Esophageal cancer: Outcome and potential benefit of esophagectomy in elderly patients.

BACKGROUND: This analysis evaluated the morbimortality and the potential benefit of esophagectomy for cancer in elderly patients. METHODS: Patients who underwent esophagectomy for EC were divided into elderly (≥70 years) and nonelderly (<70 years) groups. The groups were compared regarding patient and tumor characteristics, postoperative morbimortality, and disease-free, overall and cancer-specific survival. RESULTS: Sixty-one patients were classified into elderly, and 187 into nonelderly groups. The elderly were characterized by a higher rate of WHO score (p < 0.0001), higher cardiac (p < 0.004) and renal (p < 0.023) comorbidities. The rate of neoadjuvant therapy and especially of neoadjuvant CRT was significantly lower in elderly patients (p < 0.018 and p < 0.007). Operative morbidity was also higher in this group (p < 0.024). The 30- and 90-day mortality was 8.2 and 11.5%, respectively in elderly patients and 0.5 and 3.2% in nonelderly patients (p < 0.004 and p < 0.012). This 90-day mortality decreased when specific surgery-related deaths were taken into consideration. OS and DFS were significantly better in the nonelderly group (p < 0.003 and p < 0.005) while no difference was observed for cancer-specific survival (CSS). CONCLUSION: No difference in CSS was observed. Although elderly patients with EC had higher postoperative morbimortality, the age should not be a criterion whether to perform, or not to perform, esophagectomy. This decision must be based on the balance between the patient's general condition and aggressive disease.

Current application of the enhanced recovery after surgery protocol for patients undergoing radical cystectomy: lessons learned from European excellence centers.

PURPOSE: There is no consensus on which items of Enhanced Recovery After Surgery (ERAS) should and should not be implemented in radical cystectomy (RC). The aim of this study is to report current practices across European high-volume RC centers involved in ERAS. METHODS: Based on the recommendations of the ERAS society, we developed a survey with 17 questions that were validated by the Young Academic Urologists-urothelial group. The survey was distributed to European expert centers that implement ERAS for RC. Only one answer per-center was allowed to keep a representative overview of the different centers. RESULTS: 70 surgeons fulfilled the eligibility criteria. Of note, 28.6% of surgeons do not work with a referent anesthesiologist and 25% have not yet assessed the implementation of ERAS in their center. Avoiding bowel preparation, thromboprophylaxis, and removal of the nasogastric tube were widely implemented (> 90%application). On the other hand, preoperative carbohydrate loading, opioid-sparing anesthesia, and audits were less likely to be applied. Common barriers to ERAS implementation were difficulty in changing habits (55%), followed by a lack of communication across surgeons and anesthesiologist (33%). Responders found that performing a regular audit (14%), opioid-sparing anesthesia (14%) and early mobilization (13%) were the most difficult items to implement. CONCLUSION: In this survey, we identified the ERAS items most and less commonly applied. Collaboration with anesthesiologists as well as regular audits remain a challenge for ERAS implementation. These results support the need to uniform ERAS for RC patients and develop strategies to help departments implement ERAS.

Anesthesia for robotic thoracic surgery.

The management of the robotic thoracic surgical patient requires the knowledge of minimally invasive surgery techniques involving the chest. Over the past decade, robotic-assisted thoracic surgery has grown, and, in the future, it will take an important place in the treatment of complex thoracic pathologies. The enhanced dexterity and three-dimensional visualization make it possible to do this in the small space of the thoracic cavity. Familiarity with the robotic surgical system by the anesthesiologists is mandatory. Management of a long period of one-lung ventilation with a left-sided double-lumen endotracheal tube or an independent bronchial blocker is required, along with flexible fiberoptic bronchoscopy techniques (best continuous monitoring). Correct patient positioning and prevention of complications such as eye or nerve or crashing injuries while the robotic system is used is mandatory. Recognition of the hemodynamic effects of carbon dioxide during insufflation in the chest is required. Cost is higher and outcome is not yet demonstrated to be better as compared to video-assisted thoracic surgery. The possibility for conversion to open thoracotomy should also be kept in mind. Teamwork is mandatory, as well as good communication between all the actors of the operating theatre.

Gradual withdrawal of remifentanil delays initial post-operative analgesic demand after thyroid surgery; double-blinded, randomized controlled trial.

BACKGROUND: Mismanagement of remifentanil leads to severe side effects such as opioid-induced tolerance and hyperalgesia. Recently studies revealed an alternative withdrawal method to limit these side effects. A gradual withdrawal of remifentanil seems to be associated with less pain. The hypothesis of this double-blinded, randomized controlled trial was that a gradual withdrawal of remifentanil would be associated with less immediate post-operative pain compared to after an abrupt discontinuation of remifentanil in patients who underwent thyroid surgery. METHODS: This double-blinded, randomized controlled trial was conducted in a tertiary level hospital in Brussels (Belgium) from April until August 2017. 34 patients undergoing thyroid surgery were randomized and 29 patients completed the study. After randomization, patients undergoing thyroid surgery were allocated to two groups: one with an abrupt discontinuation of remifentanil after surgery and one with a gradual withdrawal of remifentanil after surgery. The primary outcome was the initial post-operative demand of analgesic medication. RESULTS: Gradual withdrawal of remifentanil was associated with a delayed initial post-operative demand of analgesic medication (P = 0.006). The first morphine bolus was given after 76.3 +/- 89.0 min in the group with a gradual withdrawal of remifentanil versus after 9.0 +/- 13.5 min in the group with an abrupt discontinuation of remifentanil. However, overall morphine consumption, numeric rating scale scores, Ramsay Sedation Scale scores, and quality of recovery scores (QoR-40) were similar in both groups (P > 0.05). CONCLUSION: Though overall morphine consumption, numeric rating scale scores, Ramsay Sedation Scale scores, and quality of recovery scores (QoR-40) are not altered, a gradual withdrawal of remifentanil after thyroid surgery is safe and associated with a delayed initial post-operative demand of analgesic drugs. The withdrawal process does, however, require vigilance and training. TRIAL REGISTRATION: Clinicaltrials.gov NCT03110653 (PI: Luc Barvais; date of registration: 03/31/2017).

The indication for perioperative red blood cell transfusions is a predictive risk factor for severe postoperative morbidity and mortality in children undergoing cardiac surgery.

OBJECTIVES: In paediatric cardiac surgery, red blood cell (RBC) transfusions are given to treat haemorrhage or to increase oxygen delivery (therapeutic transfusion). Sometimes, RBCs are added to the prime solution to avoid a too low haematocrit on bypass (CPB-driven transfusion). Our study investigated whether the reason for RBC transfusion might affect severe postoperative morbidity or mortality. METHODS: This retrospective cohort study was conducted in a tertiary care level, children's hospital. The charts of all patients admitted between 2006 and 2009 were reviewed. Among transfused patients, children receiving a therapeutic transfusion were compared with those receiving a CPB-driven transfusion. The primary outcome was severe postoperative morbidity or mortality. Statistically significant variables founded with univariate analysis were incorporated in the multivariable logistic regression analysis to build a model that predicts severe postoperative morbidity or mortality. This model was then adjusted for clinically relevant variables that may interfere with 'indication for transfusion'. RESULTS: One hundred and one (48%) patients in the therapeutic and 92 (26%) patients in the CPB-driven transfusion group developed severe postoperative morbidity or died (P < 0.001). A multivariable logistic regression showed that weight, ASA, calculated blood loss, intraoperative fluid balance, duration of CPB time and the indication group for transfusion [1.64 (1.03-2.62); P = 0.039] were independent risk factors for severe postoperative morbidity or mortality. The indication group for transfusion remained significant [2.0 (1.16-3.45); P = 0.013] after adjustment for significant predictors of indication for transfusion. Number of patients with infections, or neurological deficit, and length of mechanical ventilation, PICU and hospital length of stay, were significantly higher in the therapeutic compared with the CPB-driven transfusion group one. CONCLUSIONS: The indication group for transfusion has an impact on the occurrence of severe postoperative morbidity or mortality in children undergoing cardiac surgery.