Edward J. Mascha

Can anesthetic technique for primary breast cancer surgery affect recurrence or metastasis

Background: Regional anesthesia is known to prevent or attenuate the surgical stress response; therefore, inhibiting surgical stress by paravertebral anesthesia might attenuate perioperative factors that enhance tumor growth and spread. The authors hypothesized that breast cancer patients undergoing surgery with paravertebral anesthesia and analgesia combined with general anesthesia have a lower incidence of cancer recurrence or metastases than patients undergoing surgery with general anesthesia and patient-controlled morphine analgesia. Methods: In this retrospective study, the authors examined the medical records of 129 consecutive patients undergoing mastectomy and axillary clearance for breast cancer between September 2001 and December 2002. Results: Fifty patients had surgery with paravertebral anesthesia and analgesia combined with general anesthesia, and 79 patients had general anesthesia combined with postoperative morphine analgesia. The follow-up time was 32 ± 5 months (mean ± SD). There were no significant differences in patients or surgical details, tumor presentation, or prognostic factors. Recurrence- and metastasis-free survival was 94% (95% confidence interval, 87–100%) and 82% (74–91%) at 24 months and 94% (87–100%) and 77% (68–87%) at 36 months in the paravertebral and general anesthesia patients, respectively (P = 0.012). Conclusions: This retrospective analysis suggests that paravertebral anesthesia and analgesia for breast cancer surgery reduces the risk of recurrence or metastasis during the initial years of follow-up. Prospective trials evaluating the effects of regional analgesia and morphine sparing on cancer recurrence seem warranted.

Anesthetic technique for radical prostatectomy surgery affects cancer recurrence: a retrospective analysis.

Background:Regional anesthesia and analgesia attenuate or prevent perioperative factors that favor minimal residual disease after removal of the primary carcinoma. Therefore, the authors evaluated prostate cancer recurrence in patients who received either general anesthesia with epidural anesthesia/analgesia or general anesthesia with postoperative opioid analgesia. Methods:In a retrospective review of medical records, patients with invasive prostatic carcinoma who underwent open radical prostatectomy between January 1994 and December 2003 and had either general anesthesia–epidural analgesia or general anesthesia–opioid analgesia were evaluated through October 2006. The endpoint was an increase in postoperative prostate-specific antigen. Results:After adjusting for tumor size, Gleason score, preoperative prostate-specific antigen, margin, and date of surgery, the epidural plus general anesthesia group had an estimated 57% (95% confidence interval, 17–78%) lower risk of recurrence compared with the general anesthesia plus opioids group, with a corresponding hazard ratio of 0.43 (95% confidence interval, 0.22–0.83; P = 0.012) in a multivariable Cox regression model. Gleason score and tumor size (percent of prostate involved) were also independent predictors of recurrence (hazards ratios of 1.19 [1.08, 1.52], P = 0.004, and 1.17 [1.03, 1.34] for 10% size difference, P = 0.01, respectively). A similar association between epidural use and recurrence was obtained by comparing patients matched on the propensity to receive epidural versus general anesthesia. Conclusions:Open prostatectomy surgery with general anesthesia, substituting epidural analgesia for postoperative opioids, was associated with substantially less risk of biochemical cancer recurrence. Prospective randomized trials to evaluate this association seem warranted.

The effects of mild perioperative hypothermia on blood loss and transfusion requirement

Background:Anesthetic-induced hypothermia is known to reduce platelet function and impair enzymes of the coagulation cascade. The objective of this meta-analysis and systematic review was to evaluate the hypothesis that mild perioperative hypothermia increases surgical blood loss and transfusion requirement. Methods:The authors conducted a systematic search of published randomized trials that compared blood loss and/or transfusion requirements in normothermic and mildly hypothermic (34–36°C) surgical patients. Results are expressed as a ratio of the means or relative risks and 95% confidence intervals (CI); P < 0.05 was considered statistically significant. Results:Fourteen studies were included in analysis of blood loss, and 10 in the transfusion analysis. The median (quartiles) temperature difference between the normothermic and hypothermic patients among studies was 0.85°C (0.60°C versus 1.1°C). The ratio of geometric means of total blood loss in the normothermic and hypothermic patients was 0.84 (0.74 versus 0.96), P = 0.009. Normothermia also reduced transfusion requirement, with an overall estimated relative risk of 0.78 (95% CI 0.63, 0.97), P = 0.027. Conclusion:Even mild hypothermia (<1°C) significantly increases blood loss by approximately 16% (4–26%) and increases the relative risk for transfusion by approximately 22% (3–37%). Maintaining perioperative normothermia reduces blood loss and transfusion requirement by clinically important amounts.

Clinical Implications of Clinically Insignificant Stone Fragments After Extracorporeal Shock Wave Lithotripsy

PURPOSE We determined the natural history and clinical significance of small, asymptomatic, noninfection related stone fragments after extracorporeal shock wave lithotripsy (ESWL). MATERIALS AND METHODS We prospectively followed 160 patients with 4 mm. or less asymptomatic calcium oxalate/phosphate stone fragments after ESWL for 1.6 to 88.8 months (mean 23) to stone-free status, censorship or intervention. Kaplan-Meier estimates of probability to anatomical stone-free, decreased or stable status were determined as well as the probability of symptomatic episodes or required urological intervention. RESULTS Stone-free status or a decreased, stable or increased amount of residual stone occurred in 38 (23.8%), 26 (16.3%), 67 (41.9%) and 29 (18.1%) of the 160 patients, respectively. At 5 years after ESWL the probability of a stone-free, stone-free or decreased status, or stone-free, decreased or stable status was 0.36, 0.53, and 0.80, respectively. A total of 91 patients (56.9%) remained asymptomatic while 69 (43.1%) had a symptomatic episode or required intervention 1.6 to 85.4 months (mean 26) after ESWL (probability estimated at 0.71 at 5 years). CONCLUSIONS While patients with small noninfection related stone fragments after ESWL may be followed expectantly, a significantly number will require intervention or have symptomatic episodes within 2 years. The term clinically insignificant applied to any residual stone after ESWL is likely a misnomer.

Complications of invasive video-EEG monitoring with subdural grid electrodes

Objective: To evaluate the risk factors, type, and frequency of complications during video-EEG monitoring with subdural grid electrodes. Methods: The authors retrospectively reviewed the records of all patients who underwent invasive monitoring with subdural grid electrodes (n = 198 monitoring sessions on 187 patients; median age: 24 years; range: 1 to 50 years) at the Cleveland Clinic Foundation from 1980 to 1997. Results: From 1980 to 1997, the complication rate decreased (p = 0.003). In the last 5 years, 19/99 patients (19%) had complications, including two patients (2%) with permanent sequelae. In the last 3 years, the complication rate was 13.5% (n = 5/37) without permanent deficits. Overall, complications occurred during 52 monitoring sessions (26.3%): infection (n = 24; 12.1%), transient neurologic deficit (n = 22; 11.1%), epidural hematoma (n = 5; 2.5%), increased intracranial pressure (n = 5; 2.5%), and infarction (n = 3; 1.5%). One patient (0.5%) died during grid insertion. Complication occurrence was associated with greater number of grids/electrodes (p = 0.021/p = 0.052; especially >60 electrodes), longer duration of monitoring (p = 0.004; especially >10 days), older age of the patient (p = 0.005), left-sided grid insertion (p = 0.01), and burr holes in addition to the craniotomy (p = 0.022). No association with complications was found for number of seizures, IQ, anticonvulsants, or grid localization. Conclusions: Invasive monitoring with grid electrodes was associated with significant complications. Most of them were transient. Increased complication rates were related to left-sided grid insertion and longer monitoring with a greater number of electrodes (especially more than 60 electrodes). Improvements in grid technology, surgical technique, and postoperative care resulted in significant reductions in the complication rate.

Early outcome assessment for 2228 consecutive carotid endarterectomy procedures: The Cleveland Clinic experience from 1989 to 1995

PURPOSE Several randomized trials now have established guidelines regarding patient selection for carotid endarterectomy (CEA) that have been widely accepted but have little relevance unless they are considered in the context of perioperative risk. The purpose of this study was to demonstrate the feasibility of early outcome assessment using a computerized database. METHODS Since 1989 demographic information and in-hospital results for all surgical procedures performed by the members of our department have been entered into a prospective registry. For the purpose of this report, we have analyzed the stroke and mortality rates for 2228 consecutive CEAs (2046 patients), including 1924 that were performed as isolated operations and 304 that were combined with simultaneous coronary artery bypass grafting (CABG). This series incidentally contains a total of 153 reoperations for recurrent carotid stenosis. RESULTS The respective stroke and mortality rates were 0.5% and 1.8% for all isolated CEAs, 4.3% and 5.3% for all CEA-CABG procedures, and 4.6% and 2.0% for carotid reoperations. According to a multivariable statistical model, the composite stroke and mortality rate for isolated CEA was significantly influenced by female gender (p = 0.050), by the urgency of intervention (p = 0.026), and by carotid reoperations (p = 0.024). Gender (p = 0.030) and urgency (p = 0.040) also were associated with differences in the stroke rate alone; furthermore, the incidence of perioperative stroke was higher in conjunction with synthetic patching (odds ratio, 2.6; 95% confidence interval, 1.2 to 5.3) and was marginally higher with primary arteriotomy closure (odds ratio, 2.7; 95% confidence interval, 0.8 to 9.5) compared with vein patch angioplasty (1.3%). The method used to repair the arteriotomy was the only independent factor that qualified for the multivariable composite stroke and mortality models that were applied to the combined CEA-CABG procedures, but too few patients in this cohort had synthetic patches or primary closure to validate the perceived superiority of vein patching. CONCLUSIONS Prospective outcome assessment is essential to reconcile the indications for CEA with its actual results, and it may lead incidentally to important observations concerning patient care.

Cryopreservation and Thawing Is Associated with Varying Extent of Activation of Apoptotic Machinery in Subsets of Ejaculated Human Spermatozoa

Abstract We investigated the impact of cryopreservation and thawing on levels of caspases-3, -8, and -9 activity, intact mitochondrial membrane potential (Δψm), and DNA fragmentation in human spermatozoa. Eleven pools of cryopreserved and eight pools of fresh semen samples were examined. Mature and immature fractions were separated on a two-layer density gradient (47% and 90%) and further subdivided based on the externalization of phosphatidylserine and its binding to annexin V-labeled superparamagnetic microbeads (ANMB). Levels of activated caspases were assessed using fluorescein-labeled inhibitors of caspases (FLICA), Δψm using a lipophilic cationic dye, and DNA fragmentation by the terminal deoxynucleotidyl transferase-mediated dUTP nick end-labeling (TUNEL) assay. Cryopreservation was significantly associated with activation of caspases-3, -8, and -9, as well as disruption of the mitochondrial membrane potential but no significant changes were observed in DNA fragmentation. In mature sperm, caspase activation was only detected in the ANMB+ fraction, whereas in immature sperm, both ANMB+ and ANMB− fractions showed activated caspase levels. In ANMB+ immature sperm, apoptosis seemed to be triggered by a surface ligand-receptor mechanism as well as by disruption of mitochondria, whereas in ANMB− immature sperm, apoptosis was induced by activation of caspase-9 following loss of intact Δψm. These results demonstrate that selection of annexin V-negative mature spermatozoa might be of clinical relevance for fertility preservation, as this sperm fraction shows no activated apoptosis during the cryopreservation process.

Seizure outcome after temporal lobectomy for temporal lobe epilepsy A Kaplan-Meier survival analysis

Objective: To determine seizure outcome and its predictors in patients with medically refractory temporal lobe epilepsy (TLE) after temporal lobectomy (TL). Background: TL is the most common surgical procedure performed in adolescents and adults for the treatment of medically refractory TLE. Seizure outcome has been reported extensively during the first few postoperative years, but little is known beyond that time. Methods: The authors analyzed seizure outcome in 79 patients who underwent TL for epilepsy at the Duke University Medical Center from 1962 through 1984. Patients with less than 2 years of follow-up and degenerative disorders were excluded. Predictors of seizure outcome were analyzed using Kaplan-Meier survival analyses. Results: The mean follow-up was 14 years (range, 2.1 to 33.6 years). Using Engel’s classification, 65% of patients were class I, 15% were class II, 11% were class III, and 9% were class IV. At least one postoperative seizure occurred in 55% of subjects. The majority of recurrences (86%) took place within 2 years of surgery. Later recurrences tended not to lead to medical intractability. Higher monthly preoperative seizure frequency was associated with poor seizure outcome. A seizure-free state at 2 years was found to be a better predictor of long-term outcome than the 6-, 12-, and 18-month landmarks. Conclusions: TL provides sustained, long-term benefit in patients with medically refractory TLE. Seizure-free status at 2 years from the time of surgery is predictive of long-term remission.

Relation between perioperative hypertension and intracranial hemorrhage after craniotomy.

Background Previous data suggest that systemic hypertension (HTN) is a risk factor for postcraniotomy intracranial hemorrhage (ICH). The authors examined the relation between perioperative blood pressure elevation and postoperative ICH using a retrospective case control design. Methods The hospital’s database of all patients undergoing craniotomy from 1976 to 1992 was screened. Coagulopathic and unmatchable patients were excluded. There were 69 evaluable patients who developed ICH postoperatively (n = 69). A 2-to-1 matched (by age, date of surgery, pathologic diagnosis, surgical procedure, and surgeon) control group without postoperative ICH was assembled (n = 138). Preoperative, intraoperative, and postoperative blood pressure records (up to 12 h) were examined. Incidence of perioperative HTN (blood pressure ≥ 160/90 mmHg) and odds ratios for ICH were determined. Results Of the 11,214 craniotomy patients, 86 (0.77%) suffered ICH, and 69 fulfilled inclusion criteria. The incidence of preoperative HTN was similar in the ICH (34%) and the control (24%) groups. ICH occurred 21 h (median) postoperatively, with an interquartile range of 4–52 h. Sixty-two percent of ICH patients had intraoperative HTN, compared with only 34% of controls (P < 0.001). Sixty-two percent of the ICH patients had prehemorrhage HTN in the initial 12 postoperative hours versus 25% of controls (P < 0.001), with an odds ratio of 4.6 (P < 0.001) for postoperative ICH. Hospital stay (median, 24.5 vs. 11.0 days), and mortality (18.2 vs. 1.6%) were significantly greater in the ICH than in the control groups. Conclusions ICH after craniotomy is associated with severely prolonged hospital stay and mortality. Acute blood pressure elevations occur frequently prior to postcraniotomy ICH. Patients who develop postcraniotomy ICH are more likely to be hypertensive in the intraoperative and early postoperative periods.

Accuracy of office-based ultrasonography of the shoulder for the diagnosis of rotator cuff tears

BACKGROUND This prospective multi-institutional study was designed to define the accuracy of ultrasonography, when performed in an orthopaedic surgeons office, for the diagnosis of rotator cuff tears. METHODS An anatomic diagnosis and a treatment plan were made on the basis of office-based shoulder ultrasonography, physical examination, and radiographs for ninety-eight patients (ninety-nine shoulders) with a clinical diagnosis of a rotator-cuff-related problem. The results of the ultrasonographic studies were then compared with the results of magnetic resonance imaging and the operative findings. RESULTS Office-based ultrasonography led to the correct diagnosis for thirty-seven (88%) of forty-two shoulders with a full-thickness rotator cuff tear or both full and partial-thickness tears, twenty-six (70%) of thirty-seven shoulders with a partial-thickness rotator cuff tear only, and sixteen (80%) of twenty shoulders with normal tendons. In no case was the surgical approach (open or arthroscopic) that had been planned on the basis of the ultrasonography altered by the operative findings, but the operative finding of a full-thickness tear resulted in an arthroscopic cuff repair in four shoulders. Magnetic resonance imaging led to the correct diagnosis for forty (95%) of forty-two shoulders with a full-thickness rotator cuff tear or both full and partial-thickness rotator cuff tears, twenty-seven (73%) of thirty-seven shoulders with only a partial-thickness tear, and fifteen (75%) of twenty shoulders with normal tendons. There were no significant differences between magnetic resonance imaging and ultrasonography with regard to the correct identification of a full-thickness tear or its size. The sensitivity of ultrasonography for detecting tear size in the anterior-posterior dimension was 86% (95% confidence interval, 71% to 95%), and that of magnetic resonance imaging was 93% (95% confidence interval, 81% to 99%) (p = 0.26). The sensitivity of ultrasonography for detecting tear size in the medial-lateral dimension was 83% (95% confidence interval, 69% to 93%), and that of magnetic resonance imaging was 88% (95% confidence interval, 74% to 96%) (p = 0.41). CONCLUSIONS A well-trained office staff and an experienced orthopaedic surgeon can effectively utilize ultrasonography, in conjunction with clinical examination and a review of shoulder radiographs, to accurately diagnose the extent of rotator cuff tears in patients suspected of having such tears. Errors in diagnosis made on the basis of ultrasonography most often consist of an inability to distinguish between partial and full-thickness tears that are approximately 1 cm in size. In this study, such errors did not significantly affect the planned surgical approach.