Perioperative Management Of Patients Research Articles

Advancing cell-based therapy in sepsis: An anesthesia outlook.

Sepsis poses a health challenge globally owing to markedly high rates of morbidity and mortality. Despite employing bundle therapy over two decades, approaches including transient organ supportive therapy and clinical trials focusing on signaling pathways have failed in effectively reversing multiple organ failure in patients with sepsis. Prompt and appropriate perioperative management for surgical patients with concurrent sepsis is urgent. Consequently, innovative therapies focused on remedying organ injuries are necessitated. Cell therapy has emerged as a promising therapeutic avenue for repairing local damage to vital organs and restoring homeostasis during perioperative treatment for sepsis. Given the pivotal role of immune cell responses in the pathogenesis of sepsis, stem cell-based interventions that primarily modulate immune responses by interacting with multiple immune cells have progressed into clinical trials. The strides made in single-cell sequencing and gene-editing technologies have advanced the understanding of disease-specific immune responses in sepsis. Chimeric antigen receptor (CAR)-immune cell therapy offers an intriguing option for the treatment of sepsis. This review provides a concise overview of immune cell therapy, its current status, and the strides made in the context of sepsis research, discussing potential strategies for the management of patients with sepsis during perioperative stages.

Evaluating osteoporosis and bone quality in the aging spine: modern considerations for surgical management in the geriatric population.

Surgical management paradigms of spinal pathologies in the aging population carry inherent substantial risks, with surgical complications being more prevalent among patients with osteoporosis compared to those with normal bone mineral density. In this narrative review, we aim to highlight important clinical understanding and considerations in perioperative evaluation and management of patients elected to undergo spinal surgery. Osteoporosis is a well-defined risk factor for mechanical complications following spinal surgery, and as such, perioperative optimization of bone health in the setting of surgery for geriatric patients remains a critical research area alongside intraoperative surgical augmentation techniques. Surgical techniques to circumvent challenges with instrumentation of poor bone mineral density have included augmentation of pedicle screw fixation, including segmental bicortical screw fixation techniques, cement augmentation with fenestrated screws, or use of expandable pedicle screws to improve bone-implant interface. Judicious selection of treatment modalities and subsequent perioperative optimization is paramount to minimize surgical complications. Contemporary guidelines and evolving paradigms in perioperative evaluation, optimization, and management of the aging spine include the advent of quantitatively evaluating computed tomography (CT) via assessment of the magnitude of Hounsfield units. Prescribing pharmacotherapeutic agents and monitoring bone health requires a multidisciplinary team approach, including endocrinologists and geriatricians to coordinate high-quality care for advanced-age patients who require surgical management of their spinal disorders.

Perioperative management of sarcopenia in patients undergoing major surgeries in Singapore: a modified delphi consensus.

Ageing population is a worldwide phenomenon with correspondingly higher proportion of older patients being treated in the hospital setting. Sarcopenia, which increases with age, has serious negative implications on health, hospitalization and overall postoperative recovery. There is no mutual consensus on perioperative management of sarcopenia in surgical patients in Singapore. The purpose of this study is to create greater clarity pertaining to the recognition of sarcopenia, the application of assessment criteria of sarcopenia and perioperative management of surgical patients in Singapore. A modified Delphi consensus consisting of a panel of experts from Singapore forming a multidisciplinary team, including surgeons, geriatricians, anesthesiologists, physiotherapists and dieticians. Eight recommendations were proposed by the steering committee. Literature search from MEDLINE, Embase and Scopus for articles up till June 2023 were performed to support recommendation statements. The expert panel voted on agreement to recommendation statements and graded the level of evidence supporting each statement through surveys to achieve consensus, set at 85% a priori. The panelists underwent two rounds of anonymized, independent voting before reaching consensus for all eight statements. After the first round, seven statements reached consensus, including the corresponding grading for level of evidence. The statement which did not achieve consensus was revised with supporting literature and after the second round of survey, all eight statements and level of evidence reached consensus, completing the Delphi process. These eight statements covered themes to (1) encourage the identification of sarcopenia, (2) guide pre-operative and (3) post-operative management of sarcopenia. With the varying approaches in perioperative management, poor understanding of and identification of sarcopenia can result in suboptimal management of sarcopenia in surgical patients. Given the abundance of evidence linking beneficial impact on recovery and post-operative complications with prudent management of sarcopenia, it is imperative and urgent to achieve awareness and consensus.

Analysis of the guideline “Perioperative management of patients with coronary artery disease”, “Perioperative management of patients with concomitant pathology of the heart valves” and “Perioperative management of patients with concomitant morbid obesity”: modified Delphi method

INTRODUCTION: The development of clinical and methodological recommendations improves the quality of medical care and reduces the risk of complications. OBJECTIVE: To analyze the methodological recommendations “Perioperative management of patients with coronary heart disease”, “Perioperative management of patients with concomitant pathology of the valvular heart apparatus” and “Perioperative management of patients with concomitant morbid obesity” using the modified Delphi method. MATERIALS AND METHODS: A modified Delphi method was used with two rounds of questionnaires to develop a consensus. The agreement of specialists was reached in three stages: the preparatory stage, the discussion stage and the stage of developing a consensus conclusion. RESULTS: When discussing the methodological recommendation “Perioperative management of patients with coronary heart disease”, a consensus was reached on 35 out of 37 provisions and 7 out of 8 criteria for the quality of medical care. The analysis of the methodological recommendation “Perioperative management of patients with concomitant pathology of the valvular heart apparatus” showed that 57 out of 60 provisions, as well as all 13 criteria for the quality of medical care, were agreed upon. The discussion of the methodological recommendations “Perioperative management of patients with concomitant morbid obesity” showed that 22 of the 23 provisions of the recommendation and all 5 quality criteria were agreed upon. CONCLUSIONS: The results of the Delphic examination, obtained as a result of a detailed analysis by independent experts, will be useful for the co-authors of the discussed methodological recommendations before the planned revision.

Some features of the perioperative management of patients with a tumor of the chiasmal cellaric region: a review

INTRODUCTION: Tumors of the chiasmal-sellar region (CSR) account for more than 20 % of all primary intracranial neoplasms, of which pituitary adenomas account for up to 20 % of the world population. Currently, removal of these neoplasms is performed using endoscopic transsphenoidal surgical accesses. OBJECTIVE: analysis of the results of publications concerning perioperative management of patients with CSO tumors. MATERIAL AND METHODS: publications were searched and selected in bibliographic databases PubMed, Web of Science, Scopus. To study the approach to perioperative management of patients with CSF tumors, the works published from 2013 to 2023 were analyzed. Search keywords: pituitary surgery, anesthesia. Based on the analysis of current problems in anesthesia planning for patients with CSF tumors, the search was expanded with additional keywords: “pituitary tumor”, “perioperative complications”, “endocrine disorders”, “difficult airway”, “acromegaly”, “cardiologic complications, acromegaly”, “peripheral neuropathy, acromegaly”, “trigemino-cardiac reflex”, 206 publications were additionally analyzed and the main key points in anesthesia planning were summarized. A total of 230 publications were included but 161 were excluded. A total of 69 studies were selected. RESULTS: The main features of patients with CSF tumors are: water-electrolyte disorders, cardiovascular pathology, difficult airway. This determines a multidisciplinary approach in preparation for surgery. It is necessary to take into account these features when planning anesthetic support and management of the early postoperative period. In addition, endoscopic transnasal-transsphenoidal access may cause a number of complications: damage to the hypothalamic region and large vessels, and in the postoperative period: respiratory disorders, hormonal insufficiency, Water and Sodium Disturbances. CONCLUSIONS: Additional vigilance is required when preparing a patient with CSF formation for surgery. Perioperative management of a patient with CSO tumor requires a team approach with participation of neurosurgeons, neurologists, ophthalmologists, endocrinologists, cardiologists, anesthesiologists-resuscitators.

Early evaluation of circulating tumor DNA as marker of therapeutic efficacy and prognosis in breast cancer patients during primary systemic therapy

BackgroundWe assessed the potential role of serial circulating tumor DNA (ctDNA) as a biomarker to monitor treatment response to primary systemic therapy (PST) in breast cancer and evaluated the predictive value of ctDNA to further identify patients with residual disease. MethodsWe prospectively enrolled 208 plasma samples collected at three time points (before PST, after 2 cycles of treatment, before surgery) of 72 patients with stage Ⅱ-III breast cancer. Somatic mutations in plasma samples were identified using a customized 128-gene capture panel with next-generation sequencing. The correlation between early change in ctDNA levels and treatment response or long-term clinical outcomes was assessed. Results37 of 72 (51.4%) patients harbored detectable ctDNA alterations at baseline. Patients with complete response showed a larger decrease in ctDNA levels during PST. The median relative change of variant allele fraction (VAF) was −97.4%, −46.7%, and +21.1% for patients who subsequently had a complete response (n = 11), partial response (n = 11), and no response (n = 15) (p = 0.0012), respectively. In addition, the relative change of VAF between the pretreatment and first on-treatment blood draw exhibited the optimal predictive value to tumor response after PST (area under the curve, AUC = 0.7448, p = 0.02). More importantly, early change of ctDNA levels during treatment have significant prognostic value for patients with BC, there was a significant correlation between early decrease of VAF and longer recurrence-free survival compared to those with an VAF increase (HR = 12.54; 95% CI, 2.084 to 75.42, p = 0.0063). ConclusionEarly changes of ctDNA are strongly correlated with therapeutic efficacy to PST and clinical outcomes in BC patients. The integration of preoperative ctDNA evaluation could help improving the perioperative management for BC patients receiving PST.

Perioperative management and outcomes for posterior spinal fusion in patients with Friedreich ataxia: A single-center, retrospective study.

Friedreich ataxia is a rare genetic disorder associated with progressive mitochondrial dysfunction leading to widespread sequelae including ataxia, muscle weakness, hypertrophic cardiomyopathy, diabetes mellitus, and neuromuscular scoliosis. Children with Friedreich ataxia are at high risk for periprocedural complications during posterior spinal fusion due to their comorbidities. To describe our single-center perioperative management of patients with Friedreich ataxia undergoing posterior spinal fusion. Adolescent patients with Friedreich ataxia presenting for spinal deformity surgery between 2007 and 2023 were included in this retrospective case series performed at the Children's Hospital of Philadelphia. Perioperative outcomes were reviewed along with preoperative characteristics, intraoperative anesthetic management, and postoperative medical management. Seventeen patients were included in the final analysis. The mean age was 15 ± 2 years old and 47% were female. Preoperatively, 35% were wheelchair dependent, 100% had mild-to-moderate hypertrophic cardiomyopathy with preserved systolic function and no left ventricular outflow tract obstruction, 29% were on cardiac medications, and 29% were on pain medications. Intraoperatively, 53% had transesophageal echocardiography monitoring; 12% had changes in volume status on echo but no changes in function. Numerous combinations of total intravenous anesthetic agents were used, most commonly propofol, remifentanil, and ketamine. Baseline neuromonitoring signals were poor in four patients and one patient lost signals, resulting in 4 (24%) wake-up tests. The majority (75%) were extubated in the operating room. Postoperative complications were high (88%) and ranged from minor complications like nausea/vomiting (18%) to major complications like hypotension/tachycardia (29%) and need for extracorporeal membrane oxygenation support in one patient (6%). Patients with Friedreich ataxia are at high risk for perioperative complications when undergoing posterior spinal fusion and coordinated multidisciplinary care is required at each stage. Future research should focus on the utility of intraoperative echocardiography, optimal anesthetic agent selection, and targeted fluid management to reduce postoperative cardiac complications.

Tailored therapy with turoctocog alfa pegol according to patient’s lifestyle and hemorrhagic phenotype: from clinical trial to real-life

Although the use of prophylaxis regimens with prolonged half-life factors is now widespread in the world of hemophilia A, there is a lack of real-life evidence on the impact of these products on joint health, adherence, and quality of life of patients. Turoctocog alfa pegol is a glycoPEGylated recombinant factor VIII (FVIII) with an extended half-life (EHL), developed for prophylaxis, treatment of bleeds, and perioperative management in patients with hemophilia A. We report here on three cases of three patients affected by severe hemophilia A, with variable bleeding phenotype and lifestyle, to describe our clinical practice on prophylaxis with turoctocog alfa pegol. As confirmed in our cases, FVIII trough levels remained coherent with those experienced in the registration trial after the switch to the commercial EHL drug. Moreover, the cases highlight how the current clinical management of hemophilia can personalize treatment in several specific conditions.

Applications of artificial intelligence in facial plastic and reconstructive surgery: a systematic review.

Arguably one of the most disruptive innovations in medicine of the past decade, artificial intelligence is dramatically changing how healthcare is practiced today. A systematic review of the most recent artificial intelligence advances in facial plastic surgery is presented for surgeons to stay abreast of the latest in our field. Artificial intelligence applications developed for use in perioperative patient evaluation and management, education, and research in facial plastic surgery are highlighted. Selected themes include automated facial analysis with landmark detection, automated facial palsy grading and emotional assessment, generation of artificial facial profiles for testing and model training, automated postoperative patient communications, and improving ethnicity-sensitive facial morphometry norms. Inherent bias can exist in artificial intelligence models, and care must be taken to utilize algorithms trained with diverse datasets. Artificial intelligence tools are helping clinicians provide more standardized, objective, and efficient care to their patients. Increasing surgeon awareness of available tools, and their widespread implementation into clinical workflows are the next frontier. Ethical considerations must also shape the adoption of any artificial intelligence functionality. As artificial intelligence applications become a fixture in medicine, surgeons must employ them effectively to stay at the vanguard of modern medicine.

Clinical feasibility of the preoperative CALLY index to predict short- and long-term outcomes of gastric cancer patients

Background & AimsGastric cancer (GC) is a major leading cause of cancer-related death worldwide. Systemic inflammation and the nutrition-based score are feasible prognostic markers for malignancies. Emerging evidence has also revealed the C-reactive protein –albumin–lymphocyte (CALLY) index to be a prognostic marker for several cancer types. However, its clinical significance to predict surgical and oncological outcomes of GC patients remains unclear. MethodsWe assessed the preoperative CALLY index in 426 GC patients who received gastrectomy. ResultsA low preoperative CALLY index was significantly correlated to all well-established clinicopathological factors for disease development, including an advanced T stage, the presence of venous invasion, lymphatic vessel invasion, lymph node metastasis, distant metastasis, and an advanced TNM stage. A low preoperative CALLY index was also an independent prognostic factor for overall survival [hazard ratio (HR): 2.64, 95% confidence interval (CI): 1.66–4.2; P<0.0001] and disease-free survival (HR: 1.76, 95% CI: 1.01–3.05; P=0.045). Additionally, a low preoperative CALLY index was an independent predictive factor for postoperative surgical site infection (odds ratio: 2.64, 95% CI: 1.42–4.89; P=0.002). ConclusionsThe preoperative CALLY index is valuable for perioperative and oncological management of GC patients.

Pancreatic surgery and tertiary pancreatitis services warrant provision for support from a specialist diabetes team

Pancreatic surgery units undertake several complex operations, albeit with considerable morbidity and mortality, as is the case for the management of complicated acute pancreatitis or chronic pancreatitis. The centralisation of pancreatic surgery services, with the development of designated large-volume centres, has contributed to significantly improved outcomes. In this editorial, we discuss the complex associations between diabetes mellitus (DM) and pancreatic/periampullary disease in the context of pancreatic surgery and overall management of complex pancreatitis, highlighting the consequential needs and the indispensable role of specialist diabetes teams in support of tertiary pancreatic services. Type 3c pancreatogenic DM, refers to DM developing in the setting of exocrine pancreatic disease, and its identification and management can be challenging, while the glycaemic control of such patients may affect their course of treatment and outcome. Adequate preoperative diabetes assessment is warranted to aid identification of patients who are likely to need commencement or escalation of glucose lowering therapy in the postoperative period. The incidence of new onset diabetes after pancreatic resection is widely variable in the literature, and depends on the type and extent of pancreatic resection, as is the case with pancreatic parenchymal loss in the context of severe pancreatitis. Early involvement of a specialist diabetes team is essential to ensure a holistic management. In the current era, large volume pancreatic surgery services commonly abide by the principles of enhanced recovery after surgery, with inclusion of provisions for optimisation of the perioperative glycaemic control, to improve outcomes. While various guidelines are available to aid perioperative management of DM, auditing and quality improvement platforms have highlighted deficiencies in the perioperative management of diabetic patients and areas of required improvement. The need for perioperative support of diabetic patients by specialist diabetes teams is uniformly underlined, a fact that becomes clearly more prominent at all different stages in the setting of pancreatic surgery and the management of complex pancreatitis. Therefore, pancreatic surgery and tertiary pancreatitis services must be designed with a provision for support from specialist diabetes teams. With the ongoing accumulation of evidence, it would be reasonable to consider the design of specific guidelines for the glycaemic management of these patients.

Staged repair of a ruptured thoracoabdominal aortic aneurysm: a case report

BackgroundA ruptured thoracoabdominal aortic aneurysm (rTAAA) represents a considerable challenge for surgeons. To date, endovascular procedures have not been able to completely replace open repair when debranching is required.Case presentationA 73-year-old man was admitted to our hospital after complaining of left lateral abdominal pain. Enhanced computed tomography revealed a left retroperitoneal hematoma and a large, ruptured Crawford type IV TAAA. We first performed emergency resuscitative surgery to close the lacerated foramen. A graft replacement was performed 1 month after the initial surgery when the patient had stabilized. At 5 years postoperatively, neither occlusion nor anastomotic pseudoaneurysm was noted on computed tomography.ConclusionsWe provide an update on the perioperative management of patients undergoing open rTAAA repair. This procedure can be considered to ensure complete repair of an rTAAA.

The effects of anesthesia on cancer progression and anti-tumor immunity. A review

Introduction: Breast cancer is one of the most common malignancies, treated with primary surgery, or surgery after neoadjuvant chemotherapy. Many studies indicate that the peri-operative period is critical as interference with the immune system may affect prognosis. Whether certain anesthetic agents can affect the immune response and cancer progression is still unresolved. Evidence acquisition: In the current study, we review the existing clinical and experimental studies, in an attempt to extract useful information for clinical application in the anesthesia practice for patients treated with surgery for breast cancer. A bibliographic search in PubMed and ScienceDirect related to the effects of anesthesia on cancer progression and anti-tumor immunity, published from January 2000 till today was performed. Evidence synthesis: All included studies were gathered in a list and they were analysed. A total of 34 studies were found relevant to the subject in PubMed and ScienceDirect. Conclusion: The overall experience suggests that the peri-operative management of cancer patients should focus on the reduction of surgical stress, the minimization of the use of opioids, and the adoption of regional anesthetics. This could have an impact on anti-tumour immunity and the outcome of cancer patients.

Spinal Meningiomas: A Comprehensive Review and Update on Advancements in Molecular Characterization, Diagnostics, Surgical Approach and Technology, and Alternative Therapies.

Spinal meningiomas are the most common intradural, extramedullary tumor in adults, yet the least common entity when accounting for all meningiomas spanning the neuraxis. While traditionally considered a benign recapitulation of their intracranial counterpart, a paucity of knowledge exists regarding the differences between meningiomas arising from these two anatomic compartments in terms of histopathologic subtypes, molecular tumor biology, surgical principles, long-term functional outcomes, and recurrence rates. To date, advancements at the bench have largely been made for intracranial meningiomas, including the discovery of novel gene targets, DNA methylation profiles, integrated diagnoses, and alternative systemic therapies, with few exceptions reserved for spinal pathology. Likewise, evolving clinical research offers significant updates to our understanding of guiding surgical principles, intraoperative technology, and perioperative patient management for intracranial meningiomas. Nonetheless, spinal meningiomas are predominantly relegated to studies considering non-specific intradural extramedullary spinal tumors of all histopathologic types. The aim of this review is to comprehensively report updates in both basic science and clinical research regarding intraspinal meningiomas and to provide illustrative case examples thereof, thereby lending a better understanding of this heterogenous class of central nervous system tumors.

Time trends in opioid use for patients undergoing hip fracture surgery in 1997-2018: A Danish population-based cohort study.

Although opioids are a mainstay for perioperative pain management in hip fracture patients, no studies have described changes in opioid use over the last two decades. The aim of this study was to describe time trends in opioid use in a population-based cohort of patients undergoing a first-time hip fracture surgery during 1997-2018. Opioid-naïve hip fracture patients >55 years old were identified in Danish medical databases (n = 115,962). By 2-year calendar periods, we calculated prevalence rates (PR) of opioid use in the four quarters after surgery (Q1-Q4). Corresponding prevalence rate ratios (PRR) with 1997-1998 as a reference were estimated with 95% confidence intervals. Further, we calculated the median morphine milligram equivalents (MME) for each quarter. For Q1, the PR of opioid use increased from 29% in 1997-1998 to 78% in 2017-2018 corresponding to a PRR of 2.7 (2.6-2.8). For Q4, the PR was 15% in 1997-1998, peaked in 2003-2004 and then decreased, but stayed high at 13% in 2017-2018. The median MME did not increase when comparing 2017-2018 with 1997-1998, irrespective of the quarter. Tramadol was most frequently used in 1997-1998 shifting to oxycodone in 2017-2018. The PRs of opioid use in Q1 after surgery increased substantially from 1997 to 2018, but this did not translate into increased opioid use up to 1 year after hip fracture surgery or higher dosage. Our findings underline the importance of sustained focus on opioid tapering, dosage and use of opioids with the lowest potential for addiction and other adverse events. Overall, opioid use in Q1 after hip fracture surgery increased 2.7 times from 1997 to 2018, but the doses and opioid use up to 1 year after surgery remained stable. Compared to elderly, younger patients were more likely to use opioid in Q1, while the tendency was opposite in Q2-Q4. The most used opioid type changed from tramadol to oxycodone. Our findings underline the importance of personalized opioid tapering and doses, and use of opioids with the lowest potential for addiction and other adverse events.

Perioperative Considerations in Patients with Vein of Galen Malformations Undergoing Embolization–A Single-Institution Case Series

AbstractVein of Galen malformation (VOGM) is a congenital, intracranial vascular malformation, with an extracardiac shunt. Neonates can present with high output cardiac failure, pulmonary hypertension, or multiorgan failure and are at high risk of perioperative complications, especially in remote locations. We conducted a retrospective single-center analysis of the perioperative management of patients with VOGM presenting for embolization. Patients were identified by querying both the hospital billing dataset using International Classification of Diseases-10 diagnosis or billing code and the Neuro-interventional Radiology Database, from January 2011 to March 2020. As many as 14 patients were identified, 12 of which underwent definitive treatment. Six patients who underwent embolization in the neonatal period had pulmonary hypertension. Those children required varying degrees of hemodynamic and respiratory support preoperatively and experienced significant intraoperative events, including one intraoperative cardiac arrest. Caring for these critically ill patients in a remote location requires proper planning to prevent adverse outcomes.

Ultrasound Guided Maxillary Nerve Block for Perioperative Pain Management for Patients Undergoing Endoscopic Sinus Surgery: Randomized Control Trial

Background: Proper perioperative pain management remains a cornerstone of well-conducted functional endoscopic sinus surgery (FESS). In such a context, proper pain management entails the adequate provision of prolonged postoperative analgesia, the avoidance of overusing opioids, and consequently limiting their unwanted side effects. Objectives: We aimed to evaluate the effect of bilateral ultrasound-guided suprazygomatic maxillary nerve block (MNB) on postoperative pain in patients undergoing FESS. Methods: Patients eligible for FESS were randomized into two groups: the MNB group (n = 30), who underwent bilateral ultrasound-guided suprazygomatic maxillary nerve block after induction of anesthesia, and a control group (n = 30), who received multimodal analgesia, including opioids. Postoperatively, patients were observed for 48 hours. Pain scores were evaluated upon arrival to the sPACU and at 2, 6, 12, 24, 36, and 48 hours postoperatively, particularly at the time of removal of the hemostatic agent after 36 hours postoperatively. Total rescue analgesia, postoperative complications (including nausea and vomiting [PONV], hypotension, bradycardia, headache), and patient satisfaction were also diligently recorded. Results: Sixty patients who were candidates and underwent FESS surgery were enrolled randomly in both groups. The NRS pain score in the MNB group was significantly lower than that of the control group (P &lt; 0.001), especially the NRS during the removal of the hemostatic agent at T10 was significantly lower in the MNB group (P &lt; 0.001). However, at the 24 - hour point post-surgery, there were no significant differences between both groups (P = 0.568). Total rescue analgesia required was significantly lower in the MNB group compared with the control group (P &lt; 0.001) throughout the first 48 hours postoperatively. The percentage of patients with no postoperative complications (nausea, vomiting, and headache) was higher in the MNB group (76.7 %) compared with the control group (40 %). Patient satisfaction was statistically significantly higher in the MNB group (P &lt; 0.001). Conclusions: Bilateral ultrasound-guided suprazygomatic MNB appeared to be safe and advantageous, as its use was associated with a decrease in total analgesic consumption, a reduction in postoperative morbidities such as pain, nausea, and vomiting, and greater patient satisfaction.

Perioperative analgesic management in patients with bladder exstrophy: A clinical study

Background: Bladder exstrophy is a complex, rare congenital malformation with an incidence of 3.3 cases in every 100000 live births and is slightly more common in males. Primary surgical repair requires many hours of surgery with fluid and blood loss. Because of wide fluctuations in hemodynamics, a longer duration of surgery, smaller age, risk of hypothermia and post-operative intensive care may be required. We evaluated the use of continuous caudal epidural infusion of bupivacaine and fentanyl under general anesthesia for urinary bladder exstrophy-epispadias surgery in children. Aims and Objectives: Aim of the study was to evaluate the postoperative analgesia in patients undergoing surgery for bladder exstrophy. The primary objective was to assess the postoperative pain using FLACC scale and sedation score after successful caudal administration. Secondary objective was to assess the hemodynamic changes after caudal administration. Materials and Methods: A total of 13 patients aged between 9months and 13 years of either sex, weighing between 5kg to 30kg, belonging to ASA grade II to IV, underwent surgery for epispadias–exstrophy complex. Initial bolus 0.75ml/kg of 0.25% bupivacaine with fentanyl 1ug/kg was given through epidural. Postoperative analgesia was maintained by continuous infusion of 0.0625% bupivacaine @0.1ml/kg/hr in young children and 0.125% bupivacaine with fentanyl 1ug/ml in older children for 4-5 days with the help of ON-Q pump or infusion pump. Baseline hemodynamic parameters including MAP, heart rate and SpO2 was recorded at various time intervals. Postoperative pain was assessed using face, legs, activity, cry and consolability (FLACC) pain scale and sedation score was assessed by using ramsay sedation score. Results: There was a statistically significant decrease in mean pulse rate in the study group from baseline to thirty minutes after reversal (p&lt;0.001). Similar observation was made for mean arterial pressure which also showed statistically significant decrease from baseline to thirty minutes after reversal (p&lt;0.001). No change was observed in SpO2 from baseline to any other follow-up interval. Conclusion: Perioperative anesthetic and analgesic management of the bladder exstrophy patient can improve the success rate. Epidural bupivacaine with or without fentanyl infusions for short duration can provide safe analgesia.

[Expert consensus on thermal ablation of papillary thyroid cancer (2024 edition)].

Ultrasound-guided thermal ablation of papillary thyroid cancer (PTC) has been promoted in clinical practice over the past few years. Thermal ablation has the advantages of being minimally invasive, effective, and safe. However, current guidelines and consensus only focus on low-risk papillary thyroid microcarcinoma. With growing clinical application and accumulating scientific research in thermal ablation for PTC, there is considerable evidence to demonstrate that thermal ablation can treat larger PTC tumors and benefit more patients with PTC. To expand the indications and standardize the technical details and perioperative patient management for PTC ablation, experts from the Society of Tumor Ablation Therapy of the Chinese Anti-Cancer Association, the Ablation Expert Committee of the Chinese Society of Clinical Oncology (CSCO), Chinese Medical Doctor Association College of Interventionalists Tumor Ablation Committee, and Chinese Bethune Spirit Research Association Endocrinology and Diabetes Branch Interventional Endocrine Committee discussed and developed a consensus on thermal ablation of PTC based on the latest research results. This consensus aims to promote the rapid development of thermal ablation for PTC in the clinic.

Surgical treatment of degenerative stenotic lesions of the lumbar spine. Own experience of using minimally invasive techniques

Lumbar spinal stenosis is a multifactorial progressive condition mainly affecting older individuals, characterized by narrowing of the natural anatomical pathways passage of nerve structures, resulting in typical clinical symptoms. The disease affects about 103 million people in worldwide with an incidence of absolute lumbar spinal stenosis 19.4% among individuals aged 60-69 years. In the United States, about 600,000 surgical interventions for lumbar spinal stenosis are performed annually. This disease is one of the most common causes of lumbar pain and lower limbs in the elderly individuals, accompanied by claudication and ultimately leading to disability. The main cause of clinical symptoms of the lumbar spinal stenosis is the discrepancy between the sizes of nerve structures and their osteofibrous sheaths, resulting from gradually developing degenerative-dystrophic changes. Objective: To compare the outcomes of surgical treatment of patients with degenerative stenotic lesions of the lumbar spine using open and minimally invasive methods. Materials and methods. The results of surgical treatment of 97 patients with lumbar spinal stenosis aged from 28 to 81 years on the basis of the Department of Minimally Invasive and Laser Spinal Neurosurgery of the State Institution " A.P. Romodanov Neurosurgery Institute, Ukraine", " Neurosurgical Department №20 of Vinnytsia Regional Clinical Psychoneurological Hospital named after Acad. O.I. Yushchenko" of Vinnytsia Regional Council and "Spinex" Medical Center following all clinical research protocols. Patients were divided into four groups depending on the surgical intervention method. Results. The development of concepts regarding the mechanisms of occurrence and treatment methods of lumbar spinal stenosis are highlighted, as well as personal experience of using minimally invasive treatment techniques for this pathology in combination with the use of the ERAS (Enhanced Recovery After Surgery) protocol of perioperative patient management. It was found that the duration of hospital stay for patients with lumbar spinal stenosis statistically significantly desreased when using minimally invasive decompression (p≤0.05) and the ERAS rehabilitation protocol (p≤0.05). When comparing the average length of stay in the hospital of patients of the four groups, a statistically significant (p≤0.05) shorter length of stay in the hospital was observed for patients who underwent minimally invasive decompression using the ERAS rehabilitation protocol. The greatest reduction in pain intensity (according to the Numeric Pain Scale (NPS)) at 6 months post- intervention and rehabilitation was also noted in patients of this group. Conclusions. The use of minimally invasive techniques, the correct choice of surgical procedure volume (interbody fusion is desirable in surgery for degenerative spinal diseases) combined with Enhanced Recovery after Surgery protocol (ERAS) significantly improves postoperative well-being of patients, accelerates patient mobilization, and reduces the length of stay in the hospital.