Improving Outcome After Major Surgery

Preoperative beta blockers and other drugs in relation to anastomotic leakage after anterior resection for rectal cancer

AIM

Previous research has indicated that preoperative beta blocker therapy is associated with a decreased risk of complications after surgery for rectal cancer. This is thought to arise because of the anti-inflammatory activity of the drug. These results need to be reproduced and analyses extended to other drugs with such properties, as this information might be useful in clinical decision-making. The main aim of this work was to replicate previous findings of beta blocker use as a prognostic marker for postoperative leakage. We also investigated whether drug exposure might induce anastomotic leaks.

METHOD

This is a retrospective multicentre cohort study, comprising 1126 patients who underwent anterior resection for rectal cancer between 2014 and 2018. The use of any preoperative beta blocker was treated as the primary exposure, while anastomotic leakage within 12 months of surgery was the outcome. Secondary exposures comprised angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, statins and metformin. Using multivariable regression, we performed a replication analysis with a predictive aim for beta blockers only, while adjustment for confounding was done in more causally oriented analyses for all drugs. We estimated incidence rate ratio (IRR) and relative risk (RR) with 95% confidence intervals (CIs).

RESULTS

Anastomotic leakage occurred in 20.6% of patients. Preoperative beta blockers were used by 22.7% of the cohort, while the leak distribution was almost identical between exposure groups. In the main replication analysis, no association could be detected (IRR 0.95, 95% CI 0.68-1.33). In the causally oriented analyses, only metformin affected the risk of leakage (RR 1.59, 95% Cl 1.31-1.92).

CONCLUSION

While previous research has suggested that preoperative beta blocker use could be prognostic of anastomotic leakage, this study could not detect any such association. On the contrary, our results indicate that preoperative beta blocker use neither predicts nor causes anastomotic leakage after anterior resection for rectal cancer.

Determinants of postoperative complications in high-risk noncardiac surgery patients optimized with hemodynamic treatment strategies: A post-hoc analysis of a randomized multicenter clinical trial

STUDY OBJECTIVE

This post-hoc analysis of a randomized controlled trial was undertaken to establish the determinants of postoperative complications and acute kidney injury in high-risk noncardiac surgery patients supported with hemodynamic treatment strategies.

DESIGN

We conducted a post-hoc analysis of patients enrolled in the OPtimization Hemodynamic Individualized by the respiratory QUotiEnt (OPHIQUE) trial.

SETTING

Operating rooms in four university medical centers and one non-university hospital from December 26, 2018, to September 9, 2021.

PATIENTS

We enrolled 350 patients with a high risk of postoperative complications undergoing high-risk noncardiac surgery lasting 2 h or longer under general anesthesia.

INTERVENTIONS

All patients were treated according to hemodynamic treatment strategies which included cardiac output optimization by titration of fluid challenge and targeted systolic blood pressure to remain within ±10% of the reference value.

MEASUREMENTS

We assessed the association between pre-operative and intra-operative exposure of interest with a composite primary outcome of major complications or death within seven days following surgery using a multivariable logistic regression model. We also assessed the association between these exposures of interest and acute kidney injury.

MAIN RESULTS

The data of 341 patients were analyzed. In multivariate analysis, the factors independently associated with the primary outcome were age (OR = 1.04 (1.01-1.06), P = 0.002), preoperative hemoglobin concentration (OR = 0.85 (0.75-0.96), P = 0.012), non-vascular surgery (OR = 0.30 (0.17-0.53), P < 0.0001), and intraoperative surgical complications (OR = 2.08 (1.02-4.24), P = 0.046). The factors independently associated with postoperative acute kidney injury were age (OR = 1.04 (1.01-1.08), P = 0.008), preoperative creatinine concentration (OR = 1.01 (1.00-1.01), P = 0.049), non-vascular surgery (OR = 0.36 (0.20-0.66), P = 0.001), and intraoperative surgical complications (OR = 3.36 (1.50-7.55), P = 0.031).

CONCLUSIONS

Surgical complications, a lower preoperative hemoglobin concentration, age, and vascular surgery were associated with postoperative complications in a high-risk noncardiac surgery population supported with hemodynamic treatment strategies.

Neuraxial anaesthesia is associated with improved outcomes and reduced postoperative complications in patients undergoing aseptic revision total hip arthroplasty

BACKGROUND

As the incidence of primary total hip arthroplasty (THA) continues to increase, revision THA (rTHA) is becoming an increasingly common procedure. rTHA is widely regarded as a more challenging procedure, with higher complication rates and increased medical, social and economic burdens when compared to its primary counterpart. Given the complexity of rTHA and the projected increase in incidence of these procedures, patient optimisation is becoming of interest to improve outcomes. Anaesthetic choice has been extensively studied in primary THA as a modifiable risk factor for postoperative outcomes, showing favourable results for neuraxial anaesthesia compared to general anaesthesia. The impact of anaesthetic choice in rTHA has not been studied previously.

METHODS

A retrospective study was performed using the American College of Surgeons National Surgical Quality Improvement Program database. Patients who underwent rTHA between 2014 and 2017 were divided into 3 anaesthesia cohorts: general anaesthesia, neuraxial anaesthesia, and combined general-regional (neuraxial and/or peripheral nerve block) anaesthesia. Univariate and multivariate analyses were used to analyse patient characteristics and 30-day postoperative outcomes. Bonferroni correction was applied for post-hoc analysis.

RESULTS

In total, 5759 patients were identified. Of these, 3551 (61.7%) patients underwent general anaesthesia, 1513 (26.3%) patients underwent neuraxial anaesthesia, and 695 (12.1%) patients underwent combined general-regional anaesthesia. On multivariate analysis, neuraxial anaesthesia was associated with decreased odds for any-one complication (OR 0.635; p < 0.001), perioperative blood transfusion (OR 0.641; p < 0.001), and extended length of stay (OR 0.005; p = 0.005) compared to general anaesthesia.

CONCLUSIONS

Relative to those receiving general anaesthesia, patients undergoing neuraxial anaesthesia are at decreased risk for postoperative complications, perioperative blood transfusions, and extended length of stay. Prospective controlled trials should be conducted to verify these findings.

Major surgery leads to a proinflammatory phenotype: Differential gene expression following a laparotomy

BACKGROUND

The trauma of surgery is a neglected area of research. Our aim was to examine the differential expression of genes of stress, metabolism and inflammation in the major organs of a rat following a laparotomy.

MATERIALS AND METHODS

Anaesthetised Sprague-Dawley rats were randomised into baseline, 6-hr and 3-day groups (n = 6 each), catheterised and laparotomy performed. Animals were sacrificed at each timepoint and tissues collected for gene and protein analysis. Blood stress hormones, cytokines, endothelial injury markers and coagulation were measured.

RESULTS

Stress hormone corticosterone significantly increased and was accompanied by significant increases in inflammatory cytokines, endothelial markers, increased neutrophils (6-hr), higher lactate (3-days), and coagulopathy. In brain, there were significant increases in M1 muscarinic (31-fold) and α-1A-adrenergic (39-fold) receptor expression. Cortical expression of metabolic genes increased ∼3-fold, and IL-1β by 6-fold at 3-days. Cardiac β-1-adrenergic receptor expression increased up to 8.4-fold, and M2 and M1 muscarinic receptors by 2 to 4-fold (6-hr). At 3-days, cardiac mitochondrial gene expression (Tfam, Mtco3) and inflammation (IL-1α, IL-4, IL-6, MIP-1α, MCP-1) were significantly elevated. Haemodynamics remained stable. In liver, there was a dramatic suppression of adrenergic and muscarinic receptor expression (up to 90%) and increased inflammation. Gut also underwent autonomic suppression with 140-fold increase in IL-1β expression (3-days).

CONCLUSIONS

A single laparotomy led to a surgical-induced proinflammatory phenotype involving neuroendocrine stress, cortical excitability, immune activation, metabolic changes and coagulopathy. The pervasive nature of systemic and tissue inflammation was noteworthy. There is an urgent need for new therapies to prevent hyper-inflammation and restore homeostasis following major surgery.

Defining Major Surgery: A Delphi Consensus Among European Surgical Association (ESA) Members

BACKGROUND

Major surgery is a term frequently used but poorly defined. The aim of the present study was to reach a consensus in the definition of major surgery within a panel of expert surgeons from the European Surgical Association (ESA).

METHODS

A 3-round Delphi process was performed. All ESA members were invited to participate in the expert panel. In round 1, experts were inquired by open- and closed-ended questions on potential criteria to define major surgery. Results were analyzed and presented back anonymously to the panel within next rounds. Closed-ended questions in round 2 and 3 were either binary or statements to be rated on a Likert scale ranging from 1 (strong disagreement) to 5 (strong agreement). Participants were sent 3 reminders at 2-week intervals for each round. 70% of agreement was considered to indicate consensus.

RESULTS

Out of 305 ESA members, 67 (22%) answered all the 3 rounds. Significant comorbidities were the only preoperative factor retained to define major surgery (78%). Vascular clampage or organ ischemia (92%), high intraoperative blood loss (90%), high noradrenalin requirements (77%), long operative time (73%) and perioperative blood transfusion (70%) were procedure-related factors that reached consensus. Regarding postoperative factors, systemic inflammatory response (76%) and the need for intensive or intermediate care (88%) reached consensus. Consequences of major surgery were high morbidity (>30% overall) and mortality (>2%).

CONCLUSION

ESA experts defined major surgery according to extent and complexity of the procedure, its pathophysiological consequences and consecutive clinical outcomes.

Effects of Liberal Versus Restrictive Fluid Therapy on Renal Function Indices in Laparoscopic Bariatric Surgery

Background

Earlier studies have suggested the liberal administration of fluids in favor of reducing the risk of rhabdomyolysis in obese patients, but the results are conflicting.

Objectives

The present study aimed at comparing the effects of liberal and restrictive fluid therapy on renal indices in laparoscopic gastric bypass surgery.

Methods

In a double-blinded randomized clinical trial, 72 candidates of bariatric surgery were randomly assigned into two groups of restrictive and liberal fluid therapy. Indices, including BUN, creatinine, creatine kinase, GFR, and urine output were measured before and 24 hours after the surgery. The clinical trial was registered at IRCT.ir under code IRCT20170109031852N3.

Results

There was no significant difference in BUN, creatinine, creatinine kinase, and GFR indices between the two groups of liberal and restrictive fluid therapy both before and 24 hours after surgery (P > 0.05). Intragroup comparisons before and after surgery revealed that BUN decreased in both groups after the surgery (P < 0.05). Also, creatinine and GFR values improved in patients who received a liberal fluid regimen, whereas these indices remained statistically unchanged in the restrictive group before and 24 hours after the surgery (P > 0.05).

Conclusions

Two methods of liberal and restrictive fluid therapy have comparable effects on traditional renal functional indices in laparoscopic bariatric surgery. The clinical significance of observed differences in outcomes should be investigated in further studies. The use of early biomarkers of acute kidney injury is warranted.

β-Blockade in Rectal Cancer Surgery: A Simple Measure of Improving Outcomes

OBJECTIVE

To ascertain whether regular β-blocker exposure can improve short- and long-term outcomes after rectal cancer surgery.

BACKGROUND

Surgery for rectal cancer is associated with substantial morbidity and mortality. There is increasing evidence to suggest that there is a survival benefit in patients exposed to β-blockers undergoing non-cardiac surgery. Studies investigating the effects on outcomes in patients subjected to surgery for rectal cancer are lacking.

METHODS

All adult patients undergoing elective abdominal resection for rectal cancer over a 10-year period were recruited from the prospectively collected Swedish Colorectal Cancer Registry. Patients were subdivided according to preoperative β-blocker exposure status. Outcomes of interest were 30-day complications, 30-day cause-specific mortality, and 1-year all-cause mortality. The association between β-blocker use and outcomes were analyzed using Poisson regression model with robust standard errors for 30-day complications and cause-specific mortality. One-year survival was assessed using Cox proportional hazards regression model.

RESULTS

A total of 11,966 patients were included in the current study, of whom 3513 (29.36%) were exposed to regular preoperative β-blockers. A significant decrease in 30-day mortality was detected (incidence rate ratio = 0.06, 95% confidence interval: 0.03-0.13, P < 0.001). Deaths of cardiovascular nature, respiratory origin, sepsis, and multiorgan failure were significantly lower in β-blocker users, as were the incidences in postoperative infection and anastomotic failure. The β-blocker positive group had significantly better survival up to 1 year postoperatively with a risk reduction of 57% (hazard ratio = 0.43, 95% confidence interval: 0.37-0.52, P < 0.001).

CONCLUSIONS

Preoperative β-blocker use is strongly associated with improved survival and morbidity after abdominal resection for rectal cancer.

Preoperative Anxiety and Intraoperative Nociception in Patients Undergoing Thoracic Surgery

BACKGROUND

Preoperative anxiety is a common psychological state in cancer patients before surgery, inducing stress responses after surgery. Associations between preoperative anxiety and intraoperative nociception, however, have not been evaluated well. In the present study, we investigated the relationship in patients with lung cancer undergoing thoracic surgery.

MATERIALS AND METHODS

In this prospective study, 27 adult patients were enrolled. Intraoperative nociception during surgery was calculated as mean values of the nociceptive response (NR) throughout surgery. Associations between intraoperative nociception and preoperative patient characteristics including anxiety in addition to intraoperative variables were analyzed using univariate and multivariate regression analyses.

RESULTS

Multiple linear regression analysis revealed that mean NR values during surgery showed a negative correlation with preoperative anxiety (β = -0.353; P = 0.041) after adjustment for body mass index, depression, and total amount of fentanyl used during surgery. Body mass index was a confounder positively associated with mean NR during surgery.

CONCLUSIONS

Intraoperative nociception is likely associated with preoperative patient characteristics, having an inverse relationship with preoperative anxiety.

Effects of remote ischemic preconditioning on regional cerebral oxygen saturation in patients in the beach chair position during shoulder surgery: A double-blind randomized controlled trial

STUDY OBJECTIVE

The beach chair position for shoulder surgery induces cerebral hypoperfusion. We evaluated the effects of remote ischemic preconditioning (RIPC) prior to surgery to ameliorate cerebral desaturation in a double-blind randomized fashion.

DESIGN

Blinded, prospective, randomized study.

SETTING

Operating room & postoperative recovery room, tertiary university hospital.

PATIENTS

Seventy patients scheduled for shoulder surgery were recruited. After excluding 7 patients according to the exclusion criteria, 63 patients were randomized into two groups (control and RIPC).

INTERVENTIONS

Remote ischemic preconditioning was applied by briefly inflating a tourniquet on the thigh three times just after inducing anesthesia in the RIPC group.

MEASUREMENTS

The changes in regional cerebral oxygen saturation, hemodynamic values, laboratory values, and serum levels of cytokines including interleukin (IL)-1β, IL-6, IL-10 and transforming growth factor-β were measured.

MAIN RESULTS

The remote ischemic preconditioning group had higher regional cerebral oxygen saturation just after establishment of the beach chair position (P = 0.002) and lower cerebral desaturation (P = 0.007) during operation than the control group. Hemodynamic and laboratory values did not differ between the groups. There were no significant intergroup differences in cytokine levels.

CONCLUSION

Remote ischemic preconditioning before surgery ameliorates cerebral desaturation in patients in the beach chair position during shoulder surgery. Trial Registry Number: KCT0001384 (http://cris.nih.go.kr).

The Relationship Between Severe Complications, Beta-Blocker Therapy and Long-Term Survival Following Emergency Surgery for Colon Cancer

BACKGROUND

Emergency surgery for colon cancer carries significant morbidity, and studies show more than doubled mortality when comparing elective to emergency surgery. The relationship between postoperative complications and survival has been outlined. Beta-blocker therapy has been linked to improved postoperative outcomes. This study aims to assess the impact of postoperative complications on long-term survival following emergency surgery for colon cancer and to determine whether beta-blockade can reduce complications.

STUDY DESIGN

This cohort study utilized the prospective Swedish Colorectal Cancer Registry to identify adults undergoing emergency colon cancer surgery between 2011 and 2016. Prescription data for preoperative beta-blocker therapy were collected from the national drug registry. Cox regression was used to evaluate the effect of beta-blocker exposure and complications on 1-year mortality, and Poisson regression was used to evaluate beta-blocker exposure in patients with major complications.

RESULTS

A total of 3139 patients were included with a mean age of 73.1 [12.4] of which 671 (21.4%) were prescribed beta-blockers prior to surgery. Major complications occurred in 375 (11.9%) patients. Those suffering major complications showed a threefold increase in 1-year mortality (adjusted HR = 3.29; 95% CI 2.75-3.94; p < 0.001). Beta-blocker use was linked to a 60% risk reduction in 1-year mortality (adjusted HR = 0.40; 95% CI 0.26-0.62; p < 0.001) but did not show a statistically significant association with reductions in major complications (adjusted IRR = 0.77; 95% CI 0.59-1.00; p = 0.055).

CONCLUSION

The development of major complications after emergency colon cancer surgery is associated with increased mortality during one year after surgery. Beta-blocker therapy may protect against postoperative complications.

Post-Pancreaticoduodenectomy Outcomes and Epidural Analgesia: A 5-year Single-Institution Experience

BACKGROUND

Optimal pain control post pancreaticoduodenectomy is a challenge. Epidural analgesia (EDA) is used increasingly, despite inherent risks and unclear effects on outcomes.

METHODS

All pancreaticoduodenectomies (PDs) performed from January 2013 through December 2017 were included. Clinical parameters were obtained from a retrospective review of a prospective clinical database, the American College of Surgeons NSQIP prospective institutional database, and medical record review. Chi-square, Fisher's exact test, and independent-samples t-tests were used for univariable analyses. Multivariable regression was performed.

RESULTS

Six hundred and seventy-one consecutive PDs from a single institution were included (429 EDA, 242 non-EDA). On univariable analysis, EDA patients experienced significantly less wound disruption (0.2% vs 2.1%), unplanned intubation (3.0% vs 7.9%), pulmonary embolism (0.5% vs 2.5%), mechanical ventilation longer than 48 hours (2.1% vs 7.9%), septic shock (2.6% vs 5.8%), and lower pain scores. On multivariable regression (accounting for baseline group differences (ie sex, hypertension, preoperative transfusion, laboratory results, approach, and pancreatic duct size), EDA was associated with less superficial wound infections (odds ratio [OR] 0.34; 95% CI 0.14 to 0.83; p = 0.017), unplanned intubations (OR 0.36; 95% CI 0.14 to 0.88; p = 0.024), mechanical ventilation longer than 48 hours (OR 0.22; 95% CI 0.08 to 0.62; p = 0.004), and septic shock (OR 0.39; 95% CI 0.15 to 1.00; p = 0.050). Epidural analgesia improved pain scores post-PD days 1 to 3 (p < 0.001). No differences were seen in cardiac or renal complications; pancreatic fistula (B+C) or delayed gastric emptying, 30-/90-day mortality, length of stay, readmission, discharge destination, or unplanned reoperation.

CONCLUSIONS

Based on the largest single-institution series published to date, our data support the use of EDA for optimization of pain control. More importantly, our data document that EDA improved infectious and pulmonary complications significantly.

Development of a Hemodynamic Model Using Routine Monitoring Parameters for Nociceptive Responses Evaluation During Surgery Under General Anesthesia

BACKGROUND Routine hemodynamic monitoring parameters under general anesthesia, such as heart rate (HR), systolic blood pressure (SBP), and perfusion index (PI), do not solely reflect intraoperative nociceptive levels. We developed a hemodynamic model combining these 3 parameters for nociceptive responses during general anesthesia, and evaluated nociceptive responses to surgical skin incision. MATERIAL AND METHODS We first retrospectively performed discriminant analysis using 3 values - HR, SBP, and PI - to assess response to skin incision during tympanoplasty, laparoscopic cholecystectomy, and open gastrectomy to determine if combined use of these parameters differentiates nociceptive levels among these 3 surgeries. Secondly, ordinal logistic regression analysis was applied using the 3 parameters to develop an equation representing nociceptive response during general anesthesia, and then evaluated its utility to discern nociceptive responses to skin incision. RESULTS We developed the following hemodynamic model as calculated nociceptive response= -1+2/(1+ exp(-0.01 HR -0.02 SBP +0.17 PI)), and prospectively determined that calculated nociceptive responses to small skin incision for laparoscopic surgery were significantly lower than responses to large skin incision for laparotomy. CONCLUSIONS Our hemodynamic model using HR, SBP, and PI likely reflects nociceptive levels at skin incision during general anesthesia, and quantitatively discerned the difference in nociceptive responses to skin incision between laparoscopy and laparotomy. This model could be applicable to assess either real-time nociceptive responses or averaged nociceptive responses throughout surgery without using special equipment.

Enhanced Recovery After Surgery-The Importance of the Perianesthesia Nurse on Program Success

Continued advancements in perioperative care and anesthesia technology have improved surgical outcomes and accelerated the patient's ability to resume preoperative activities. With the current emphasis on decreased utilization of expensive hospital resources, a shorter length of stay while maintaining patient satisfaction is encouraged for maximum reimbursement. Through the implementation of evidence-based protocols that standardize care and promote patient medical optimization, the surgical stress response, complications, and time spent in the hospital can be reduced. Enhanced recovery after surgery uses a multidisciplinary and multimodal evidence-based approach to maximize patient recovery. Perianesthesia nurses are critical to its success and have an obligation to understand and participate in the process to optimize patient outcomes. After completing this educational article, the reader will be able to recognize the importance of the perianesthesia nurse in implementing an enhanced recovery after surgery program; review the patient benefits of enhanced recovery; and describe the impact of multimodal pain management on patient length of stay and patient mobility.

Fluoroscopy-guided biodegradable spacer implantation using local anesthesia: safety and efficacy study in patients with massive rotator cuff tears

BACKGROUND

The management of massive rotator cuff tears (MRCTs) is challenging and associated with a high failure rates. Studies have shown that advanced age, lower American Society of Anesthesiologists physical status score and concomitant comorbidities are associated with higher risks of death and postoperative complications. This study was designed to assess the safety and efficacy of fluoroscopy-guided biodegradable spacer implantation under local anesthesia, in patients with MRCT and comorbidities completely or partially contraindicating surgeries under general anesthesia.

METHODS

In this open-label, single arm, prospective study, subjects with MRCTs underwent subacromial fluoroscopy-guided implantation with a biodegradable spacer (InSpace™ system) under local anesthesia. Fifteen patients were treated and assessed. Follow-up visits were scheduled according to routine clinical practice. Shoulder function was evaluated using Constant (CS) and American Shoulder and Elbow Society (ASES) scores.

RESULTS

All patients demonstrated an overall improvement in the total CS and ASES beginning at 6 weeks and sustained by at least 12 months postoperatively. Of the 15 patients who reached the 1-year follow-up, 85% showed a clinically significant improvement of at least 15 points in their Constant score starting at 6 weeks postoperation and maintained throughout the entire follow-up period.

CONCLUSIONS

We conclude that in this initial patient's cohort, fluoroscopy-guided implantation of InSpace™ system under local anesthesia, represented an effective alternative to the existing procedures. This procedure may be considered as a treatment option for elderly patients or for patients with multiple comorbidities complicating or contraindicating surgery under general anesthesia. Technically easy, this technique can be an effective tool in the armamentarium of most orthopedic surgeons. Level of proof: single-arm prospective study, Level II.

Postoperative management

Most patients undergoing major aortic surgery have multiple comorbidities and are at high risk of postoperative complications that affect multiple organ systems. Different aortic pathologies and surgical repair techniques have specific impact on the postoperative course. Ischemia-reperfusion injury is the common denominator in aortic surgery and influences the integrity of end-organ function. Common postoperative problems include hemodynamic instability due to the immediate inflammatory response, renal impairment, spinal cord ischemia, respiratory failure with prolonged mechanical ventilation, and gastrointestinal symptoms such as ileus or mesenteric ischemia. Focused care bundles to establish homeostasis and a team working toward an early functional recovery determine the success of effective rehabilitation and outcomes after aortic surgery.

Postoperative acute kidney injury in high-risk patients undergoing major abdominal surgery

PURPOSE

Acute kidney injury (AKI) is a frequent complication in high-risk patients undergoing major surgery and is associated with longer hospital stay, increased risk for nosocomial infection and significantly higher costs.

MATERIALS AND METHODS

A prospective observational study exploring the incidence of AKI (AKIN classification at any stage) in high-risk patients within 48 hours after major abdominal surgery was conducted. Patients' preoperative characteristics, intraoperative management, and outcome were evaluated for associations with AKI using a logistic regression model.

RESULTS

Data from 258 patients were analyzed. Thirty-one patients (12%) developed AKI, reaching the AKIN stage 1. No patient reached an AKIN stage higher than 1. AKI patients were older (75.2 vs 70.2 years; P = 0.0113) and had a higher body mass index (26.5 vs 25.1 kg/m(2)). In addition, AKI patients had a significantly longer ICU length of stay (3.4 vs 2.4 days; P= .0017). Creatinine levels of AKI patients increased significantly compared to the preoperative levels at 24 (P= .0486), 48 (P= .0011) and 72 hours (P= .0055), while after 72 hours it showed a downwards trend. At ICU discharge, 28 out of 31 patients (90.3%) recovered preoperative levels. Multivariate analysis identified age (OR 1.088; P= .002) and BMI (OR 1.124; P= .022) as risk factors for AKI development. Moreover, AKI development was an independent risk factor for ICU stays longer than 48 hours (OR 2.561; P= .019).

CONCLUSIONS

Mild AKI is a not rare complication in high-risk patients undergoing major abdominal surgery. Although in almost the totality of cases, the indicators of renal function recovered to preoperative levels, post-operative AKI represents a primary risk factor for a prolonged ICU stay.

A Novel Approach to Major Surgery: Tracking Its Pathophysiologic Footprints

BACKGROUND

To study the 'metabolic profile' of different surgical procedures and correlate it with pertinent surgical details and postoperative complications.

METHODS

We conducted a prospective pilot study of 70 patients, ten for each of the seven following groups: (1) laparoscopic cholecystectomy, (2) incisional hernia repair, (3) laparoscopic and (4) open colon surgery, (5) upper gastrointestinal, (6) hepatic, and (7) pancreatic resections. Biochemical assessment included white blood cell count (WBC), C-reactive protein (CRP), glucose, triglycerides (TG), albumin (Alb), and pre-albumin (Pre-Alb), from the day before surgery until 5 days thereafter. Biological markers were compared for major versus minor surgery groups, which were defined on a clinical basis. Univariable analysis was used to identify risk factors for postoperative complications and p < 0.05 was the significance threshold.

RESULTS

Common findings in all surgery groups were the acute inflammatory response (↑: WBC, CRP, ↓: TG, Alb, pre-Alb). Using cut-off values of 240 min operative (OR) time and 300 ml estimated blood loss (EBL), laparoscopic cholecystectomy, incisional hernia repair, and laparoscopic colectomy could be distinguished from open colectomy, upper gastrointestinal, liver, and pancreas resections. In a biochemical level, increased CRP and reduced postoperative Alb levels were highly discriminative of all types of 'major surgery.' Significant risk factors for postoperative complications were age, male gender, malignancy, longer OR time, higher blood loss, high CRP, and low Alb levels.

CONCLUSIONS

Biochemically, CRP and Alb levels can help quantify the magnitude of the surgical trauma, which is correlated with adverse outcomes.

The effect of local anesthetic on pro-inflammatory macrophage modulation by mesenchymal stromal cells

Administering local anesthetics (LAs) peri- and post-operatively aims to prevent or mitigate pain in surgical procedures and after tissue injury in cases of osteoarthritis (OA) and other degenerative diseases. Innovative tissue protective and reparative therapeutic interventions such as mesenchymal stromal cells (MSCs) are likely to be exposed to co-administered drugs such as LAs. Therefore, it is important to determine how this exposure affects the therapeutic functions of MSCs and other cells in their target microenvironment. In these studies, we measured the effect of LAs, lidocaine and bupivacaine, on macrophage viability and pro-inflammatory secretion. We also examined their effect on modulation of the macrophage pro-inflammatory phenotype in an in vitro co-culture system with MSCs, by quantifying macrophage tumor necrosis factor (TNF)-α secretion and MSC prostaglandin E2 (PGE2) production. Our studies indicate that both LAs directly attenuated macrophage TNF-α secretion, without significantly affecting viability, in a concentration- and potency-dependent manner. LA-mediated attenuation of macrophage TNF-α was sustained in co-culture with MSCs, but MSCs did not further enhance this anti-inflammatory effect. Concentration- and potency-dependent reductions in macrophage TNF-α were concurrent with decreased PGE2 levels in the co-cultures further indicating MSC-independent macrophage attenuation. MSC functional recovery from LA exposure was assessed by pre-treating MSCs with LAs prior to co-culture with macrophages. Both MSC attenuation of TNF-α and PGE2 secretion were impaired by pre-exposure to the more potent bupivacaine and high dose of lidocaine in a concentration-dependent manner. Therefore, LAs can affect anti-inflammatory function by both directly attenuating macrophage inflammation and MSC secretion and possibly by altering the local microenvironment which can secondarily reduce MSC function. Furthermore, the LA effect on MSC function may persist even after LA removal.

Stroke volume variation to guide fluid therapy: is it suitable for high-risk surgical patients? A terminated randomized controlled trial

Background

Perioperative goal-directed fluid therapy (GDFT) may improve outcome after high-risk surgery. Minimal invasive measurement of stroke volume variation (SVV) has been recommended to guide fluid therapy. We intended to study how perioperative GDFT with arterial-based continuous SVV monitoring influences postoperative complications in a high-risk surgical population.

Methods

From February 1st 2012, all ASA 3 and 4 patients undergoing abdominal surgery in two university hospitals were assessed for randomization into a control group or GDFT group. An arterial-line cardiac output monitor was used to measure SVV, and fluid was given after an algorithm in the intervention group. Restrictions of the method excluded patients undergoing laparoscopic surgery, patients with atrial fibrillation and patients with severe mitral/aortal stenosis. To detect a decrease in number of complication from 40 % in the control group to 20 % in the GDFT group, n = 164 patients were needed (power 80 %, alpha 0.05, two-sided test). To include the needed amount of patients, the study was estimated to last for 2 years.

Results

After 1 year, 30 patients were included and the study was halted due to slow inclusion rate. Of 732 high-risk patients scheduled for abdominal surgery, 391 were screened for randomization. Of those, n = 249 (64 %) were excluded because a laparoscopic technique was preferred and n = 95 (24 %) due to atrial fibrillation.

Conclusions

Our study was stopped due to a slow inclusion rate. Methodological restrictions of the arterial-line cardiac output monitor excluded the majority of patients. This leaves the question if this method is appropriate to guide fluid therapy in high-risk surgical patients.

Trial registration

ClinicalTrials.gov: NCT01473446.

Electronic supplementary material

The online version of this article (doi:10.1186/s13741-015-0016-x) contains supplementary material, which is available to authorized users.

Effect of penehyclidine hydrochloride on heart rate variability in hysteroscopy

In order to evaluate the effect of different doses of penehyclidine hydrochloride (penehyclidine) on heart rate (HR) and HR variability (HRV) in hysteroscopy, 180 patients (American Society of Anesthesiologists grade I-II) were randomized equally to three groups: 0.5 mg penehyclidine and intravenous anesthesia (group I), 1.0 mg penehyclidine and intravenous anesthesia (group II) and saddle anesthesia combined with intravenous anesthesia (control group). HR and HRV, including total power (TP), low-frequency power (LF), high-frequency power (HF) and the LF to HF ratio (LF/HF), were recorded prior and subsequent to the induction of anesthesia (T₀ and T₁, respectively), following the start of surgery (T₂) and following completion of surgery (T₃). HR was lower at T₂ than at T₀ in the control patients, but no differences were observed in groups I and II. The HR at T₂ was increased in group II compared with that in group I. TP in group II was significantly higher compared with that in group I at T₂. At T₁ and at T₂, the LF and HF values were lower in group I than those in the controls. Patients in group II also had higher LF and HF at T₂ than patients in group I. The HF was higher at T₂ than that at T₀ in the controls; however, the HF and LF did not change significantly within groups I and II. No significant differences were observed in the LF/HF ratio among the three groups. At a dose of 0.5 mg, penehyclidine stabilized HRV and did not alter the autonomic nervous modulation of HR. A penehyclidine dose of 1.0 mg may be superior to a dose of 0.5 mg in maintaining HR, but is less effective at balancing sympathetic and parasympathetic activity.

Impact of analgesic modality on stress response following laparoscopic colorectal surgery: a post-hoc analysis of a randomised controlled trial

BACKGROUND

Epidural analgesia is perceived to modulate the stress response after open surgery. This study aimed to explore the feasibility and impact of measuring the stress response attenuation by post-operative analgesic modalities following laparoscopic colorectal surgery within an enhanced recovery after surgery (ERAS) protocol.

METHODS

Data were collected as part of a double-blinded randomised controlled pilot trial at two UK sites. Patients undergoing elective laparoscopic colorectal resection were randomised to receive either thoracic epidural analgesia (TEA) or continuous local anaesthetic infusion to the extraction site via wound infusion catheter (WIC) post-operatively. The aim of this study was to measure the stress response to the analgesic modality by measuring peripheral venous blood samples analysed for serum concentrations of insulin, cortisol, epinephrine and interleukin-6 at induction of anaesthesia, at 3, 6, 12 and 24 h after the start of operation. Secondary endpoints included mean pain score in the first 48 h, length of hospital stay, post-operative complications and 30-day re-admission rates.

RESULTS

There was a difference between the TEA and WIC groups that varies across time. In the TEA group, there was significant but transient reduced level of serum epinephrine and a higher level of insulin at 3 and 6 h. In the WIC, there was a significant reduction of interleukin-6 values, especially at 12 h. There was no significant difference observed in the other endpoints.

CONCLUSIONS

There is a significant transient attenuating effect of TEA on stress response following laparoscopic colorectal surgery and within ERAS as expressed by serum epinephrine and insulin levels. Continuous wound infusion with local anaesthetic, however, attenuates cytokine response as expressed by interleukin-6.

Preoperative and early postoperative quality of life after major surgery - a prospective observational study

BACKGROUND

Changes in health-related quality of life (HRQoL) several days after surgery have rarely been investigated. We aimed to estimate the perioperative change of HRQoL, to identify patients with clinically relevant decrease in postoperative HRQoL and to establish factors associated with this decrease in HRQoL at day 30 after major surgery.

METHODS

Patients scheduled for major surgery at a university hospital were enrolled. Based on the HRQoL SF-12 questionnaire, the preoperative physical component summary (PCS) score, preoperative mental component summary (MCS) score, and postoperative PCS and MCS scores at day 30 were recorded. Minimal clinically important difference (MCID) was defined as those with a decrease of at least one half of the standard deviation (SD) of preoperative PCS or MCS scores. Differences between the groups with or without decreased HRQoL were investigated using univariate comparisons. A multiple logistic regression model was performed to evaluate the predictive value of potential perioperative variables.

RESULTS

The mean ± SD preoperative PCS score was 38.5 ± 10.6, postoperative score was 35.1 ± 7.8 (p = .004) in 85 patients. Thirty-five patients (41.2%) had a clinically relevant decrease of the postoperative PCS score. A normal to high preoperative exercise metabolic capacity measured with metabolic equivalent of task (MET) (p = .01) was a predictor of the decrease in postoperative PCS. The mean preoperative MCS scores (p = .395) were 42.2 (SD 12.8) preoperative, and 43.45 (SD 12.4) postoperative, respectively.

CONCLUSIONS

Major surgery decreases postoperative PCS scores of HRQoL at 30 days. A normal to high exercise capacity was a predictor of a clinically relevant decrease of postoperative PCS scores.

TRIAL REGISTRATION

07-107 (Ethical Committee NAC of Geneva University Hospitals).

Survival after postoperative morbidity: a longitudinal observational cohort study

Background

Previous studies have suggested that there may be long-term harm associated with postoperative complications. Uncertainty exists however, because of the need for risk adjustment and inconsistent definitions of postoperative morbidity.

Methods

We did a longitudinal observational cohort study of patients undergoing major surgery. Case-mix adjustment was applied and morbidity was recorded using a validated outcome measure. Cox proportional hazards modelling using time-dependent covariates was used to measure the independent relationship between prolonged postoperative morbidity and longer term survival.

Results

Data were analysed for 1362 patients. The median length of stay was 9 days and the median follow-up time was 6.5 yr. Independent of perioperative risk, postoperative neurological morbidity (prevalence 2.9%) was associated with a relative hazard for long-term mortality of 2.00 [P=0.001; 95% confidence interval (CI) 1.32–3.04]. Prolonged postoperative morbidity (prevalence 15.6%) conferred a relative hazard for death in the first 12 months after surgery of 3.51 (P<0.001; 95% CI 2.28–5.42) and for the next 2 yr of 2.44 (P<0.001; 95% CI 1.62–3.65), returning to baseline thereafter.

Conclusions

Prolonged morbidity after surgery is associated with a risk of premature death for a longer duration than perhaps is commonly thought; however, this risk falls with time. We suggest that prolonged postoperative morbidity measured in this way may be a valid indicator of the quality of surgical healthcare. Our findings reinforce the importance of research and quality improvement initiatives aimed at reducing the duration and severity of postoperative complications.

Association of obesity with inflammation and pain after total hip arthroplasty

BACKGROUND

The prevalence of obesity is increasing, and obesity often leads to degenerative joint disease requiring total hip arthroplasty (THA). Obesity is a proinflammatory state associated with an increase in chronic, low-grade inflammatory response. As such, it may augment the postoperative inflammatory response, which has been associated with postoperative pain and complications.

QUESTIONS/PURPOSES

We determined whether severity of obesity was associated with (1) severity of inflammatory response, as measured by the in vivo circulating levels of cytokines and ex vivo functional reactivity of mononuclear blood cells, and (2) severity of pain, as measured by verbal pain scores and analgesic consumption, in the first 24 hours after THA.

METHODS

We studied 60 patients (20 normal weight, 20 overweight, 20 obese) undergoing elective primary unilateral THA in this prospective cross-sectional study. Blood samples were collected for C-reactive protein and cytokine levels, including IL-1β, IL-2, IL-6, IL-8, and tumor necrosis factor α (TNF-α), from patients before and 24 hours after surgery. Cytokine response of whole blood was evaluated ex vivo with or without two standard activators, phorbol-12-myristate-13-acetate and lipopolysaccharide, using standardized blood sample from patients at 24 hours. These standard immune activators are implicated in the inflammatory response to gram-negative infection, translocation of microbial products, pathophysiology of septic shock syndrome in human, and tumor promotion. Pain response was gauged using verbal pain scores (on a 0- to 10-point scale, where 0 = no pain and 10 = worst pain) at rest and with activity at 24 hours after surgery and analgesic consumption of volume of epidural analgesic solution for the first 24 hours after surgery.

RESULTS

No correlation was found between BMI and postoperative spontaneous circulating cytokine levels. However, after activation of blood leukocytes with lipopolysaccharide, there was a significant positive correlation between the BMI and IL-1β, IL-6, and TNF-α levels (r = 0.26-0.32; p = 0.03, p = 0.03, and p = 0.01, respectively), suggesting priming of the innate immune system in obesity and potential for excessive postoperative inflammatory response. Obesity was not associated with increased pain or analgesic consumption in the first 24 hours after surgery.

CONCLUSIONS

Obesity is associated with a proinflammatory state after THA as demonstrated by enhanced cytokine reactivity. Larger studies exploring the specific impact of obesity and inflammation on surgical outcomes, including pain, are warranted.

LEVEL OF EVIDENCE

Level II, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Epidural technique for postoperative pain: gold standard no more?

Epidural analgesia is a well-established technique that has commonly been regarded as the gold standard in postoperative pain management. However, newer, evidence-based outcome data show that the benefits of epidural analgesia are not as significant as previously believed. There are some benefits in a decrease in the incidence of cardiovascular and pulmonary complications, but these benefits are probably limited to high-risk patients undergoing major abdominal or thoracic surgery who receive thoracic epidural analgesia with local anaesthetic drugs only. There is increasing evidence that less invasive regional analgesic techniques are as effective as epidural analgesia. These include paravertebral block for thoracotomy, femoral block for total hip and knee arthroplasty, wound catheter infusions for cesarean delivery, and local infiltration analgesia techniques for lower limb joint arthroplasty. Wound infiltration techniques and their modifications are simple and safe alternatives for a variety of other surgical procedures. Although pain relief associated with epidural analgesia can be outstanding, clinicians expect more from this invasive, high-cost, labour-intensive technique. The number of indications for the use of epidural analgesia seems to be decreasing for a variety of reasons. The decision about whether to continue using epidural techniques should be guided by regular institutional audits and careful risk-benefit assessment rather than by tradition. For routine postoperative analgesia, epidural analgesia may no longer be considered the gold standard.

Standard perioperative management in gastrointestinal surgery

INTRODUCTION

The outcome of patients who are scheduled for gastrointestinal surgery is influenced by various factors, the most important being the age and comorbidities of the patient, the complexity of the surgical procedure and the management of postoperative recovery. To improve patient outcome, close cooperation between surgeons and anaesthesiologists (joint risk assessment) is critical. This cooperation has become increasingly important because more and more patients are being referred to surgery at an advanced age and with multiple comorbidities and because surgical procedures and multimodal treatment modalities are becoming more and more complex.

OBJECTIVE

The aim of this review is to provide clinicians with practical recommendations for day-to-day decision-making from a joint surgical and anaesthesiological point of view. The discussion centres on gastrointestinal surgery specifically.