Gabriel E. Mena

A call for new standard of care in perioperative gynecologic oncology practice: Impact of enhanced recovery after surgery (ERAS) programs

Enhanced recovery after surgery (ERAS) programs aim to hasten functional recovery and improve postoperative outcomes. However, there is a paucity of data on ERAS programs in gynecologic surgery. We reviewed the published literature on ERAS programs in colorectal surgery, general gynecologic surgery, and gynecologic oncology surgery to evaluate the impact of such programs on outcomes, and to identify key elements in establishing a successful ERAS program. ERAS programs are associated with shorter length of hospital stay, a reduction in overall health care costs, and improvements in patient satisfaction. We suggest an ERAS program for gynecologic oncology practice involving preoperative, intraoperative, and postoperative strategies including; preadmission counseling, avoidance of preoperative bowel preparation, use of opioid-sparing multimodal perioperative analgesia (including loco-regional analgesia), intraoperative goal-directed fluid therapy (GDT), and use of minimally invasive surgical techniques with avoidance of routine use of nasogastric tube, drains and/or catheters. Postoperatively, it is important to encourage early feeding, early mobilization, timely removal of tubes and drains, if present, and function oriented multimodal analgesia regimens. Successful implementation of an ERAS program requires a multidisciplinary team effort and active participation of the patient in their goal-oriented functional recovery program. However, future outcome studies should evaluate the efficacy of an intervention within the pathway, include objective measures of symptom burden and control, study measures of functional recovery, and quantify outcomes of the program in relation to the rates of adherence to the key elements of care in gynecologic oncology such as oncologic outcomes and return to intended oncologic therapy (RIOT).

Impact of smoking on perioperative pulmonary and upper respiratory complications after laparoscopic gynecologic surgery

OBJECTIVE To determine the impact of smoking on the rate of pulmonary and upper respiratory complications following laparoscopic gynecologic surgery. METHODS We retrospectively identified all patients who underwent laparoscopic gynecologic surgery at one institution between January 2000 and January 2009. Pulmonary and upper respiratory complications were defined as atelectasis, pneumonia, upper respiratory infection, acute respiratory failure, hypoxemia, pneumothorax, or pneumomediastinum occurring within 30 days after surgery RESULTS Nine hundred three patients underwent attempt at laparoscopic surgery. Fifty-four were excluded because of conversion to laparotomy and 31 because of insufficient data. Of the 818 patients included, 356 (43%) had cancer. A total of 576 (70%) patients were never smokers, 156 (19%) were past smokers, and 86 (10%) were current smokers (smoked within 6 weeks before surgery). These three groups were similar with regard to median body mass index, operative time, and length of hospital stay. Compared to never and past smokers, current smokers were more likely to undergo high-complexity laparoscopic procedures (10.4%, 15.4%, and 19.8%, respectively; p=0.015) and had younger median age 49 years, 51 years, and 46 years, respectively; p=0.035. Nineteen (2.3%) patients experienced pulmonary complications - symptomatic atelectasis (n=9), pneumonia (n=5), acute respiratory failure (n=2), hypoxemia (n=1), pneumomediastinum (n=1), and pneumothorax (n=2). The rate of pulmonary complications was 2.1% (12 of 564 patients) in never smokers, 4.5% (7 of 156 patients) in past smokers, and zero in current smokers. CONCLUSION In this cohort, smoking history did not appear to impact postoperative pulmonary and upper respiratory complications. In smokers scheduled for operative procedures, laparoscopy should be considered when feasible.

Pain Management in an Enhanced Recovery Pathway After Thoracic Surgical Procedures

Pain management is the backbone of enhanced recovery after thoracic surgery (ERATS) care maps, which aim to save time in the operating room, shorten hospital stays, and reduce pain-related adverse events. We describe a systematic approach developed at our institutions to manage pain in patients undergoing thoracic surgical procedures.

Severe perioperative bleeding in renal cell carcinoma after elective pericardiocentesis associated left ventricular puncture: case report

In the United States during the year 2015, approximately 61,560 patients are expected to be diagnosed with kidney cancer and 14,080 to die from the disease. We present the case of a patient with renal cell carcinoma who suffered severe perioperative bleeding and coagulopathy after emergency sternotomy. We also engage in relevant aspects of perioperative anesthesia care including the considerations and management of coagulopathy, liver failure and renal failure in the oncologic patient. The case is a 49-year-old man with vena cava tumor thrombus who underwent radiologic tumor embolization, left radical nephrectomy, and inferior vena cava (IVC) thrombectomy. Postoperatively, he developed sepsis, multiple organ failure, and a pericardial effusion requiring pericardiocentesis. During pericardiocentesis, he suffered an iatrogenic left entricular perforation, requiring an emergency sternotomy and left ventricular repair. Cancer patients are often challenging for surgical and anesthesia teams, emergency care requires an organized and comprehensive approach. The use of recombinant factor VIIa NovoSeven can help in managing severe postoperative bleeding after cardiothoracic surgery in oncologic patients, but further studies should be done to confirm this.

Summary Comment to: “Severe Perioperative Bleeding in Renal Cell Carcinoma after Elective Pericardiocentesis Associated Left Ventricular Puncture: Case Report”

After the publication of our work “Severe Perioperative Bleeding in Renal Cell Carcinoma after Elective Pericardiocentesis Associated Left Ventricular Puncture: Case Report”, we have received comments from our coworkers and colleagues at other institutions in reference to our approach in this difficult case [1]. Sharing the experiences of surgical and anesthetic teams when facing adverse situations in the management of cancer patients can help health professionals to better understand the complexity of pathophysiologic processes and the course of action that could benefit the patient. In this letter, we want to highlight the most relevant aspects discussed in this article as well as give a concise message that, hopefully, can help in the management of cancer patients in this particular situation.

Anesthetic Considerations for Mediastinal Staging Procedures for Lung Cancer

Tumor staging is critical for the treatment of lung malignancies. Invasive techniques of lung tumor staging can be accomplished via mediastinoscopy, endobronchial ultrasound, and video-assisted thoracoscopy. Anesthesiologists taking care of patients undergoing mediastinal staging procedures might face different challenges. In this narrative review, the authors summarize the literature on the anesthetic considerations for mediastinal staging procedures.

Bowel surgery in an Enhanced Surgical Recovery Programme (ESRP) for gynaecologic surgery: Is recovery still enhanced or do we need to take a step back?

Objectives: The aim of this study was to assess the impact of ERAS approach (“fluid restrictive & drainless”) on open liver resections for HCC comparing their outcome with open resections in pre-ERAS period and with laparoscopic surgery. Methods: 207 patients undergoing minor liver resection for HCC were divided into three groups: Group A, open minor resections in pre-ERAS period (95 patients); Group B, laparoscopic ERAS resections (55 patients); Group C, open ERAS resections (57 patients). Results: Blood loss was lower in group C and B compared with group A. Postoperative morbidity was 26.5% in group A, 16.3% in group B and 12.1% in group C (p<0.05). Ascites was less frequent in group B (7.5%) and C (6.2%) compared with group A (12%). Median time for functional recovery in groups B (3 days) and C (3 days) was shorter compared with group A (5 days). Conclusion: The laparoscopic approach was associated with reduced blood loss and postoperativemorbidity. In patients who are not candidates to minimally-invasive approach, ERAS management seems to be associated with a reduction in blood loss and postoperative morbidity. Results achieved in this group of patients were more similar to those of laparoscopy than to pre-ERAS open surgery. Disclosure of interest: None declared.

Implementation of an Enhanced Surgical Recovery Programme (ESRP) in gynaecologic oncology: Has the development of a preoperative order set improved compliance for preventive analgesia and deep venous thromboembolic (DVT) prophylaxis?

Javier D. Lasala , Jagtar Singh Heir , Gabriel E. Mena , Alpa M. Nick , Larissa A. Meyer , Maria D. Iniesta , Mark F. Munsell , Gloria Salvo , Juan P. Cata , Ifeyinwa Ifeanyi , Vijaya Gottumukkala , Katherine E. Cain , Pedro T. Ramirez . Anaesthesiology, University of Texas MD Anderson Cancer Center, Houston, United States; Gyn Onc & Reproductive Med, University of Texas MD Anderson Cancer Center, Houston, United States; Biostatistics, University of Texas MD Anderson Cancer Center, Houston, United States; 4 Pharmacy Clinical Programs, University of Texas MD Anderson Cancer Center, Houston, United States