Javier Lasala

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).

Association between Perioperative Blood Transfusions and Clinical Outcomes in Patients Undergoing Bladder Cancer Surgery: A Systematic Review and Meta-Analysis Study.

Background. Perioperative blood transfusions are associated with poor survival in patients with solid tumors including bladder cancer. Objective. To investigate the impact of perioperative blood transfusions on oncological outcomes after radical cystectomy. Design. Systematic review and meta-analysis. Setting and Participants. Adult patients who underwent radical cystectomy for bladder cancer. Intervention. Packed red blood cells transfusion during or after radical cystectomy for bladder cancer. Outcome Measurements and Statistical Analysis. Recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS). We calculated the pooled hazard ratio (HR) estimates and 95% confidence intervals by random and fixed effects models. Results and Limitation. Eight, seven, and five studies were included in the OS, CSS, and RFS analysis, respectively. Blood transfusions were associated with 27%, 29%, and 12% reduction in OS, CSS, and RFS, respectively. A sensitivity analysis supported the association. This study has several limitations; however the main problem is that it included only retrospective studies. Conclusions. Perioperative BT may be associated with reduced RFS, CSS, and OS in patients undergoing RC for BC. A randomized controlled study is needed to determine the causality between the administration of blood transfusions and bladder cancer recurrence.

Preoperative Echocardiographic Parameters of Diastolic Dysfunction Did Not Provide a Predictive Value for Postoperative Atrial Fibrillation in Lung and Esophageal Cancer Surgery

OBJECTIVE To evaluate the predictive value of preoperative transthoracic echocardiography in the development of postoperative atrial fibrillation after non-cardiac thoracic surgery. DESIGN This was a retrospective study. SETTING Academic hospital. PARTICIPANTS A total of 703 adult patients with non-small cell lung cancer. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Retrospective data of 177 non-cardiac thoracic surgical oncologic patients undergoing lung or esophageal cancer surgery with preoperative transthoracic echocardiograms (TTE) (within 30 days before surgery) were analyzed. The Wilcoxon rank sum test was used to evaluate the difference in continuous variables. Fishers exact test or the chi-square test was used to evaluate the association between two categoric variables. Logistic regression models were used for multivariate analysis to include important and significant covariates. Among the demographic and echocardiographic variables measured age, systemic hypertension, e` septal, e` lateral and E/e` ratio were significantly different between patients who would develop postoperative atrial fibrillation (POAF) and those who did not. The logistic regression models only identify age as a predictor factor of POAF. CONCLUSIONS These results were similar to those published elsewhere on POAF incidence and risk factors. The preoperative echocardiographic variables in this study did not provide predictive value for POAF in non-cardiac thoracic surgery.

A Randomized Controlled Study of the Use of Video Double-Lumen Endobronchial Tubes Versus Double-Lumen Endobronchial Tubes in Thoracic Surgery

OBJECTIVE To compare the incidence of fiberoptic bronchoscope (FOB) use (1) during verification of initial placement and (2) for reconfirmation of correct placement following repositioning, when either a double-lumen tube (DLT) or video double-lumen tube (VDLT) was used for lung isolation during thoracic surgery. DESIGN A randomized controlled study. SETTING Single-center university teaching hospital. PARTICIPANTS The study comprised 80 patients who were 18 years or older requiring lung isolation for surgery. INTERVENTIONS After institutional review board approval, patients were randomized prior to surgery to either DLT or VDLT usage. Attending anesthesiologists placed the Mallinckrodt DLT or Vivasight (ET View Ltd, Misgav, Israel) VDLT with conventional laryngoscopy or video laryngoscopy then verified correct tube position through the view provided with either VDLT external monitor or FOB. MEASUREMENTS AND MAIN RESULTS Data collected included: sex, body mass index, successful intubation and endobronchial placement, intubation time, confirmation time of tube position, FOB use, quality of view, dislodgement of tube, and ability to forewarn dislodgement of endobronchial cuff and complications. FOB use for verification of final position of the tube (VDLT 13.2% [5/38] v DLT 100% [42/42], p < 0.0001), need for FOB to correct the dislodgement (VDLT 7.7% [1/13] v DLT 100% [14/14], p < 0.0001), dislodgement during positioning (VDLT 61.5% [8/13] v DLT 64.3% [9/14], p = ns), dislodgement during surgery (VDLT 38.5% [5/13] v DLT 21.4% [3/14], p = ns), and ability to forewarn dislodgement of endobronchial cuff (VDLT 18.4% [7/38] v DLT 4.8% [2/42], p = 0.078). CONCLUSION This study demonstrated a reduction of 86.8% in FOB use, which was a similar reduction found in other published studies.

Best practice in the administration of analgesia in postoncological surgery

The rationale for using multimodal analgesia after any major surgery is achievement of adequate analgesia while avoiding the unwanted effects of large doses of any analgesic, in particular opioids. There are two reasons why we can hypothesize that multimodal analgesia might have a significant impact on cancer-related outcomes in the context of oncological orthopedic surgery. First, because multimodal analgesia is a key component of enhanced-recovery pathways and can accelerate return to intended oncological therapy. And second, because some of the analgesic used in multimodal analgesia (i.e., COX inhibitors, local analgesics and dexamethasone) can induce apoptosis in cancer cells and/or diminish the inflammatory response during surgery which itself can facilitate tumor growth.

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.

Lack of Association Between Dexamethasone and Long-Term Survival After Non–Small Cell Lung Cancer Surgery

OBJECTIVE To evaluate the association between the use of intraoperative dexamethasone with an increase in recurrence-free survival (RFS) and overall survival (OS) after non-small cell lung cancer (NSCLC) surgery. DESIGN This was a propensity score-matched (PSM) retrospective study. SETTING Single academic center. PARTICIPANTS The study comprised patients with stage I through IIIa NSCLC. Patients were excluded if they were younger than 18 years, had missing data, and died within 30 days after surgery. MEASUREMENTS AND MAIN RESULTS Primary outcomes of the study were RFS and OS. The data were PSM. RFS and OS were evaluated using univariate and multivariate Cox proportional hazards models after PSM to assess the association between intraoperative dexamethasone use and the primary outcomes. A p value of<0.05 was considered statistically significant. After PSM, 436 patients were included in each treatment group. Adjusting for significant covariates, the multivariate analysis demonstrated no association between the use of dexamethasone and RFS (hazard ratio [95% confidence interval]: 0.98 [0.78-1.24]; p = 0.915). The multivariate analysis also demonstrated no association between the administration of dexamethasone and OS (hazard ratio [95% confidence interval]: 1.08 [0.81-1.44]; p = 0.58). CONCLUSIONS This study demonstrated that intraoperative dexamethasone administration to NSCLC patients was not associated with a significant impact on RFS and OS. The results were similar to a previous study on ovarian cancer patients. A randomized controlled study should be conducted to confirm the results of this study.

S22. History of Airway Management

Introduction: The Wood Library-Museum uses SydneyPlu (SP) as its catalog system to keep track of books, journals, living history interviews, and museum objects. This presentation explains how SP functions, some of the recent audio-visual (AV) additions, and some of the problems associated with data entry and retrieval. Methods: SP is a commercial product existing in the cloud with headquarters in Vancouver. All data entry and retrieval are via the Web, the WLM making the transition from in-house SP in 2010. Currently, the WLM has about 9000 records in SP. Data entry into SP is facilitated by a library of forms to fit the type of artifact being accessed. Including and since his WLM fellowship in 1998, FLS has digitized more than 1000 AV artifacts including reel-to-reel and cassette audio tapes, VHS, and beta video tapes and 16-mm film. Both digitization and cataloging are time-consuming activities. Although only about half through digitizing the van load of material FLS brought to Iowa City in January 2014, he and the WLM staff thought it best to start cataloging the AV material so that at least some could be identified by those desiring to do research in the AV area. Ms Jimenez, along with the SP staff, created a form especially for data entry related to AV material. Data entry for an artifact is not as simple as one might imagine. Terms used to describe the artifact must make sense to those trying to retrieve it. Therefore, SP uses authority fields, similar to drop-down menu items, to restrict the choices allowed for data entry and to simplify searching. MESH key words is an example. Author names is another authority field requiring careful construction. Searching for “Bob Stoelting” and “Robert Stoelting” must give the same results. One of the more difficult considerations, particularly when working with digital files, is where to find the file. If one is looking for a book, it can be found on the shelf using the Dewey Decimal System locator. Digital files are not so easy to track. Currently, FLS has accumulated more than 2500 files and 400 GB of data. These data are backed up X3 on portable hard drives with at least one copy remotely located. Transferring the data to servers at the WLM is a trivial process. What is not trivial is populating the field in SP that points to the location of the file on the WLM servers. YouTube has solved the problem nicely by creating a URL for each file as it is uploaded, allowing public access via a hot link. The situation for the WLM is not the same. Once the record has been initiated, the location of the file on the WLM servers must be entered. Does the WLM want to create a process so that anyone with appropriate credentials can have access to the SP catalog, do a search, find the AV file, and stream it or download it? That means the location field would be a URL. Or, does the WLM want the location field to be a location on its server, thus keeping the file contents totally in house and available only via request? FLS has entered a large amount of data into the file name, making it easier to identify what the file content is, resulting in some very long file names. For entry of the file location, itmay be possible, once the file is present on theWLM server, or even in the cloud, to click and drag the file name to the file locator field. Does the WLM want to rent up to several terabytes of cloud space, making safekeeping of the data someone else’s problem? And lastly, who is the person to enter into SP the location of the file? Results: AV data entry into SP has just begun, using the AV template. The best method of data retrieval is yet to be determined. Conclusion: Cataloging and retrieval of AV material is not a trivial process and is very time consuming.

Perioperative Pain Management

It is estimated that 75% of patients undergoing any surgery in the United States experience inadequate pain control. Surgical pain has the features of nociceptive, inflammatory, and neuropathic pain. Therefore, it has been recommended that more than one analgesic modality (multimodal analgesia) will be necessary to achieve adequate perioperative pain control, thus avoiding the unwanted effects of large doses of single analgesics, in particular opioids. A multimodal analgesic technique entails the preoperative initiation, intraoperative continuation, and postoperative maintenance of a combination of regional anesthesia/analgesia techniques (whenever possible) with two or more systemic analgesics. In the postoperative period, the addition of systemic analgesics is important; in particular when regional anesthesia techniques are discontinued, as during this time patients may experience severe distress and discomfort (“analgesic gap period”).

Systolic anterior motion of the mitral valve—the mechanism of postural hypotension following left intrapericardial pneumonectomy

Systolic anterior motion (SAM) is defined as displacement of the distal portion of the anterior leaflet of the mitral valve toward the left ventricular outflow tract obstruction. SAM can occur in patients without hypertrophic cardiomyopathy (HOCM) and is a well-recognized cause for unexplained sudden hypotension in perioperative settings. We present a case of persistent orthostatic hypotension caused by SAM following left intrapericardial pneumonectomy and mediastinal lymph node dissection for squamous cell carcinoma of the lung invading intrapericardial portion of the inferior pulmonary vein. Diagnosis of SAM was possible with the use of transesophageal echocardiography (TEE).