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Schnabl SM, Garbe C, Breuninger H, Walter V, Aebischer V, Eckardt J, Ghoreschi FC, Häfner HM, Scheu A. Risk analysis of systemic side effects of tumescent local anaesthesia in the surgical treatment of geriatric and multimorbid patients with skin cancer. J Eur Acad Dermatol Venereol 2023; 37:65-74. [PMID: 36152007 DOI: 10.1111/jdv.18588] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 08/17/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Due to demographic change and increased UV exposure, the number of dermatosurgical procedures in the elderly is increasing. Data on the occurrence of systemic side effects during and after treatment with tumescent local anaesthesia are limited and do not refer to details such as volume and composition of local anaesthetics or epinephrine additive. OBJECTIVES The aim of this study was to investigate the risk of systemic side effects in elderly patients undergoing skin tumour surgery with tumescent local anaesthesia. METHODS Investigation of systemic complications in patients (≥75 years) who underwent head and neck skin tumour surgery under tumescent local anaesthesia at the Department of Dermatology, University Medical Centre Tübingen, between October 2018 and March 2020. RESULTS In total 782 patients (479 males, 303 females) with a mean age of 83.3 years (range: 75.1-102.2 years) could be included. A total of 2940 procedures were performed. Patients were assigned to two groups. The old-old group (≥75-84 years) included 491 patients and the oldest-old group (≥85 years) included 291 patients. The total inpatient stay and thus mean follow-up period was 4.9 days (range 1-28 days). 92.0% (719/782) suffered from pre-existing comorbidities. Systemic complications occurred in 10.2% (80/782; old-olds: 8.6%, oldest-olds: 13.1%). Hypertensive crisis (>180/120 mmHg) requiring intervention (6.7%) that occurred intraoperatively or during the inpatient stay was the most frequent systemic complication. Cardiac arrhythmias occurred postoperatively in 0.8% of cases. No life-threatening complications directly related to tumescent local anaesthesia were found. CONCLUSIONS Skin tumour surgery in tumescent local anaesthesia for the elderly is safe, and complications caused by general anaesthesia can be avoided. Systemic complications can occur, but are usually mild, are caused by pre-existing diseases and perioperative excitement, and can be rapidly detected and well treated by monitoring. There is no direct correlation of complications to high-tumescent concentrations or volume quantities.
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Affiliation(s)
| | - Claus Garbe
- Department of Dermatology, University of Tuebingen, Tuebingen, Germany
| | - Helmut Breuninger
- Department of Dermatology, University of Tuebingen, Tuebingen, Germany
| | - Vincent Walter
- Department of Dermatology, University of Tuebingen, Tuebingen, Germany
| | | | - Julia Eckardt
- Department of Dermatology, Venereology and Allergology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Franziska Carola Ghoreschi
- Department of Dermatology, Venereology and Allergology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | | | - Alexander Scheu
- Department of Dermatology, University of Tuebingen, Tuebingen, Germany
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Nayak SP, Pokharkar H, Gurawalia J, Dev K, Chanduri S, Vijayakumar M. Efficacy and Safety of Lateral Approach-Video Endoscopic Inguinal Lymphadenectomy (L-VEIL) over Open Inguinal Block Dissection: a Retrospective Study. Indian J Surg Oncol 2019; 10:555-562. [PMID: 31496610 DOI: 10.1007/s13193-019-00951-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 06/03/2019] [Indexed: 11/28/2022] Open
Abstract
This retrospective study compared the immediate post-operative short-term outcomes of Lateral Approach-Video Endoscopic Inguinal Lymphadenectomy (L-VEIL) and open surgery approach in patients with TNM stage N0 and N1 tumors. Inguinal lymphadenectomies performed for various TNM stage N0 and N1 cancers between January 2011 and December 2015 at a single center were analyzed by collecting data from operation theater records and case files. Mean blood loss, operative time, drain output, nodal yield, nodal positivity, and complications were analyzed as post-procedural outcomes. Among the 116 surgeries performed, 92 were open surgery and 24 were L-VEIL. Compared with open surgery, L-VEIL led to significantly lower blood loss (64.8 mL vs. 23.3 mL; p = 0.002), mean nodal yield (11.04 vs. 8.38; p = 0.001), and mean hospital stay (3.08 vs. 8 days; p < 0.001). However, the operative time was similar for both the groups (94.5 vs. 68.1 min; p = 0.08). Complications that were significantly low in L-VEIL were flap necrosis [RR 1.29; 95% CI (1.03-1.72); p < 0.001], wound dehiscence [RR 1.25; 95% CI (1.19-1.51); p = 0.005), wound infection [RR 1.34; 95% CI (1.19-1.51); p = 0.003], readmission [RR 1.3; 95% CI (1.17-1.44); p = 0.005], and re-surgery [p = 0.014]. Occurrence of complications such as lymphocele [RR 1.25; 95% CI (0.33-4.78); p = 0.5], lymphorrhea [RR 1.27; 95% CI (1.15-1.40); p = 0.5], and pedal edema [p = 0.2] were similar for both the approaches. L-VEIL was effective and safe compared with open inguinal block dissection in treatment of various TNM stage N0 and N1 urogenital and skin cancers.
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Affiliation(s)
- Sandeep P Nayak
- 1Department of Surgical Oncology, Fortis Hospital and MACS Clinic, Jayanagar 4th Block West, Bangalore, 560 011 India
| | | | - Jaiprakash Gurawalia
- Department of Surgical Oncology, Kidwai Cancer Institute, Bangalore, Karnataka India
| | - Kapil Dev
- Department of Surgical Oncology, Kidwai Cancer Institute, Bangalore, Karnataka India
| | - Srinivas Chanduri
- Department of Surgical Oncology, Kidwai Cancer Institute, Bangalore, Karnataka India
| | - M Vijayakumar
- 3Vice Chancellor, Yenepoya University, Mangalore, Karnataka India
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Locke MC, Davis JC, Brothers RJ, Love WE. Assessing the outcomes, risks, and costs of local versus general anesthesia: A review with implications for cutaneous surgery. J Am Acad Dermatol 2018; 78:983-988.e4. [DOI: 10.1016/j.jaad.2018.01.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 01/03/2018] [Accepted: 01/07/2018] [Indexed: 01/01/2023]
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Moody JA, Botham SJ, Dahill KE, Wallace DL, Hardwicke JT. Complications following completion lymphadenectomy versus therapeutic lymphadenectomy for melanoma - A systematic review of the literature. Eur J Surg Oncol 2017; 43:1760-1767. [PMID: 28756017 DOI: 10.1016/j.ejso.2017.07.003] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Revised: 05/24/2017] [Accepted: 07/11/2017] [Indexed: 11/17/2022] Open
Abstract
PURPOSE Completion lymph node dissection (CLND) following a positive sentinel lymph node biopsy (SLNB) has been reported to be less morbid than lymphadenectomy for palpable disease (therapeutic lymph node dissection; TLND). The reporting of morbidity data can be heterogeneous, and hence no 'average' surgical complication rates of these procedures has been reported. This review aims to determine complications rates to inform patients undergoing surgery for metastatic melanoma. METHODS A systematic review of English-language literature from 2000 to 2017, reporting morbidity information about CLND and TLND for melanoma, was performed. The methodological quality of the included studies was performed using the methodological index for non-randomised studies (MINORS) instrument and Detsky score. Pooled proportions of post-operative complications were constructed using a random effects statistical model. RESULTS After application of inclusion and exclusion criteria, 18 articles progressed to the final analysis. In relation to TLND (1627 patients), the overall incidence of surgical complications was 39.3% (95% CI 32.6-46.2); including wound infection/breakdown 25.4% (95% CI: 20.9-30.3); lymphoedema 20.9% (95% CI: 13.8-29.1); and seroma 20.4% (95% CI: 15.9-25.2). For CLND (1929 patients), the overall incidence of surgical complications was 37.2% (95% CI 27.6-47.4); including wound infection/breakdown 21.6% (95% CI: 13.8-30.6); lymphoedema 18% (95% CI: 12.5-24.2); and seroma 17.9% (95% CI: 10.3-27). The complication rate was marginally lower for CLND but not to statistical significance. DISCUSSION This study provides information about the incidence of complications after CLND and TLND. It can be used to counsel patients about the procedures and it sets a benchmark against which surgeons can audit their practice.
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Affiliation(s)
- J A Moody
- GKT School of Medical Education, King's College London, Great Maze Pond, London, SE1 9RT, United Kingdom; College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, United Kingdom
| | - S J Botham
- Warwick Medical School, The University of Warwick, Coventry, CV4 7AL, United Kingdom
| | - K E Dahill
- Warwick Medical School, The University of Warwick, Coventry, CV4 7AL, United Kingdom
| | - D L Wallace
- Department of Plastic Surgery, University Hospitals of Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry, CV2 2DX, United Kingdom
| | - J T Hardwicke
- Warwick Medical School, The University of Warwick, Coventry, CV4 7AL, United Kingdom; Department of Plastic Surgery, University Hospitals of Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry, CV2 2DX, United Kingdom.
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Morton SK, Morton AP. Melanoma and pregnancy. Australas J Dermatol 2017; 58:259-267. [PMID: 28185271 DOI: 10.1111/ajd.12568] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Accepted: 08/15/2016] [Indexed: 12/28/2022]
Abstract
Melanoma is the most common cancer in women during their reproductive years and kills more young Australians than any other single cancer. Care of women whose pregnancy is complicated by a diagnosis of malignancy is complex. The risk of delaying treatment to the mother, the short-term and long-term risks of premature delivery to the child, and the immediate risks to the foetus and long-term risks to the child of maternal treatment with surgery, radiotherapy or medical therapies must be considered.
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Affiliation(s)
- Sarah Kym Morton
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Adam Park Morton
- Department of Obstetric Medicine, Mater Health Services, Brisbane, Queensland, Australia
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Abstract
Supplemental Digital Content is available in the text. Published ahead of print February 18, 2016 BACKGROUND: Tumescent lidocaine anesthesia consists of subcutaneous injection of relatively large volumes (up to 4 L or more) of dilute lidocaine (≤1 g/L) and epinephrine (≤1 mg/L). Although tumescent lidocaine anesthesia is used for an increasing variety of surgical procedures, the maximum safe dosage is unknown. Our primary aim in this study was to measure serum lidocaine concentrations after subcutaneous administration of tumescent lidocaine with and without liposuction. Our hypotheses were that even with large doses (i.e., >30 mg/kg), serum lidocaine concentrations would be below levels associated with mild toxicity and that the concentration-time profile would be lower after liposuction than without liposuction. METHODS: Volunteers participated in 1 to 2 infiltration studies without liposuction and then one study with tumescent liposuction totally by local anesthesia. Serum lidocaine concentrations were measured at 0, 2, 4, 6, 8, 10, 12, 14, 16, 18, and 24 hours after each tumescent lidocaine infiltration. Area under the curve (AUC∞) of the serum lidocaine concentration-time profiles and peak serum lidocaine concentrations (Cmax) were determined with and without liposuction. For any given milligram per kilogram dosage, the probability that Cmax >6 μg/mL, the threshold for mild lidocaine toxicity was estimated using tolerance interval analysis. RESULTS: In 41 tumescent infiltration procedures among 14 volunteer subjects, tumescent lidocaine dosages ranged from 19.2 to 52 mg/kg. Measured serum lidocaine concentrations were all <6 μg/mL over the 24-hour study period. AUC∞s with liposuction were significantly less than those without liposuction (P = 0.001). The estimated risk of lidocaine toxicity without liposuction at a dose of 28 mg/kg and with liposuction at a dose of 45 mg/kg was ≤1 per 2000. CONCLUSIONS: Preliminary estimates for maximum safe dosages of tumescent lidocaine are 28 mg/kg without liposuction and 45 mg/kg with liposuction. As a result of delayed systemic absorption, these dosages yield serum lidocaine concentrations below levels associated with mild toxicity and are a nonsignificant risk of harm to patients.
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Affiliation(s)
- Jeffrey A Klein
- From the *Department of Dermatology, University of California, Irvine, Medical Sciences, Irvine, California; and †Department of Statistics, University of California, Riverside, Riverside, California
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Söderman M, Thomsen JB, Sørensen JA. Complications following inguinal and ilioinguinal lymphadenectomies: a meta-analysis. J Plast Surg Hand Surg 2016; 50:315-320. [DOI: 10.3109/2000656x.2016.1173560] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Kendler M, Micheluzzi M, Wetzig T, Simon JC. Electrochemotherapy Under Tumescent Local Anesthesia for the Treatment of Cutaneous Metastases. Dermatol Surg 2013; 39:1023-32. [DOI: 10.1111/dsu.12190] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kendler M, Simon JC, Wetzig T. Local anesthesia with lidocaine and prilocaine, using the tumescent technique, for the radiofrequency ablation of lower extremity varicose veins. Int J Dermatol 2013; 52:739-44. [DOI: 10.1111/ijd.12025] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Michael Kendler
- Department of Dermatology, Venerology and Allergology; University of Leipzig; Leipzig; Germany
| | - Jan C. Simon
- Department of Dermatology, Venerology and Allergology; University of Leipzig; Leipzig; Germany
| | - Tino Wetzig
- Department of Dermatology, Venerology and Allergology; University of Leipzig; Leipzig; Germany
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Conroy PH, O'Rourke J. Tumescent anaesthesia. Surgeon 2013; 11:210-21. [PMID: 23375489 DOI: 10.1016/j.surge.2012.12.009] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2012] [Revised: 12/14/2012] [Accepted: 12/17/2012] [Indexed: 10/27/2022]
Abstract
Tumescent anaesthesia describes the practice of injecting a very dilute solution of local anaesthetic combined with epinephrine and sodium bicarbonate into tissue until it becomes firm and tense (tumescent). It was initially described in the field of liposuction but now surgical applications for the technique are widely varied ranging across vascular surgery, breast surgery, plastic surgery and ENT procedures. It is widely used in both hospital- and office-based environments and may form the sole method of anaesthesia for surgery. Advantages include a reduction in blood loss through both epinephrine-induced vasoconstriction as well as hydrostatic compression from the tumescent effect. Sodium bicarbonate reduces pain associated with the injection of an acidic local anaesthetic solution. Due to the unique pharmacokinetic profile of this technique lidocaine doses of 35 mg/kg bodyweight have been shown to be safe for liposuction procedures. Tumescent lidocaine is absorbed very slowly from subcutaneous tissues producing lower, and more delayed, peak blood levels compared to other routes, as well as extended postoperative analgesia. Slow systemic absorption allows the rapid hepatic plasma clearance of lidocaine to maintain safe local anaesthetic blood levels. This slow absorption from subcutaneous tissue has been likened to a depot injection. Careful attention must be given to appropriate local anaesthetic dosage alterations in cases of co-administration with agents affecting hepatic drug clearance or conditions reducing liver blood supply. Adherence to these pharmacological principles has produced an exemplary safety record for this technique to date.
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Affiliation(s)
- Patrick H Conroy
- Department of Anaesthesia and Intensive Care Medicine, Adelaide, Meath & National Children's Hospital, Tallaght, Dublin 24, Ireland.
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