Moderate Intra-Abdominal Pressure Levels in Robot-Assisted Radical Prostatectomy Seem to Have No Negative Impact on Clinical Outcomes.

Introduction: Radical prostatectomy is increasingly performed laparoscopically with robot assistance (RALRP). RALRP, as with all laparoscopic procedures, requires a pneumoperitoneum, which might result in peritoneal inflammatory response reactions and postoperative pain. The aim of this retrospective single-centre study was to analyse the effects of a pneumoperitoneum during RARLP on clinical outcomes. Methods: All patients who underwent robot-guided prostatectomy in our clinic were included, with the exception of patients who were converted to open prostatectomy. C-reactive protein was used as a marker for the primary outcome, namely the postoperative inflammatory response. Intra-abdominal pressure (IAP) was evaluated as a potential factor influencing inflammation. In addition, the waist-hip ratio was used to estimate the amount of visceral adipose tissue, and the administration of dexamethasone was considered as a factor influencing inflammation. The Visual Analogue Scale (VAS) was used to determine postoperative pain. Patients were consecutively recruited between 1 September 2020 and 31 March 2022. Results: A total of 135 consecutive patients were included. The median waist-hip ratio was 0.55. The median duration of the pneumoperitoneum was 143 min. The median values of the average and maximum IAP values were 10 mmHg and 15 mmHg, respectively. The mean CRP of the first postoperative day was 6.2 mg/dL. The median VAS pain level decreased from 2 to 1 from the first to the third postoperative day. On the first postoperative day, 16 patients complained of shoulder pain. In addition, 134 patients were given some form of opioid pain treatment following surgery. Conclusion: We could not identify any relevant associations between the duration and IAP of the pneumoperitoneum and the indirect markers of inflammation or indicators of pain, or between the latter and the amount of visceral adipose tissue. In addition, we found no significant effect of the administration of dexamethasone on postoperative inflammation. The results point to a noninferior tolerability of moderate pressure during the procedure compared to the commonly utilised higher pressure, yet this must be confirmed in randomised controlled trials.

Sevoflurane consumption pattern by individual anaesthesiologists varies widely despite using the same high-end workstations in the same hospital.

Volatile anaesthetics are potent greenhouse gasses but contemporary workstations enable considerable savings while improving patient safety. Institutions may provide this technology to reduce the ecological footprint but proper training and motivation is required to maximize their ecologic and financial benefit. This study aims to compare the sevoflurane consumption of 22 anaesthesiologists in a medium sized hospital 4 years after flow-i workstations (Getinge, Sweden) entered into service, in three airway approaches: intubated patients, laryngeal mask ventilation, and mask anaesthesia. Typical sevoflurane consumption for each anaesthesiologist was defined as the mean cumulative consumption in the chronologically first 50 cases meeting the inclusion criteria for each airway group in 2019. The potential savings, if everyone were to adopt the approach of the more economical anaesthesiologists (15th percentile), was calculated. The CO2 equivalent emissions were calculated using a GWP20 of 702 and a GWP100 of 195. The median [range] consumption after 45 min was 10.9 [7.5-18.4] ml in intubated patients and 9.0 [7.4-15.3] ml in patients with laryngeal mask, and 9.9 [3.4-20.9] ml after 8 min with mask ventilation. This corresponds to a double to six fold consumption between the least and most wasteful approach. The typical CO2 equivalent emissions (GWP20) per anaesthesiologist varied between 8.0 and 19.6 kg/45 min in intubated airways, between 7.9 and 16.3 kg/45 min in LMA, and between 3.6 and 22.3 kg/8 min in mask ventilation. Despite using the same workstations in the same hospital, the typical sevoflurane consumption differed dramatically between 22 anaesthesiologists. In addition to providing advanced workstations, proper education is required to achieve the behavior change needed to reduce the pollution and financial waste associated with volatile anaesthetics.

Minimizing sevoflurane wastage by sensible use of automated gas control technology in the flow-i workstation: an economic and ecological assessment.

Both ecological and economic considerations dictate minimising wastage of volatile anaesthetics. To reconcile apparent opposing stakes between ecological/economical concerns and stability of anaesthetic delivery, new workstations feature automated software that continually optimizes the FGF to reliably obtain the requested gas mixture with minimal volatile anaesthetic waste. The aim of this study is to analyse the kinetics and consumption pattern of different approaches of sevoflurane delivery with the same 2% end-tidal goal in all patients. The consumption patterns of sevoflurane of a Flow-i were retrospectively studied in cases with a target end-tidal sevoflurane concentration (Etsevo) of 2%. For each setting, 25 cases were included in the analysis. In Automatic Gas Control (AGC) regulation with software version V4.04, a speed setting 6 was observed; in AGC software version V4.07, speed settings 2, 4, 6 and 8 were observed, as well as a group where a minimal FGF was manually pursued and a group with a fixed 2 L/min FGF. In 45 min, an average of 14.5 mL was consumed in the 2L-FGF group, 5.0 mL in the minimal-manual group, 7.1 mL in the AGC4.04 group and 6.3 mL in the AGC4.07 group. Faster speed AGC-settings resulted in higher consumption, from 6.0 mL in speed 2 to 7.3 mL in speed 8. The Etsevo target was acquired fastest in the 2L-FGF group and the Etsevo was more stable in the AGC groups and the 2L-FGF groups. In all AGC groups, the consumption in the first 8 min was significantly higher than in the minimal flow group, but then decreased to a comparable rate. The more recent AGC4.07 algorithm was more efficient than the older AGC4.04 algorithm. This study indicates that the AGC technology permits very significant economic and ecological benefits, combined with excellent stability and convenience, over conventional FGF settings and should be favoured. While manually regulated minimal flow is still slightly more economical compared to the automated algorithm, this comes with a cost of lower precision of the Etsevo. Further optimization of the AGC algorithms, particularly in the early wash-in period seems feasible. In AGC mode, lower speed settings result in significantly lower consumption of sevoflurane. Routine clinical practice using what historically is called "low flow anaesthesia" (e.g. 2 L/min FGF) should be abandoned, and all anaesthesia machines should be upgraded as soon as possible with automatic delivery technology to minimize atmospheric pollution with volatile anaesthetics.

Impact of opioid-free anesthesia on complications after deep inferior epigastric perforator flap surgery: A retrospective cohort study.

This study measured the number of complications after deep inferior epigastric perforator (DIEP) flap reconstruction performed under opioid-free anesthesia (OFA) combined with goal-directed fluid therapy or opioid anesthesia with liberal fluid therapy (OA). This retrospective cohort study consisted of 204 patients who underwent DIEP flap reconstruction at AZSint Jan Brugge between April 2014 and March 2019. Primary outcomes were complications, according to the Clavien-Dindo classification and the length of hospital stay (LOS). The secondary outcomes were flap failure, postoperative nausea and vomiting (PONV), postoperative pain, postoperative opioid consumption, and postoperative skin flap temperature. OFA included a combination of dexmedetomidine, lidocaine, and ketamine without any opioid administered pre- or intraoperatively. OA included a combination of sufentanil and remifentanil. OFA patients received strict goal-directed fluid therapy, whereas OA patients received liberal fluids to maintain perfusion pressure. All patients except 7 (TIVA with remifentanil) received inhalation anesthesia combined with an infusion of propofol. Of the 204 patients, 55 received OFA and 149 received OA. There were no differences in major complications, but fewer minor complications in the OFA group (17.9% vs. 51.4% and P < 0.001). Flap failure occurred in three patients of the OA group. Six patients developed flap thrombosis (five OA patients and one OFA patient). OFA was associated with fewer postoperative opioids, shorter LOS, less PONV, and less pain. In patients without previous nausea, the PONV incidence was higher in the OA group than in the OFA group (12.7% vs. 43.6% and P < 0.001). Patients with previous nausea more frequently required postoperative opioids and had a nausea rate of 60.87%.

Visualising improved peritoneal perfusion at lower intra-abdominal pressure by fluorescent imaging during laparoscopic surgery: A randomised controlled study.

BACKGROUND: Laparoscopy is the gold standard for many surgical procedures and is embraced as minimally invasive surgery in the enhanced recovery after surgery programme. Lowering intra-abdominal pressure during laparoscopy may decrease the degree of surgical injury and further enhance patient outcomes. This study aims to assess the effect of low pressure pneumoperitoneum on peritoneal perfusion during laparoscopic surgery. MATERIALS AND METHODS: We performed a prospective randomized intervention study in 30 adults undergoing colorectal robot assisted laparoscopic surgery at a secondary care medical center in the Netherlands between June and December 2018. A 3 min video recording of the parietal peritoneum was made with the Da Vinci® Firefly mode following intravenous injection of 0.2 mg/kg indocyanine green at a pneumoperitoneum pressure of 8, 12 or 16 mmHg. Observers were blinded for the level of intra-abdominal pressure that was used. Fluorescent intensity in [-] over time was extracted from each video in MATLAB. Time to reach maximal fluorescent intensity (TMFI) and maximum fluorescent intensity (MFI) were compared among groups. The study was registered at clinicaltrials.gov (NCT03928171). RESULTS: Mean TMFI was shorter at low pressure (8 mmHg) than standard pressure (12 and 16 mmHg): 44 ± 12 versus 58 ± 18 s (p = 0.032), respectively. Mean MFI was higher at 8 mmHg than 12 and 16 mmHg (222 ± 25 versus 188 ± 54, p = 0.033). Regression analysis identified intra-abdominal pressure, mean arterial pressure and female gender as significant predictors of peritoneal perfusion. CONCLUSION: Low pressure pneumoperitoneum was associated with improved perfusion of the parietal peritoneum. Current available evidence supported feasibility and enhanced postoperative recovery. Future investigations should focus on optimizing factors that facilitate lower intra-abdominal pressure and explore effects on other clinically relevant patient outcomes such as anastomotic leakage and immune homeostasis.

Lung-protective ventilation for the surgical patient: international expert panel-based consensus recommendations.

Postoperative pulmonary complications (PPCs) occur frequently and are associated with substantial morbidity and mortality. Evidence suggests that reduction of PPCs can be accomplished by using lung-protective ventilation strategies intraoperatively, but a consensus on perioperative management has not been established. We sought to determine recommendations for lung protection for the surgical patient at an international consensus development conference. Seven experts produced 24 questions concerning preoperative assessment and intraoperative mechanical ventilation for patients at risk of developing PPCs. Six researchers assessed the literature using questions as a framework for their review. The modified Delphi method was utilised by a team of experts to produce recommendations and statements from study questions. An expert consensus was reached for 22 recommendations and four statements. The following are the highlights: (i) a dedicated score should be used for preoperative pulmonary risk evaluation; and (ii) an individualised mechanical ventilation may improve the mechanics of breathing and respiratory function, and prevent PPCs. The ventilator should initially be set to a tidal volume of 6-8 ml kg-1 predicted body weight and positive end-expiratory pressure (PEEP) 5 cm H2O. PEEP should be individualised thereafter. When recruitment manoeuvres are performed, the lowest effective pressure and shortest effective time or fewest number of breaths should be used.

Twelve-Year Experience with Roux-en-Y Gastric Bypass as a Conversional Procedure for Vertical Banded Gastroplasty: Are We on the Right Track?

BACKGROUND: Vertical banded gastroplasty (VBG) has high rates of long-term complications. Conversion to Roux-en-Y gastric bypass (RYGB) is considered optimal; however, there are limited data on the late results of these conversions. We aimed to analyze our single-center long-term outcomes of patients requiring conversional RYGB for a failed VBG. METHODS: The records of patients who underwent RYGB as a conversional procedure after VBG from November 2004 to December 2016 were reviewed. Follow-up data were obtained by direct telephone calls with patients, electronic files, and general practitioner reports. Characteristics, indications of conversion, long-term (> 30 days) morbidities, weight records, obesity-related comorbidities, and overall patient satisfaction were analyzed. RESULTS: Overall, 305 VBG patients (82% female) underwent conversional RYGB during the study period. The mean pre-RYGB body mass index (BMI) was 35.6 (23-66) kg/m2. Conversions were indicated in 61% of patients because of simultaneous VBG complications and weight regain. After a median follow-up of 74.3 (5-151) months, 225 (73.8%) patients agreed to participate. The mean BMI and percentage of total weight loss (%TWL) were 28.6 (18-45) kg/m2 and 17.4%, respectively. Nearly all conversion indications were addressed effectively. Surgical reintervention was mandatory in 28 of 225 patients (12.4%) due to complications. Approximately 85% of patients reported complete remission of obesity-related comorbidities, and four-fifths were fully satisfied. CONCLUSION: RYGB resolves VBG complications, improves quality of life, and results in prolonged stable weight loss. It has a key role in the management of obesity-related comorbidities and in expert hands is the preferred conversional procedure for patients with failed VBG.

Perioperative Care of Patients With Obstructive Sleep Apnea Undergoing Upper Airway Surgery: A Review and Consensus Recommendations.

IMPORTANCE: To date, no consensus exists regarding optimal perioperative care of patients with obstructive sleep apnea (OSA) undergoing upper airway (UA) surgery. These patients are at risk related to anesthesia and postoperative analgesia, among other risks associated with difficult airway control, and may require intensified perioperative management. OBJECTIVE: To provide a consensus-based guideline by reviewing available literature and collecting expert opinion during an international consensus meeting with experts from relevant speciliaties. EVIDENCE REVIEW: In a consensus meeting conducted on April 4, 2018, a total of 47 questions covering preoperative, intraoperative, and postoperative care were formulated by 12 international experts with extensive clinical experience in the field of UA surgery for OSA. Systematic literature searches were performed by an independent information specialist and 6 researchers according to the Oxford and GRADE systems, and 164 articles published on or before December 31, 2011, were included in the analysis. Two moderators chaired the meeting according to the Amsterdam Delphi Method, including iteration of literature conclusions, expert discussion, and voting rounds. Consensus was reached when there was 70% or more agreement among experts. FINDINGS: Of 47 questions, 35 led to a recommendation or statement. The remaining 12 questions provided no additional information and were excluded in the judgment of experts. Consensus was reached for 32 recommendations. For 1 question there was less than 70% agreement among experts; therefore, consensus was not achieved. Highlights of these recommendations include (1) postoperative bleeding is a complication described for all types of UA surgery; (2) OSA is a relative risk factor for difficult mask ventilation and intubation, and plans for difficult airway management should be considered and implemented; (3) safe perioperative care should be provided, with aspects such as OSA severity, adherent use of positive airway pressure, type of surgery, and comorbidities taken into account; (4) although there is no direct evidence to date, in patients undergoing UA surgery, preoperative treatment with positive airway pressure may reduce the risk of postoperative airway complications; and (5) alternative pain management options perioperatively to reduce opioid use should be considered. CONCLUSIONS AND RELEVANCE: This consensus contains 35 recommendations and statements on the perioperative care of patients with OSA undergoing UA surgery and may be used as a guideline in daily practice.

Is opioid-free general anesthesia for breast and gynecological surgery a viable option?

PURPOSE OF REVIEW: Opioid-free anesthesia (OFA) was introduced to avoid tolerance and hyperalgesia, allowing reduction in postoperative opioids. OFA focused initially on postoperative respiratory safety for patients undergoing ambulatory surgery and for obstructive sleep apnea syndrome patients otherwise requiring intensive care admission. What about using OFA in plastic and oncological breast surgery, in deep inferior epigastric perforators flap surgery, and in gynecological laparoscopy? RECENT FINDINGS: OFA requires the use of other drugs to block the unwanted reactions from surgical injury. This can be achieved with a single drug at a high dose or with a combination of different drugs at a lower dose, such as with alpha-2-agonists, ketamine, lidocaine, and magnesium, each working on a different target and therefore described as multitarget anesthesia. Three factors can explain OFA success: improved analgesia with less postoperative opioids, the near absence of postoperative nausea and vomiting if no opioid is needed postoperatively, and reduced inflammation enhancing the recovery after surgery. SUMMARY: Opioid-free general anesthesia is a viable option for breast and gynecological surgery and its use will only increase when anesthesiologists listen to their patients' experiences after undergoing surgery under general anesthesia.

Anaesthetic Factors Affecting Outcome After Bariatric Surgery, a Retrospective Levelled Regression Analysis.

BACKGROUND: Deep neuromuscular block (NMB) and opioid-free anaesthesia (OFA) improve surgical workspace and reduce post-operative opioid consumption, but its impact on perioperative outcomes is unknown. This observational study compared complications and healthcare resource utilization after bariatric surgery, with or without continuous deep NMB or OFA. METHODS: We included all 9246 patients who underwent laparoscopic bariatric surgery at our institution from January 2009 to February 2017. Continuous clinical deep NMB was defined as receiving a continuous infusion of rocuronium with a dose of > 1 mg/kg IBW for each hour or sugammadex > 2 mg/kg total body weight at the time of reversal. We analysed the effect of continuous clinical deep NMB and OFA and covariates on 1 month post-operative complications using the Clavien-Dindo (CD) classification (grades II-V) and healthcare utilization (hospital length of stay [LOS], rates of reoperations within 1 week, high-dependency care unit admissions, and readmissions within 1 month). Covariates included experience of the attending anaesthesiologist, patient age, sex, body mass index, American Society of Anesthesiologists physical status score, obstructive sleep apnoea syndrome, diabetes, hypertension, surgery type, surgical team experience, and neostigmine use. RESULTS: OFA, continuous deep NMB, surgical and anaesthesia team experience, younger age, and surgery type were associated with fewer complications. OFA was associated with lower healthcare resource utilization. Reduced LOS was also associated with younger age, surgical team experience, and surgery type, but not continuous deep NMB. CONCLUSION: Continuous deep NMB and OFA were associated with fewer complications after bariatric surgery.

Perioperative management of obstructive sleep apnea in bariatric surgery: a consensus guideline.

BACKGROUND: The frequency of metabolic and bariatric surgery (MBS) is increasing worldwide, with over 500,000 cases performed every year. Obstructive sleep apnea (OSA) is present in 35%-94% of MBS patients. Nevertheless, consensus regarding the perioperative management of OSA in MBS patients is not established. OBJECTIVES: To provide consensus based guidelines utilizing current literature and, when in the absence of supporting clinical data, expert opinion by organizing a consensus meeting of experts from relevant specialties. SETTING: The meeting was held in Amsterdam, the Netherlands. METHODS: A panel of 15 international experts identified 75 questions covering preoperative screening, treatment, postoperative monitoring, anesthetic care and follow-up. Six researchers reviewed the literature systematically. During this meeting, the "Amsterdam Delphi Method" was utilized including controlled acquisition of feedback, aggregation of responses and iteration. RESULTS: Recommendations or statements were provided for 58 questions. In the judgment of the experts, 17 questions provided no additional useful information and it was agreed to exclude them. With the exception of 3 recommendations (64%, 66%, and 66% respectively), consensus (>70%) was reached for 55 statements and recommendations. Several highlights: polysomnography is the gold standard for diagnosing OSA; continuous positive airway pressure is recommended for all patients with moderate and severe OSA; OSA patients should be continuously monitored with pulse oximetry in the early postoperative period; perioperative usage of sedatives and opioids should be minimized. CONCLUSION: This first international expert meeting provided 58 statements and recommendations for a clinical consensus guideline regarding the perioperative management of OSA patients undergoing MBS.

Perioperative analgesic profile of dexmedetomidine infusions in morbidly obese undergoing bariatric surgery: a meta-analysis and trial sequential analysis.

BACKGROUND: Opioid-sparing analgesia for bariatric surgery in morbidly obese can potentially prevent catastrophic airway complications. Our meta-analysis attempts to consolidate the evidence on dexmedetomidine evaluating its analgesic and safety profile. METHODS: Trails comparing perioperative dexmedetomidine infusion to conventional analgesic regimens for bariatric surgery were searched. Comparisons were made for 24-hour and postanesthesia care unit (PACU) morphine consumed, PACU pain scores, postoperative nausea and vomiting pain scores, and heartrate. Meta-regression was performed for length of stay to evaluate various analgesic control subgroups. RESULTS: Six trials were included in the final analysis. Dexmedetomidine infusion (reported in 5 intraoperative subgroups and 2 postoperative subgroups) decreased 24-hour morphine by 18.13±6.11 mg (random effects: P<.001, I2 = 95.48%). Despite the small number of included studies, the sample size for avoiding a false positive result was adequate as the trial sequential analysis found the present sample size (362) to be well past the required "sample size" (n = 312) for 85% power. Meta-regression for infusion dose on morphine consumption difference found a predictability of 49% (coefficient = 39.93, random-effects, Tau2 = 396.08), and predictability of the model improved to 68% on inclusion of time of initiation of infusion. The dexmedetomidine group had lower PACU morphine consumption (by 6.91±1.19, I2 = 34.37%), lower pain scores (scale of 0-10±2.27, I2 = 88.14%), lower postoperative nausea and vomiting incidence (odds ratio =±0.26, I2 = 0%), and lower heart rate (73.25 versus. 83.50) (mean difference =±10.15 I2 = 94.04%). No adverse events were reported across trials. CONCLUSION: Perioperative dexmedetomidine infusion in obese patients undergoing bariatric surgery is a promising and safe alternative. Both intraoperative or postoperative infusions lead to significant opioid sparing in early and extend postoperative recovery phase. Morbidly obese patients receiving perioperative dexmedetomidine infusions have overall better pain control and lower incidence of postoperative nausea-vomiting. All the aforementioned merits come with a stable hemodynamic profile and without any reported major adverse events.

Deep Neuromuscular Blockade Improves Laparoscopic Surgical Conditions: A Randomized, Controlled Study.

INTRODUCTION: Sustained deep neuromuscular blockade (NMB) during laparoscopic surgery may facilitate optimal surgical conditions. This exploratory study assessed whether deep NMB improves surgical conditions and, in doing so, allows use of lower insufflation pressures during laparoscopic cholecystectomy. We further assessed whether use of low insufflation pressure improves patient pain scores after surgery. METHODS: This randomized, controlled, blinded study (NCT01728584) compared use of deep (1-2 post-tetanic-counts) or moderate (train-of-four ratio 10%) NMB, and lower (8 mmHg) or higher (12 mmHg; 'standard') insufflation pressure in a 2 × 2 factorial design. Primary endpoint was surgeon's overall satisfaction with surgical conditions, rated at end of surgery using an 11-point numerical scale. Post-operative pain scores were also evaluated. Data were analyzed using analysis of covariance. RESULTS: Of 127 randomized patients, 120 had evaluable data for the primary endpoint. Surgeon's score of overall satisfaction with surgical conditions was significantly higher with deep versus moderate NMB indicated by a least-square mean difference of 1.1 points (95% confidence interval 0.1-2.0; P = 0.026). Furthermore, strong evidence of an effect was observed for standard versus low pressure: least-square mean difference of 3.0 points (95% confidence interval 2.1-4.0; P < 0.001). No significant difference was observed in average pain scores within 24 h post-surgery for low versus standard pressure [0.17 (95% confidence interval -0.67 to +0.33); P = 0.494]. CONCLUSIONS: Although associated with significantly improved surgical conditions, deep NMB alone was insufficient to promote use of low insufflation pressure during laparoscopic cholecystectomy. Furthermore, low insufflation pressure did not result in reduced pain, compared with standard pressure. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov identifier, NCT01728584. FUNDING: Merck Sharp and Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA.