Quality Control of Breast Cancer Surgery Samples: Introducing Time Stamp Checking.

Background: Analytical information obtained from clinical tissue samples has recently become more important due to recent advancements in the clinical practice of medicine, for example, gene panel testing. However, acquiring and managing the sample quality, which greatly influences the analyses, are not sufficient and hence requires immediate attention. We introduced time stamp (TS) recording and documentation using the Standard PREanalytical Code (SPREC) for breast cancer surgery samples to monitor and control their quality. Materials and Methods: The TS recording used SPREC for quality control of each sample by recording seven factors: type of sample, type of collection, warm ischemia time (WIT), cold ischemia time (CIT), fixation type, fixation time (FT), and long-term storage. The responsibilities to record each factor were assigned among group members (breast surgeons, anesthesiologists, pathologists, operating room nurses, and medical technologists in pathology). Results: Records based on SPREC were recorded for 393 surgical cases of first-time breast cancer patients performed at the Kanagawa Cancer Center from May 2018 to April 2019. The vascular clamp time was defined as when skin flap formation was completed, regardless of the surgical procedure. An anesthesiologist recorded the vascular clamp time and sample collection time, and the pathologist recorded the fixation start time and fixation end time. WIT was 23 (3-116) minutes (breast-conserving surgery, 11 [3-38] minutes; mastectomy, 26 [5-116] minutes; and nipple-sparing mastectomy, 39 [31-43] minutes), CIT was 37 (3-1052) minutes, and FT was 43 (17-115) hours. The median CIT and FT were significantly shortened after introducing the TS system, and the variabilities were reduced. Conclusion: A TS system for quality control of breast cancer surgical sample functions well due to the establishment of highly versatile WIT and a working group consisting of multiple members of different occupations who shared roles.

Effects of goal-directed fluid therapy on enhanced postoperative recovery: An interventional comparative observational study with a historical control group on oesophagectomy combined with ERAS program.

BACKGROUND AND AIMS: The Enhanced Recovery after Surgery (ERAS) program has been proposed as a postoperative recovery-enhancing strategy. We frequently apply the Modified-ERAS program following oesophagectomy. This study aims to elucidate the impact of goal-directed fluid therapy (GDT) for the perioperative management of oesophageal cancer on the postoperative recovery of patients undergoing oesophagectomy. METHODS: This is an interventional before-after comparative observational study conducted at Kanagawa Cancer Centre, Japan. Patients who underwent elective oesophagectomy for oesophageal cancer were recruited. Group H (retrospectively collected) received intraoperative and postoperative management consisting of fluid administration without haemodynamic monitoring and the M-ERAS program, while Group S prospectively received management consisting of GDT and the M-ERAS program. The primary endpoint was the speed of gastrointestinal functional recovery, while secondary endpoints were the level of postoperative mobilisation, incidence of complications, postoperative length of hospital stay (LOS), and nutritional status after discharge. RESULTS: The proportion of patients who completely egested Gastrografin by postoperative day 4, the level of postoperative mobilisation, and achievement ratio for a 100-m walk on the first postoperative attempt were significantly higher in Group S than in Group H (P = 0.034, P = 0.0197, and P < 0.0001, respectively). No significant differences were observed in the postoperative LOS and incidence of complications within 30 days between the groups. The serum albumin levels at 6 months after discharge was higher in Group S than in Group H (P = 0.0002). CONCLUSIONS: The GDT-ERAS program enhanced postoperative gastrointestinal recovery and mobilisation, as well as postoperative nutritional status and protein synthesis. The program did not affect either postoperative LOS or the incidence of complications. TRIAL REGISTRATION: UMIN registration number: UMIN000013705, https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000015999.

The effect of intraoperative use of high-dose remifentanil on postoperative insulin resistance and muscle protein catabolism: a randomized controlled study.

OBJECTIVE: We investigated the effect of the intraoperative use of a high dose remifentanil on insulin resistance and muscle protein catabolism. DESIGN: Randomized controlled study. PATIENTS AND INTERVENTION: Thirty-seven patients undergoing elective gastrectomy were randomly assigned to 2 groups that received remifentanil at infusion rates of 0.1 µg·kg(-1)·min(-1) (Group L) and 0.5 µg·kg(-1)·min(-1) (Group H). MAIN OUTCOME MEASURES: Primary efficacy parameters were changes in homeostasis model assessment as an index of insulin resistance (HOMA-IR) and 3-methylhistidine/creatinine (3-MH/Cr). HOMA-IR was used to evaluate insulin resistance, and 3-MH/Cr was used to evaluate the progress of muscle protein catabolism. Intraoperative stress hormones, insulin, and blood glucose were assessed as secondary endpoints. RESULTS: Eighteen patients in Group L and 19 in Group H were examined. HOMA-IR values varied within normal limits in both groups during surgery, exceeding normal limits at 12 h after surgery and being significantly elevated in Group L. There were no significant differences in the 3-MH/Cr values between the 2 groups at any time point. The stress hormones (adrenocorticotropic hormone, cortisol, and adrenaline) were significantly elevated in Group L at 60 min after the start of surgery and at the initiation of skin closure. There were no significant differences in insulin values, but blood glucose was significantly elevated in Group L at 60 min after the start of surgery and at the start of skin closure. CONCLUSION: Use of high-dose remifentanil as intraoperative analgesia during elective gastrectomy reduced postoperative insulin resistance, although it did not reduce postoperative muscle protein catabolism.

Preoperative management of surgical patients by "shortened fasting time": a study on the amount of total body water by multi-frequency impedance method.

AIM: Preoperative fasting is an established procedure to be practiced for patients before surgery, but optimal preoperative fasting time still remains controversial. The aim of this study was to investigate the effect of "shortened preoperative fasting time" on the change in the amount of total body water (TBW) in elective surgical patients. TBW was measured by multi-frequency impedance method. METHODS: The patients, who were scheduled to undergo surgery for stomach cancer, were divided into two groups of 15 patients each. Before surgery, patients in the control group were managed with conventional preoperative fasting time, while patients in the "enhanced recovery after surgery (ERAS)" group were managed with "shortened preoperative fasting time" and "reduced laxative medication." TBW was measured on the day before surgery and the day of surgery before entering the operating room. Defecation times and anesthesia-related vomiting and aspiration were monitored. RESULTS: TBW values on the day of surgery showed changes in both groups as compared with those on the day before surgery, but the rate of change was smaller in the ERAS group than in the control group (2.4±6.8% [12 patients] vs. -10.6±4.6% [14 patients], p<0.001). Defecation times were less in the ERAS group. Vomiting and aspiration were not observed in either group. CONCLUSION: The results suggest that preoperative management with "shorted preoperative fasting time" and "reduced administration of laxatives" is effective in the maintenance of TBW in elective surgical patients.

Oral rehydration therapy for preoperative fluid and electrolyte management.

AIM: Preoperative fluid and electrolyte management is usually performed by intravenous therapy. We investigated the safety and effectiveness of oral rehydration therapy (ORT) for preoperative fluid and electrolyte management of surgical patients. METHODS: The study consisted of two studies, designed as a prospective observational study. In a pilot study, 20 surgical patients consumed 1000 mL of an oral rehydration solution (ORS) until 2 h before induction of general anesthesia. Parameters such as serum electrolyte concentrations, fractional excretion of sodium (FENa) as an index of renal blood flow, volume of esophageal-pharyngeal fluid and gastric fluid (EPGF), and patient satisfaction with ORT were assessed. In a follow-up study to assess the safety of ORT, 1078 surgical patients, who consumed ORS until 2 h before induction of general anesthesia, were assessed. RESULTS: In the pilot study, water, electrolytes, and carbohydrate were effectively and safely supplied by ORT. The FENa value was increased at 2 h following ORT. The volume of EPGF collected following the induction of anesthesia was 5.3±5.6 mL. In the follow-up study, a small amount of vomiting occurred in one patient, and no aspiration occurred in the patients. CONCLUSION: These results suggest that ORT is a safe and effective therapy for the preoperative fluid and electrolyte management of selected surgical patients.

Preoperative fluid and electrolyte management with oral rehydration therapy.

PURPOSE: We hypothesized that oral rehydration therapy using an oral rehydration solution may be effective for preoperative fluid and electrolyte management in surgical patients before the induction of general anesthesia, and we investigated the safety and effectiveness of oral rehydration therapy as compared with intravenous therapy. METHODS: Fifty female patients who underwent breast surgery were randomly allocated to two groups. Before entry to the operation room and the induction of general anesthesia, 25 patients drank 1000 ml of an oral rehydration solution ("oral group") and 25 patients were infused with 1000 ml of an intravenous electrolyte solution ("intravenous group"). Parameters such as electrolyte concentrations in serum and urine, urine volume, vital signs, vomiting and aspiration, volumes of esophageal-pharyngeal fluid and gastric fluid (EPGF), and patient satisfaction with the therapy (as surveyed by a questionnaire) were assessed. RESULTS: After treatment, the serum sodium concentration and the hematocrit value, which both declined within the normal limits, were significantly higher in the oral group than in the intravenous group (sodium, 140.8 +/- 2.9 mEq x l(-1) in the oral group and 138.7 +/- 1.9 mEq x l(-1) in the intravenous group; P = 0.005; hematocrit, 39.03 +/- 4.16% in the oral group and 36.15 +/- 3.41% in the intravenous group; P = 0.01). No significant difference was observed in serum glucose values. Urine volume was significantly larger in the oral group (864.9 +/- 211.5 ml) than in the intravenous group (561.5 +/- 216.0 ml; P < 0.001). The fractional excretion of sodium (FENa), as an index of renal blood flow, was increased in both groups following treatment (0.8 +/- 0.5 in the oral group and 0.8 +/- 0.3 in the intravenous group). Patient satisfaction with the therapy favored the oral rehydration therapy, as judged by factors such as "feeling of hunger", "occurrence of dry mouth", and "less restriction in physical activity". The volume of EPGF collected following the induction of anesthesia was significantly smaller in the oral group than in the intravenous group (6.03 +/- 9.14 ml in the oral group and 21.76 +/- 30.56 ml in the intravenous group; P < 0.001). No adverse events or adverse reactions were observed in either group. CONCLUSION: The results suggest that the oral rehydration therapy with an oral rehydration solution before surgery is superior to the current preoperative intravenous therapy for the provision of water, electrolytes, and carbohydrates, and this therapy should be considered as an alternative to the intravenous therapy for preoperative fluid and electrolyte management in selected surgical patients in whom there is no reason to suspect delayed gastric emptying.

[A case of monoplegia from conversion disorder after spinal anesthesia].

Neurological complications related to spinal anesthesia are exceptional, but their consequences are serious. We report a case of conversion disorder, which was initially diagnosed as monoplegia caused by spinal anesthesia. The patient was a 36-year-old, 88 kg woman with a history of psychogenic aphonia. She underwent plastic surgery for both toes under spinal anesthesia. On the following day, her left leg remained paralyzed with loss of sensation below the knee level. She practiced walking according to rehabilitation program, but paralysis became worse gradually. As the hospitalization was prolonged, she refused to be discharged from the hospital and began to demand the compensation. Her symptoms had not been correlated with the correct anatomical patterns of neurological deficit. The reflexes and muscle's tonus were normal and EMG gave normal findings. The result of neurological diagnosis, confirmed the diagnosis of conversion disorder causing her monoplegia because she was under psychic stressful circumstances from her family. Conversion disorder as a cause of monoplegia after surgery under spinal anesthesia should be kept in mind.