Duraiyah Thangathurai

Zero Ischemia Anatomical Partial Nephrectomy: A Novel Approach

PURPOSE We present a novel concept of zero ischemia anatomical robotic and laparoscopic partial nephrectomy. MATERIALS AND METHODS Our technique primarily involves anatomical vascular microdissection and preemptive control of tumor specific, tertiary or higher order renal arterial branch(es) using neurosurgical aneurysm micro-bulldog clamps. In 58 consecutive patients the majority (70%) had anatomically complex tumors including central (67%), hilar (26%), completely intrarenal (23%), pT1b (18%) and solitary kidney (7%). Data were prospectively collected and analyzed from an institutional review board approved database. RESULTS Of 58 cases undergoing zero ischemia robotic (15) or laparoscopic (43) partial nephrectomy, 57 (98%) were completed without hilar clamping. Mean tumor size was 3.2 cm, mean ± SD R.E.N.A.L. score 7.0 ± 1.9, C-index 2.9 ± 2.4, operative time 4.4 hours, blood loss 206 cc and hospital stay 3.9 days. There were no intraoperative complications. Postoperative complications (22.8%) were low grade (Clavien grade 1 to 2) in 19.3% and high grade (Clavien grade 3 to 5) in 3.5%. All patients had negative cancer surgical margins (100%). Mean absolute and percent change in preoperative vs 4-month postoperative serum creatinine (0.2 mg/dl, 18%), estimated glomerular filtration rate (-11.4 ml/minute/1.73 m(2), 13%), and ipsilateral kidney function on radionuclide scanning at 6 months (-10%) correlated with mean percent kidney excised intraoperatively (18%). Although 21% of patients received a perioperative blood transfusion, no patient had acute or delayed renal hemorrhage, or lost a kidney. CONCLUSIONS The concept of zero ischemia robotic and laparoscopic partial nephrectomy is presented. This anatomical vascular microdissection of the artery first and then tumor allows even complex tumors to be excised without hilar clamping. Global surgical renal ischemia is unnecessary for the majority of patients undergoing robotic and laparoscopic partial nephrectomy at our institution.

Radical cystectomy for elderly patients with bladder carcinoma

The authors evaluated the experiences at their institution with radical cystectomy and urinary diversion performed on elderly bladder carcinoma patients to determine whether age had an impact on the clinical or functional results for this group of patients.

A Critical Analysis of Perioperative Mortality From Radical Cystectomy

PURPOSE Operative mortality from radical cystectomy has decreased as a result of improvements in surgical and anesthetic care. We reviewed the perioperative deaths from a large group of patients treated with radical cystectomy for primary bladder cancer. MATERIALS AND METHODS All perioperative mortalities from radical cystectomy were identified from a single high volume institution. The medical records were reviewed to assess the cause of death as well as possible contributing factors. RESULTS From August 1971 to December 2001, 1,359 patients with primary bladder cancer were treated with radical cystectomy and pelvic iliac lymphadenectomy at our institution. Of these patients, 27 (2%) died within 30 days of surgery or before discharge from hospital. Median patient age at surgery was 67 years (range 47 to 78) and males accounted for 81% of the patients. The median time to death was 28 days from cystectomy (range 0 to 80). Most deaths were cardiovascular related (including acute myocardial infarction, cerebrovascular accident, arterial thrombosis) or due to septic complications with resulting multi-organ system failure, followed by pulmonary embolism, hepatic failure and hemorrhage. Septic related mortality was most often associated with postoperative urine or bowel leak. While most deaths occurred before hospital discharge, 2 patients died at home due to a late pulmonary embolus. No association was seen between pathological stage or type of urinary diversion and mortality. CONCLUSIONS Perioperative mortality from radical cystectomy is low in this group of patients. Most deaths are due to cardiovascular or septic complications. Careful patient selection and meticulous surgical technique may help decrease the incidence of perioperative mortality.

Anatomic renal artery branch microdissection to facilitate zero-ischemia partial nephrectomy.

BACKGROUND Robot-assisted and laparoscopic partial nephrectomies (PNs) for medial tumors are technically challenging even with the hilum clamped and, until now, were impossible to perform with the hilum unclamped. OBJECTIVE Evaluate whether targeted vascular microdissection (VMD) of renal artery branches allows zero-ischemia PN to be performed even for challenging medial tumors. DESIGN, SETTING, AND PARTICIPANTS A prospective cohort evaluation of 44 patients with renal masses who underwent robot-assisted or laparoscopic zero-ischemia PN either with anatomic VMD (group 1; n=22) or without anatomic VMD (group 2; n=22) performed by a single surgeon from April 2010 to January 2011. INTERVENTION Zero-ischemia PN with VMD incorporates four maneuvers: (1) preoperative computed tomographic reconstruction of renal arterial branch anatomy, (2) anatomic dissection of targeted, tumor-specific tertiary or higher-order renal arterial branches, (3) neurosurgical aneurysm microsurgical bulldog clamp(s) for superselective tumor devascularization, and (4) transient, controlled reduction of blood pressure, if necessary. MEASUREMENTS Baseline, perioperative, and postoperative data were collected prospectively. RESULTS AND LIMITATIONS Group 1 tumors were larger (4.3 vs 2.6 cm; p=0.011), were more often hilar (41% vs 9%; p=0.09), were medial (59% and 23%; p=0.017), were closer to the hilum (1.46 vs 3.26 cm; p=0.0002), and had a lower C index score (2.1 vs 3.9; p=0.004) and higher RENAL nephrometry scores (7.7 vs 6.2; p=0.013). Despite greater complexity, no group 1 tumor required hilar clamping, and perioperative outcomes were similar to those of group 2: operating room time (4.7 and 4.1h), median blood loss (200 and 100ml), surgical margins for cancer (all negative), major complications (0% and 9%), and minor complications (18% and 14%). The median serum creatinine level was similar 2 mo postoperatively (1.2 and 1.3mg/dl). The study was limited by the relatively small sample size. CONCLUSIONS Anatomic targeted dissection and superselective control of tumor-specific renal arterial branches facilitate zero-ischemia PN. Even challenging medial and hilar tumors can be excised without hilar clamping. Global surgical renal ischemia has been eliminated for most patients undergoing PN at our institution.

Intraoperative evaluation of tissue perfusion in high-risk patients by invasive and noninvasive hemodynamic monitoring.

OBJECTIVE Although invasive monitoring has not been effective in late stages after organ failure has occurred, early postoperative monitoring revealed differences in survivor and nonsurvivor patterns and provided goals for improving outcome. We searched for the earliest divergence of survivor and nonsurvivor circulatory changes as an approach to earlier preventive therapy. The aim was to describe the intraoperative time course of circulatory dysfunction in survivors and nonsurvivors among high-risk elective surgery patients using both the thermodilution pulmonary artery catheter (PAC) and multicomponent noninvasive monitoring. DESIGN Prospective intraoperative description of circulatory dysfunction. SETTING University-run county hospital. PATIENTS Two hundred nine consecutively monitored high-risk elective surgery patients. MEASUREMENTS AND MAIN RESULTS We evaluated the data of high-risk elective surgery patients using both PAC and multicomponent noninvasive monitoring. The latter consisted of the following: a) an improved bioimpedance method for estimating cardiac output; b) the standard pulse oximetry to screen for pulmonary problems; c) transcutaneous oxygen and carbon dioxide tension sensors to evaluate tissue perfusion; and d) routine noninvasive blood pressure and heart rate. The current noninvasive impedance cardiac output estimations closely approximated those of the thermodilution method; r2 = .74, p < .001; the precision and bias was -0.124 +/- 0.75 L/min/m2. Outcome measures included intraoperative description of circulatory patterns of high-risk surgical patients who survived compared with nonsurvivors. Hypotension, low cardiac index, arterial hemoglobin desaturation, low transcutaneous oxygen, high transcutaneous carbon dioxide tensions, low oxygen delivery, and low oxygen consumption developed intraoperatively gradually over time; the abnormalities were more pronounced in the nonsurvivors than in the survivors. CONCLUSIONS The survivors had slightly higher mean arterial pressure, cardiac index, and mixed venous oxygen saturation, as well as significantly higher oxygen delivery, oxygen consumption, transcutaneous oxygen tension, and transcutaneous oxygen tension/FIO2 ratios, than did the nonsurvivors. The data suggest that blood flow, oxygen delivery, and tissue oxygenation of the nonsurvivors became inadequate toward the end of the operation. Noninvasive monitoring provides similar information to that of the PAC; both approaches revealed low-flow and poor tissue perfusion that were worse in the nonsurvivors. The continuous on-line real-time displays of hemodynamic trends facilitate early recognition of acute circulatory dysfunction.

Continuous intraoperative noninvasive cardiac output monitoring using a new thoracic bioimpedance device

OBJECTIVES To compare a new noninvasive bioimpedance device with the standard thermodilution method during the intraoperative period in high-risk patients undergoing oncological surgery. DESIGN Prospectively collected data with retrospective analysis. SETTING The study was undertaken at a university hospital, single institution. PARTICIPANTS Twenty-three selected adults undergoing extensive, ablative oncological surgery. INTERVENTIONS Simultaneous measurements of cardiac output by a new bioimpedance method and the standard thermodilution method during the intraoperative and immediate postoperative periods. MEASUREMENTS AND MAIN RESULTS The correlation coefficient between the two methods was r = 0.89, p < 0.001. Bias and precision analysis between the two techniques showed a mean bias of 0.1 L/min and SD of the bias [precision] of 1.0 L/min [95% level of agreement +2.1 L/min to -1.9 L/min]. After software enhancement, data from the last 11 monitored patients showed improved correlation between the two methods; r = 0.93, mean bias -0.1 L/min, and precision 0.8 L/min. Electrical and motion-induced interference only transiently impaired the performance of the new impedance method. CONCLUSION This new impedance device is a safe, reliable, clinically acceptable alternative to the invasive thermodilution method in the operating room environment.

Invasive and noninvasive haemodynamic monitoring of acutely ill sepsis and septic shock patients in the emergency department.

&NA; The objective of this study was to describe early circulatory events of patients presenting to the emergency department (ED) with severe sepsis or septic shock. Invasive and noninvasive monitoring were used to evaluate sequential patterns of both central haemodynamics and peripheral tissue perfusion/oxygenation and to test the hypothesis that increased cardiac output is an early compensation to increased body metabolism. This is a prospective observational study of 45 patients who entered the ED with severe sepsis or septic shock in an urban academic ED. Invasive clinical monitoring was performed using a radial artery catheter and a thermodilution pulmonary artery catheter. Noninvasive monitoring consisted of an improved thoracic electrical bioimpedance device to estimate cardiac output; pulse oximetry for arterial saturation to reflect changes in pulmonary function, and transcutaneous oxygen (PtcO2) and carbon dioxide tensions (PtcCO2) as a reflection of tissue perfusion. Survivors had higher cardiac index, mean arterial pressure (MAP), and better tissue perfusion as measured by PtcO2. oxygen delivery, and oxygen consumption. Oxygen extraction ratio was higher in the nonsurvivors (p < 0.05) and there were episodes of high PtcCO2 values in the nonsurvivors. No significant differences were found in the heart rate. PAOP (wedge pressure) and SaO2 by pulse oximetry between the two groups. It is concluded that ED monitoring septic patients provides a unique opportunity to document early physiologic interactions, between cardiac. pulmonary, and tissue perfusion functions in surviving and nonsurviving patients with septic shock. The data is consistent with the concept that increased cardiac output is an earlty compensatory response to increased body metabolism Real time haemodvnamic monitoring of pattients in the ED provides early warning of outcome and may be used to guide therapy

Innovations in laparoscopic and robotic partial nephrectomy: a novel 'zero ischemia' technique.

Purpose of review To describe a novel ‘zero ischemia’ technique for laparoscopic and robotic partial nephrectomy. Recent findings Laparoscopic partial nephrectomy has been performed in 15 patients without the need for warm ischemia by utilizing pharmalogically induced hypotension. This consecutive series includes complex tumors in patients with multiple comorbidities. Herein we describe our current practice, initial results, and several practical considerations associated with the application of this novel technique. Summary Initial results with our ‘zero ischemia’ technique have been encouraging. Evaluation of long-term outcomes is ongoing.

Spinal artery syndrome masked by postoperative epidural analgesia

PurposeWe report a case of a patient who developed a postoperative anterior spinal artery syndrome that was masked by the use of epidural analgesia. We wish to alert other anaesthetists that the use of epidural anaesthesia in this setting may mask the symptoms and delay the diagnosis of this rare complication.Clinical featuresThe patient was a 22-yr-old obese man with metastatic testicular carcinoma who underwent a left-sided thoracoabdominal retropentoneal tumour resection. A lumbar epidural catheter was placed preoperatively for pain management. Postoperatively, the patient developed bilateral lower extremity weakness, which was at first attributed to epidural administration of local anaesthetics. Despite discontinuation of the local anaesthetics, the symptoms persisted. Further work-up led to the diagnosis of anterior spinal artery syndrome. The patient was sent to a rehabilitation hospital and had a partial recovery.ConclusionAntenor spinal artery syndrome can occur following retropentoneal surgery. It is important to recognize the potential for this complication when postoperative epidural analgesia is contemplated, especially following a left-sided surgical dissection. The use of epidural local anaesthetics iminediately after surgery delays the diagnosis of a postoperative neurological deficit. Moreover, when the deficit is recognized the epidural itself may be falsely blamed for postoperative paraplegia. If epidural analgesia is used, opioids may be preferred over local anaesthetics in the iminediate postoperative period to prevent masking of an antenor spinal artery syndrome.RésuméObjectifRapporter un cas de syndrome de l’artère spinale anténeure masqué par une anesthésie épidurale dans le but de prévenir les anesthésistes que, dans ces conditions, l’anesthésie épidurale peut dissimuler les symptômes de cette complication exceptionnelle et en retarder le diagnostic.Éléments cliniquesUn patient obèse âgé de 22 ans atteint d’un carcinome testiculaire métastatique a subi une résection thoracoabdominale de tumeur rétropéntonéale. Un cathéter lombaire épidural avait été inséré avant l’intervention pour le traitement de la douleur. En postopératoire, le patient a présenté une faiblesse bilatérale des membres inféneurs qui fut d’abord attnbuée à l’administration épidurale de l’anesthésique local. Malgré l’interruption de l’anesthésie régionale, les symptômes ont persisté. Un bilan ultérieur a conduit au diagnostic de syndrome de l’artère spinale anténeure. Une récupération partielle a suivi son hospitalisation dans un centre de réhabilitation.ConclusionLe syndrome de l’artère spinale antérieure peut survenir après une chirurgie rétropéntonéale. II est important de reconnaître l’éventualité de cette complication si on considère administrer une anesthésie épidurale, surtout après une dissection du côté gauche du corps. L’administration épidurale d’un anesthésique local immédiatement après la chirurgie retarde le diagnostic d’un déficit neurologique postopératoire. En outre, même si on parvient à diagnostiquer un déficit, l’épidurale peut être blâmée à tort pour la paraplégie postopératoire. Si l’analgésie épidurale est choisie, il est préférable d’utiliser un morphinique plutôt qu’un anesthésique local à la pénode postopératoire iminédiate pour éviter que le syndrome de l’artère spinale anténeure ne passe inaperçu dans l’iminédiat.

NMDA Receptor Blockade Prevents Nitroglycerin‐Induced Headaches

Nitroglycerin is commonly used in patients who are at risk for developing cardiac ischemia or infarction, especially in the postoperative period. Patients receiving nitroglycerin often complain of headache. In spite of this side effect, nitroglycerin is still the drug of choice for cardiac ischemia. Nitric oxide, which is liberated from nitroglycerin, appears to play a role in the development of the headache via activation of NMDA receptors. 1-3