Can machine learning provide preoperative predictions of biological hemostasis after extracorporeal circulation for cardiac surgery?

OBJECTIVES: The goal of this study was to improve decision making regarding the transfusion of patients at the end of extracorporeal circulation for cardiac surgery through machine learning predictions of the evolution of platelets counts, prothrombin ratio, and fibrinogen assay. METHODS: Prospective data with information about patient preoperative biology and surgery characteristics were collected at Institut Mutualiste Montsouris Hospital (Paris, France) for 10 months (n = 598). For each outcome of interest, instead of arbitrarily choosing 1 machine learning algorithm, we trained and tested a variety of algorithms together with the super learning algorithm, a state-of-the-art ensemble method that aggregates all the predictions and selects the best performing algorithm (total, 137 algorithms). We considered the top-performing algorithms and compared them to more standard and interpretable multivariable linear regression models. All algorithms were evaluated through their root mean squared error, a measure of the average difference between true and predicted values. RESULTS: The root mean squared error of the top algorithms for predicting the difference between pre- and postoperative platelet counts, prothrombin ratio, and fibrinogen assay were 38.27 × 10e9/L, 8.66%, and 0.44 g/L, respectively. The linear models had similar performances. CONCLUSIONS: Our machine learning algorithms accurately predicted prothrombin ratio and fibrinogen assay and less accurately platelet counts. As such, our models could provide an aid-decision tool for anesthetists in an operating room; future clinical trials addressing this hypothesis are warranted.

Construction of reference criteria to admit patients to intermediate care units in France: a Delphi survey of intensivists, anaesthesiologists and emergency medicine practitioners (first part of the UNISURC project).

OBJECTIVES: No consensus criteria describe the medical eligibility of the patients to intermediate care units (IMCUs). In this first part of the UNISURC project, we aimed to develop criteria based on a consensus of physicians from the main specialties involved in IMCU admission decisions. DESIGN: We selected criteria from IMCU literature, scoring systems and intensive care unit nursing workload. We submitted these criteria to a panel of experts in a Delphi survey. We used a two-round Delphi survey procedure to assess the validity and feasibility of each criterion. SETTING: Medical practitioners in either public or private French institutions and proposed by the national scientific societies of anaesthesiology, emergency medicine and intensive care. The Delphi rounds took place in 2015-2016. OUTCOME MEASURES: Validity and feasibility of the proposed criteria; uniformity of the judgement across the primary specialty and the hospital category of the responders. RESULTS: The criteria submitted to vote were classified as one of: chronic factor (CF); acute factor (AF); specific pathway (SP); nursing activity (NA) and hospital environment (HE). Of 189 experts invited, 81 (41%) responded to the first round and 62 of them (76%) responded to the second round. A definite selection of 63 items was made, distributed across 6 CF, 18 AF, 31 SP, 3 NA and 5 HE. Validity and feasibility were influenced by the specialty or the public/private status of the institution of the responders for a few items. CONCLUSION: We created a set of 63 consensus criteria with acceptable validity and feasibility to assess the medical eligibility of the patients to IMCUs. The second part of the UNISURC project will assess the distribution of each criterion in a prospective multicentre national cohort. TRIAL REGISTRATION NUMBER: NCT02590172.

Guidelines on perioperative optimization protocol for the adult patient 2023.

OBJECTIVE: The French Society of Anesthesiology and Intensive Care Medicine [Société Française d'Anesthésie et de Réanimation (SFAR)] aimed at providing guidelines for the implementation of perioperative optimization programs. DESIGN: A consensus committee of 29 experts from the SFAR was convened. A formal conflict-of-interest policy was developed at the outset of the process and enforced throughout. The entire guidelines process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence. METHODS: Four fields were defined: 1) Generalities on perioperative optimization programs; 2) Preoperative measures; 3) Intraoperative measures and; 4) Postoperative measures. For each field, the objective of the recommendations was to answer a number of questions formulated according to the PICO model (population, intervention, comparison, and outcomes). Based on these questions, an extensive bibliographic search was carried out using predefined keywords according to PRISMA guidelines and analyzed using the GRADE® methodology. The recommendations were formulated according to the GRADE® methodology and then voted on by all the experts according to the GRADE grid method. As the GRADE® methodology could have been fully applied for the vast majority of questions, the recommendations were formulated using a "formalized expert recommendations" format. RESULTS: The experts' work on synthesis and application of the GRADE® method resulted in 30 recommendations. Among the formalized recommendations, 19 were found to have a high level of evidence (GRADE 1±) and ten a low level of evidence (GRADE 2±). For one recommendation, the GRADE methodology could not be fully applied, resulting in an expert opinion. Two questions did not find any response in the literature. After two rounds of rating and several amendments, strong agreement was reached for all the recommendations. CONCLUSIONS: Strong agreement among the experts was obtained to provide 30 recommendations for the elaboration and/or implementation of perioperative optimization programs in the highest number of surgical fields.

Postoperative analgesia after surgical repair of distal radius fracture: a randomized comparison between distal peripheral nerve blockade and surgical site infiltration.

BACKGROUND: Pain following open reduction and internal fixation of distal radius fracture (DRF) can be significant. This study compared the intensity of pain up to 48 hours after volar plating for DRF, associated to either an ultrasound guided distal nerve block (DNB) or surgical site infiltration (SSI). METHODS: In this prospective single blind randomized study, 72 patients scheduled for DRF surgery under 1.5% lidocaine axillary block were allocated to receive, at the end of surgery, either an ultrasound-guided median and radial nerves block with ropivacaine 0.375% (DNB) performed by the anesthesiologist or a SSI with the same drug regimen, performed by the surgeon. Primary outcome was the duration between analgesic technique (H0) and pain reappearance (Numerical Rating Scale (NRS 0-10)>3). Secondary outcomes were the quality of analgesia, the quality of sleep, the magnitude of motor blockade, and the patient satisfaction. The study was built on a statistical hypothesis of equivalence. RESULTS: Fifty-nine patients were included in the final per-protocol analysis (DNB=30, SSI=29). Time to reach NRS>3 was (in median [95%CI]) 267 min [155;727] and 164 min [120;181] respectively after DNB and SSI (difference=103 min [-22;594] - rejection of equivalence hypothesis). Pain intensity throughout the 48 hours, quality of sleep, opiate consumption, motor blockade and patient satisfaction was not significantly different between groups. CONCLUSIONS: Although DNB provides a longer analgesia than SSI, both techniques gave comparable level of pain control during the first 48 hours after surgery, without any difference in the incidence of side effects or patient satisfaction.

Immediate postoperative pain does not predict pain at home after ambulatory single-port sleeve gastrectomy.

PURPOSE: Single-port sleeve gastrectomy (SPSG) is increasingly performed in an ambulatory setting. Pain intensity when returning home remains a problem. The challenge is to be able to predict the evolution of postoperative pain (POP) at home by using parameters collected during the hospital stay. This study aimed to investigate whether immediate POP in the postanesthesia care unit (PACU) can predict pain intensity 24 h after surgery. METHODS: Single-center retrospective study in patients with obesity who underwent ambulatory SPSG. POP and opiate requirements during PACU stay were registered. Patients were followed up at home during the first 4 postoperative days. The primary outcome was the correlation between opiate requirements in the PACU and Numerical Rating Scale (NRS) at home 24 h after surgery. Secondly, logistic regression was used to identify risk factors for moderate/intense pain 24 h after surgery. RESULTS: Ninety-four patients were included during the study period. Twenty-two patients had NRS > 3/10 24 h after surgery. No correlation was found between the total dose of morphine in the PACU and pain intensity 24 h after surgery (r2 = - 0.07; P = 0.49). No predictive factor for moderate/intense pain 24 h after surgery was found. CONCLUSION: No correlation was found between opiate requirements in the PACU and pain at home 24 h after SPSG. Based on these results, it does not seem possible to predict intense pain at home from pain profile and morphine requirement during the immediate postoperative period.

Ketamine as a component of multimodal analgesia for pain management in bariatric surgery: A systematic review and meta-analysis of randomized controlled trials.

Introduction: Anaesthesia in morbidly obese people is challenging with a high dose of opioid consumption. This systematic review and meta-analysis of randomised controlled trials (RCTs) summaries evidence comparing ketamine to placebo for pain management after bariatric surgery. Methods: We used PRISMA 2020 and AMSTAR 2 guidelines to conduct this study. The random-effects model was adopted using Review Manager Version 5.3 for pooled estimates. Results: Seven RCTs published between 2009 and 2021 were eligible, including a total of 412 patients (202 patients in the ketamine group and 210 patients in the control group). In the ketamine group total opioid consumption during the first 24 h postoperatively was reduced (mean difference, MD = -5.89; 95% CI [-10.39, -1.38], p = 0.01), lower pain score at 4 h (MD = -0.81; 95% CI [-1.52, -0.10], p = 0.03), pain score at 8 h (MD = -1.00; 95% CI [-1.21, -0.79], p < 0.01), and shorter hospital stay (MD = -0.10; 95% CI [-0.20, -0.01], p = 0.03). There was no significant difference between the two groups regarding duration of anaesthesia (MD = -3.42; 95% CI [-8.62, 1.82], p = 0.20), or sedation score (MD = -0.02; 95% CI [-0.21, 0.17], p = 0.84). As concern the postoperative complications, risks of postoperative nausea and vomiting(OR = 0.75; 95% CI [0.27, 2.04], p = 0.56), hallucinations (OR = 5.47; 95% CI [0.26, 117.23], p = 0.28), dizziness (OR = 1.05; 95% CI [0.14, 7.78], p = 0.96), and euphoria (OR = 5.77; 95% CI [0.65, 51.52], p = 0.12) were not different between the two groups either. Conclusion: Ketamine could be an effective and safe technique for pain management following bariatric surgery. It reduces opioid consumption, postoperative pain, and hospital stay.RegistrationThis review was registered in PROSPERO (CRD42022296484).

Critical Preoperative Hemoglobin Value to Predict Anemia-Related Complications After Cardiac Surgery.

OBJECTIVES: Preoperative anemia is frequent in patients undergoing cardiac surgery and is associated with increased postoperative complications. The purpose of this observational study was to estimate the critical preoperative hemoglobin threshold associated with the occurrence of complications after cardiac surgery. DESIGN: A retrospective observational cohort study. SETTING: A tertiary-care medical center from January 2019 to April 2020. PARTICIPANTS: A total of 1,004 patients undergoing elective cardiac surgery were included. INTERVENTIONS: None (observational study). MEASUREMENTS AND MAIN RESULTS: The primary study endpoint was to define the hemoglobin threshold that predicted the occurrence of postoperative major complications after elective cardiac surgery. Postoperative complications were a composite criterion, including transient ischemic attack or stroke, myocardial infarction, acute kidney injury, respiratory failure, mediastinitis, or mesenteric ischemia. A discrimination threshold was determined by using receiver operating characteristic curves. The discrimination threshold for hemoglobin concentration with the best sensitivity/specificity ratio for the occurrence of postoperative complications was 13 g/dL for male patients and 11.8 g/dL for female patients. The incidence of postoperative complications was 17.2% in the total population. Independent risks were preoperative hemoglobin concentration, red blood cell transfusion, European System for Cardiac Operative Risk Evaluation II, and the type of surgery. CONCLUSIONS: The critical preoperative hemoglobin thresholds associated with the occurrence of postoperative complications with the best sensitivity/specificity ratio were 13 g/dL for men and 11.8 g/dL for women, which were very similar to the World Health Organization criteria defining anemia.

Feasibility and outcomes of multiple simultaneous laparoscopic liver resections.

INTRODUCTION: Surgeons often remain reluctant to consider laparoscopic approach in multiple liver tumors. This study assessed feasibility and short-term results of patients who had more than 3 simultaneous laparoscopic liver resections (LLR). METHODS: All consecutive patients who underwent LLR for primary or secondary malignancies between 2009 and 2019 were analyzed. After exclusion of major LLR, patients were divided into three groups: less than three (Group A), between three and five (Group B), and more than five resections (Group C) in the same procedure. Intraoperative details, postoperative outcomes, and textbook outcome (TO) were compared in the 3 groups. RESULTS: During study period, 463 patients underwent minor LLR. Among them, 412 (88.9%) had less than 3 resections, 38 (8.2%) between 3 and 5 resections, and 13 (2.8%) more than 5 resections. Despite a difficulty score according to IMM classification comparable in the 3 groups (with high difficulty grade 3 procedures of 16.5% vs. 15.7% vs. 23.1% in Group A, B, and C, respectively, p = 0.124), mean operative time was significantly longer in Group C (p = 0.039). Blood loss amount (p = 0.396) and conversion rate (p = 0.888) were similar in the 3 groups. Rate of R1 margins was not significantly different between groups (p = 0.078). Achievement of TO was not different between groups (p = 0.741). In multivariate analysis, non-achievement of TO was associated with difficulty according to IMM classification (OR = 2.29 (1.33-3.98)). CONCLUSION: Since intra- and post-operative outcomes and quality of resection are comparable, multiple liver resections should not preclude the laparoscopic approach.

Aerodynamic analysis of hospital ventilation according to seasonal variations. A simulation approach to prevent airborne viral transmission pathway during Covid-19 pandemic.

During the Covid-19 pandemic, location of the SARS-CoV-2 infected patients inside the hospital is a major issue to prevent viral cross-transmission. The objective of this study was to evaluate the risk of contamination through aerosol by using a global approach of the multiple environmental parameters to simulate, including seasonal context. A computational fluid dynamic (CFD) simulation based on the Lattice Boltzmann Method approach was used to predict airflow on the entire floor of a private hospital in Paris. The risk of contamination outside the rooms was evaluated by using a water vapor mass fraction tracker. Finally, the air contamination was estimated by a "cough model" producing several punctual emissions of contaminated air from potentially infected patients. In a winter configuration, the simulation showed a well-balanced ventilation on the floor and especially inside the rooms. After cough emissions from COVID-positive rooms, no significant contamination was observed in the circulation area, public waiting space and nurse office. On the contrary, in a summer configuration, the temperature difference due to the impact of the sun radiation between both sides of the building created additional air transport increasing the contamination risk in neighboring rooms and public spaces. Airborne spread was limited to rooms during winter conditions. On the contrary, during summer conditions, market airflow with potentially contaminated air coming from rooms located on the side of the building exposed to solar radiation was evidenced. These observations have implications to locate infected patients inside the building and for the conception of future health care structures.

Predictors of discharge timing and unplanned readmission after laparoscopic liver resection.

BACKGROUND: The aim of the study was to determine the predictors of discharge timing and 90-day unplanned readmission after laparoscopic liver resection (LLR). METHODS: Consecutive LLR performed at the "Institut Mutualiste Montsouris" between 2000 and 2019 were retrieved from a prospectively maintained database. Length of stay (LOS) was stratified according to surgical difficulty and was categorized as early (LOS<25th percentile), routine (25th percentile<75th percentile), and delayed discharge otherwise. Uni-and-multivariate analyses were conducted to determine the factors associated with the time of discharge and 90-day unplanned readmission. RESULTS: Early discharge occurred in 15.7% patients whereas delayed discharge occurred in 20.6% patients. Concomitant pancreatic resections (OR 26.8, 95% CI 5.75-125, p < 0.0001) and removal of colorectal primary tumors (OR 7.14, 95% CI 3.98-12.8, p < 0.0001) were the strongest predictors of delayed discharge whereas ERP implementation was the strongest predictor of early discharge (OR 7.4, 95% CI 4.60-11.9, p < 0.0001). Unplanned readmission rate was lower among early discharged patients (7.4% vs. 23.8%, p < 0.0001). Bile leakage was the strongest predictor of 90-day unplanned readmission (OR 3.8, 95% CI 1.12-15.8, p = 0.045). CONCLUSION: Concomitant colorectal or pancreatic resections were the strongest predictors of delayed discharge. Postoperative bile leakage was the strongest predictor of 90-day unplanned readmission following LLR.

Cognitive status of patients judged fit for discharge from the post-anaesthesia care unit after general anaesthesia: a randomized comparison between desflurane and propofol.

BACKGROUND: The Aldrete's score is used to determine when a patient can safely leave the Post-Anaesthesia Care Unit (PACU) and be transferred to the surgical ward. The Aldrete score is based on the evaluation of vital signs and consciousness. Cognitive functions according to the anaesthetic strategy at the time the patient is judged fit for discharge from the PACU (Aldrete's score ≥ 9) have not been previously studied. The aim of this trial was to assess the cognitive status of inpatients emerging either from desflurane or propofol anaesthesia, at the time of PACU discharge (Aldrete score ≥ 9). METHODS: Sixty adult patients scheduled for hip or knee arthroplasty under general anaesthesia were randomly allocated to receive either desflurane or propofol anaesthesia. Patients were evaluated the day before surgery using Digit Symbol Substitution Test (DSST), Stroop Color Test and Verbal Learning Test. After surgery, the Aldrete score was checked every 5 min until reaching a score ≥ 9. At this time, the same battery of cognitive tests was applied. Each test was evaluated separately. Cognitive status was reported using a combined Z score pooling together the results of all 3 cognitive tests. RESULTS: Among the 3 tests, only DSST was significantly reduced at Aldrete Score ≥ 9 in the Desflurane group. Combined Z-scores at Aldrete Score ≥ 9 were (in medians [interquartils]): - 0.2 [- 1.2;+ 0.6] and - 0.4 [- 1.1;+ 0.4] for desflurane and propofol groups respectively (P = 0.62). Cognitive dysfunction at Aldrete score ≥ 9 was observed in 3 patients in the Propofol group and in 2 patients in the Desflurane group) (P = 0.93). CONCLUSION: No difference was observed in cognitive status at Aldrete score ≥ 9 between desflurane and propofol anaesthesia. Although approximately 10% of patients still had cognitive dysfunctions, an Aldrete score ≥ 9 was associated with satisfactory cognitive function recovery in the majority of the patients after lower limb arthroplasty surgery under general anaesthesia. TRIAL REGISTRATION: Clinical Trials identifier NTC02036736 .

Unplanned admission after ambulatory anaesthesia in France: analysis of a database of 36,584 patients.

BACKGROUND: Unplanned admission (UA) after ambulatory procedures is an unexpected event that has organisational and financial impacts. This study was undertaken to determine the current rate of UA in France and to evaluate the factors associated with the occurrence of this event. METHOD: This is a retrospective analysis of a database of 36,584 patients issued from a private hospital in France. This study received an IRB approval. All of the patients that received ambulatory anaesthesia between April 2015 and June 2017 were included in this database. RESULTS: The overall rate of UA was 1.8% (95%CI: 1.3-2.3]. Hospitalisation after endoscopic procedures (gastrointestinal endoscopy and bronchial fibroscopy) was 1.1% (95%CI: 0.3-1.9), whereas it was 2.5% (95%CI: 1.8-3.2) after surgical procedures (p < 0.01). Organisational concerns, medical reason and surgical complications accounted respectively for one third of the hospitalisations. Pain was liable in 13% of cases, whereas PONV, residual sedation and urinary retention accounted respectively for 6.9%, 2.8% and 2.6% of cases. In a multivariate analysis, age > 60 years, ASA status > 2, general anaesthesia and the type of the procedures were identified risk factors. CONCLUSIONS: In this large cohort of ambulatory patients, the rate of UA remains significant. This is probably related, at least partly, to more invasive procedures scheduled in ambulatory setting. However, organisational problems occurred still frequently. Some factors appear to be easily improvable by appropriate preoperative information, better operating theatre scheduling and better analgesic strategy.

Does Chemotherapy-Induced Liver Injury Impair Postoperative Outcomes After Laparoscopic Liver Resection for Colorectal Metastases?

BACKGROUND: Chemotherapy-associated liver injuries (CALI) have been associated with poor postoperative outcome after open liver resection. To date, no data concerning any correlation of CALI and laparoscopic liver resection (LLR) are available. In the present study, we evaluated the impact of CALI on short-term outcomes in patients undergoing LLR. MATERIALS AND METHODS: All patients who underwent in our department LLR for colorectal liver metastases (CRLM) from 2000 to 2016 were retrospectively reviewed. Patients were divided in 4 groups according to their pathological histology. In group 1 patients had normal liver parenchyma. Group 2 included patients with steatosis and steatohepatitis. Patients with sinusoidal obstruction syndrome (SOS) and nodular regenerative hyperplasia (NRH) were allocated to group 3, whereas the remaining with fibrosis and cirrhosis, were assigned to group 4. RESULTS: A total of 490 LLR for CRLM were included in the study. Perioperative details and morbidity did not differ significantly between the four groups. Subgroup analysis showed that NRH was associated with higher amount of blood loss (p = 0.043), overall (p = 0.021) and liver-specific morbidity (p = 0.039). CONCLUSION: NRH is a severe form of CALI that may worsen the short-term outcomes of patients undergoing LLR for CRLM. However, the remaining forms of CALI do not have a significant impact on perioperative outcomes after LLR.

Analysis of economic impact of laparoscopic liver resection according to surgical difficulty.

INTRODUCTION: The advantages of laparoscopic liver resection (LLR) are well known, but their financial costs are poorly evaluated. The aim of this study was to analyze the economic impact of surgical difficulty on LLR costs, and to identify clinical factors that most affect global charges. METHODS: All patients who underwent LLR from 2014 to 2018 in a single French center were included. The IMM classification was used to stratify surgical difficulty, from group I through group III. The costing method was done combining top-down and bottom-up approaches. A multivariate analysis was performed in order to identify clinical factors that most affect global charges. RESULTS: Two hundred seventy patients were included (Group I: n = 136 (50%), Group II: n = 60 (22%), Group III: n = 74 (28%)). Total expenses significantly increased (p < 0.001) from Group I to Group III, but there was no difference regarding financial income (p = 0.133). Technical platform expenses significantly increased (p < 0.001) from Group I to Group III and represented the main expense among all costs with a total of 4 930 ± 2 601€. Among technical platform expenses, the anesthesia platform represented the main expense. In multivariate analysis, the four clinical factors that affected global charges in the whole study population were operating time (p < 0.001), length of stay (p < 0.001), admission in ICU (p < 0.001) and the occurrence of major complication (p < 0.05). An admission in ICU was the clinical factor that affected most global charges, as an ICU stay had a 39.1% increase effect on global charges in the whole study population. CONCLUSION: LLR is a cost-effective procedure. The more complex is the LLR, the higher is the hospital cost. An admission in ICU was the clinical factor that most affected global charges.

Surgical Revascularization With Cardiopulmonary Bypass on a Patient With Severe COVID-19.

The coronavirus disease 2019 (COVID-19) may lead to an acute respiratory distress syndrome by an inappropriate cytokine response and may predispose to a prothrombotic state through multiple pathways. Both can complicate the management of cardiac surgery with cardiopulmonary bypass, which is known to activate the hemostatic system and to exacerbate systemic inflammatory response. Little is known about the impact of cardiac surgery with cardiopulmonary bypass on viral pneumonia, particularly with the new coronavirus. In this article, we describe the case of a diabetic patient with COVID-19 and a concomitant 3-vessel disease with a formal indication for surgical revascularization, who unexpectedly presented with a high heparin resistance during cardiopulmonary bypass. Emphasis is placed on the importance of multidisciplinary team discussions before surgery, on the thorough preoperative assessment, and on the perioperative management, particularly regarding mechanical ventilation and anticoagulation.

Relevance of blood loss as key indicator of the quality of surgical care in laparoscopic liver resection for colorectal liver metastases.

BACKGROUND: The development of laparoscopic liver resection has led to the hypothesis that intraoperative blood loss may be a key indicator of surgical care quality. This study assessed short- and long-term results of patients according to three levels of intraoperative blood loss during laparoscopic liver resection for colorectal liver metastasis. METHODS: All patients who underwent laparoscopic liver resection for colorectal liver metastasis between 2000 and 2018 were included. Difficulty of laparoscopic liver resection was defined according to the Institut Mutualiste Montsouris classification. Three levels of the extent of intraoperative blood loss were defined: massive (≥1,000 mL), substantial (≥75th percentile of intraoperative blood loss within each grade of difficulty), and normal intraoperative blood loss. RESULTS: During study period, 317 patients underwent laparoscopic liver resection for colorectal liver metastasis. Among them, 213 (67.2%), 80 (25.2%), and 24 (7.6%) patients had normal, substantial, and massive intraoperative blood loss, respectively. Twenty-six patients (8.2%) required transfusion. Massive intraoperative blood loss came from a major hepatic vein in 54% of cases and were managed by laparoscopy in 83% of the cases. Laparoscopic liver resection difficulty grade (odds ratio = 3.15; P = .053) and number of colorectal liver metastasis (odds ratio = 1.24; P = .020) were independently associated with massive intraoperative blood loss. Risks factors for substantial intraoperative blood loss were bi-lobar colorectal liver metastasis (odds ratio = 3.12; P = .033) and sinusoidal obstruction syndrome (odds ratio = 3.27; P = .004). The level of intraoperative blood loss was not associated with severe complications nor overall and disease-free survival. Requirement of transfusion was associated with severe complications (odds ratio = 7.27; P = .002) and decreased 1-, 3-, and 5-year overall survival (87%, 68%, and 61% vs 95%, 88%, and 79%; P = .042). CONCLUSION: The extent of intraoperative blood loss did not affect short- and long-term results of laparoscopic liver resection for colorectal liver metastasis. Massive intraoperative blood loss was often incidental and, 83% of the time, manageable by laparoscopy. Rather than intraoperative blood loss, transfusion is a better relevant indicator of laparoscopic liver resection surgical quality.

Guidelines: Anaesthesia in the context of COVID-19 pandemic.

OBJECTIVES: The world is currently facing an unprecedented healthcare crisis caused by the COVID-19 pandemic. The objective of these guidelines is to produce a framework to facilitate the partial and gradual resumption of intervention activity in the context of the COVID-19 pandemic. METHODS: The group has endeavoured to produce a minimum number of recommendations to highlight the strengths to be retained in the 7 predefined areas: (1) protection of staff and patients; (2) benefit/risk and patient information; (3) preoperative assessment and decision on intervention; (4) modalities of the preanaesthesia consultation; (5) specificity of anaesthesia and analgesia; (6) dedicated circuits and (7) containment exit type of interventions. RESULTS: The SFAR Guideline panel provides 51 statements on anaesthesia management in the context of COVID-19 pandemic. After one round of discussion and various amendments, a strong agreement was reached for 100% of the recommendations and algorithms. CONCLUSION: We present suggestions for how the risk of transmission by and to anaesthetists can be minimised and how personal protective equipment policies relate to COVID-19 pandemic context.

Does the difficulty grade of laparoscopic liver resection for colorectal liver metastases correlate with long-term outcomes?

INTRODUCTION: Prognosis of patients with colorectal liver metastases (CRLM) is strongly correlated with the oncological outcome after liver resection. The aim of this study was to analyze the impact of laparoscopic liver resection (LLR) difficulty score (IMM difficulty score) on the oncological results in patients treated for CRLM. METHODS: All patients who underwent LLRs for CRLM from 2000 to 2016 in our department, were retrospectively reviewed. Data regarding difficulty classification, -according to the Institute Mutualiste Montsouris score (IMM)-, recurrence rate, recurrence-free survival (RFS), overall survival (OS) and data regarding margin status were analyzed. RESULTS: A total of 520 patients were included. Patients were allocated into 3 groups based on IMM difficulty score of the LLR they underwent: there were 227 (43,6%), 84 (16,2%) and 209 (40,2%) patients in groups I, II and III, respectively. The R1 resection rate in group I, II and III were 8,8% (20/227), 11,9% (10/84) and 12,4% (26/209) respectively (p = 0.841). Three- and 5-year RFS rates were 77% and 73% in group I, 58% and 51% in group II, 61% and 53% in group III, respectively (p = 0.038). Three and 5-year OS rates were 87% and 80% for group I, 77% and 66% for group II, 80% and 69% for group III respectively (p = 0.022). CONCLUSION: The higher LLR difficulty score correlates with significant morbidity and worse RFS and OS, although the more technically demanding and difficult cases are not associated with increased rates of positive resection margins and recurrence.