Perioperative Phase Research Articles

Transcarotid revascularization in obese patients.

Transcarotid revascularization (TCAR) is a minimally invasive hybrid surgical carotid stenting technique which utilizes cerebral flow reversal as embolic protection during carotid lesion manipulation. This investigation was performed to define the perioperative risks associated with this operation in the obese patient. A retrospective review of tandem carotid revascularization databases maintained at two high-volume health systems was performed to capture all TCARs performed between 2015 and 2022. A threshold of body mass index of 35kg/m2 defined the "obese" patient. Demographics, intraoperative, perioperative, and follow-up characteristics were compared using univariate analysis. We performed 793 TCAR procedures that qualified for study inclusion within the prespecified time. After applying our obesity definition, 129 patients qualified as obese and were compared to the remainder. There were no significant differences in baseline demographics as comparable Charlson Comorbidity Indices were noted between groups; however, obese patients had a significantly higher prevalence of hypertension, hyperlipidemia, and diabetes. Intraoperative, case complexity in the obese patients did not seem to be increased, as measured by operative time (68.4 ± 23.0 vs 64.2 ± 25.8min, p = 0.09), fluoroscopic time (4.9 ± 3.2 vs 4.6 ± 3.6min, p = 0.38), and estimated blood loss (40.6 ± 49.0 vs 46.6 ± 49.4min, p = 0.22). Similarly, no disparities were observed with respect to ipsilateral stroke (3.1 vs. 1.7%, p = 0.29), contralateral stroke (0 vs. 0.2%, p > 0.99), death (0 vs. 1.1%, p = 0.61), and stroke/death (3.1 vs. 3.0%, p > 0.99) in the 30-day perioperative period. Both cohorts were followed for approximately 1year (12.0 ± 13.4 vs 11.6 ± 13.4months, p = 0.76). During this period, rates of ipsilateral stroke (3.1% vs. 2.7%, p > 0.99), contralateral stroke (1.1 vs. 0.8%, p > 0.99), and death (4.7 vs. 6.2%, p = 0.68) were similar. TCAR performed in the obese population was not more challenging by intraoperative characteristics and did not result in a statistically higher incidence of adverse events in the perioperative phase.

Brentuximab Vedotin Induces Long-Term Remission in T-cell PTLD without Evidence of Graft Rejection

A 63-year-old male with a history of bilateral lung transplant in 2013 for end-stage COPD, complicated by acute rejection in the peri-operative phase, presented with constitutional symptoms and a paraspinal soft tissue lesion at the T10 level.

Surgical Planning in Penetrating Abdominal Crohn's Disease.

Crohn's disease (CD) is increasing globally, and the disease location and behavior are changing toward more colonic as well as inflammatory behavior. Surgery was previously mainly performed due to ileal/ileocaecal location and stricturing behavior, why many anticipate the surgical load to decrease. There are, however, the same time data showing an increasing complexity among patients at the time of surgery with an increasing number of patients with the abdominal perforating disease, induced by the disease itself, at the time of surgery and thus a more complex surgery as well as the post-operative outcome. The other major cause of abdominal penetrating CD is secondary to surgical complications, e.g., anastomotic dehiscence or inadvertent enterotomies. To improve the care for patients with penetrating abdominal CD in general, and in the peri-operative phase in particular, the use of multidisciplinary team discussions is essential. In this study, we will try to give an overview of penetrating abdominal CD today and how this situation may be handled. Proper surgical planning will decrease the risk of surgically induced penetrating disease and improve the outcome when penetrating disease is already established. It is important to evaluate patients prior to surgery and optimize them with enteral nutrition (or parenteral if enteral nutrition is ineffective) and treat abdominal sepsis with drainage and antibiotics.

MP56-02 NEOADJUVANT PEMBROLIZUMAB MAY RESULT IN LONG-TERM OUTCOME IMPROVEMENT IN BIOMARKER-UNSELECTED PATIENTS WITH MUSCLE-INVASIVE BLADDER CANCER (MIBC): UPDATED RESULTS FROM PURE-01

You have accessJournal of UrologyCME1 May 2022MP56-02 NEOADJUVANT PEMBROLIZUMAB MAY RESULT IN LONG-TERM OUTCOME IMPROVEMENT IN BIOMARKER-UNSELECTED PATIENTS WITH MUSCLE-INVASIVE BLADDER CANCER (MIBC): UPDATED RESULTS FROM PURE-01 Luigi Nocera, Marco Moschini, Daniele Raggi, Laura Marandino, Maurizio Colecchia, Roberta Lucianò, Ewan Gibb, Jeffrey Ross, Antonella Messina, Giuseppina Calareso, Andrea Gallina, Federico Dehò, Alberto Briganti, Francesco Montorsi, and Andrea Necchi Luigi NoceraLuigi Nocera More articles by this author , Marco MoschiniMarco Moschini More articles by this author , Daniele RaggiDaniele Raggi More articles by this author , Laura MarandinoLaura Marandino More articles by this author , Maurizio ColecchiaMaurizio Colecchia More articles by this author , Roberta LucianòRoberta Lucianò More articles by this author , Ewan GibbEwan Gibb More articles by this author , Jeffrey RossJeffrey Ross More articles by this author , Antonella MessinaAntonella Messina More articles by this author , Giuseppina CalaresoGiuseppina Calareso More articles by this author , Andrea GallinaAndrea Gallina More articles by this author , Federico DehòFederico Dehò More articles by this author , Alberto BrigantiAlberto Briganti More articles by this author , Francesco MontorsiFrancesco Montorsi More articles by this author , and Andrea NecchiAndrea Necchi More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002639.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: PURE-01 trial provided several activity signals mainly represented by pathological response endpoints. We aimed to report updated results on recurrence-free survival (RFS) and overall survival (OS) at longer follow-up. METHODS: From 02/2017 to 06/2020, 136 patients were treated. RFS was defined as the time from first pembrolizumab dose to either: i) radiological progression, ii) local or distant recurrence, iii) death from any cause. Statistical analyses consisted of Kaplan-Meier analyses and Cox regression models. RESULTS: Of all 136 patients, 120 (88%) were males and median age was 68 years (IQR 62-74), while 76 patients (56%) exhibited a PD-L1 CPS≥10% on the TURB specimen pre-therapy. At radical cystectomy pathology, 57 (42%), 25 (18%), 34 (25%) and 20 (15%) patients harbored respectively ypT0N0, ypT1/a/isN0, ypT2-4N0 and ypTanyN+ disease. Finally, 9 patients (7%) received also adjuvant chemotherapy: 3 ypT2-4N0 and 6 ypTanyN+ patients. After a median follow-up of 27 months (IQR 21-38), 22 patients (16%) experienced a recurrence, while 14 patients (10%) died. At Kaplan-Meier curves (Figure 1), patients treated with neoadjuvant pembrolizumab exhibited a 36-month OS of 95%, 86%, 93% and 56% for respectively ypT0N0, ypT1/a/isN0, ypT2-4N0 and ypTanyN+ stages. Similarly, they exhibited a 36-month RFS of 94%, 96%, 67% and 44% for respectively ypT0N0, ypT1/a/isN0, ypT2-4N0 and ypTanyN+ stages. In ITT population, 36-month RFS and OS for CPS≥10% vs CPS>10 cohorts were respectively 88% vs 72% and 91% vs 79%. At multivariable Cox regression analyses, only age (HR 1.1, p=0.02) and ypTanyN+ stage (HR 9.0, p=0.02) represented independent predictors of overall mortality, after adjustment for stage, CPS ≥10% and adjuvant chemotherapy. Similarly, when recurrence represented the outcome, only ypT2-4N0 (HR 8.6, p=0.007) and ypTanyN+ (HR 15.9, p=0.001) stages represented independent predictors. CONCLUSIONS: Pembrolizumab followed by radical cystectomy confirms to be an effective treatment for patients with MIBC, unselected for biomarkers and for cisplatin eligibility. This data should be tested towards the data emerging in adjuvant setting and in light of the ongoing randomized perioperative phase 3 trials. Source of Funding: NA © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e971 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Luigi Nocera More articles by this author Marco Moschini More articles by this author Daniele Raggi More articles by this author Laura Marandino More articles by this author Maurizio Colecchia More articles by this author Roberta Lucianò More articles by this author Ewan Gibb More articles by this author Jeffrey Ross More articles by this author Antonella Messina More articles by this author Giuseppina Calareso More articles by this author Andrea Gallina More articles by this author Federico Dehò More articles by this author Alberto Briganti More articles by this author Francesco Montorsi More articles by this author Andrea Necchi More articles by this author Expand All Advertisement PDF DownloadLoading ...

Anesthesia Management for Section Cesarean Delivery in Patient with Severe Mitral Stenosis

<p><strong>Background</strong>: Heart defects in pregnancy is one main nonobstetric factor causing morbidity and mortality in pregnant women. Mitral stenosis is common in pregnancy. The choice of anesthetic management has to consider hemodynamics, type of heart disease, and drugs used. Neuraxial anesthesia has been significantly used because it is considered safer than general anesthesia</p><p><strong>Case</strong>: A 26-year-old woman with gestational age 32-34 weeks with severe mitral stenosis, moderate mitral regurgitation, severe tricuspid regurgitation, pulmonary hypertension, pericardial effusion, and atrial fibrillation underwent cesarean section with a low dose of spinal anesthesia using 5mg bupivacaine heavy 0.5% and Fentanyl 50 mcg. The sensory and motoric block was achieved in 5 minutes. Hemodynamic was stable during the perioperative phase. There was no heart failure or postoperative hemodynamic deterioration.</p><p><strong>Conclusion</strong>: Low-dose spinal anesthesia using 5 mg of bupivacaine and fentanyl adjuvant can be used in cesarean section in patients with severe mitral stenosis due to rapid onset, adequate block level, stable hemodynamic, block duration, and healthy born babies.</p><p><strong>Keywords</strong>: Pregnancy; mitral stenosis; C-section; neuraxial block; low dose</p>

Clinical controversy and research thoughts on lymphadenectomy of gastric cancer

Lymphadenectomy, as one of the controversial foci in clinic, is an extremely important part of radical surgery for gastric cancer. So far, the preliminary consensus has been reached on the scope and number of lymph node dissection, based on the etiological mechanism, disease progression, diagnosis and treatment prognosis of gastric cancer. At present, some clinical issues of lymphadenectomy in curative gastrectomy are still need to be addressed. Firstly, standardized procedure in lymph node dissection for gastric cancer is a prerequisite to decrease the incidence of postoperative complications and to improve the prognosis of gastric cancer patients. Furthermore, the plausible treatment strategy in perioperative phase is also deemed as the other key method to offer a benefit of survival rate for advanced stage patients after lymphadenectomy. Last but not least, the technologies for enhancement the prediction accuracy of lymph node metastasis preoperatively or intraoperatively should be worthy in-depth study.

A1C as a Prognosticator of Perioperative Complications of Diabetes: A Narrative Review.

Hemoglobin A1c (A1C) or glycated hemoglobin reflects the levels of blood glucose during the previous 8–12 weeks duration. It also helps us to diagnose diabetes in some cases, during the preoperative screening, who were initially missed out. Although the number of patients with diabetes undergoing various surgeries has increased many times, the role of A1C as a predictor for the complications during the perioperative phase remains intriguing. This could be due to various factors such as lack of best shreds of evidence, various cut-off levels of target A1C, variations of the patient population, presence of other comorbid conditions, and so on. This narrative review article presents the role of A1C as a reflector of perioperative adverse events in various surgeries and discusses the controversies surrounding it. We searched “PubMed Central” database with search criteria of “hemoglobin A1c, glycated hemoglobin, and perioperative complications” with publication date from January 01, 2010, to January 31, 2020, and found a total of 214 articles. We included only the relevant articles to our topic and added a few more articles that we found as “secondary references” from those articles to suit the structured headings of our narrative review and made it a total of fifty. To our knowledge, the majority of the studies published on this topic are of the “Retrospective analysis” type of study, besides no narrative review article available to date in the literature. We suggest that assessment of A1C levels preoperatively can be used as a routine practice for major procedures in patients with diabetes and for patients who have persistent high glucose values during preoperative screening regardless of whether a diagnosis of diabetes is established or not. We found that a cut-off of 8% is acceptable for the majority of the surgical procedures. However, it is better to have a cut-off of 7% or lower for procedures such as spine and joint replacement surgeries, cardiac surgeries, and so on. Further prospective studies involving a large population preferably with a multicenter design would provide us more clarity on this topic.

155: ENDOSCOPICALLY DERIVED OESOPHAGEAL ADENOCARCINOMA ORGANOIDS TO ASSESS POTENTIAL RESPONSE TO NEO-ADJUVANT THERAPY AND VIROTHERAPY

Abstract Background and aim Organoids are 3D models that retain the architecture and function of the organ from which they are derived. Culture of oesophageal adenocarcinoma organoids from individual’s standard endoscopic biopsies to assess response to therapy could dramatically alter the neo-adjuvant treatment paradigm, giving clarity over who will benefit from preoperative therapy, including novel treatment methodologies. Immune checkpoint blockade (ICB) has been shown to be effective in oesophageal adenocarcinoma. Combining Oncolytic Virotherapy with ICB could enhance the action of ICB alone, through selective infection of tumour cells accompanied by immunogenic cell death, with release of neo-tumour antigens and alteration of the tumour microenvironment. Methods This study uses organoids derived from endoscopic biopsies to assess the viability of an oncolytic herpes simplex virus in the treatment of oesophageal adenocarcinoma. Samples were taken at routine staging endoscopy using standard biopsy forceps. Tissue specimens were dissociated using the Miltenyi tumour dissociation kit before being suspended in Matrigel in Oesophageal adenocarcinoma conditioned media. Media was changed every 48 hours with domes being split every 7–10 days. After >6 passages organoids were incubated with an oncolytic herpes simplex virus lacking ICP 34.5 and 47. Growth was monitored, and green fluorescence protein expression measured using the Incucyte SX5 Live Cell Analysis system. Results Organoids were successfully established and cultured beyond 6 passages for patients with oesophageal adenocarcinoma. Organoids incubated with an oncolytic herpes simplex virus demonstrated significantly reduced growth compared to untreated organoids with increased expression of green fluorescence protein indicating viral infection. Conclusion We have demonstrated a successful methodology to culture Oesophageal adenocarcinoma organoids from endoscopic biopsies. Further work to determine their responses to standard chemotherapy used in the perioperative phase will help to assess their potential for providing bespoke therapy in the future. Oncolytic herpes simplex virus is able to infect and cause lysis of OAC organoids supporting its potential use in driving an increased inflammatory tumour microenvironment which could be combined with immune checkpoint blockade to induce durable responses for patients.

Understanding potential barriers and enablers to a perioperative early phase cell therapy trial

Background aimsEarly-phase cell therapy clinical trials depend on patient and physician involvement, yet barriers can impede their participation. MethodsTo optimize engagement for a planned cell therapy trial to prevent perioperative cardiac complications, the authors conducted semi-structured interviews with at-risk patients and physicians who could potentially be involved in the study. The authors used the theoretical domains framework to systematically identify potential barriers and enablers. ResultsForty-one interviews were conducted to reach data saturation, and four overall potential barriers to participation (themes) were identified. Theme 1 emphasizes that patients and physicians need accessible information to better understand the benefits and risks of the novel therapy and trial procedures and to address misconceptions. Theme 2 underscores the need for clarity on whether the trial's primary purpose is safety or efficacy, as this may influence patient and physician decisions. Theme 3 recognizes the resource and logistic realities for patients (e.g., convenient follow-up appointments) and physicians (e.g., personnel to assist in trial procedures, competing priorities). Theme 4 describes the importance of social influences (e.g., physicians and family, peers/colleagues) that may affect decisions to participate and the importance of patient preferences (e.g., availability of physicians to discuss the trial, including caregivers in discussions). ConclusionsProspectively addressing these issues may help optimize feasibility prior to conducting an expensive, resource-intensive trial.

Best Practices for Postoperative Management of Posterior Sacroiliac Joint Fusion.

Sacroiliac joint (SIJ) pain is a common cause of low back pain. Traditionally, treatment for SIJ joint pain and dysfunction has consisted of physical therapy, medication management, SIJ injections, and SIJ ablations. Improved recognition of the SIJ as an etiology for back pain has led to advances in treatment options. Radiofrequency of the lateral sacral branches has been shown to be effective, though evidence is fraught with inconsistent patient selection, study design and procedural technique. It also does not directly address the mechanical dysfunction of the SIJ. In order to create a more enduring approach SIJ fusion has become an attractive option to reduce pain and to improve function. This method of SI joint treatment requires guidance in the perioperative phase of care from both the physicians and advanced practice providers (APP). In order to improve care and outcomes of those undergoing posterior SI joint fusion the American Society of Pain and Neuroscience appointed an expert panel of physicians and advanced practice providers to create a best practice for the post operative care of this approach. As with any best practice, the panel considered current peer reviewed literature and clinical expertise to create guidance today. This is intended to be a living document with modifications as additional evidence comes to light in data publication. The goals of this paper are to focus on (1) wound care, (2) medication use, (3) physical activity and (4) therapeutic exercises.

Perioperative Antithrombotic Management During Gastroenterological Surgery in Patients With Thromboembolic Risks: Current Status and Future Prospects.

Antiplatelet medicines and anticoagulants are two types of antithrombotic pharmaceuticals, with anticoagulants including warfarin and direct oral anticoagulants (DOACs). During the perioperative phase, patients receiving antithrombotic therapy must balance two risks: bleeding and thromboembolism. To date, there are no defined recommendations for antithrombotic drug management in gastroenterological (GE) surgery, and the management strategy varies greatly between hospitals. The perioperative treatment of antithrombotic medications should be centralized according to the mechanism of each drug, and a suitable management strategy should be established. The proposed perioperative management for patients undergoing antithrombotic therapy is as follows: (1) in the case of antiplatelet medication, aspirin monotherapy is continued; (2) for patients on warfarin, it is substituted by DOAC bridging (preferred) or heparin bridging; and (3) in the case of DOACs, the short-term withdrawal of DOACs (typically 1-2 days) without heparin bridging is indicated. In the current review, the current state and future prospects of perioperative antithrombotic medication treatment during gastroenterological surgery are discussed.

Perioperative experiences and needs of patients who undergo colorectal cancer surgery and their family caregivers: a qualitative study.

Purpose Colorectal cancer (CRC) surgeries are major, complex, and often associated with debilitating symptoms or significant deconditioning that may impair patients’ quality of life. Little is known about how patients and family caregivers cope and their unmet needs during this daunting perioperative phase. This study aimed to explore the experiences and needs of CRC patients who undergo surgery and their family caregivers.MethodsAn exploratory qualitative design was adopted. A total of 27 participants comprising fifteen outpatients who had undergone colorectal cancer surgery and twelve family caregivers were recruited through purposive sampling from a public tertiary hospital in Singapore between December 2019 and November 2020. Individual, audio-recorded, semi-structured interviews were conducted, transcribed verbatim, and analyzed using thematic analysis.ResultsFour themes emerged: initial reactions to the diagnosis, impact of the illness and surgery, personal coping, and external support. The lack of apparent assessments on the psychological well-being of patients was found despite several participants exhibiting early signs of distress. Access to psychological support provided by healthcare professionals or peers was selective, and knowledge deficit was prevalent, especially in the preoperative stage.ConclusionPsychological priming and strengthening are important for CRC patients’ and their caregivers’ adaptive coping throughout the treatment continuum. Technology-based, dyadic psychoeducation should be offered preoperatively to ease CRC patients’ acceptance of their diagnosis and adjustment to life after surgery while at the same time reduce the burden of family carers.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00520-022-06963-1.

CONUT score predicts early morbidity after liver transplantation: a collaborative study

Introduction: Liver transplantation (LT) is burdened by the risk of postoperative morbidity. Identifying patients at higher risk of developing complications can help allocate resources in the perioperative phase. Controlling Nutritional Status (CONUT) score, based on lymphocyte count, serum albumin and cholesterol levels, has been applied to various surgical specialties, proving reliable in predicting complications and prognosis. Our study aims to investigate the role of the CONUT score in predicting the development of early complications (within 90 days) after LT.

Ultrasound-Guided Comparison of Psoas Compartment Block and Supra-Inguinal Fascia Iliaca Compartment Block for Pain Management in Pediatric Developmental Dysplasia of Hip Surgeries.

BackgroundThe aim of this study was to compare psoas compartment block (PCB) and supra-inguinal fascia iliaca compartment block (SFIB) in terms of pain management and the need for additional systemic analgesia in the perioperative phase of developmental dysplasia of the hip (DDH).Materials and MethodsSixty pediatric patients were randomized into the PCB group and the SFIB group. The Numeric Rating Scale (NRS) pain scores were used to assess postoperative pain during the initial 24 h after extubation. Sufentanil consumption, patient-controlled analgesia (PCA) demands, and complications were also recorded.ResultsThe NRS pain scores were significantly lower in the PCB group than in the SFIB group at 0, 4, 8, 12, and 24 h after extubation (all P < 0.01). Postoperatively, 13.8% of patients in the PCB cohort received additional administration of sufentanil, in contrast to 63.3% of the SFIB cohort (P < 0.01). In the PCB group, 0 (0-0) mcg/kg sufentanil was administered, while in the SFIB group 0.1 (0-0.2) mcg/kg (P < 0.01). In addition, the PCB group had fewer PCA demands than the SFIB group within the initial 24 h (P < 0.01). It took less operating time to achieve SFIB as compared to PCB (P < 0.01). No adverse events related to two techniques were recorded.ConclusionsPCB provided a better perioperative pain management in pediatric patients with the DDH surgeries compared to SFIB. It also reduced the need for supplementary systemic analgesia.

Airway recommendations for perioperative patients during the COVID-19 pandemic: a scoping review.

PurposeNumerous guideline recommendations for airway and perioperative management during the COVID-19 pandemic have been published. We identified, synthesized, and compared guidelines intended for anesthesiologists.SourceMember society websites of the World Federation of Societies of Anesthesiologists and the European Society of Anesthesiologists were searched. Recommendations that focused on perioperative airway management of patients with proven or potential COVID-19 were included. Accelerated screening was used; data were extracted by one reviewer and verified by a second. Data were organized into themes based on perioperative phase of care.Principal findingsThirty unique sets of recommendations were identified. None reported methods for systematically searching or selecting evidence to be included. Four were updated following initial publication. For induction and airway management, most recommended minimizing personnel and having the most experienced anesthesiologist perform tracheal intubation. Significant congruence was observed among recommendations that discussed personal protective equipment. Of those that discussed tracheal intubation methods, most (96%) recommended videolaryngoscopy, while discordance existed regarding use of flexible bronchoscopy. Intraoperatively, 23% suggested specific anesthesia techniques and most (63%) recommended a specific operating room for patients with COVID-19. Postoperatively, a minority discussed extubation procedures (33%), or care in the recovery room (40%). Non-technical considerations were discussed in 27% and psychological support for healthcare providers in 10%.ConclusionRecommendations for perioperative airway management of patients with COVID-19 overlap to a large extent but also show significant differences. Given the paucity of data early in the pandemic, it is not surprising that identified publications largely reflected expert opinion rather than empirical evidence. We suggest future efforts should promote coordinated responses and provide suggestions for studying and establishing best practices in perioperative patients.Study registrationOpen Science Framework (https://osf.io/a2k4u/); date created, 26 March 2020.Supplementary InformationThe online version contains supplementary material available at 10.1007/s12630-022-02199-z.

The Role of Sarcopenia and Myosteatosis in Short- and Long-Term Outcomes Following Curative-Intent Surgery for Hepatocellular Carcinoma in a European Cohort.

Simple SummaryRecent studies have shown that pathological changes of body composition, in particular reduced muscle mass (sarcopenia) and impaired muscle quality (myosteatosis), are linked to poor outcomes in a variety of clinical conditions. Hepatocellular carcinoma (HCC) is the most frequent primary malignant tumor of the liver in the Western hemisphere and remains a prominent cause of cancer-associated mortality. The present study investigates the prognostic value of alterations in body composition in predicting perioperative morbidity, mortality and long-term oncological outcome in HCC using preoperative computed-tomography-based segmentation. Our study found supporting evidence for the relevance of muscle quality over quantity in a European population and verifies the predictive role of myosteatosis in patients suffering from HCC, with a particularly significant value in the earlier perioperative phase.Alterations of body composition, especially decreased muscle mass (sarcopenia) and impaired muscle quality (myosteatosis), are associated with inferior outcomes in various clinical conditions. The data of 100 consecutive patients who underwent partial hepatectomy for hepatocellular carcinoma (HCC) at a German university medical centre were retrospectively analysed (May 2008–December 2019). Myosteatosis and sarcopenia were evaluated using preoperative computed-tomography-based segmentation. We investigated the predictive role of alterations in body composition on perioperative morbidity, mortality and long-term oncological outcome. Myosteatotic patients were significantly inferior in terms of major postoperative complications (Clavien–Dindo ≥ 3b; 25% vs. 5%, p = 0.007), and myosteatosis could be confirmed as an independent risk factor for perioperative morbidity in multivariate analysis (odds ratio: 6.184, confidence interval: 1.184–32.305, p = 0.031). Both sarcopenic and myosteatotic patients received more intraoperative blood transfusions (1.6 ± 22 vs. 0.3 ± 1 units, p = 0.000; 1.4 ± 2.1 vs. 0.3 ± 0.8 units, respectively, p = 0.002). In terms of long-term overall and recurrence-free survival, no statistically significant differences could be found between the groups, although survival was tendentially worse in patients with reduced muscle density (median survival: 41 vs. 60 months, p = 0.223). This study confirms the prognostic role of myosteatosis in patients suffering from HCC with a particularly strong value in the perioperative phase and supports the role of muscle quality over quantity in this setting. Further studies are warranted to validate these findings.

The effects of antithrombotic therapy in ab interno trabeculotomy with a spatula-shaped microhook.

To evaluate the effects of the discontinuation of antithrombotic drugs on intraocular pressure (IOP) reduction and complications from ab interno trabeculotomy for patients with glaucoma. We performed a retrospective chart review on the data of patients treated with antithrombotic agents who have undergone ab interno trabeculotomy through Tanito microhook combined with cataract surgery at the Asahi General Hospital and the Tokyo University Hospital, with 6 months of follow-up. The patients were classified into two groups depending on whether they discontinued (AT-) or continued (AT+) antithrombotic therapy during the perioperative phase. The demographics, pre- and postoperative IOP, medication score, best-corrected visual acuity (BCVA), and postoperative complications were analyzed preoperatively and postoperatively at 1 week and 1–6 months. The series included 44 eyes from 44 Japanese patients. The AT- and AT+ groups included 21 eyes from 21 patients and 23 eyes from 23 patients, respectively. The decrease in IOP from the baseline at 1 week postoperative was significantly different between the two groups (p = 0.009), but there were no significant differences observed in the other visits. Hyphema and IOP spikes exceeding 30 mmHg occurred in 10% and 10% of AT- participants, and in 43% and 26% of AT+ participants, respectively. Hyphema and spikes with hyphema occurred more frequently in the AT+ than in the AT- group (p = 0.02 and p = 0.05). The number of patients who had spikes was not significantly different (p = 0.27). In trabeculotomy using the Tanito microhook®, discontinuing antithrombotic therapy had better IOP-lowering effects and less postoperative complications.

CONUT Score Predicts Early Morbidity After Liver Transplantation: A Collaborative Study.

Introduction: Liver transplantation (LT) is burdened by the risk of post-operative morbidity. Identifying patients at higher risk of developing complications can help allocate resources in the perioperative phase. Controlling Nutritional Status (CONUT) score, based on lymphocyte count, serum albumin, and cholesterol levels, has been applied to various surgical specialties, proving reliable in predicting complications and prognosis. Our study aims to investigate the role of the CONUT score in predicting the development of early complications (within 90 days) after LT.Methods: This is a retrospective analysis of 209 patients with a calculable CONUT score within 2 months before LT. The ability of the CONUT score to predict severe complications, defined as a Comprehensive Complication Index (CCI) ≥42.1, was examined. Inverse Probability Treatment Weighting was used to balance the study population against potential confounders.Results: Patients with a CCI ≥42.1 had higher CONUT score values (median: 7 vs. 5, P-value < 0.0001). The CONUT score showed a good diagnostic ability regarding post-LT morbidity, with an AUC = 0.72 (95.0%CI = 0.64–0.79; P-value < 0.0001). The CONUT score was the only independent risk factor identified for a complicated post-LT course, with an odds ratio = 1.39 (P-value < 0.0001). The 90-day survival rate was 98.8% and 87.5% for patients with a CONUT score <8 and ≥8, respectively.Conclusions: Pre-operative CONUT score is a helpful tool to identify patients at increased post-LT morbidity risk. Further refinements in the score composition, specific to the LT population, could be obtained with prospective studies.

The use of a vascular occlusion test combined with near-infrared spectroscopy in perioperative care: a systematic review.

In the perioperative phase oxygen delivery and consumption can be influenced by different factors, i.e. type of surgery, anesthetic and cardiovascular drugs, or fluids. By combining near-infrared spectroscopy (NIRS) monitoring of regional tissue oxygen saturation (StO2) with an ischemic provocation test, the vascular occlusion test (VOT), local tissue oxygen consumption and vascular reactivity at the microcirculatory level can be assessed. This systematic review aims to give an overview of the clinical information that VOT-derived NIRS values can provide in the perioperative period. After performing a systematic literature search, we included 29 articles. It was not possible to perform a meta-analysis because of the lack of comparable data and the observational nature of the majority of the included articles. We have clustered the found articles in two groups: non-cardiac surgery and cardiac surgery. We found that VOT-derived NIRS values show a wide variability and are influenced by the effects of anesthetics, cardiovascular drugs, fluids, and by the type of surgery. Additionally, deviations in VOT-derived NIRS values are also associated with adverse patients' outcomes, such as postoperative complications, prolonged mechanical ventilation and prolonged hospital length of stay. However, given the variability in VOT-derived NIRS values, clinical applicability remains elusive. Future clinical interventional trials might provide additional insight into the potential of VOT associated with NIRS to optimize perioperative care by targeting specific interventions to optimize the function of the microvasculature.

Effect of Propofol and Etomidate on the Proliferation, Cell-cycle Distribution, Apoptosis and Necrosis of Pancreatic Tumour Cells.

The influence of surgical interventions and anaesthesiological procedures on tumour progression was investigated as early as the 1920s. In current cancer management, the perioperative phase is increasingly being considered a vulnerable period with an increased risk of tumour cell dissemination due to medication, surgical manipulation, and immunosuppression. The extent to which narcotics administered in the perioperative setting influence the oncological outcomes of patients with pancreatic cancer is still unclear. To investigate the effect of propofol and etomidate on the proliferation, cell-cycle distribution, apoptosis, and necrosis of pancreatic tumour cells in vitro, PaTu 8988t and Panc-1 pancreatic cancer cells were treated with 0-1,000 μM propofol or etomidate for 24 h each. Cell proliferation was measured with enzyme-linked immunosorbent-bromodeoxyuridine assay. The apoptosis rate was analysed with annexin V staining and the cell-cycle distribution with flow cytometry. Propofol at 1,000 μM induced apoptosis and inhibited cell proliferation. The cell cycle showed an increased S-phase and reduced cells in the G1-phase. At 100 μM, propofol significantly inhibited proliferation of the pancreatic cancer cell line PaTu 8988t and reduced cells in the G2-phase in the cell cycle. Etomidate had no effects on cell-cycle distribution, proliferation, apoptosis, and necrosis at the concentrations used. In this study, propofol was shown to have anticancer effects by induction of apoptosis and inhibition of cell proliferation, while etomidate did not affect pancreatic cancer cells. However, it is too early to make any recommendation for changes in clinical practice and further clinical studies are warranted to investigate the effect of anaesthetics on cancer progression.