246, and 459+/-246 pg/ml in patients injected with 0.1, 1, and 10 microg/kg rhIL-10, respectively. Values for 24-hr TNF-alpha area under the curve decreased from 8988+/-3551 pg x hr/ml in control patients to 2284+/-494, 3950+/-955, and 2420+/-931 pg x hr/ml for the 0.1, 1, and 10 microg/kg rhIL-10 dose groups, respectively (P=0.045). There was also a trend toward reduced plasma levels of IL-2, IL-8, and interferon-gamma in rhIL-10-pretreated patients. Although none of the patients who received placebo or 0.1 or 1 microg/kg rhIL-10 developed an IgM antibody response directed against OKT3 during the first 10 days, this occurred in all three patients who received the highest rhIL-10 dose. In two of these patients, neutralization of OKT3 was associated with a reversible acute rejection episode. CONCLUSIONS: Pretreatment with doses of up to 1 microg/kg rhIL-10 is safe and reduces the release of TNF-alpha induced by OKT3. However, higher doses might promote early sensitization to OKT3.

Prevention of OKT3 nephrotoxicity after kidney transplantation.

In our experience the use of OKT3 as prophylaxis in renal transplantation has been associated with an increased incidence of both delayed graft function and thromboses of graft vessels. OKT3 nephrotoxicity might have been favored by restriction of perioperative fluid infusion to prevent pulmonary edema and by the use of very high dose (30 mg/kg) of methylprednisolone (mPDS) before the first OKT3 injection to reduce the release of cytokines. This led us to modify our perioperative management in three ways: (1) hydration status was optimalized; (2) the calcium-channel blocker diltiazem, considered beneficial for recovery of graft function, was administered on the day of transplantation; and (3) the dose of mPDS given before the first OKT3 injection was fixed at 8 mg/kg. Comparison of two consecutive series of patients (group 1, control patients, N = 172; group 2, managed as described above, N = 173) showed that: (1) the incidence of delayed graft function fell from 52% in group 1 to 22% in group 2 (P < 0.0001): (2) the incidence of pulmonary edema was not significantly increased in group 2 (3.5% vs. 1.7% in group 1, P = 0.5); and (3) the frequency of intragraft thrombosis fell from 7.6% in group 1 to 1.2% in group 2 (P = 0.0034). Multivariate analysis showed that the volemia/diltiazem program and avoidance of high mPDS dose were the most important factors responsible for the reduced occurrence of delayed graft function and graft vessels thrombosis, respectively. We conclude that a combined strategy of appropriate dosage of steroids before the first OKT3 injection, administration of a calcium-channel blocker and optimalization of volemia is safe and efficiently prevents against OKT3 nephrotoxic effects.

Endoscopic treatment of an oral cephalocele. Case report.

This report describes an unusual cephalocele originating in the temporobasal region and protruding through the sphenopetral area into the oral cavity. A rapid and nonaggressive endoscopic procedure was performed. The relationship between this type of cephalocele, spontaneous anteroinferior temporal encephaloceles, and nasopharyngeal brain heterotopia is discussed.

Tropisetron in the prevention of postoperative nausea and vomiting.

STUDY OBJECTIVES: To evaluate the efficacy of tropisetron, a selective 5-HT(3) receptor antagonist, in preventing nausea and vomiting in high-risk inpatients undergoing various surgical procedures. DESIGN: Prospective, open, nonrandomized, observational, interventional study. SETTING: Postanesthesia care unit, and surgical wards of the University Hospital Center, Charleroi. PATIENTS: A total of 1,132 elective surgical inpatients (>15 years of age) in two separate surveys. The first prospective survey covered all surgical adult inpatients (n = 671) after various surgical procedures over a 3-month period. A new 3-month survey was performed to assess the effectiveness of the preventive measure and included another 461 patients. INTERVENTIONS: Risk factors associated with nausea and vomiting were recorded in the first survey and used to establish an antiemetic policy. This consisted in the administration of tropisetron 2 mg intravenously after anesthesia induction, if two patient-related risk factors associated with high-risk surgery and general anesthesia were present. MEASUREMENTS AND MAIN RESULTS: Nausea frequency and intensity, assessed every 4 hours using a visual analog scale (VAS), frequency and times of vomiting episodes and the need for rescue medication were recorded for 72 hours postoperatively. Nausea was experienced by 18.8% and vomiting by 9.8% of the patients in the first survey (211 high risk-patients of 671). In the second survey, 137 patients of 461, considered at high-risk received prophylactic tropisetron. The proportion of patients having nausea decreased to 11.1% (p,178 0.01) and vomiting episodes to 2.8% (p < 0.001). Twenty-six of the tropisetron-treated patients (19%) suffered subsequent postoperative nausea and vomiting (PONV). Patient satisfaction with tropisetron was high. CONCLUSION: Prophylactic tropisetron can reduce the incidence of PONV in selected high-risk inpatients undergoing various types of surgical procedures.

Local ablative treatments for liver metastases: the current situation.

Surgical resection is the optimal treatment for liver metastases. However, due to their multifocality and/or insufficient remnant liver volume, the majority of liver metastases are unresectable. For this reason, several local ablative techniques have been developed, aiming to produce selective tumour destruction and thus increase the rate of patients amenable to curative-intent treatments. Among these techniques, cryoablation and radiofrequency ablation only have proven to have a curative potential, while transarterial chemoembolization and alcohol injection should be considered as palliative options only. The local recurrences after cryoablation and radiofrequency are equivalent, inferior to 10%, highly dependent of selection criteria. In contrast, morbidity is significantly increased after cryoablation, leading most of the teams to prefer the radiofrequency approach. Two major limitations for radiofrequency are, first, the risk to provoke heat biliary lesion in case of metastases located proximally to hilar plate, and second, the risk of insufficient ablation due to a cooling effect in case of metastases near to major vessels. Keeping in mind these limitations, selective use of radiofrequency may offer a significant benefit by allowing complete tumour clearance in patients with unresectable liver metastases.

First results of a clinical pilot study on intraarterial chemotherapy with haemofiltration of locally advanced gastrointestinal cancers.

Intra-arterial chemotherapy combined with haemofiltration enables the administration of drugs to confined neoplastic tissue while limiting the systemic drug exposure. During the procedure, the cytotoxic drugs are injected into the arterial supply of the tumour and the venous blood coming from the tumour bed is pumped out and filtered trough haemofiltration unit in order to extract the cytotoxic drug not fixed on the tumour. The patients selected for such treatment failed previous intravenous chemotherapy. Thirteen patients underwent intra-arterial chemotherapy injections combined with haemofiltration procedures: 8 unresectable liver metastases from colorectal cancer and 5 pelvic recurrences from rectal cancer. Fluorouracil, mitomycin C and doxorubicin were infused. One out of thirteen patients presented a complete regression of his liver metastases, 5/13 presented a partial regression, 2/13 patients did not show any significant modification of the size of their lesions and were classified as stable disease, 5/13 patients showed a progression of their neoplastic disease. No nephrotoxicity or major gastrointestinal side effects were observed. Intra-arterial chemotherapy combined with haemofiltration procedure is a therapeutic modality that could be considered in patients with locally advanced cancer who failed previous first line intravenous chemotherapy.

[Multidisciplinary approach of hepatic metastasis of colorectal origin]. / Approche multidisciplinaire des métastases hépatiques d'origine colorectale.

Surgery remains the only potentially curative treatment for liver metastases. After margin free resection, approximately 30% of the patients present long-term survival. Due to the metastases number and/or volume, only 10 to 15% of the patients are candidates for curative-intent surgery. Thus, the objectives of the diagnostic and therapeutic management are to select adequately the patients for surgery and to improve resection rate by the use of neoadjuvants methods. Positron emission tomography could improve the preoperative detection of hepatic and extrahepatic metastases leading to the exclusion of some patients from useless surgical exploration. For patients with initially resectable tumors, no benefit has been demonstrated for adjuvant chemotherapy. For non resectable metastases, two neoadjuvants methods should be evaluated, chemotherapy to reduce tumor volume and portal vein embolization of the tumor side to improve the hepatic functional reserve and allow larger resection. For non-accessible lesion, selective tumor destruction using radiofrequency offers promising perspectives. In conclusion, the multiplication of the diagnostic and therapeutic methods certainly improve the global management of patients with liver metastases but also makes more difficult the individual choice for the best treatment. For this reason, a multimodal approach is absolutely mandatory.

[The treatment of morbid obesity with gastroplasty]. / Traitement de l'obésité morbide par gastroplastie.

Morbid obesity is related to a severe decrease in life expectancy. No medical or dietary treatment offers an alternative to control hypertension, apnea syndrome, orthopedic diseases, ..., caused by overweight. With respect to a serious preoperative evaluation and a severe selection (psychologic, dietetic, ...) Silastic Ring Vertical Gastroplasty is considered in our experience (more than 300 cases) and in the literature as the gold standard for surgical treatment of obesity. The long term follow-up (24-66 months) of 100 consecutive operated patients shows a positive response on hypertension (96%), apnea syndrome (92%), diabetes (85%), gastroesophageal reflux (76%), orthopedic diseases (74%) and cardiorespiratory insufficiency (74%). Considering our experience in the medical and surgical management of patients operated in our department or referred from other centers for complications after different procedures, we actually propose SRVG as the treatment of choice for morbid obesity.

[The anesthesiology-recovery department]. / Le Service d'Anesthésiologie Réanimation.

The Department of Anesthesiology and Reanimation is organised in units with clinical activities, which include the pre-operative care of patients, anesthesiological care and immediate post-operative supervision. Two post-operative treatment rooms also form part of the department. The main fields of research of the various units result from collaborations with other departments of Hôpital Erasme, in particular with regard to the development of advanced techniques or fit within the confines of the speciality.