Physiological and operative severity score for the enumeration of mortality and morbidity scoring systems for assessment of patient outcome and impact of surgeons' and anesthesiologists' performance in hepatopancreaticobiliary surgery.

CONTEXT: The physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) is a scoring system used to predict morbidity and mortality. AIMS: We compared the physiological and operative risk, the expected morbidity and mortality, and the observed postoperative mortality among patients operated by different surgeons and anesthetized by different anesthesiologists. SETTINGS AND DESIGN: This was a retrospective, single center study. SUBJECTS AND METHODS: The anesthetic records of 159 patients who underwent hepatopancreaticobiliary surgery were analyzed for the physiological and operative severity, POSSUM morbidity, POSSUM and Portsmouth POSSUM (P-POSSUM) mortality scoring systems, observed mortality in 30-days, 3, 6, and 12 months postoperatively, duration of surgery, and units of packed red blood cells (PRBC) transfused. These variables were compared among patients operated by five different surgeons and anesthetized by seven different anesthesiologists. STATISTICAL ANALYSIS: One-way analysis of variance was used for normally and Kruskal-Wallis test for nonnormally distributed responses. Differences in percentages of postoperative mortality were assessed by Chi-squared test. RESULTS: The physiological severity, POSSUM morbidity, POSSUM and P-POSSUM mortality scores, and observed mortality at 1, 3, 6, and 12 months postoperatively did not differ among patients operated by different surgeons and anesthetized by different anesthesiologists. Duration of surgery (P < 0.001), PRBC units transfused (P = 0.002), and operative severity (P = 0.001) differed significantly among patients operated by different surgeons. CONCLUSIONS: The physiological severity score, POSSUM and P-POSSUM scores did not differ among patients operated by different surgeons and anesthetized by different anesthesiologists. The different operative severity scores did not influence the observed mortality in the postoperative period.

Sugammadex at both high and low doses does not affect the depth of anesthesia or hemodynamics: a randomized double blind trial.

Previous studies have shown that sugammadex decreases the anesthetic depth when administered to reverse the neuromuscular blockade produced by rocuronium/vecuronium. The aim of the present study was to investigate the effect of sugammadex alone on anesthetic depth and hemodynamics. Sixty patients scheduled for abdominal surgery participated in the study. Anesthesia was induced with thiopental/fentanyl and maintained with N2O/oxygen and sevoflurane concentrations adjusted to maintain Entropy and Bispectral Index (BIS) values between 40 and 50. Cis-atracurium 0.2 mg/kg was administered for neuromuscular blockade which was monitored with a TOF-Watch® SX acceleromyograph. State entropy (SE), response entropy (RE), Bispectral Index (BIS), systolic (SAP) and diastolic blood pressure (DAP), heart rate (HR), SpO2, end-tidal CO2 and sevoflurane concentrations were recorded every 3 min intraoperatively. Sugammadex 2 mg/kg (Group-2), 4 mg/kg (Group-4) or 16 mg/kg (Group-16) was given intravenously when a count of two responses of the train-of-four (TOF) or a post-tetanic count (PTC) 1-3 appeared or when no response at all (PTC = 0) was observed, respectively. The overall SE values, thus the primary outcome of the study, were 44 ± 11, 43 ± 10 and 43 ± 11 for Group-2, Group-4 and Group-16, respectively (p = 0.812). Also, the secondary endpoints, namely RE, BIS, SAP and DAP, HR and SpO2 did not differ between the three groups. Comparisons between Group-2 versus Group-4, Group-2 versus Group-16 and Group-4 versus Group-16 showed no differences (p > 0.05) for all the studied variables. Sugammadex alone at low, medium or high clinical doses has no effect on anesthetic depth as assessed by Entropy and BIS or on hemodynamics.

Diagnostic and Therapeutic Challenges of Intrahepatic Biliary Cystadenoma and Cystadenocarcinoma: A Report of 10 Cases and Review of the Literature.

The objective of this study was to present our experience with intrahepatic biliary cystadenomas and cystadenocarcinomas in 10 patients surgically managed in our department. Intrahepatic biliary cystadenomas and cystadenocarcinomas are rare cystic tumors that are often misdiagnosed preoperatively as simple cysts or hydatid cysts. They recur after incomplete resection and entail a risk of malignant transformation to cystadenocarcinoma. A retrospective review was conducted of patients with histologically confirmed intrahepatic biliary cystadenomas and cystadenocarcinomas between August 2004 and February 2013 who were surgically managed in our department. A total of 10 patients, 9 female and 1 male (mean age, 50 years), with cystic liver were reviewed. The size of the cysts ranged between 3.5 and 16 cm (mean, 10.6). Five patients had undergone previous interventions elsewhere and presented with recurrences. Liver resections included 6 hepatectomies, 2 bisegmentectomies, 1 extended right hepatectomy, and 1 enucleation due to the central position and the large size of the lesion. Pathology reports confirmed R0 resections in all cases. All patients were alive after a median follow-up of 6 years (range, 1-10 years), and no recurrence was detected. Intrahepatic biliary cystadenoma and cystadenocarcinoma should be considered in differential diagnosis in patients with liver cystic tumors. Because of the high recurrence rate and difficult accurate preoperative diagnosis, formal liver resection is mandatory. Enucleation with free margins is an option and is indicated where resection is impossible.

Clinical presentation and management of gastro-intestinal and pancreatic secondary metastatic tumors.

PURPOSE: As progress regarding the treatment has occurred over recent years in oncology, more patients with metastatic disease are presented for diagnosis and further management. The purpose of this study was to reveal the incidence, location and to describe the clinical characteristics and outcome in a series of patients diagnosed with pancreatic, small and large bowel metastatic tumors that underwent metastasectomy. METHODS: A total of 12 patients (7 male and 5 female) diagnosed with extrahepatic gastrointestinal (GI) and pancreatic metastases from 2001 to 2013 were operated for resection of secondary metastatic tumors to the small and large bowel and the pancreas. Four out of 12 patients were asymptomatic and a secondary tumor was detected during follow up. RESULTS: The median interval revealing the metastatic tumor since the management of the primary tumor was 6.5 years (range 1-27). Primary tumors were malignant melanoma (4 patients), renal cell carcinoma (RCC; 2 patients), leiomyosarcoma of the uterus (2 patients), lobular breast cancer, mesenchymal chondrosarcoma of the skull, endometrial adenocarcinoma and a non-Hodgkin lymphoma (one case each). The median follow-up was 15 months (range 4-120). CONCLUSIONS: Metastatic secondary tumors have to be considered especially when the patient's medical history includes a previous malignancy. They may also occasionally present as the initial manifestation of an occult primary lesion leading to diagnostic difficulty. Although radical surgery is the most effective approach, treatment and survival grossly depend on histological type and the stage of the primary disease. Hence, management of these patients should be individualized by a multidisciplinary team.

Propofol or sevoflurane anaesthesia does not affect hepatic integrity as assessed by the M30 & M65 cell death markers & liver enzymes.

BACKGROUND & OBJECTIVES: General anaesthetics may induce apoptosis. The pro-apoptotic/necrotic markers M30 (caspase-cleaved cytokeratin-18) and M65 (intact cytokeratin-18) have been used to identify early apoptosis in liver disease. The aim of this study was to detect the effect of propofol and sevoflurane anaesthesia on these markers and blood transaminase levels in female patients undergoing elective surgery. METHODS: Sixty-seven women undergoing mastectomy or thyroidectomy under general anaesthesia were randomly allocated to the propofol or sevoflurane groups. Venous blood samples for measuring the apoptotic and necrotic markers M30 and M65 as well as for measuring the alanine aminotransferase (ALT) and the aspartate aminotransferase (AST) liver enzymes were collected before induction of anaesthesia, immediately after completion of surgery, and 24 and 48 h postoperatively. RESULTS: The M30 values preoperatively and 0, 24 and 48 h postoperatively were 280±229, 300±244, 267±198 and 254±189 U/l in the propofol group and 237±95, 242±109, 231±94 and 234±127 U/l in the sevoflurane group, respectively. The M30 values did not differ within or between the groups. The M65 levels at the same time intervals were 470±262, 478±271, 456±339 and 485±273 in the propofol group and 427±226, 481±227, 389±158 and 404±144 U/l in the sevoflurane group, respectively. No significant changes were found in the M65 either within or between the propofol and the sevoflurane groups. The ALT and AST levels did not change at these time intervals. INTERPRETATION & CONCLUSIONS: Under the present study design propofol or sevoflurane anaesthesia did not induce apoptosis or affected the liver function as assessed by the M30, M65 markers and liver enzymes in patients undergoing mastectomy or thyroidectomy under general anaesthesia.

Neuroendocrine differentiation in embryonal type hepatoblastoma.

Hepatoblastoma, a malignant tumor which arises occasionally in older children but very rarely in adults, exhibits divergent differentiation with embryonal cells, fetal hepatocytes and immature elements. This report describes an embryonal type hepatoblastoma with neuroendocrine differentiation in a 16-year-old patient, which was diagnosed postoperatively. Clinical and radiologic work-up failed to reveal a primary gastrointestinal malignancy and no primary lesions were detected in any other organ. This feature of hepatoblastoma is considered to be a multidirectional differentiation of the small epithelial or stem cells of the liver. At 2-year follow up, the patient remains symptom-free, with normal laboratory and diagnostic imaging studies, and no recurrent or metastatic disease identified.

Seronegative cat-scratch disease diagnosed by PCR detection of Bartonella henselae DNA in lymph node samples.

Cat scratch disease (CSD), the typical clinical manifestation of Bartonella infections usually follows a typical benign self-limited course. Nevertheless, a variety of unusual clinical manifestations and confusing imaging features can lead to misinterpretations and render the disease a diagnostic dispute. Routine laboratory tests exhibit varying reported sensitivity and are usually unhelpful in diagnosis, as serology fails in terms of specificity and/or sensitivity. Herein we report a case of seronegative Bartonella infection presenting as symptomatic suppurative lymphadenitis with abscess formation, which was surgically drained. Diagnosis was established by PCR analysis from lymph nodes samples obtained during the procedure. PCR detection of specific DNA fragments from lymph node biopsy provides a sensitive detection of disease. The technique should be considered for patients with suspected CSD and negative serology, since serological assays exhibit low sensitivity. In ambiguous cases, surgical exploration may provide tissue for diagnosis; it is well tolerated and affords improved recovery.

Seronegative cat-scratch disease diagnosed by PCR detection of Bartonella henselae DNA in lymph node samples

Cat scratch disease (CSD), the typical clinical manifestation of Bartonella infections usually follows a typical benign self-limited course. Nevertheless, a variety of unusual clinical manifestations and confusing imaging features can lead to misinterpretations and render the disease a diagnostic dispute. Routine laboratory tests exhibit varying reported sensitivity and are usually unhelpful in diagnosis, as serology fails in terms of specificity and/or sensitivity. Herein we report a case of seronegative Bartonella infection presenting as symptomatic suppurative lymphadenitis with abscess formation, which was surgically drained. Diagnosis was established by PCR analysis from lymph nodes samples obtained during the procedure. PCR detection of specific DNA fragments from lymph node biopsy provides a sensitive detection of disease. The technique should be considered for patients with suspected CSD and negative serology, since serological assays exhibit low sensitivity. In ambiguous cases, surgical exploration may provide tissue for diagnosis; it is well tolerated and affords improved recovery.

An assessment of subarachnoid block: a survey of 175 articles and recommendations for improvement.

BACKGROUND: Assessment of subarachnoid block, particularly the sensory component, may be incomplete and influence the conclusions of studies involving subarachnoid anesthesia, as well as their application in routine clinical practice. METHODS: We manually searched 175 articles concerning subarachnoid block published from 2006 to 2009 in 8 anesthesia journals to determine the components of the subarachnoid anesthetic procedure recorded as well as the extent of sympathetic and motor block. RESULTS: The level of subarachnoid injection was reported in 86% of the articles, baricity in 84%, concentration of local anesthetic in 77%, patient's position in 75%, needle size in 77%, and needle type in 71%. The stimulus used for assessing sensory block was reported in 69% of the articles; 17% described the block as unilateral or bilateral, and 11% described the lines along which the stimulus was applied. Motor and sympathetic block were assessed in 40% and 18% of studies, respectively. CONCLUSIONS: These results suggest incomplete description of tools and assessment of sensory block in studies involving subarachnoid anesthesia. We propose a checklist to facilitate a more standardized evaluation of the extent of subarachnoid anesthesia.

Pylorus-preserving pancreaticoduodenectomy after transhiatal esophagectomy sparing the right gastroepiploic vessels and gastric tube.

INTRODUCTION: Pancreaticoduodenectomy after transhiatal esophagectomy is a technically demanding procedure in sense of preserving the blood supply to the gastric tube. CASE REPORT: We report a case of pylorus-preserving pancreaticoduodenectomy for pancreatic head cancer, 13 years after a transhiatal esophagectomy, sparing the gastric tube and the right gastroepiploic artery and vein. DISCUSSION: This type of operation is less time-consuming and less invasive, since no further reconstruction of the alimentary tract or the vascular system is applied.