Lidocaine Infusion Improves the Functionality of Intraoperative Nerve Monitoring During Thyroid Surgery: A Prospective, Randomized, Double-Blinded Study.

BACKGROUND: Intraoperative nerve monitoring (IONM) to assess the recurrent laryngeal nerve function during thyroid surgery is becoming the standard of care across many institutions. The successful deployment and data analysis from the IONM require complete laryngeal relaxation and reflex suppression. We investigated the role of intravenous lidocaine infusion (IVLI) to provide such operating conditions, under a lighter plane of anesthesia and fewer hemodynamic fluctuations. METHODS: Sixty-five patients were randomly assigned to lidocaine group (LG) or placebo group (PG) based on the computer-generated coding developed by the pharmacy department. The study medication (SM) was delivered by the pharmacist in a pre-filled coded syringe to the investigator 30 min prior to the surgery. All the patients were anesthetized by narcotic and inhalation based general anesthesia. The SM was administered at the rate of 1.5mg/kg/h following a loading dose of 1 mg/kg. Dragonfly® laryngeal surface electrode and Nerveana® nerve locator system were used for IONM during surgery. RESULTS: The proportion of patients requiring lower strength stimulating current (StMC) at 0.5 mA was significantly higher in the LG than in the PG (X2 (1, N = 61) = 10.1615, P = 0.001434). Similarly, the proportion of patients with the drop in the aggregate impedance level (DAIL) by < 50% at the end of surgery was significantly higher in the LG than in the PG (X2 (1, N = 61) = 15.982, P = 0.000064). In addition, the proportion of patients with the hypotensive episodes requiring rescue medications more than twice during surgery was significantly lower in the LG than in the PG (X2 (1, N = 61) = 0.0183, P < 0.05). CONCLUSIONS: The enhanced laryngeal relaxation and the reflex suppression afforded by the IVLI could have enabled a lower StMC to elicit a positive signal. The lower StMC promotes less intense laryngeal alterations as evidenced by the lower DAIL in the LG. IVLI can enhance the functionality of the IONM during prolonged operating time and the resultant increased number of IONM stimulations, while providing a stable hemodynamic environment.

Synchronous Esophageal and Lung Cancer.

Synchronous lung and esophageal cancers are rare but represent a unique challenge to thoracic surgeons. The literature is limited but series describe long-term survival with curative surgery for concomitant esophageal and lung cancer. Preoperative risk assessment is critical because surgical resection of both cancers requires adequate cardiopulmonary function and performance status. Chemotherapy and radiation are used as adjuvant therapy or as primary treatment of unresectable lesions. Although long-term survival for patients with concomitant lung and esophageal cancer is lower than that of patients with either one alone, survival with curative surgery is higher than that of patients with metastatic disease of either primary.

Laparoscopic vs open partial colectomy in elderly patients: Insights from the American College of Surgeons - National Surgical Quality Improvement Program database.

AIM: To compare the outcomes between the laparoscopic and open approaches for partial colectomy in elderly patients aged 65 years and over using the American College of Surgeons - National Surgical Quality Improvement Program (ACS NSQIP) database. METHODS: The ACS NSQIP database for the years 2005-2011 was queried for all patients 65 years and above who underwent partial colectomy. 1:1 propensity score matching using the nearest- neighbor method was performed to ensure both groups had similar pre-operative comorbidities. Outcomes including post-operative complications, length of stay and mortality were compared between the laparoscopic and open groups. χ(2) and Fisher's exact test were used for discrete variables and Student's t-test for continuous variables. P < 0.05 was considered significant and odds ratios with 95%CI were reported when applicable. RESULTS: The total number of patients in the ACS NSQIP database of the years 2005-2011 was 1777035. We identified 27604 elderly patients who underwent partial colectomy with complete data sets. 12009 (43%) of the cases were done laparoscopically and 15595 (57%) were done with open. After propensity score matching, there were 11008 patients each in the laparoscopic (LC) and open colectomy (OC) cohorts. The laparoscopic approach had lower post-operative complications (LC 15.2%, OC 23.8%, P < 0.001), shorter length of stay (LC 6.61 d, OC 9.62 d, P < 0.001) and lower mortality (LC 1.6%, OC 2.9%, P < 0.001). CONCLUSION: Even after propensity score matching, elderly patients in the ACS NSQIP database having a laparoscopic partial colectomy had better outcomes than those having open colectomies. In the absence of specific contraindications, elderly patients requiring a partial colectomy should be offered the laparoscopic approach.