Sunil Kumar Sahai

Serum brain naturietic peptide measurements reflect fluid balance after pancreatectomy

BACKGROUND Overaggressive fluid resuscitation in elderly patients requiring pancreatectomy can delay recovery and increase morbidity. Despite advancements, no accurate and reproducible methods exist to evaluate effective intravascular volume status in the postoperative setting. We hypothesized that sequential measurement of currently available serum proteins will indicate fluid balance. STUDY DESIGN Clinicopathologic (n = 44) and echocardiogram (echo) data (n = 18) were collected on patients receiving pancreatectomy or diagnostic laparoscopy (n = 5). Measured fluid balance, serum BUN, creatinine (CR), and brain natriuretic peptide (BNP) levels were recorded on postoperative days (POD) 1 to 7 (only POD1 for diagnostic laparoscopy). ANOVA and bivariate random effect models examined the correlation between BNP and BUN/CR and fluid balance. Linear mixed-effect models examined the correlation between factors associated with vascular stiffness and BNP, BUN/CR, and fluid balance. RESULTS On POD1 after diagnostic laparoscopy, the fluid balance was positive by 3,265 mL and was accompanied by a >300-point increase in BNP (p = 0.0083). After pancreatectomy, a similar increase in BNP (250 pg/mL) and fluid balance (4,492 mL) on POD1 was observed. During the return to euvolemia, the change in serum BNP levels correlated with fluid balance changes during POD 1 to 3 (p = 0.039), and BUN/CR levels correlated with fluid balance during POD 4 to 7. Patients with risk factors associated with cardiovascular stiffness or echo evidence of poor compliance experienced higher BNP during the postoperative period. CONCLUSIONS Fluid loading at surgery is accompanied by an increase in serum BNP, and return to a balanced fluid state after pancreatectomy is paralleled by changes in BNP and BUN/CR levels.

Meta-analysis of cardiovascular toxicity risks in cancer patients on selected targeted agents

PurposeThe purpose was to estimate the risk and severity of cardiovascular toxicities associated with selected targeted agents.MethodsWe searched English-language literature for randomized clinical trials published between January 1, 2000 and November 30, 2013 of targeted cancer therapy drugs approved by the FDA by November 2010. One hundred ten studies were eligible. Using meta-analytic methods, we calculated the relative risks of several cardiovascular toxicities [congestive heart failure (CHF), decreased left ventricular ejection fraction (DLVEF), myocardial infarction (MI), arrhythmia, and hypertension (HTN)], adjusting for sample size using the inverse-variance technique. For each targeted agent and side effect, we calculated the number needed to harm. Results: Regarding CHF, trastuzumab showed significantly greater risk of all-grade and high-grade CHF. There was significant increased risk of all-grade DLVEF with sorafenib, sunitinib, and trastuzumab and high-grade DLVEF with bevacizumab and trastuzumab. Sorafenib was associated with significant increased all-grade risk of MI based on one study. None was associated with high-grade risk of MI or increased risk of arrhythmia. Bevacizumab, sorafenib, and sunitinib had significant increased risk of all-grade and high-grade HTN.ConclusionsSeveral of the targeted agents were significantly associated with increased risk of specific cardiovascular toxicities, CHF, DLVEF, and HTN. Several had significant increased risk for high-grade cardiovascular toxicities (CHF, DLVEF, and HTN). Patients receiving such therapy should be closely monitored for these toxicities and early and aggressive treatment should occur. However, clinical experience has demonstrated that some of these toxicities may be reversible and due to secondary effects.

Meta-analysis: Risk of congestive heart failure (CHF) in selected targeted agents.

64 Background: Congestive heart failure (CHF) is among the most serious cardiovascular side effects of targeted agents (TA) impacting the clinical outcomes (including survival) of cancer patients on this therapy. Although clinical trials have reported this toxicity, often sample sizes are small and systemic evaluations are lacking. The objective of this study is to estimate risk and severity of CHF due to selected TAs. METHODS We identified 110 English language studies of 26 TAs approved by the Food and Drug Administration as of November 2013 via MEDLINE. Of those, 8 studies including nearly 8000 patients provided TA-related data on the incidence and severity of CHF. Using meta-analytic methods, we calculated the relative risks of CHF, adjusting for sample size using the inverse variance technique. For each TA, we also determined the number needed to harm. RESULTS See table. CONCLUSIONS In 5 studies including more than 7,000 patients, trastuzumab showed significantly greater risk of CHF. For every 9 patients treated with trastuzumab, there was 1 additional case of CHF compared to control regimens. A careful patient selection before therapy and early detection of CHF by judicious monitoring of patients on this therapy may prevent serious complications and allow maintenance of cancer treatment. [Table: see text].

Perioperative Implications of Neoadjuvant Therapies and Optimization Strategies for Cancer Surgery

Patients with cancer having either cancer- or non-cancer-related surgery present to the perioperative clinician with a unique set of challenges. Adequate assessment, risk stratification, and optimization of these patients requires the perioperative physician to be familiar with the natural history of the cancer, the systemic effects of the malignant disease on the body, and also the effects of neoadjuvant treatments on the major organ systems. Deconditioning is a multisystem disorder that is related to cancer treatments, sedentary lifestyle, and the malignant disease itself. It is being increasingly recognized as condition that is amenable to reversal with appropriate “prehabilitation” strategies. This article will give the reader an overview of the perioperative issues and optimization strategies for patients awaiting cancer surgery.

Perioperative Medical Evaluation of the Patient Undergoing RARP

Prostate cancer surgery is an elective event that is designed to prevent progression and metastases that are predicted to occur many years from diagnosis without curative therapy. Therefore perioperative deaths or significant comorbidity represent a significant detriment in the impact of surgery compared to watchful waiting. While surgeons may commonly utilize a patient’s primary and specialty medical teams to prepare one for surgery, large institutions such as the University of Texas MD Anderson Cancer Center have dedicated departments designed to assist with the medical issues surrounding cancer therapy. In this chapter, the director of MD Anderson’s Internal Medicine Perioperative Assessment Center (IMPAC) outlines the indications and strategies available to optimize a patient’s journey towards a safe surgical cure.

Preoperative Evaluation of the Oncology Patient

This review focuses on the unique perioperative concerns of patients with cancer undergoing surgery. Importantly, not all surgical procedures are intended as cures: some patients who have cancer also undergo surgery for noncancer issues. Also, many of these patients have undergone prior chemotherapy and/or radiation therapy that can introduce perioperative concerns. These previous treatments, unique to patients with cancer, can adversely affect their cardiovascular, pulmonary, gastrointestinal, renal, and endocrine systems. This article also summarizes many important effects of a wide variety of chemotherapy agents in use today.