Surgical treatment of hepatocellular carcinoma: Evidence-based outcomes

Surgeons may be severely criticized from the perspective of evidence-based medicine because the majority of surgical publications appear not to be convincing. In the top nine surgical journals in 1996, half of the 175 publications refer to pilot studies lacking a control group, 18% to animal experiments, and only 5% to randomized controlled trials (RCT). There are five levels of clinical evidence:level 1 (randomized controlled trial), level 2 (prospective concurrent cohort study), level 3 (retrospective historical cohort study), level 4 (pre-post study), and level 5 (case report). Recently, a Japanese evidence-based guideline for the surgical treatment of hepatocellular carcinoma (HCC) was made by a committee (Chairman, Professor Makuuchi and five members). We searched the literature using the Medline Dialog System with four Keywords:HCC, surgery, English papers, in the last 20 years. A total of 915 publications were identified systematically reviewed. At the first selection (in which surgery-dominant papers were selected), 478 papers survived. In the second selection (clearly concluded papers), 181 papers survived. In the final selection (clinically significant papers), 100 papers survived. The evidence level of the 100 surviving papers is shown here:level-1 papers (13%), level-2 papers (11%), level-3 papers (52%), and level-4 papers (24%);therefore, there were 24% prospective papers and 76% retrospective papers. Here, we present a part of the guideline on the five main surgical issues:indication to operation, operative procedure, peri-operative care, prognostic factor, and post-operative adjuvant therapy.

Adjuvant therapy for gastric cancer:Current and future directions

The management of gastric cancer continues to evolve. Whilst surgery alone is effective when tumours present early,a large proportion of patients are diagnosed with loco-regionally advanced disease,resulting in high locoregional and distant relapse rates,with subsequent poor survival. Early attempts at improving outcomes following resection were disappointing;however,randomized trials have now established either post-operative chemoradiotherapy(INT0116) or peri-operative chemotherapy as standard adjuvant therapies in the Western world. There remain,however,significant differences in the approach to management between the West and East. In Asia,where there is the highest incidence of gastric cancer,extended resection followed by adjuvant chemotherapy represents the standard of care. This review discusses current standard adjuvant therapy in gastric adenocarcinoma,as well as recent and ongoing trials investigating novel(neo)adjuvant approaches,which hope to build on the successes of previous studies.

Controversies in fluid therapy: Type, dose and toxicity

Fluid therapy is perhaps the most common intervention received by acutely ill hospitalized patients; however, a number of critical questions on the efficacy and safety of the type and dose remain. In this review, recent insights derived from randomized trials in terms of fluid type, dose and toxicity are discussed. We contend that the prescription of fluid therapy is context-specific and that any fluid can be harmful if administered inappropriately. When contrasting ‘‘crystalloid vs colloid'', differences in efficacy are modest but differences in safety are significant. Differences in chloride load and strong ion difference across solutions appear to be clinically important. Phases of fluid therapy in acutely ill patients are recognized, including acute resuscitation, maintaining homeostasis, and recovery phases. Quantitative toxicity(fluid overload) is associated with adverse outcomes and can be mitigated when fluid therapy basedon functional hemodynamic parameters that predict volume responsiveness and minimization of non-essential fluid. Qualitative toxicity(fluid type), in particular for iatrogenic acute kidney injury and metabolic acidosis, remain a concern for synthetic colloids and isotonic saline, respectively. Physiologically balanced crystalloids may be the ‘‘default'' fluid for acutely ill patients and the role for colloids, in particular hydroxyethyl starch, is increasingly unclear. We contend the prescription of fluid therapy is analogous to the prescription of any drug used in critically ill patients.

Risk and management of post-operative infectious complications in inflammatory bowel disease: A systematic review

BACKGROUND Indications for surgery in inflammatory bowel disease(IBD)include treatment-refractory disease or severe complications such as obstruction,severe colitis,dysplasia,or neoplasia.Infectious complications following colorectal surgery in IBD are significant,particularly in high-risk patients.AIM To gather evidence on risk factors associated with increased post-operative infectious complications in IBD and explore management strategies to reduce morbidity and mortality.METHODS A systematic review adhering to PRISMA-P guidelines was conducted.MEDLINE(PubMed)and Cochrane Library databases were searched using specific key-words.Inclusion criteria encompassed studies involving patients with IBD under-going abdominal surgery with infectious complications within 30 d postoper-atively.Exclusion criteria included patients under 18 years and non-infectious complications.Selected papers were analyzed to identify factors contributing to post-operative infections.A narrative analysis was performed to provide eviden-ce-based recommendations for management.The data were then extracted and assessed based on the Reference Citation Analysis(https://www.referencecitation-analysis.com/).RESULTS The initial database search yielded 1800 articles,with 330 articles undergoing full-text review.After excluding duplicates and irrelevant papers,35 articles were included for analysis.Risk factors for post-operative complications in patients with IBD included hypoalbuminemia,malnutrition,preoperative abscess,and obesity.Perioperative blood transfusion was associated with increased infectious complications.Medications such as 5-aminosalicylates and immunomodulators did not increase post-operative complications.Corticosteroids were associated with an increased risk of complications.Ustekinumab and vedolizumab showed similar rates of infectious complic-ations compared to other treatments.The impact of minimally invasive surgery on post-operative complications varied across studies.CONCLUSION In order to reduce post-operative infectious complications in patients with IBD,a comprehensive approach involving multiple disciplines is necessary.

A Retrospective Comparison of Interscalene Continuous Catheter Verse Single-Injection with Liposomal Bupivacaine in Total Shoulder Arthroplasty

Background: One common method of pain control for total shoulder arthroplasty is long-duration delivery of local anesthetic via interscalene brachial plexus block (ISB) with a continuous catheter. Alternatively, liposomal bupivacaine has also been administered as an ISB as a means to prolong the analgesic effect. This study was completed to measure the non-inferiority of single-injection ISB with liposomal bupivacaine compared with ISB continuous catheter for total shoulder arthroplasty. Methods: We performed a retrospective chart review of patients who underwent total shoulder arthroplasty using either an ISB continuous catheter or a single injection ISB with liposomal bupivacaine for post operative analgesia. The primary goal of this study was to determine if single-injection with liposomal bupivacaine conferred non-inferior pain scores compared to the continuous catheter. Secondary outcomes evaluated oxygen saturation as a measure of hemidiaphragmatic paresis, post operative opioid requirements, and difference in cost. Results: We identified 333 patients for the study: 126 received continuous catheter and 207 received single-injection with liposomal bupivacaine. The median length of stay was 1 day. Pain scores for those treated with single-injection with liposomal bupivacaine were non-inferior to pain scores of those treated with the continuous catheter on post-op days 0, 1 and 2. Pain scores were lower for single-injection with liposomal bupivacaine patients on days 3 and 4, however they did not reach statistical significance. There was no significant difference in oxygen saturation between the two groups. Both groups had similar daily morphine milligram equivalent requirements. Liposomal bupivacaine ISB was also found to be less expensive. Conclusion: Single-injection ISB with liposomal bupivacaine provides non-inferior analgesia at a reduced cost compared with continuous catheter ISB for total shoulder arthroplasty.

The role of anesthesia in peri-operative neurocognitive disorders:Molecular mechanisms and preventive strategies

Peri-operative neurocognitive disorders(PNDs)include postoperative delirium(POD)and postoperative cognitive dysfunction(POCD).Children and the elderly are the two populations most vulnerable to the development of POD and POCD,which results in both high morbidity and mortality.There are many factors,including neuroinflammation and oxidative stress,that are associated with POD and POCD.General anesthesia is a major risk factor of PNDs.However,the molecular mechanisms of PNDs are poorly understood.Dexmedetomidine(DEX)is a useful sedative agent with analgesic properties,which significantly improves POCD in elderly patients.In this review,the current understanding of anesthesia in PNDs and the protective effects of DEX are summarized,and the underlying mechanisms are further discussed.

Operable gastro-oesophageal junctional adenocarcinoma: Where to next?

Oesophageal junctional adenocarcinoma is a challeng-ing and increasingly common disease. Optimisation ofpre-operative staging and consolidation of surgery inlarge volume centres have improved outcomes, howev-er the preferred adjunctive treatment approach remainsa matter of debate. This review examines the benefitsof neoadjuvant, peri-operative, and post-operative che-motherapy and chemoradiotherapy in this setting in anattempt to reach an evidence based conclusion. Recentfindings relating to the molecular characterisation ofoesophagogastric cancer and their impact on therapeu-tics are explored, in addition to the potential benefitsof fluoro-deoxyglucose positron emission tomography(FDG-PET) directed therapy. Finally, efforts to decreasethe incidence of junctional adenocarcinoma using earlyintervention in Barrett's oesophagus are discussed,including the roles of screening, endoscopic mucosalresection, ablative therapies and chemoprevention.

Perioperative Materno-Fetal Morbimortality Related to the Caesarean in the Hospital Setting in Mali

Introduction: During childbirth by Caesarean, several types of anesthesia can be used. The Caesarean, the most practiced surgical delivery technique in obstetrics, has a risk for complications for both the pregnant women and newborns. Objective: To evaluate the importance of the complications due to Caesarean in the Teaching hospital Gabriel Toure. Patient and Methods: We conducted a cross sectional survey in the departments of intensive care unit and gyneco-obstetric from January to August 2017 in the University hospital Gabriel Touré of Bamako. Our study population was pregnant women who gave birth to children by Caesarean. We included all cases of preventive and emergent Caesarean under loco-regional or general anesthesia. Data were compiled from the obstetrical files of the patients, the anesthetic consultation registry and the databasis of the department of gyneco-obstetric. The test of khi2 of Pearson was used for the comparison of our results with a value of p < 0.05 considered as statistically significant. The consent of the patients or parents was gotten. The survey didn’t include a potentially dangerous act. Results: During the study period, 1875 childbirths have been recorded of which 633 were by Caesarean (33.7%). We collected and analyzed 524 files of Caesarean. The mortality rate was 1.5% in pregnant women and 15% in newborns. The average age was 26.6 ± 6.9 ans. Pregnant women were referrals in 59.4% of the cases. The most frequent motive of referrals was high blood pressure and pregnancy in 66.6%. The Caesarean was indicated in most of the cases on previously operated uterus in 22% and eclampsia was present in 14%. The maternal mortality had occurred in a context of hemorrhage in 50% of the cases. The factors of maternal morbi-mortality were the mode of admission, iterative Caesarean, t surgeon, context of the Caesarean, realization of the anesthetic consultation and the technic of anesthesia (p = 0.05). The factors of fetal mortality were the realization of endo-tracheal intubation, technic of anesthesia, realization of the anesthesia consultation, context of the Caesarean, iterative Caesarean and the mode of admission (p ≤ 0.05). Conclusion: The caesarean is associated with a high risk of maternal complications and a very important fetal mortality. The anesthesia consultation in the follow-up of pregnancy would reduce this high mortality.

Exploration of Syndrome Differentiation Patterns in Coronary Heart Disease Patients during Peri-Operative Stage of Coronary Artery Bypass Graft

Objective: To explore the patterns of Syndrome Differentiation (SD) of coronary heart disease (CHD) patients in peri-operative stage of coronary artery bypass graft (CABG).Methods: One week after operation, thirty-seven CHD patients, who received CABG of internal mammary artery or great saphena vein under conventional general anesthesia with low or middle temperature extracorporeal circulation were differentiated as various syndromes, with the pre- or post-operational EKG, color Doppler echocardiography were done during and after operation. The hemodynamic parameters were monitored.Results: In the CHD patients, 64.9% were differentiated as Qi-Yin deficiency, 67.6% were complicated with phlegm syndrome and 62.2% with blood stasis, suggesting that Qi-deficiency, phlegm and stasis are the basic pathogenetic factors in patients with CABG. Moreover, the peri-operative syndrome was correlated with the condition of coronary artery lesion, heart and lung functions before operation, and the extracorporeal circulation time during the operation.Conclusion: TCM SD conducting in peri-operative stage might be useful in exploring the patterns of syndrome alteration which provided a basis for preventing peri-operative complications and elevating success rate of operation.

Correlation study between pre-operative platelet aggregation rate and peri-operative blood product application in patients with off-pump coronary artery bypass grafting

Objective To explore the impact of pre-operative platelet aggregation rate(PAR)on off-pump coronary artery bypass grafting(OPCABG),meanwhile to study the relationship between platelet function and blood product application during peri-operative period in relevant patients.Methods A total of 172 patients receiving OPCABG in our hospita from 2014-01 to 2015-09 were en-

Implementation of the pre-operative rehabilitation recovery protocol and its effect on the quality of recovery after colorectal surgeries

Background:Patients’recovery after surgery is the major concern for all perioperative clinicians.This study aims to minimize the side effects of peri-operative surgical stress and accelerate patients’recovery of gastrointestinal(GI)function and quality of life after colorectal surgeries,an enhanced recovery protocol based on pre-operative rehabilitation was implemented and its effect was explored.Methods:A prospective randomized controlled clinical trial was conducted,patients were recruited from January 2018 to September 2019 in this study.Patients scheduled for elective colorectal surgeries were randomly allocated to receive either standardized enhanced recovery after surgery(S-ERAS)group or enhanced recovery after surgery based on pre-operative rehabilitation(group PR-ERAS).In the group PR-ERAS,on top of recommended peri-operative strategies for enhanced recovery,formatted rehabilitation exercises pre-operatively were carried out.The primary outcome was the quality of GI recovery measured with I-FEED scoring.Secondary outcomes were quality of life scores and strength of handgrip;the incidence of adverse events till 30 days post-operatively was also analyzed.Results:A total of 240 patients were scrutinized and 213 eligible patients were enrolled,who were randomly allocated to the group S-ERAS(n=104)and group PR-ERAS(n=109).The percentage of normal recovery graded by I-FEED scoring was higher in group PR-ERAS(79.0%vs.64.3%,P<0.050).The subscores of life ability and physical well-being at post-operative 72 h were significantly improved in the group PR-ERAS using quality of recovery score(QOR-40)questionnaire(P<0.050).The strength of hand grip post-operatively was also improved in the group PR-ERAS(P<0.050).The incidence of bowel-related and other adverse events was similar in both groups till 30 days post-operatively(P>0.050).Conclusions:Peri-operative rehabilitation exercise might be another benevolent factor for early recovery of GI function and life of quality after colorectal surgery.Newer,more surgery-specific rehabilitation recovery protocol merits further exploration for these patients.

Comparison of two different renorrhaphy techniques in retroperitoneal laparoscopic partial nephrectomy for complex tumor

Background Partial nephrectomy is currently the standard treatment for clinical T1 renal neoplasms, as it can provide oncologic outcomes equivalent to radical nephrectomy. The aim was to evaluate the efficacy of self-retaining suture （SRS） in renorrhaphy technique in retroperitoneal laparoscopic partial nephrectomy （LPN） for a single renal mass of moderate or high complexity by assessing peri-operative outcomes. Methods A retrospective analysis was done of 64 patients between 2010 and 2012 for complex renal mass （RENAL score 〉7） in whom retroperitoneal LPN was performed with two layers using continuous knotless barbed suture （Quill PDO SRS group; n=34） and absorbable vicryl （non-SRS group; n=30）, respectively. Cases were matched for RENAL score. All the surgical procedures were performed by the same surgeon with experience of more than 500 cases of LPN. Comparisons were made in patients and preoperative outcomes and peri-operative complications between SRS group and non-SRS group. Results Mean warm ischemia time （WIT） in SRS group was less than non-SRS group （18.0 vs. 24.8 minutes, P=-0.021）. Renorrhaphy suture cost in SRS group was lower than non-SRS group （$269.6 vs. $335.8, P=0,001）. There were no significant differences between the two groups for postoperative changes in creatinine and estimated glomerular filtration rate and the rate of peri-operative complications. Conclusion SRS was safe for complex renal tumor with two layers, continuous and unknot suture, during LPN and would reduce the WIT and renorrhaphy suture cost significantly.

Detecting flap compromise:an updated review of techniques to monitor microsurgical flaps postoperatively in breast reconstruction

Breast reconstructive surgery utilizing free tissue transfer has revolutionized the restoration of aesthetic and functional outcomes for patients.Even for the most routine free flap procedures,substantial hospital resources and costs are necessary.The effectiveness of free flap surgery,along with any reconstructive procedure,hinges upon meticulous patient selection,thorough pre-operative planning,well-informed peri-operative decision-making,and diligent post-operative monitoring and care for the patient.This article presents a review of standard clinical care monitoring techniques during the post-operative period,as well as the diverse strategies currently employed for post-operative flap monitoring.