Maged Mikhail

Radical Cystectomy in the Treatment of Invasive Bladder Cancer: Long-Term Results in 1,054 Patients

PURPOSE To evaluate our long-term experience with patients treated uniformly with radical cystectomy and pelvic lymph node dissection for invasive bladder cancer and to describe the association of the primary bladder tumor stage and regional lymph node status with clinical outcomes. PATIENTS AND METHODS All patients undergoing radical cystectomy with bilateral pelvic iliac lymphadenectomy, with the intent to cure, for transitional-cell carcinoma of the bladder between July 1971 and December 1997, with or without adjuvant radiation or chemotherapy, were evaluated. The clinical course, pathologic characteristics, and long-term clinical outcomes were evaluated in this group of patients. RESULTS A total of 1,054 patients (843 men [80%] and 211 women) with a median age of 66 years (range, 22 to 93 years) were uniformly treated. Median follow-up was 10.2 years (range, 0 to 28 years). There were 27 (2.5%) perioperative deaths, with a total of 292 (28%) early complications. Overall recurrence-free survival at 5 and 10 years for the entire cohort was 68% and 66%, respectively. The 5- and 10-year recurrence-free survival for patients with organ-confined, lymph node-negative tumors was 92% and 86% for P0 disease, 91% and 89% for Pis, 79% and 74% for Pa, and 83% and 78% for P1 tumors, respectively. Patients with muscle invasive (P2 and P3a), lymph node-negative tumors had 89% and 87% and 78% and 76% 5- and 10-year recurrence-free survival, respectively. Patients with nonorgan-confined (P3b, P4), lymph node-negative tumors demonstrated a significantly higher probability of recurrence compared with those with organ-confined bladder cancers (P <.001). The 5- and 10-year recurrence-free survival for P3b tumors was 62% and 61%, and for P4 tumors was 50% and 45%, respectively. A total of 246 patients (24%) had lymph node tumor involvement. The 5- and 10-year recurrence-free survival for these patients was 35%, and 34%, respectively, which was significantly lower than for patients without lymph node involvement (P <.001). Patients could also be stratified by the number of lymph nodes involved and by the extent of the primary bladder tumor (p stage). Patients with fewer than five positive lymph nodes, and whose p stage was organ-confined had significantly improved survival rates. Bladder cancer recurred in 311 patients (30%). The median time to recurrence among those patients in whom the cancer recurred was 12 months (range, 0.04 to 11.1 years). In 234 patients (22%) there was a distant recurrence, and in 77 patients (7%) there was a local (pelvic) recurrence. CONCLUSION These data from a large group of patients support the aggressive surgical management of invasive bladder cancer. Excellent long-term survival can be achieved with a low incidence of pelvic recurrence.

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.

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.

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

Myocardial Ischemia Complicating Therapy of Status Asthmaticus

Received for publication November 1986, revised January 1987, and accepted March 1987. THE EFFICACY of intravenous isoproterenol for severe status asthmaticus in children is well documented. 1-5 Intravenous sympathomimetics can often alleviate problems associated with intubating and mechanically ventilating such patients. Toxicity with these drugs, however, has induced myocardial ischemia6 and fatal myocardial infarction7 in two children with asthma who had no history of heart disease. This report describes the occurrence of severe myocardial ischemia in a child with asthma during the treatment of severe status asthmaticus.

Bronchial air leak during transhiatal esophagectomy

T HE ANESTHETIC and surgical management of esophagectomy are challenging because of the anatomic location of the esophagus in the posterior mediastinum, where it is in close proximity to the aorta, heart, and tracheobronchial tree. Esophagectorny may be accomplished either by a partially blinded, blunt dissection through the esophageal hiatus or under direct vision via thoracotomy. Traditionally, a thoracotomy combined with upper abdominal and neck incisions has been preferred because of the excellent surgical exposure gained. The transhiatal approach, which uses only an upper abdominal incision together with a neck incision, has gained popularity. This technique appears to have fewer adverse effects on postoperative respiratory function and is associated with decreased incidence of respiratory complications.l,2 Transhiatal esophagectomy (THE) also decreases the overall operative time. 3,4 Anesthetic management of THE may be less complicated because this approach does not require single-lung ventilation; however, the blunt transhiatal dissection can increase intraoperative blood loss. 4 Brisk bleeding may occur from the azygous vein, aberrant vessels from the aorta, or splenic and hepatic injuries. 5-7 Moreover, multiple adhesions resulting from cancer or coexisting inflammation potentially increase the risk of vascular and tracheobronchial injury. Although the risks of pneumothorax, hypotension from transient obstruction of venous return, arrhythmias, and massive bleeding are generally recognized, s,9 that of tracheobronchial injury has not been emphasized in the anesthesia literature. This case report describes a patient who experienced a sudden decrease in minute ventilation during THE that was caused by a bronchial leak during dissection and mobilization of the esophagus. direct laryngoscopy without difficulty. Five milliliters of air was placed in the endotracheal tube cuff, and no air leak was detectable. Anesthesia was maintained with isoflurane and supplemental doses of vecuronium, fentanyl, and ketamine. The patient was ventilated with an Ohmeda Modulus CD machine using a tidal volume of 700 mL and rate of 10 breaths/rain with peak airway pressures of 22 cmI-IzO. Right radial artery and fight internal central jugular catheters were placed. The patient was positioned supine, and surgery proceeded without incident. During the transhiatal mobilization of the esophagus, the ventilator bellows were suddenly noted to collapse with a 4 L/rain fresh gas flow into the circle breathing system. Tidal volume could be maintained only with a minimal fresh gas flow of 8 L/min. The inspired oxygen concentration was increased from 60% to 100%. The endotracheal pilot balloon was checked and found to be intact. Breath sounds were auscultated and noted to be present and equal bilaterally. The ventilator circuit was checked for a gas leak, and the possibility of ventilator malfunction was ruled out. Arterial saturation remained greater than 97% by pulse oximetry. The surgeons were notified of the large air leak and asked to inspect the surgical field. On close examination of the mediastinum through the esophageal hiatus, a large air leak, originating from the left lower lobe bronchus just below the carina, was found. Ventilation was accomplished by rapid low-pressure breaths that facilitated surgical repair of the bronchial leak. After the repair, the suture line was tested and showed no sign of a gas leak at sustained airway pressures of 40 cmH20, Flexible bronchoscopy was also performed to evaluate the repair and exclude narrowing of the lef~ bronchial lumen, The patient was then ventilated with smaller tidai volumes (450 mL) for the remainder of the operation, At the completion of the surgery, the epidural catheter was activated with 10 mL of bupivacaine 0.25%. The patient was then extubated under deep anesthesia to avoid any coughing on the endotracheal tube. He recovered from the anesthesia and surgery uneventually and was discharged from the hospital on the l l th postoperative day.

Atrioventricular block secondary to straining

Cardiac arrest while straining during a bowel movement is not unusual in elderly patients. Sinus bradycardia caused by increased vagal tone can lead to severe myocardial and cerebral hypoperfusion with cardiac arrest. We describe a female postoperative patient who, while straining on a bedside commode, developed varying degrees of atrioventricular heart block, necessitating placement of a permanent pacemaker.

Pain relief and sedation in the intensive care unit

p , AIN, fear, and anxiety are common and often overlooked problems in patients in the intensive care unit (ICU). Holland et al 1 have shown that sedative and pain medications are often prescribed to satisfy the expectations of the medical staff or to provide a convenient nursing condition rather than in response to the actual needs and fears of the patient? Pain, fear, and anxiety influence many aspects of the physician-patient relationship. Appropriate relief is often associated with amelioration of the patients complaints even if the underlying disease is not controlled. Historically, even before the advancement of Western medicine, pain and discomfort have concerned every patient and physician and every attempt was taken to alleviate them, frequently without much success. Despite major advances in technology, pharmacology, and pain management techniques, pain in the ICU patient remains largely underevaluated and poorly treated. Discomfort, pain, fear, anxiety, and sleep deprivation result in physiologic and psychological stress with important sequelae. TM Hemodynamic disturbances from catecholamine release may be manifested as hypertension, tachycardia, and cardiac arrhythmias. A neuroendocrine stress response increases production of adrenocorticoid hormones (corticotropin, cortisol, and aldosterone), angiotensin, antidiuretic hormone, and catecholamines, resulting in hyperglycemia, protein catabolism, fluid retention, and electrolyte disturbances. The negative protein balance can lead to poor wound healing and a depressed immune response. The circadian rhythm is reversed, leading to further neuroendocrine and sleep disturbances, s-7 Psychological consequences of pain include insomnia, depression, anxiety, and psychosis. s-t~ It is not surprising that the posttraumatie stress disorder is increasingly reported among patients with the adult respiratory distress syndrome who have been on ventilators. Moreover, patients who are placed on high doses of opiates and benzodiazepines often subsequently develop acute withdrawal states. PROBLEM AREAS IN CRITICALLY ILL PATIENTS

MANAGING EXPECTATIONS BEFORE THE CANCER INTENSIVE CARE UNIT

Sir: The last decade has seen major advances in both the surgical and medical approaches to cancer. This, combined with the advent of new medical technologies has markedly affected the oncologists attitude towards cancer patients. Where once optimism was reserved for only a select few, now it is offered perhaps more often than it should be. This untempered enthusiasm can lead to unrealistic patient and family expectations and cause difficulties later on in the Intensive Care Unit (ICU). This imbalance of family and patient expectations versus medical reality can be most acutely felt when the issue of a Do Not Resuscitate (DNR) order is breached. The oncologist is justifiably buoyed by the recent advances in chemotherapy, radiation therapy, and more aggressive surgical approaches. However, the transference of that enthusiasm can often cause problems later on as the patient ultimately deteriorates to an ICU setting. The intensivist can face poorly managed family and patient expectations which can lead to a delay in obtaining a DNR order when the appropriate time has come. This can place the intensivist in the uncomfortable position of deciding whether to withhold costly medical interventions, at the end of life, which ultimately will not affect patient outcome. Managing patient and family expectations from the beginning, by guiding them through all of the possible stages of the disease process, makes logical sense both ethically, economically, and legally. A wellinformed family who knows the expected course of the disease process is far less likely to sue later for a perceived bad outcome. In some instances the ICU is the place where the family ultimately gains an acceptance of the patients terminal condition. Unfortunately, the intensivist is often called upon to treat and manage a terminal condition aggressively with invasive monitors, ventilator therapy, and ionotropic drugs only to withdraw support abruptly once an acceptance of futility is reached. In this instance the ICU is unintentionally used to facilitate a DNR status, by demonstrating the medical futility of the situation through the show of intensive care measures. Intensivists are caught in the ethical, medical, and legal dilemma of whether to use inotropic drugs in such situations, while at the same time the nursing team becomes frustrated and confused as to the true status of the patient. The ICU is then transformed into a high-priced hospice, which can lead to disillusionment on the part of the entire ICU team. Managing patient and family expectations through early preparation and discussion of the entire possible disease course is recommended to avoid problems with DNR status when the patient ultimately ends up in the ICU. Well managed expectations will result in conservation of scarce ICU resources, improved physician-family relations, reduced stress on the ICU care team, and a more ethically and legally sound basis for removal of care in terminal situations.