Intraoperative laparoscopic complications for urological cancer procedures

AIM: To structure the rate of intraoperative complications that requires an intraoperative or perioperative resolution. METHODS: We perform a literature review of Medline database. The research was focused on intraoperative laparoscopic procedures inside the field of urological oncology. General rate of perioperative complications in laparoscopic urologic surgery is described to be around 12.4%. Most of the manuscripts published do not make differences between pure intraoperative, intraoperative with postoperative consequences and postoperative complications. RESULTS: We expose a narrative statement of complications, possible solutions and possible preventions for most frequent retroperitoneal and pelvic laparoscopic surgery. We expose the results with the following order: retroperitoneal laparoscopic surgery(radical nephrectomy, partial nephrectomy, nephroureterectomy and adrenalectomy) and pelvic laparoscopic surgery(radical prostatectomy and radical cystectomy).CONCLUSION: Intraoperative complications vary from different series. More scheduled reports should be done in order to better understand the real rates of complications.

Intraoperative complication rates in cataract surgery performed by resident trainees and staff surgeons in a tertiary eyecare center in Hungary

AIM: To compare the incidence of intraoperative complications during primary phacoemulsification(phaco) surgery between resident surgeons(residents) and staff surgeons(specialists) and to objectively determine the difficulty of stages in phaco surgery. METHODS: This retrospective study included cases of phaco cataract surgery performed between January and December 2019. There were no exclusion criteria. For each patient, demographics, clinical history, case complexity, type of surgeon, and operative details were reviewed. Primary outcomes included intraoperative complication rates and the objective measure of difficulty in the steps of the surgery performed by residents and specialists.RESULTS: A total of 3272 cases were included;7.4%(n=241) of cases were performed by residents. The overall complication rate was 5.4%(n=177). The intraoperative complication rate was significantly higher(P<0.001) in residents(n=33, 13.7%) than in specialists(n=144, 4.8%). The most frequent complications were posterior capsule tear(n=85, 2.6%), anterior capsule tear(n=50, 1.53%), zonular fiber loss(n=45, 1.38%), and dropped nucleus(n=15, 0.46%). Objectively, the most difficult steps during surgery were phaco in 66(60.0%), capsulorhexis in 21(19.1%), irrigation/aspiration in 13(11.8%), hydrodissection in 9(8.2%), and intraocular lens(IOL) implantation in 1(0.9%) case. CONCLUSION: Intraoperative complication rates are higher in residents than in specialists. The order of objective difficulty in phaco surgery steps is in line with the subjective findings of other surveys, revealing that the most challenging parts of phaco surgery are phaco and capsulorhexis.

Prediction of Intraoperative Trifecta Achievement during Laparoscopic Partial Nephrectomy

Purpose: We introduce the concept of intraoperative Trifecta during laparoscopic partial nephrectomy (LPN) as the simultaneous achievement of estimated blood loss (EBL) < 500 ml, warm ischemia time (WIT) < 20 minutes and minimal changes of the intraoperative course. The study’s aim was to find preoperative factors that could predict the likelihood of achieving intraoperative Trifecta and build a surgical nomogram. Methods: We retrospectively evaluated 122 patients who underwent LPN. Preoperative factors like age, sex, body-mass index (BMI), kidney function, tumor characteristics (R.E.N.A.L. score) and Charlson-Comorbidity-Index (CCI) were recorded. Intraoperative complication (IOC) was graded according to the Rosenthal classification. R software was used to find a predicting model for achievement of Trifecta using preoperative variables and a nomogram was built. Results: The surgical features include median EBL of 100 ml having 6.5% bleed > 500 ml, median WIT of 12 minutes having 7.3% more than 20 minutes. There was recorded a 12.3% IOC with a mean Rosenthal’s grade of 0.2. Intraoperative Trifecta was achieved in 105 patients (86%) and three preoperative factors were chosen for the predictive model: BMI (p = 0.041), CCI (p = 0.037) and RENAL score (p = 0.002). A nomogram was generated and the ROC-AUC of the model was 75.8%. Conclusion: We have defined an intraoperative Trifecta concept as the achievement of EBL < 500 ml, WIT < 20 minutes and minimal changes of the intraoperative course. A nomogram was developed from preoperative factors like BMI, CCI and R.E.N.A.L. score. It can be used to estimate the probability of Trifecta achievement in patients treated with LPN.

With two episodes of right retromandibular angle subcutaneous emphysema during right upper molar crown preparation:A case report

BACKGROUND Subcutaneous emphysema is a well-known complication of oral surgery,especially during mandibular wisdom tooth extraction.However,subcutaneous emphysema secondary to dental procedures such as crown preparation is rare.The main symptom of emphysema is swelling and crepitus on palpation.Uncontrolled emphysema may spread along the fascial planes and cause deep space infections or a pneumomediastinum.CASE SUMMARY In this paper,we report a 34-year-old female who underwent upper molar tooth preparation for crowns and subsequently developed extensive subcutaneous emphysema on the retromandibular angle on two different occasions.The treatment plan for this patient involved close observation of the airway,and administration of dexamethasone and antibiotics via intravenous drip or orally.Ice bag compression was quickly applied and medication was prescribed to alleviate discomfort and promote healing.Although the main reason is unclear,the presence of a fissure in the molar is an important clue which may contribute to the development of subcutaneous emphysema during crown preparation.It is imperative for dental professionals to recognize such pre-disposing factors in order to minimize the risk of complications.CONCLUSION This case highlights the need for prompt diagnosis and management of subcutaneous emphysema because of the risk of much more serious complications.Awareness of relatively“benign”subcutaneous emphysema during any dental procedure is critical not only for inexperienced dentists,but also for those who work in rural and remote settings as members of surgical teams.In this study,we review the clinical presentation,mechanism,and differential diagnosis of subcutaneous emphysema.

Enhanced recovery after surgery strategy to shorten perioperative fasting in children undergoing non-gastrointestinal surgery:A prospective study

BACKGROUND Enhanced recovery after surgery strategies are increasingly implemented to improve the management of surgical patients.AIM To evaluate the effects of new perioperative fasting protocols in children≥3 mo of age undergoing non-gastrointestinal surgery.METHODS This prospective pilot study included children≥3 mo of age undergoing nongastrointestinal surgery at the Children’s Hospital(Zhejiang University School of Medicine)from January 2020 to June 2020.The children were divided into either a conventional group or an ERAS group according to whether they had been enrolled before or after the implementation of the new perioperative fasting strategy.The children in the conventional group were fasted using conventional strategies,while those in the ERAS group were given individualized fasting protocols preoperatively(6-h fasting for infant formula/non-human milk/solids,4-h fasting for breast milk,and clear fluids allowed within 2 h of surgery)and postoperatively(food permitted from 1 h after surgery).Pre-operative and postoperative fasting times,pre-operative blood glucose,the incidence of postoperative thirst and hunger,the incidence of perioperative vomiting and aspiration,and the degree of satisfaction were evaluated.RESULTS The study included 303 patients(151 in the conventional group and 152 in the ERAS group).Compared with the conventional group,the ERAS group had a shorter pre-operative food fasting time[11.92(4.00,19.33)vs 13.00(6.00,20.28)h,P<0.001],shorter preoperative liquid fasting time[3.00(2.00,7.50)vs 12.00(3.00,20.28)h,P<0.001],higher preoperative blood glucose level[5.6(4.2,8.2)vs 5.1(4.0,7.4)mmol/L,P<0.001],lower incidence of thirst(74.5%vs 15.3%,P<0.001),shorter time to postoperative feeding[1.17(0.33,6.83)vs 6.00(5.40,9.20),P<0.001],and greater satisfaction[7(0,10)vs 8(5,10),P<0.001].No children experienced perioperative aspiration.The incidences of hunger,perioperative vomiting,and fever were not significantly different between the two groups.CONCLUSION Optimizing fasting and clear fluid drinking before non-gastrointestinal surgery in children≥3 mo of age is possible.It is safe and feasible to start early eating after evaluating the recovery from anesthesia and the swallowing function.

Renal pseudoaneurysm after rigid ureteroscopic lithotripsy:A case report

BACKGROUND Ureteroscopic lithotripsy(URSL) is a common surgical treatment for ureteral stones.Although flexible ureteroscopy can be used to treat ureteral and renal stones in a single procedure,rigid ureteroscopy can only be used to treat ureteral stones;nonetheless,rigid ureteroscopy remains mainstream in Taiwan owing to its late introduction and flexible ureteroscopy is not covered by national health insurance.Hematuria is a common complication that occurs when the scope passes through stricture sites or when mucosal damage occurs during lithotripsy,but this is usually self-limited.Prolonged hematuria requiring intervention is termed persistent hematuria.Persistent hematuria is less common and few studies have reported the development and etiology of renal pseudoaneurysm after flexible ureteroscopy for renal stones.Herein,we present the first reported case of renal pseudoaneurysm after rigid URSL for ureteral stone.CASE SUMMARY The patient was a 57-year-old man who developed renal pseudoaneurysm with active bleeding after rigid ureteroscopy.He presented with gross hematuria and intolerable left flank pain after left URSL.Severe anemia was noted(hemoglobin level,6.8 g/d L).Contrast enhanced computed tomography revealed one pseudoaneurysm each in the upper and lower renal cortex.He was managed via transcatheter arterial embolization with microcoils,which relieved the symptoms.CONCLUSION To the best of our knowledge,ours is the first case report on renal pseudoaneurysm after rigid URSL.Because renal pseudoaneurysms are difficult to access,underlying hypertension,clinical signs such as refractory flank pain,and gross hematuria should be carefully monitored following similar endourological procedures.

Clinical features and diagnosis for Chinese cases with malignant hyperthermia： a case cluster from 2005 to 2007

Background Malignant hyperthermia （MH）, manifesting as MH crisis during and/or after general anesthesia, is a potentially fatal disorder in response to volatile anesthetics and depolarizing muscle relaxants. Though typical features of MH episode can provide clues for clinical diagnosis, MH susceptibility is confirmed by in vitro caffeine-halothane contracture test （CHCT） in western countries. It is traditionally thought that MH has less incidence and fewer typical characteristics in Chinese population than their western counterparts because of the different genetic background. In this study, we investigated the clinical features of MH in Chinese cases and applied the clinical grading scale and CHCT for diagnosis of MH. Methods A cluster of three patients with MH, from January 2005 to December 2007, were included in the study. Common clinical presentations and the results of some lab examinations were reported in detail. The method of the clinical grading scale of diagnosis of MH was applied to estimate the qualitative likelihood of MH and predict MH susceptibility. Muscle fibers of femoral quadriceps of the patients were collected and CHCT was performed to confirm the diagnosis of MH. Results The clinical grading scales of diagnosis of the disease for these cases were all ranked grade D6, suggesting almost diagnosed ones. And the results of caffeine test were positive correspondingly, indicating that the patients should be diagnosed as MH susceptibility （MHS） according to diagnostic criteria of the North America MH group, which were already confirmed by clinical presentations and biochemical results. Conclusions These Chinese cases manifest as MH crisis. The clinical grading scale of diagnosis of MH may provide clues for clinical diagnosis. CHCT can also be used in confirming diagnosis of MH in Chinese cases though they have different genetic background from their western counterparts.

Anesthetic considerations of an emergency decompressive craniotomy complicated with Ebstein＇s anomaly and atrial septal defect

Despite considerable published papers regarding Ebstein＇s anomaly （EA） patients receiving open-heart tricuspid valve replacement, non-cardiac emergency surgeries were rarely reported. We report a case of emergency decormpressive craniotormy in a patient with EA. Anesthesiologists should pay special attention to the complications and anesthetic management during the non-cardiac surgeries performed in EA patients.hile papers regarding Ebstein＇s anomaly （EA）patients receiving open-heart tricuspid valve replacement are numerous, the reports of non-cardiac emergency surgeries have not been to the same degree.We report a case of emergency decompressive craniotomy in a patient with EA. This case report describes the symptoms and anesthetic management during the surgery.

Safety and visual outcomes following posterior chamber phakic intraocular lens bilensectomy

Background:To evaluate the safety,efficacy,refractive outcomes and causes for bilensectomy[phakic intraocular lens(plOL)explantation with cataract surgery and pseudophakic intraocular lens(IOL)implantation]in patients previously implanted with posterior chamber plOLs(PC plOLs).Methods:This multi-center retrospective study included 87 eyes of 55 patients who underwent bilensectomy for PC plOL with a follow-up time of 12 months.The uncorrected and corrected distance visual acuities(UDVA,CDVA),endothelial cell density before and after bilensectomy were assessed,as well as the cause of bilensectomy and intra or postoperative complications.Results:There was a statistically significant improvement in UDVA and CDVA after bilensectomy(P=0.00).The main reason for bilensectomy was cataract development(93.1%of the cases),followed by miscalculation of lens size,and corneal edema.The endothelial cell count remained stable without a statistically significant change after surgery(P=0.67).The refractive efficacy index was 0.8,none of the patients lost lines of CDVA after surgery,73%of the patients were within±1.0D(spherical equivalent)of the target refraction.Intraoperative complications were one posterior capsule rupture with the IOL implanted in the sulcus,and three eyes required the use of pupil expanders for adequate pupil dilation.Postoperatively,one eye developed retinal detachment.The three plOLs models explanted were the implantable collamer lens(ICL);implantable phakic contact lens(IPCL)and the phakic refractive lens(PRL).Conclusions:Good safety and visual outcomes were observed one year after bilensectomy for PC plOLs.There were few intra and postoperative complications and there was no significant endothelial cell loss after the bilensectomy procedure.

Safety and visual outcomes following posterior chamber phakic intraocular lens bilensectomy

Background:To evaluate the safety,efficacy,refractive outcomes and causes for bilensectomy(phakic intraocular lens–pIOL–explantation with cataract surgery and pseudophakic intraocular lens implantation)in patients previously implanted with posterior chamber pIOLs.Methods:This multi-center retrospective study included 87 eyes of 55 patients who underwent bilensectomy for posterior chamber pIOL with a follow up time of 12 months.The uncorrected and best corrected distance visual acuities(UDVA,CDVA),endothelial cell density before and after bilensectomy were assessed,as well as the cause of bilensectomy and intra or postoperative complications.Results:There was a statistically significant improvement in uncorrected and best corrected visual acuities after bilensectomy(p=0.00).The main reason for bilensectomy was cataract development(93.1%of the cases),followed by miscalculation of lens size,and corneal edema.The endothelial cell count remained stable without a statistically significant change after surgery(p=0.67).The refractive efficacy index was 0.8,none of the patients lost lines of CDVA after surgery,73%of the patients were within±1 D(spherical equivalent)of the target refraction.Intraoperative complications were one posterior capsule rupture with the intraocular lens(IOL)implanted in the sulcus,and 3 eyes required the use of pupil expanders for adequate pupil dilation.Postoperatively,one eye developed retinal detachment.The three pIOLs models explanted were the Implantable Collamer Lens(ICL),Implantable Phakic Contact Lens(IPCL)and the Phakic Refractive Lens(PRL).Conclusions:Good safety and visual outcomes were observed 1 year after bilensectomy for posterior chamber phakic intraocular lenses(PC pIOLs).There were few intra and postoperative complications and there was no significant endothelial cell loss after the bilensectomy procedure.

Analysis of 1-year Consecutive Application with Focused Transthoracic Echocardiography in Noncardiac Surgery

Point-of-care transthoracic echocardiography （TTE） is an evolving field in anesthesia field and verified to have the potential to provide rapid diagnostic information during the hemodynamic collapse in operating room.[1] In this retrospective observatory study, we retrieved all the data of 1-year consecutive use of intraoperative echocardiography in patients with circulatory collapse or undergoing selective high-risk noncardiac surgery.