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BACKGROUND AND OBJECTIVE - Soft tissue sarcomas (STS) are a rare and heterogeneous group of malignant tumors that are often treated through surgical resection. Current intraoperative margin assessment methods are limited and highlight the need for an improved approach with respect to time and specificity. Here we investigate the potential of near-infrared Raman spectroscopy for the intraoperative differentiation of STS from surrounding normal tissue.
MATERIALS AND METHODS - In vivo Raman measurements at 785 nm excitation were intraoperatively acquired from subjects undergoing STS resection using a probe based spectroscopy system. A multivariate classification algorithm was developed in order to automatically identify spectral features that can be used to differentiate STS from the surrounding normal muscle and fat. The classification algorithm was subsequently tested using leave-one-subject-out cross-validation.
RESULTS - With the exclusion of well-differentiated liposarcomas, the algorithm was able to classify STS from the surrounding normal muscle and fat with a sensitivity and specificity of 89.5% and 96.4%, respectively.
CONCLUSION - These results suggest that single point near-infrared Raman spectroscopy could be utilized as a rapid and non-destructive surgical guidance tool for identifying abnormal tissue margins in need of further excision. Lasers Surg. Med. 48:774-781, 2016. © 2016 Wiley Periodicals, Inc.
© 2016 Wiley Periodicals, Inc.
OBJECTIVE - To investigate the association between perioperative patient characteristics and treatment modalities (eg, vasopressor use and volume of fluid administration) with complications and failure rates in patients undergoing head and neck free tissue transfer (FTT).
STUDY DESIGN - A retrospective review of medical records.
SETTING - Perioperative hospitalization for head and neck FTT at 1 tertiary care medical center between January 1, 2009, and October 31, 2011.
SUBJECTS AND METHODS - Consecutive patients (N=235) who underwent head and neck FTT. Demographic, patient characteristic, and intraoperative data were extracted from medical records. Complication and failure rates within the first 30 days were collected
RESULTS - In a multivariate analysis controlling for age, sex, ethnicity, reason for receiving flap, and type and volume of fluid given, perioperative complication was significantly associated with surgical blood loss (P=.019; 95% confidence interval [CI], 1.01-1.16), while the rate of intraoperative fluid administration did not reach statistical significance (P=.06; 95% CI, 0.99-1.28). In a univariate analysis, FTT failure was significantly associated with reason for surgery (odds ratio, 5.40; P=.03; 95% CI, 1.69-17.3) and preoperative diagnosis of coronary artery disease (odds ratio, 3.60; P=.03; 95% CI, 1.16-11.2). Intraoperative vasopressor administration was not associated with either FTT complication or failure rate.
CONCLUSIONS - FTT complications were associated with surgical blood loss but not the use of vasoactive drugs. For patients undergoing FTT, judicious monitoring of blood loss may help stratify the risk of complication and failure.
© American Academy of Otolaryngology—Head and Neck Surgery Foundation 2014.
BACKGROUND - The HeartWare (HW) (Framingham, MA) and the HeartMate II (HM II) (Thoratec Inc, Pleasanton, CA) continuous-flow left ventricular assist devices (CF-LVADs) are commonly used to bridge patients to transplantation. We hypothesized that there are differences in perioperative blood product (BP) use and chest tube (CT) output between CF-LVAD types.
METHODS - We retrospectively evaluated BP use in 71 patients who were implanted with a CF-LVAD (HM II = 38; HW = 33) by median sternotomy for bridge to transplantation (BTT) indications from 2009 to 2013. Detailed BP use data were collected during the intraoperative and postoperative periods and included packed red blood cells, platelets, fresh frozen plasma, and cryoprecipitate.
RESULTS - Preoperative characteristics (age, left ventricular ejection fraction, previous sternotomy, ischemic cause), and risk stratification scores (Interagency Registry for Mechanically Assisted Circulatory Support [INTERMACS]) profile, Leitz-Miller score, Kormos score) were comparable between groups (all p > 0.05). Total average intraoperative and postoperative BP use was different between device types: HW = 8.3 ± 13 versus HM II = 12.6 ± 14.0 units (p = 0.002) and HW = 6.1 ± 12.0 units compared with HM II = 13.5 ± 24.1 units (p = 0.022), respectively. Average postoperative CT output for HW (3,231 ± 3,648 mL) and HM II (3,463 ± 3,050) (p < 0.008) were different between device types. Multivariate analysis revealed that a higher preoperative Leitz-Miller score, implantation of an HM II CF-LVAD, previous sternotomy, and a longer duration of cardiopulmonary bypass (CPB) time were independently associated with increased need for BP use, whereas only use of the HM II device and a longer bypass time predicted a greater CT output.
CONCLUSIONS - Compared with HM II, implantation of the HW CF-LVAD was associated with reduced intraoperative and postoperative BP use and decreased CT output. Increased awareness of device-related differences in bleeding and BP use may improve CF-LVAD patient outcomes.
Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.
BACKGROUND - Opioids are commonly used for preoperative pain management in patients undergoing spine surgery. The objective of this investigation was to assess whether preoperative opioid use predicts worse self-reported outcomes in patients undergoing spine surgery.
METHODS - Five hundred and eighty-three patients undergoing lumbar, thoracolumbar, or cervical spine surgery to treat a structural lesion were included in this prospective cohort study. Self-reported preoperative opioid consumption data were obtained at the preoperative visit and were converted to the corresponding daily morphine equivalent amount. Patient-reported outcome measures were assessed at three and twelve months postoperatively via the 12-Item Short-Form Health Survey and the EuroQol-5D questionnaire, as well as, when appropriate, the Oswestry Disability Index and the Neck Disability Index. Separate multivariable linear regression analyses were then performed.
RESULTS - At the preoperative evaluation, of the 583 patients, 56% (326 patients) reported some degree of opioid use. Multivariable analyses controlling for age, sex, diabetes, smoking, surgery invasiveness, revision surgery, preoperative Modified Somatic Perception Questionnaire score, preoperative Zung Depression Scale score, and baseline outcome score found that increased preoperative opioid use was a significant predictor (p < 0.05) of decreased 12-Item Short-Form Health Survey and EuroQol-5D scores, as well as of increased Oswestry Disability Index and Neck Disability Index scores at three and twelve months postoperatively. Every 10-mg increase in daily morphine equivalent amount taken preoperatively was associated with a 0.03 decrease in the 12-Item Short-Form Health Survey physical component summary and mental component summary scores, a 0.01 decrease in the EuroQol-5D score, and a 0.5 increase in the Oswestry Disability Index and Neck Disability Index score at twelve months postoperatively. Higher preoperative Modified Somatic Perception Questionnaire and Zung Depression Scale scores were also significant negative predictors (p < 0.05).
CONCLUSIONS - Increased preoperative opioid consumption, Modified Somatic Perception Questionnaire score, and Zung Depression Scale score prior to undergoing spine surgery predicted worse patient-reported outcomes. This suggests the potential benefit of psychological and opioid screening with a multidisciplinary approach that includes weaning of opioid use in the preoperative period and close opioid monitoring postoperatively.
LEVEL OF EVIDENCE - Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
Copyright © 2014 by The Journal of Bone and Joint Surgery, Incorporated.
BACKGROUND - A surgical scoring system, akin to the obstetrician's Apgar score, has been developed to assess postoperative risk. To date, evaluation of this scoring system has been limited to general and vascular services. The authors attempt to externally validate and expand the Surgical Apgar Score across a wide breadth of surgical subspecialties.
METHODS - Intraoperative data for 123,864 procedures including all surgical subspecialties were collected and associated with Surgical Apgar Scores (created by the summation of point values associated with the lowest mean arterial pressure, lowest heart rate, and estimated blood loss). Patients' death records were matched to the corresponding score, and logistic regression models were created in which mortality within 7, 30, and 90 days was regressed on the Apgar score.
RESULTS - Lower Surgical Apgar Scores were associated with an increased risk of death. The magnitude of this association varied by subspecialty. Some subspecialties exhibited higher odds ratios, suggesting that the score is not as useful for them. For most of the subspecialties the association between the Apgar score and mortality decreased as the time since surgery increased, suggesting that predictive ability ceases to be helpful over time. After adjusting for the patient's American Society of Anesthesiologists classification, Apgar scores remained associated with death among most of the subspecialties.
CONCLUSION - A previously published methodology for calculating risk among general and vascular surgical patients can be applied across many surgical services to provide an objective means of predicting and communicating patient outcomes in surgery as well as planning potential interventions.
BACKGROUND - Risk factors for the development of acute respiratory distress syndrome (ARDS) in the intensive care unit (ICU) include positive fluid balance, high tidal volumes (TVs), high airway pressures, and transfusion of blood products. However, research examining intraoperative factors such as fluid resuscitation, mechanical ventilation strategies, and blood administration on the postoperative development of ARDS is lacking.
METHODS - We assessed patients admitted to the ICU with postoperative hypoxemic respiratory failure requiring mechanical ventilation for the development of ARDS in the first 7 postoperative days using established clinical and radiological criteria. Data on risk factors for ARDS were obtained from the electronic anesthetic and medical records. Logistic regression was used to examine the independent association between fluid resuscitation, TV per ideal body weight, and number of blood products transfused during surgery and the postoperative development of ARDS, adjusting for important clinical covariates.
RESULTS - Of the 89 patients with postoperative respiratory failure, 25 developed ARDS. Compared with those who received <10 mL/kg/h fluid resuscitation in the operating room, patients receiving >20 mL/kg/h fluid resuscitation had a 3.8 times higher adjusted odds of developing ARDS (P = 0.04), and those receiving 10 to 20 mL/kg/h had a 2.4 times higher adjusted odds of developing ARDS (P = 0.14). TV per ideal body weight and the number of blood units transfused were not associated with ARDS development in this study.
CONCLUSIONS - This cohort study provides evidence to suggest a relationship between intraoperative fluid resuscitation and the development of ARDS. Larger prospective trials are required to confirm these findings.
Aortic valvular stenosis remains the most common debilitating valvular heart lesion. Despite the benefit of aortic valve (AV) replacement, many high-risk patients cannot tolerate surgery. AV implantation treats aortic stenosis without subjecting patients to sternotomy, cardiopulmonary bypass (CPB), and aorta cross-clamping. This transcatheter procedure is performed via puncture of the left ventricular (LV) apex or percutaneously, via the femoral artery or vein. Patients undergo general anesthesia, intense hemodynamic manipulation, and transesophageal echocardiography (TEE). To elucidate the role of the anesthesiologist in the management of transcatheter AV implantation, we review the literature and provide our experience, focusing on anesthetic care, intraoperative events, TEE, and perioperative complications. Two approaches to the aortic annulus are performed today: transfemoral retrograde and transapical antegrade. Iliac artery size and tortuosity, aortic arch atheroma, and pathology in the area of the (LV) apex help determine the preferred approach in each patient. A general anesthetic is tailored to achieve extubation after procedure completion, whereas IV access and pharmacological support allow for emergent sternotomy and initiation of CPB. Rapid ventricular pacing and cessation of mechanical ventilation interrupts cardiac ejection and minimizes heart translocation during valvuloplasty and prosthesis implantation. Although these maneuvers facilitate exact prosthesis positioning within the native annulus, they promote hypotension and arrhythmia. Vasopressor administration before pacing and cardioversion may restore adequate hemodynamics. TEE determines annulus size, aortic pathology, ventricular function, and mitral regurgitation. TEE and fluoroscopy are used for positioning the introducer catheter within the aortic annulus. The prosthesis, crimped on a valvuloplasty balloon catheter, is implanted by inflation. TEE immediately measures aortic regurgitation and assesses for aortic dissection. After repair of femoral vessels or LV apex, patients are allowed to emerge and assessed for extubation. Observed and published complications include aortic regurgitation, prosthesis embolization, mitral valve disruption, hemorrhage, aortic dissection, CPB, stroke, and death. Transcatheter AV implantation relies on intraoperative hemodynamic manipulation for success. Transfemoral and transapical approaches pose unique management challenges, but both require rapid ventricular pacing, the management of hypotension and arrhythmias during beating-heart valve implantation, and TEE. Anesthesiologists will care for debilitated patients with aortic stenosis receiving transcatheter AV implantation.
BACKGROUND - Criterion requiring intraoperative parathyroid hormone (IOPTH) drops >50% from the highest, preincision or preexcision level, 10 minutes after the abnormal gland's excision predicts operative success with 98% accuracy. The purpose of this study is to correlate IOPTH dynamics with recurrent hyperparathyroidism (RecHPT) and eucalcemia with high PTH (HPTH).
METHODS - We followed 383 consecutive patients with parathyroidectomy guided by IOPTH monitoring using the above criterion for >6 months. Calcium and PTH levels were measured for 50 months (range, 6-173). Patients were divided in 2 groups: group 1 comprised 302 participants with IOPTH levels that decrease to the normal range (NR), and group 2, with 81 participants who had >50% IOPTH decrease but remained above the normal range. The incidence of RecHPT and eucalcemia with HPTH was evaluated.
RESULTS - RecHPT was found in 2% (8/383) of patients and eucalcemia with HPTH was present in 19% (74/383). In group 1, 17% (52/302) had eucalcemia with HPTH, whereas in group 2, this incidence was 27% (22/81; P = .04). However, only 2% of those (6/302) in group 1 and 2.5% (2/81) in group 2 developed RecHPT (P = .76). Conversely, 70.5% of those (57/81) in group 2 were eucalcemic with normal PTH.
CONCLUSION - Although postoperative eucalcemia with HPTH was significantly higher among patients with IOPTH above the normal range than in patients in group 1, the incidence of RecHPT was not increased. The majority of patients in whom IOPTH did not drop to the normal range continue to be biochemically normal after the operation.
Intra-operative brain shift limits the usefulness of image-guided neurosurgery systems (IGNS), which are based on pre-operative images. Methods that are being developed to address this problem need intra-operative measurements as input. In this work, we present an intra-operative surface shift measurement technique that relies on a tracked 3D laser range scanner. This scanner acquires both 3D range data and 2D images, which are co-registered. We compare two methods to derive displacements at every point in the field of view. The first one relies on the registration of the 2D images; the second relies on the direct 3D registration of the 3D range data. Our results, based on five data sets, show that the 2D method is preferable.
Imprint cytology (touch prep) is often used for intraoperative examination of sentinel nodes in breast cancer. This allows axillary lymph node dissection (ALND) to be performed immediately for tumor-positive nodes. We evaluated the accuracy of touch prep examination of sentinel nodes and its role in the surgical treatment of breast cancer. We analyzed 169 breast cancer patients who underwent 170 lymphatic mapping procedures with intraoperative touch prep examination. Results from the touch prep were correlated with histopathology and clinical variables. There were 115 true-negative, 35 true-positive, 15 false-negative, and 5 false-positive results. Touch prep had a sensitivity of 70 per cent and specificity of 96 per cent. Positive predictive value, negative predictive value, and diagnostic accuracy were all 88 per cent. The false-negative rate was 30 per cent and correlated with the size of the nodal metastasis and number of involved nodes, but not other patient factors. Touch prep is useful for the evaluation of sentinel nodes in breast cancer, but it has a lower sensitivity than initially reported, particularly in patients with micrometastases. False positive results occur, although they may be reduced after experience with the technique. We recommend that suspicious findings on touch prep should be confirmed by frozen section and that ALND only be performed for histologically documented metastases. We currently perform touch prep only in patients who are at high risk of nodal metastasis or will undergo mastectomy. This improves operative efficiency and limits the impact of false positive and negative results without dramatically increasing the number of patients who require a second surgical procedure.