Revisión crítica de las recomendaciones sobre fluidoterapia perioperatoria y monitorización hemodinámica de Recuperación intensificada en cirugía del adulto (RICA): Declaración de posición del Grupo de Trabajo de Fluidoterapia y Monitorización hemodinámica de la Sección de Hemostasia, Medicina transfusional y Fluidoterapia (SHTF) de la Sociedad Española de Anestesiología y Reanimación (SEDAR) / A critical review of the Perioperative Fluid Therapy and Hemodynamic Monitoring recommendations of the Enhanced Recovery of the Adult Pathway (RICA): A position statement of the Fluid Therapy and Hemodynamic Monitoring Subcommittee of the Hemostasis, Transfusion Medicine and Fluid Therapy Section (SHTF) of the Spanish Society of Anesthesiology and Critical Care (SEDAR)

En un esfuerzo por estandarizar el manejo perioperatorio y mejorar los resultados posoperatorios de los pacientes adultos sometidos a cirugía, el Ministerio de Sanidad, a través del Grupo Español de Rehabilitación Multimodal (GERM) y el Instituto Aragonés de Ciencias de la Salud, en colaboración con diversas sociedades científicas españolas, y sobre la base de la evidencia disponible, publicó en 2021 la guía Recuperación intensificada en cirugía del adulto (RICA). Dicho documento incluye 12 medidas perioperatorias relacionadas con la fluidoterapia y la monitorización hemodinámica. La administración de fluidos y la monitorización hemodinámica no son sencillas, pero están directamente relacionadas con los resultados de los pacientes. El Subcomité de Fluidoterapia y monitorización hemodinámica de la Sección de Hemostasia, Medicina transfusional y Fluidoterapia (SHTF) de la Sociedad Española de Anestesiología y Reanimación (SEDAR) ha analizado dichas recomendaciones, concluyendo que deberían ser revisadas, ya que no siguen la metodología adecuada. (AU)

In an effort to standardize perioperative management and improve postoperative outcomes of adult patients undergoing surgery, the Ministry of Health, through the Spanish Multimodal Rehabilitation Group (GERM), and the Aragonese Institute of Health Sciences, in collaboration with multiple Spanish scientific societies and based on the available evidence, published in 2021 the Spanish Intensified Adult Recovery (RICA) guideline. This document includes 12 perioperative measures related to fluid therapy and hemodynamic monitoring. Fluid administration and hemodynamic monitoring are not straightforward but are directly related to postoperative patient outcomes. The Fluid Therapy and Hemodynamic Monitoring Subcommittee of the Hemostasis, Transfusion Medicine and Fluid Therapy Section (SHTF) of the Spanish Society of Anesthesiology and Critical Care (SEDAR) has reviewed these recommendations and concluded that they should be revised as they do not follow an adequate methodology. (AU)

Registro observacional prospectivo sobre la utilización del tratamiento antitrombótico durante el periodo perioperatorio y periprocedimiento en el «mundo real»: estudio REQXAA / Prospective observational registry of perioperative and periprocedural management of antithrombotic therapy in “real world”: the REQXAA study

Introducción y objetivos: Existe escasa evidencia acerca del impacto de las actuales recomendaciones sobre la utilización del tratamiento antitrombótico durante el periodo perioperatorio y periprocedimiento en el «mundo real». El objetivo de este estudio es analizar la utilización de los fármacos antitrombóticos en una población de pacientes que van a someterse a una cirugía/procedimiento, así como evaluar la implicación que tiene su retirada o mantenimiento en la incidencia de eventos adversos trombóticos y/o hemorrágicos. Métodos: Estudio observacional prospectivo, multicéntrico y multiespecialidad de pacientes en tratamiento antitrombótico que precisen alguna intervención. El objetivo principal fue la incidencia de eventos trombóticos y hemorrágicos a 30 días en función del uso periintervención de los fármacos antitrombóticos. Resultados: Se incluyó a un total de 1.266 pacientes (el 63,5% varones; media de edad, 72,6 años). El 48,6% de ellos se encontraban anticoagulados (la mayoría por fibrilación auricular; CHA2DS2-VASC, 3,7) y el 53,3%, antiagregados, con mayor frecuencia por cardiopatía isquémica. El 66,7% tenía un riesgo isquémico bajo y el 51,9%, un riesgo hemorrágico de la intervención bajo. El tratamiento antitrombótico periprocedimiento según las recomendaciones actuales fue idóneo únicamente en el 57,3% de los casos. Los pacientes con un uso inadecuado de los fármacos antitrombóticos periprocedimiento presentaron una incidencia de eventos adversos trombóticos y hemorrágicos significativamente mayor. Conclusiones: A pesar de las recomendaciones actuales acerca de la utilización de fármacos antitrombóticos en el periodo perioperatorio/periprocedimiento, su implementación en el «mundo real» continúa siendo baja. Un uso inadecuado se asocia con un aumento de la incidencia de eventos adversos, tanto trombóticos como hemorrágicos.(AU)

Introduction and objectives: There is scarce real-world evidence on the management of perioperative antithrombotic treatment according to current recommendations. The aim of this study was to analyze the management of antithrombotic treatment in patients undergoing surgery or another invasive intervention and to assess the consequences of this management on the occurrence thrombotic or bleeding events. Methods: This prospective, observational, multicenter and multispecialty study analyzed patients receiving antithrombotic therapy who underwent surgery or another invasive intervention. The primary endpoint was defined as the incidence of adverse (thrombotic and/or hemorrhagic) events after 30 days of follow-up with respect to management of perioperative antithrombotic drugs. Results: We included 1266 patients (male: 63.5%; mean age 72.6 years). Nearly half of the patients (48.6%) were under chronic anticoagulation therapy (mainly for atrial fibrillation; CHA2DS2-VASC: 3.7), while 53.3% of the patients were under chronic antiplatelet therapy (mainly for coronary artery disease). Low ischemic and hemorrhagic risk was found in 66.7% and 51.9%, respectively. Antithrombotic therapy management was in line with current recommendations in only 57.3% of the patients. Inappropriate management of antithrombotic therapy was an independent risk factor for both thrombotic and hemorrhagic events. Conclusions: The implementation of recommendations on the perioperative/periprocedural management of antithrombotic therapy in real-world patients is poor. Inappropriate management of antithrombotic treatment is associated with an increase in both thrombotic and hemorrhagic events.(AU)

European Society of Gynaecological Oncology guidelines for the peri-operative management of advanced ovarian cancer patients undergoing debulking surgery.

The European Society of Gynaecological Oncology (ESGO) developed and established for the first time in 2016, and updated in 2020, quality indicators for advanced ovarian cancer surgery to audit and improve clinical practice in Europe and beyond. As a sequela of the continuous effort to improve oncologic care in patients with ovarian cancer, ESGO issued in 2018 a consensus guidance jointly with the European Society of Medical Oncology addressing in a multidisciplinary fashion 20 selected key questions in the management of ovarian cancer, ranging from molecular pathology to palliation in primary and relapse disease. In order to complement the above achievements and consolidate the promoted systemic advances and surgical expertise with adequate peri-operative management, ESGO developed, as the next step, clinically relevant and evidence-based guidelines focusing on key aspects of peri-operative care and management of complications as part of its mission to improve the quality of care for women with advanced ovarian cancer and reduce iatrogenic morbidity. To do so, ESGO nominated an international multidisciplinary development group consisting of practicing clinicians and researchers who have demonstrated leadership and expertise in the care and research of ovarian cancer (18 experts across Europe). To ensure that the guidelines are evidence based, the literature published since 2015, identified from a systematic search, was reviewed and critically appraised. In the absence of any clear scientific evidence, judgment was based on the professional experience and consensus of the development group. The guidelines are thus based on the best available evidence and expert agreement. Prior to publication, the guidelines were reviewed by 117 independent international practitioners in cancer care delivery and patient representatives.

Effect of multimodal analgesia on perioperative insulin resistance in patients with colon cancer.

BACKGROUND: High risk of post-surgery complications have always been related with uncontrolled blood glucose, while the relationship between blood glucose and analgesia has not been compared on radical resection of colon cancer. The aim of this study is to investigate the effects of multimodal analgesia on perioperative insulin resistance in patients undergoing radical resection of colon cancer. METHODS: Sixty patients with colon cancer scheduled for radical resection surgery were equally divided into two groups randomly, the control group (TAP group) received general anesthesia and the transversus abdominis plane block analgesia, and the experimental group (GEA group) received extra epidural anesthesia. The analgesic efficacy was evaluated with visual analog scale (VAS). Insulin resistance indicators like fasting plasma glucose (FPG), resistin (RESIS), fasting insulin (FINS), homeostasis model assessment (HOMA) levels, and inflammation indicator interleukin-6 (IL-6) were evaluated during the surgery. RESULTS: IL-6 increase was significant in the TAP group than that in GEA group (P < 0.01). The insulin resistance increased significantly in TAP group than that in GEA group including HOMA (P < 0.05) and FPG (P < 0.05). There was no significant difference in RESIS levels and VAS scores in the two groups. CONCLUSION: Epidural anesthesia leads to less inflammation in radical resection of colon cancer and the insulin level and insulin resistance increased after the surgeries based on FINS and HOMA..

Regional anesthesia prevents cancer recurrence after oncosurgery! What is wrong with the hypothesis?

Several studies have investigated the hypothesis of the efficacy of regional anesthesia (RA) techniques in preventing cancer recurrence when used perioperatively during oncological surgeries. Although theoretically, the association appears beneficial, the patient outcomes after cancer surgeries with or without RA were comparable, that is, the use of RA did not improve patient survival or prevent cancer recurrence after surgery. Another problem with this data is its retrospective nature which makes its interpretation difficult. Moreover, there are a lot of other confounding factors like comorbidities, tumor biology, nosocomial infections, duration of hospital stay, and baseline immunity, which is not comparable, and hence make standardization for a well-designed prospective study difficult. Return to intended oncologic therapy (RIOT) involves treatment in the form of radiation or chemotherapy which, if received on time after the planned oncosurgery, could provide a better chance of preventing cancer recurrence and improved survival. However, none of the retrospective studies have correlated cancer recurrence with delay in RIOT or not receiving RIOT as a cause of cancer recurrence. This paper discusses why even a well-designed, prospective trial could possibly never establish the efficacy of RA in preventing cancer recurrence and improving survival due to the complexities involved in a patient undergoing oncosurgery.

Impacts of postoperative changes of segmental mobility on neurological improvement after laminoplasty for cervical ossification of the posterior longitudinal ligament.

ABSTRACT: Several studies have demonstrated that the dynamic factor at the mobile segment affects the severity of myelopathy in patients with cervical ossification of the posterior longitudinal ligament (C-OPLL), and posterior decompression supplemented with posterior instrumented fusion at the mobile segment provides good neurological improvement. However, there have been few reports of changes in range of motion at the mobile segment (segmental ROM) after laminoplasty (LP). The aim of this study was thus to retrospectively investigate changes in segmental ROM after LP and the impacts of these changes on neurological improvement in patients with C-OPLL.A total of 51 consecutive patients who underwent LP for C-OPLL since May 2010 and were followed for at least 2 years after surgery were included in this study. Neurological status was assessed using the Japanese Orthopaedic Association (JOA) score before surgery and at 2-year follow-up. Segmental ROM at the responsible level for myelopathy was measured preoperatively and at 2-year follow-up using lateral flexion-extension radiographs of the cervical spine.The mean JOA score improved significantly from 10.7 points preoperatively to 13.5 points at 2 years after surgery (mean recovery rate, 45.0%). The mean segmental ROM decreased significantly from 6.5 degrees before surgery to 3.2 degrees at 2 years after surgery. In the good clinical outcome group (recovery rate of the JOA score ≥50%; n = 22), the mean segmental ROM decreased significantly from 5.8 degrees preoperatively to 3.0 degrees postoperatively. It also decreased significantly from 7.1 degrees to 3.4 degrees in the poor clinical outcome group (recovery rate of the JOA score <50%; n = 29).This study showed that segmental ROM was stabilized after LP in most patients with C-OPLL. Neither preoperative nor postoperative segmental ROM showed significant differences between the good and poor clinical outcome groups and neither a postoperative increase nor decrease of segmental ROM significantly affected the recovery rate of the JOA score.

Universal approach for full endoscopic decompression and percutaneous transpedicular fixation of the lumbar spine: A medial central approach (ACM).

ABSTRACT: Cohort study.This study aimed to determine the effectiveness of the universal approach of full endoscopy and percutaneous transpedicular fixation via a medial central approach (ACM) performed to surgically treat patients with lumbar degenerative surgical pathologies.Alternatives to interventionist treatments available to patients with lumbar degenerative surgical pathologies are related to recovery from minimally invasive surgery. Considering this, full endoscopic spinal decompression (full endoscopy) and percutaneous transpedicular fixation via an ACM represent advances in neurosurgical procedures, in particular, spinal surgery. Thus, the introduction of endoscopic and minimally invasive surgeries for the lumbar region has become 1 of the most important advances in modern surgery.A cohort of 79 patients undergoing full endoscopy and percutaneous transpedicular fixation was evaluated 6 times in 1 year. Pain intensity was measured using the visual analog scale (VAS), and lumbar functionality was measured using the Oswestry Disability Index (ODI). Six evaluations were performed: before surgery and on discharge after surgery as well as at 1, 3, 6, and 12 months after surgery.Before the ACM was applied, the VAS pain score was 8.52. At 11 hours post-surgery, the pain score reduced to 2.59 points (a difference of 5.73 points; P = 0.001). Of the 10 ODI domains evaluated, a difference was found between the period prior to surgery and 1 month later (P < 0.01).The universal approach to full endoscopy and lumbar percutaneous transpedicular fixation via an ACM is highly effective for patients with lumbar surgical degenerative pathologies.

Perioperative Neurological Evaluation and Management to Lower the Risk of Acute Stroke in Patients Undergoing Noncardiac, Nonneurological Surgery: A Scientific Statement From the American Heart Association/American Stroke Association.

Perioperative stroke is a potentially devastating complication in patients undergoing noncardiac, nonneurological surgery. This scientific statement summarizes established risk factors for perioperative stroke, preoperative and intraoperative strategies to mitigate the risk of stroke, suggestions for postoperative assessments, and treatment approaches for minimizing permanent neurological dysfunction in patients who experience a perioperative stroke. The first section focuses on preoperative optimization, including the role of preoperative carotid revascularization in patients with high-grade carotid stenosis and delaying surgery in patients with recent strokes. The second section reviews intraoperative strategies to reduce the risk of stroke, focusing on blood pressure control, perioperative goal-directed therapy, blood transfusion, and anesthetic technique. Finally, this statement presents strategies for the evaluation and treatment of patients with suspected postoperative strokes and, in particular, highlights the value of rapid recognition of strokes and the early use of intravenous thrombolysis and mechanical embolectomy in appropriate patients.

Efficacy of active forced air warming during induction of anesthesia to prevent inadvertent perioperative hypothermia in intraoperative warming patients: Comparison with passive warming, a randomized controlled trial.

BACKGROUND: This study aimed to evaluate the efficacy of peri-induction forced air warming to prevent inadvertent perioperative hypothermia, defined as a reduction in body temperature to <36.0°C during the perioperative period, in intraoperatively warmed patients receiving major surgery lasting >120 minutes. METHODS: In total, 130 patients scheduled for elective surgery under general anesthesia lasting >120 minutes were divided into 2 groups: peri-induction warming (n = 65) and control (n = 65). Patients in the peri-induction warming group were warmed during the anesthetic induction period using a forced-air warmer set at 47°C, whereas patients in the control group were covered passively with a cotton blanket. All patients were warmed with a forced-air warmer during surgery. Body temperature was measured using a tympanic membrane thermometer in the pre- and postoperative periods and using a nasopharyngeal temperature probe during surgery. Patients were evaluated for shivering scale score, thermal comfort scale score, and satisfaction score in the post-anesthesia care unit. RESULTS: The incidence rates of intraoperative and postoperative hypothermia were lower in the peri-induction warming group than in the control group (19.0% vs 57.1%, P < .001; 3.3% vs 16.9%, P = .013, respectively). Body temperature was higher in the peri-induction warming group (P < .001). However, intraoperative blood loss, as well as postoperative thermal comfort scale score, shivering scale score, and patient satisfaction score, were similar between groups. Post-anesthesia care unit duration was also similar between groups. CONCLUSIONS: Peri-induction active forced air warming is an effective, simple, and convenient method to prevent inadvertent perioperative hypothermia in intraoperatively warmed patients undergoing major surgery lasting >120 minutes.

Preoperative Assessment and Perioperative Management of the Patient with Pulmonary Vascular Disease.

The incidence of pulmonary hypertension (PH) in patients undergoing noncardiac surgery has increased steadily over the past decade. Patients with known PH have significantly higher perioperative morbidity and mortality than those without PH. Moreover, a substantial number of patients may have occult disease. It, therefore, is of paramount importance for perioperative providers to recognize high-risk patients and treat them appropriately. This review first provides an overview of PH pathophysiology, then estimates the perioperative incidence of PH and its impact on surgical outcomes, and finally outlines a perioperative management strategy.

Perioperative Management of Rheumatic Disease and Therapies.

Patients with rheumatic disease, including those with systemic lupus erythematous, rheumatoid arthritis, and spondyloarthritis, use total hip and knee arthroplasties at high rates. They represent a particularly vulnerable population in the perioperative setting because of their diseases and the immunosuppressant therapies used to treat them. Careful planning among internists, medical specialists, and the surgical team must therefore occur preoperatively to minimize risks in the postoperative period, particularly infection. Management of immunosuppressant medications, such as conventional synthetic disease-modifying antirheumatic drugs and targeted therapies including biologics, is one avenue by which this infectious risk can be mitigated.

Perioperative anemia: clinical practice update.

Perioperative medicine is an evolving area of medicine in which collaboration between internists, hospitalists, surgeons and anesthesiologists is the key to delivering high-quality care. Research in all areas of perioperative medicine, including perioperative anemia, is constantly evolving. Perioperative anemia is a major contributor to mortality and morbidity in the perioperative period. It is associated with an increased likelihood of postoperative wound complications, infections, delirium, increased length of stay and increased risk of readmissions. However, there is a lack of comprehensive guidelines for management of perioperative anemia. We performed an exhaustive review of contemporary literature on perioperative anemia and present evaluation and management recommendations that have the potential to impact clinical practice in the perioperative period.

Association between perioperative fluid administration and postoperative outcomes: a 20-year systematic review and a meta-analysis of randomized goal-directed trials in major visceral/noncardiac surgery.

BACKGROUND: Appropriate perioperative fluid management is of pivotal importance to reduce postoperative complications, which impact on early and long-term patient outcome. The so-called perioperative goal-directed therapy (GDT) approach aims at customizing perioperative fluid management on the individual patients' hemodynamic response. Whether or not the overall amount of perioperative volume infused in the context of GDT could influence postoperative surgical outcomes is unclear. METHODS: We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing the efficacy of GDT approach between study population and control group in reducing postoperative complications and perioperative mortality, using MEDLINE, EMBASE and the Cochrane Controlled Clinical trials register. The enrolled studies were grouped considering the amount infused intraoperatively and during the first 24 h after the admission in the critical care unit (perioperative fluid). RESULTS: The metanalysis included 21 RCTs enrolling 2729 patients with a median amount of perioperative fluid infusion of 4500 ml. In the studies reporting an overall amount below or above this threshold, the differences in postoperative complications were not statically significant between controls and GDT subgroup [43.4% vs. 34.2%, p value = 0.23 and 54.8% vs. 39.8%; p value = 0.09, respectively]. Overall, GDT reduced the overall rate of postoperative complications, as compared to controls [pooled risk difference (95% CI) = - 0.10 (- 0.14, - 0.07); Chi2 = 30.97; p value < 0.0001], but not to a reduction of perioperative mortality [pooled risk difference (95%CI) = - 0.016 (- 0.0334; 0.0014); p value = 0.07]. Considering the rate of organ-related postoperative events, GDT did not reduce neither renal (p value = 0.52) nor cardiovascular (p value = 0.86) or pulmonary (p value = 0.14) or neurological (p value = 0.44) or infective (p value = 0.12) complications. CONCLUSIONS: Irrespectively to the amount of perioperative fluid administered, GDT strategy reduces postoperative complications, but not perioperative mortality. TRIAL REGISTRATION: CRD42020168866; Registration: February 2020 https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=168866.

Rapid response to the alpha-1 adrenergic agent phenylephrine in the perioperative period is impacted by genomics and ancestry.

The emergence of genomic data in biobanks and health systems offers new ways to derive medically important phenotypes, including acute phenotypes occurring during inpatient clinical care. Here we study the genetic underpinnings of the rapid response to phenylephrine, an α1-adrenergic receptor agonist commonly used to treat hypotension during anesthesia and surgery. We quantified this response by extracting blood pressure (BP) measurements 5 min before and after the administration of phenylephrine. Based on this derived phenotype, we show that systematic differences exist between self-reported ancestry groups: European-Americans (EA; n = 1387) have a significantly higher systolic response to phenylephrine than African-Americans (AA; n = 1217) and Hispanic/Latinos (HA; n = 1713) (31.3% increase, p value < 6e-08 and 22.9% increase, p value < 5e-05 respectively), after adjusting for genetic ancestry, demographics, and relevant clinical covariates. We performed a genome-wide association study to investigate genetic factors underlying individual differences in this derived phenotype. We discovered genome-wide significant association signals in loci and genes previously associated with BP measured in ambulatory settings, and a general enrichment of association in these genes. Finally, we discovered two low frequency variants, present at ~1% in EAs and AAs, respectively, where patients carrying one copy of these variants show no phenylephrine response. This work demonstrates our ability to derive a quantitative phenotype suited for comparative statistics and genome-wide association studies from dense clinical and physiological measures captured for managing patients during surgery. We identify genetic variants underlying non response to phenylephrine, with implications for preemptive pharmacogenomic screening to improve safety during surgery.

Factores perioperatorios, inmunidad y recurrencia del cáncer / Perioperative factors, immunity and cancer recurrence

Introducción: Los criterios de calidad en la cirugía oncológica radical se basan en la extirpación completa del tumor, con márgenes libres, sin enfermedad macroscópica residual, con una linfadenectomía adecuada y mínima manipulación tumoral posible. A pesar de conseguir estos objetivos, puede quedar enfermedad residual no visible o micrometástasis, con potencial de crecimiento y diseminación dependiendo de la capacidad tumoral y de las defensas del huésped. Objetivos: Evaluar la influencia de los factores perioperatorios sobre la inmunidad del paciente oncológico intervenido quirúrgicamente y el efecto potencial de los fármacos anestésicos en la recurrencia, así como otros factores perioperatorios que pueden afectar la diseminación tumoral a largo plazo. Métodos: Se realizó una búsqueda bibliográfica electrónica de los artículos de los últimos 10 años que cumplieran con el objetivo trazado. Desarrollo: Durante el periodo perioperatorio la activación de la respuesta al estrés quirúrgico desencadena una serie de reacciones neuroendocrinas, humorales e inmunitarias complejas. La cirugía, con indudable potencial curativo, se relaciona con un estado de inmunosupresión por activación del eje HPA (hipotálamo- hipofisario- adrenal) y la inflamación. Por otro lado, la anestesia produce cambios biomoleculares que afectan la inmunidad celular y el número de NK (natural killer), que puede influir en la recurrencia del cáncer a largo plazo. Conclusiones: Disminuir el estrés quirúrgico y el psicológico, controlar el dolor quirúrgico, mantener normotermia, y una juiciosa transfusión sanguínea, además una técnica anestésica con disminución del consumo de opiáceos, puede resultar favorecedora para proteger la respuesta inmune antimetastásica del organismo y puede tener un efecto benéfico en la enfermedad oncológica(AU)

Introduction: The quality criteria in radical oncological surgery are based on complete tumor removal, with free margins, without residual macroscopic disease, with adequate lymphadenectomy and minimal possible tumor manipulation. Despite achieving these objectives, non-visible residual disease or micrometastasis may remain, likely to grow and spread depending on tumor capacity and the host's defenses. Objectives: To evaluate the influence of perioperative factors on the immunity of cancer patients operated on and the potential effect of anesthetic drugs on recurrence, as well as other perioperative factors that may affect long-term tumor spread. Methods: An electronic bibliographic search was carried out of the articles published in the last ten years and that fulfilled the established objective. Development: During the perioperative period, activation of the response to surgical stress triggers a series of complex neuroendocrine, humoral and immune reactions. Surgery, with unquestionable curative potential, is related to a state of immunosuppression due to activation of the hypothalamic-pituitary-adrenal axis and inflammation. On the other hand, anesthesia produces biomolecular changes that affect cellular immunity and the number of natural killers, which can influence cancer recurrence in the long term. Conclusions: To reduce surgical and psychological stress, to control surgical pain, to maintain normothermia, and a judicious blood transfusion, in addition to an anesthetic technique with reduced opiates usage, can be beneficial to protect the body's antimetastatic immune response and can have a beneficial effect on oncological disease(AU)

Comparison of 1-Year Pre- and Post-Transcatheter Aortic Valve Replacement Hospitalization Rates: A Population-Based Cohort Study.

BACKGROUND: Rehospitalization rates post-transcatheter aortic valve replacement (TAVR) are high; however, it is not known how these compare with pre-TAVR hospitalization rates. Our objective was to determine the association between the index TAVR and hospitalization rates pre- and postprocedure. METHODS: A retrospective observational study was performed including all TAVR procedures performed in Ontario, Canada, between 2013 and 2017. Patients who died during the index hospitalization were excluded. The primary outcome was all-cause hospitalization within 1 year of TAVR discharge. Hospitalization rates per person-year were calculated and compared for each of the following analogous time periods pre- and post-index TAVR: 1 to 30, 31 to 90, 91 to 365, and 1 to 365 days. Poisson regression models were used to generate rate ratios to compare hospitalization rates. RESULTS: The final study cohort included 2547 patients. In the year before TAVR, 60.2% of patients were hospitalized, compared with 45.9% in the year following the procedure. The rate ratio (RR) for the year post-TAVR compared with pre-TAVR was 0.82 (95% confidence interval [CI], 0.77- 0.88). When comparing each parallel time period post- vs pre-TAVR, all intervals were associated with significant reductions in hospitalization after TAVR, except the 30-day periprocedural period. The largest change in hospitalization rates occurred in the 31 to 90 days post- vs the corresponding period pre-TAVR (RR: 0.57; 95% CI, 0.50-0.64) CONCLUSION: TAVR is associated with a significant and sustained reduction in all-cause hospitalization in the year following the procedure compared with the preprocedural period.

Application value of ERAS in perioperative period of precise hepatectomy for hepatocellular carcinoma patients.

PURPOSE: To explore the efficacy and reliability of enhanced recovery after surgery (ERAS) applied in the perioperative period of precise hepatectomy for hepatocellular carcinoma (HCC). METHODS: The propensity score matching and a retrospective cohort study were employed. The clinical and pathological data of 122 hepatocellular carcinoma (HCC) patients with surgical indications admitted to our hospital from March 2014 to March 2016 were collected. These 122 patients were subjected to propensity score matching and divided into ERAS group and Control group. The surgical situation, postoperative recovery [postoperative alanine aminotransferase (ALT), total bilirubin (TBiL) and C-reactive protein (CRP) levels], postoperative complications, postoperative hospital stay, hospitalization costs and patient satisfaction score were observed and compared between the two groups. All patients were followed up to record their postoperative survival. RESULTS: The average drainage tube removal time, bowel sound time, postoperative flatus time and postoperative hospital stay of patients were overtly shorter in ERAS group than in Control group. Besides, the postoperative numerical rating scale (NRS) score and the incidence rate of moderate and severe pain after surgery were lower in ERAS group than in Control group. The total hospitalization cost was significantly lower in ERAS group than in Control group. The patient satisfaction score was obviously higher in ERAS group than in Control group. ERAS group had fewer cases of postoperative vomiting, abdominal distension, biliary fistula, intestinal obstruction, large-volume ascites, liver failure, wound infection, pulmonary infection and abdominal infection than Control group, but the differences were not statistically significant. The ALT, TBiL and CRP levels of patients were notably lower in ERAS group than in Control group at d 7 after surgery. Based on the follow-up results, there was no significant difference in overall survival between the two groups. CONCLUSION: ERAS applied in the perioperative period of HCC patients receiving precise hepatectomy is reliable and effective and has positive significance for the promotion of postoperative rehabilitation, which is worthy of popularization in clinical practice.

Perioperative Deep Vein Thrombosis in Patients With Lower Extremity Fractures: An Observational Study.

This study aimed to investigate deep vein thrombosis (DVT) in patients with lower extremity fractures who received anticoagulation treatment in the perioperative stage. We collected the patients' clinical data and diagnosed DVT using Doppler ultrasonography. Preoperative, postoperative, and 1-month postoperative examinations were performed. The patients were divided into thrombosis and non-thrombosis groups according to ultrasonographic findings. A total of 404 patients were included in the study. The preoperative, postoperative, and 1-month postoperative incidence rates were, respectively, 35%, 55%, and 40% for DVT and 12%, 22%, and 20% for DVT in the uninjured contralateral lower extremity. The incidence of perioperative DVT decreased over time from 223 (55%) to 161 (40%). Multivariate analysis revealed that the independent risk factors for preoperative that of DVT were age (odds ratio [OR]: 1.03; 95% CI: 1.01-1.04; P = .000); postoperative that of DVT were age (OR: 1.04; 95% CI: 1.03-1.05; P = .000), blood loss (OR: 1.001; 95% CI: 1.000-1.002; P = .018), and American Society of Anesthesiologists classification (OR: 2.07; 95% CI: 1.16-3.72; P = .014); and 1-month postoperative that of DVT were age (OR: 1.05; 95% CI: 1.03-1.07; P = .000), respectively. In conclusion, the incidence of perioperative DVT decreased over time in patients who received anticoagulation treatment. Age was an important risk factor for perioperative DVT.

Reasons for Conversion and Adverse Intraoperative Events in Robotically Enhanced Minimally Invasive Coronary Artery Revascularization.

OBJECTIVE: The transition from sternotomy access to minimally invasive coronary artery bypass grafting is associated with steep learning curves. This study reports the reasons for sternotomy conversions from robotically enhanced minimally invasive direct coronary artery bypass grafting (RE-MIDCAB) and describes potential risk reduction strategies. METHODS: The perioperative data of 759 RE-MIDCAB patients (mean age 65.9 ± 10 years, 25.5% female, 30.2% multivessel disease) operated between July 1, 2002 and November 30, 2018 were reviewed for the reasons of conversion and adverse intraoperative events. Hybrid revascularization was planned in 204 (26.9%) patients. RESULTS: Sternotomy conversion occurred in 30 (4.0%) patients. Lung adhesions and unsuccessful single-lung ventilation prohibited safe RE-MIDCAB internal thoracic artery (ITA) harvesting in 11 (36.7%) and 1 (3.3%) patients, respectively. ITA dysfunction (n = 11, 36.7%) and inadequate target vessel visualization (n = 3, 10.0%) were among the anatomical reasons for conversions. Adverse intraoperative events included ventricle perforation (n = 1, 3.3%) and sustained ventricular arrhythmia (n = 1, 3.3%). The in-hospital mortality and mean length of hospitalization for sternotomy conversion were 3.3% (n = 1 of 30) and 13.4 ± 14.5 days, respectively. Perioperative morbidities included pneumonia (n = 4, 13.3%). Premorbid renal dysfunction predicted sternotomy conversion at the 5% level of significance. CONCLUSIONS: RE-MIDCAB provides an attractive surgical platform for primary- or hybrid coronary artery procedures. The progressive increase in patient risk profiles, strict quality control, and focus on clinical governance require awareness of reasons that potentially contribute RE-MIDCAB to sternotomy conversion to ensure safe and sustainable programs.