Increased body mass index is associated with operative difficulty during robot-assisted radical prostatectomy.

Objective: This study aimed to identify factors associated with surgeon perception of robot-assisted radical prostatectomy (RARP) difficulty. Patients and Methods: This study surveyed surgeons performing RARP between 2017 and 2018 and asked them to rate operative conditions and difficulty as optimal, good, acceptable, or poor. These answers were stratified as optimal or suboptimal for this study. Associations between surgeon responses and variables hypothesized to affect surgical difficulty, including anatomic factors such as pelvic diameter and prostate volume:pelvic diameter ratio, were assessed. Results: Between November 2017 and September 2018, a total of 100 patients were prospectively enrolled in the study of which 58 cases were rated as optimal and 42 were rated as suboptimal. Of the evaluated variables, only increasing clinical T stage (odds ratio [OR] 1.49, 95% confidence interval [CI] 1.03-2.15, p = 0.03) and increasing body mass index (BMI) (OR 1.14, 95% CI 1.03-1.26, p = 0.01) were associated with increased difficulty; 90-day complication rates were similar between the optimal and suboptimal cohorts (17.3% vs. 23.8%, respectively; p = 0.5). The number of patients with previous surgery, pelvic diameter, and prostate size:pelvic diameter ratio were not significantly different between cohorts (p > 0.05 for all). Operative time (ρ = 0.23, p = 0.02) and estimated blood loss (EBL) (ρ = 0.38, p = 0.0001) were correlated with suboptimal difficulty. Conclusion: The factors associated with surgeon-reported RARP difficulty were patient BMI and clinical T stage among surgeons with significant RARP experience. These data should be incorporated into surgical decision making and patient counseling prior to performing a RARP.

Intraoperative Dexmedetomidine and Ketamine Infusions in an Enhanced Recovery After Thoracic Surgery Program: A Propensity Score Matched Analysis.

OBJECTIVES: To assess the impact of intraoperative dexmedetomidine and ketamine on postoperative pain and opioid consumption within an ERAS program in thoracic pulmonary oncologic surgery. DESIGN: Retrospective, propensity-score matched analysis SETTING: Enhanced Recovery After Surgery (ERAS) program. PARTICIPANTS: Patients undergoing thoracic pulmonary oncologic surgery between March 2016 and April 2020. INTERVENTIONS: Continuous infusion of dexmedetomidine and ketamine. MEASUREMENTS & MAIN RESULTS: The authors initially analyzed data of 1,630 patients undergoing thoracic pulmonary oncologic surgery within their ERAS program. In total, 117 matched pairs were included in this analysis. Patients in the intraoperative dexmedetomidine + ketamine group were more likely to be opioid-free (76.6% vs 60.9%, P<0.01). Raw analysis showed lower pain scores at PACU admission (2.8±2.0 vs 3.4±2.0, P=0.03) and less opioid consumption at PACU admission (5 MED [0-10] vs 7.5 MED [0-15], P=0.03) in the dexmedetomidine + ketamine group; however, these differences were not present after adjusting for multiplicity. There were no significant differences in the length of PACU stay (1.9 hours [1.5-2.8] vs 2.0 hours [1.4-2.9], P=0.48) or hospital stay (three days [two-five] vs three days [two-five], P=0.08). Both groups had similar rates of pulmonary complications (5.9% vs 9.4%, P=0.326), ileus (0.9% vs 0.9%, P=1.00), and 30-day readmission (2.6% vs 4.3%, P=0.722). CONCLUSIONS: There were no differences in postoperative pain scores and opioid consumption throughout their hospital stay between patients receiving concomitant dexmedetomidine and ketamine infusions versus patients who did not receive these infusions during thoracic surgery.

Effect of reversal of deep neuromuscular block with sugammadex or moderate block by neostigmine on shoulder pain in elderly patients undergoing robotic prostatectomy.

BACKGROUND: For some laparoscopic procedures, deep neuromuscular block has been shown to facilitate lower insufflation pressures and lower patient pain scores, and enhance postoperative recovery. We investigated the impact of deep neuromuscular block and its reversal on postoperative shoulder pain and outcomes after robotic prostate surgery. METHODS: Elderly men undergoing robotic prostatectomy were randomised to deep neuromuscular block (target post-tetanic twitch of 1-2 at the facial nerve) with sugammadex reversal or moderate neuromuscular block (target 1-2 train-of-four ratio) with neostigmine reversal. The primary endpoint was postoperative shoulder pain. The secondary endpoints included intraoperative insufflation pressure, surgical rating score, incidence of residual neuromuscular block, and postoperative recovery. RESULTS: A total of 50 subjects for each treatment arm were included in the analysis. The degree of neuromuscular block had no effect on the incidence of shoulder pain (deep block group 12% vs moderate block group 10%; P=1.0) or average insufflation pressure (median [inter-quartile range]) (13.3 [12.5-13.6] mm Hg vs 13.3 [11.7-14] mm Hg, P=0.86). After surgery, the deep block group had a higher normalised train-of-four ratio (0.98 [0.79-1.11] vs 0.85 [0.74-1.00]; P=0.008). The presence of postoperative shoulder pain was associated with higher BMI (31.8 [28-33.9] kg m-2vs 28 [24.8-31.1] kg m-2; P=0.036) and longer insufflation time (186 [156-257] min vs 154 [126-198] min; P=0.028). CONCLUSIONS: The use of deep neuromuscular block during surgery does not decrease postoperative shoulder pain or enhance recovery after robotic prostatectomy. CLINICAL TRIAL REGISTRATION: NCT03210376.

Case report on intravenous octreotide for the treatment of intraoperative vasoplegia following thymoma resection.

Octreotide is a somatostatin analog known for its role in the treatment of acute variceal bleeding, enterocutaneous fistula and carcinoid syndrome. The reduction of portal pressure from splanchnic vasoconstriction has been attributed to the inhibition of nitric oxide synthesis, guanylate cyclase and release of glucagon. Octreotide has many therapeutic applications as a result of the ubiquitous nature of somatostatin receptors throughout the body. The effects of octreotide on vascular tone make it potentially useful in the treatment of intraoperative vasoplegia, hypotension with low systemic vascular resistance with preserved cardiac output that is refractory to adrenergic agonists. We present a case in which a patient undergoing thymoma resection developed vasoplegia that was effectively treated with octreotide. We believe that this case illustrates the need for further investigation on the potential efficacy of octreotide as an adjunct for the treatment of vasoplegia and other forms of shock.

Determining the Safety and Efficacy of Enhanced Recovery Protocols in Major Oncologic Surgery: An Institutional NSQIP Analysis.

BACKGROUND: Enhanced-recovery (ER) protocols are increasingly being utilized in surgical practice. Outside of colorectal surgery, however, their feasibility, safety, and efficacy in major oncologic surgery have not been proven. This study compared patient outcomes before and after multispecialty implementation of ER protocols at a large, comprehensive cancer center. METHODS: Surgical cases performed from 2011 to 2016 and captured by an institutional NSQIP database were reviewed. Following exclusion of outpatient and emergent surgeries, 2747 cases were included in the analyses. Cases were stratified by presence or absence of ER compliance, defined by preoperative patient education and electronic medical record order set-driven opioid-sparing analgesia, goal-directed fluid therapy, and early postoperative diet advancement and ambulation. RESULTS: Approximately half of patients were treated on ER protocols (46%) and the remaining on traditional postoperative (TP) protocols (54%). Treatment on an ER protocol was associated with decreased overall complication rates (20% vs. 33%, p < 0.0001), severe complication rates (7.4% vs. 10%, p = 0.010), and median hospital length of stay (4 vs. 5 days, p < 0.0001). There was no change in readmission rates (ER vs. TP, 8.6% vs. 9.0%, p = 0.701). Subanalyses of high magnitude cases and specialty-specific outcomes consistently demonstrated improved outcomes with ER protocol adherence, including decreased opioid use. CONCLUSIONS: This assessment of a large-scale ER implementation in multispecialty major oncologic surgery indicates its feasibility, safety, and efficacy. Future efforts should be directed toward defining the long-term oncologic benefits of these protocols.

Myasthenia Gravis and Thymoma Surgery: A Clinical Update for the Cardiothoracic Anesthesiologist.

Myasthenia gravis (MG) is a rare neuromuscular disorder characterized by skeletal muscle weakness. Patients with MG who have thymoma and thymic hyperplasia have indications for thymectomy. The perioperative care of patients with MG scheduled for thymus resection should be focused on optimizing their neuromuscular function, identifying factors related to postoperative mechanical ventilation, and avoiding of triggers associated with myasthenic or cholinergic crisis. Minimally invasive surgical techniques, use of regional analgesia, and avoidance or judicious administration of neuromuscular blocking drugs (NMBs) is recommended during the perioperative period. If NMBs are used, sugammadex appears to be the drug of choice to restore adequately the neuromuscular transmission. In patients with postoperative myasthenic crisis, plasma exchange or intravenous immune globulin and mechanical support is recommended.

Impact of Regional Anesthesia on Gastroesophageal Cancer Surgery Outcomes: A Systematic Review of the Literature.

Regional anesthesia may play a beneficial role in long-term oncological outcomes. Specifically, it has been suggested that it can prolong recurrence-free survival and overall survival after gastrointestinal cancer surgery, including gastric and esophageal cancer, by modulating the immune and inflammatory response. However, the results from human studies are conflicting. The goal of this systematic review was to summarize the evidence on the impact of regional anesthesia on immunomodulation and cancer recurrence after gastric and esophageal surgery. We conducted a literature search of 5 different databases. Two independent reviewers analyzed the quality of the selected manuscripts according to prespecified inclusion and exclusion criteria. Randomized controlled trials were assessed for potential sources of bias by using the Cochrane Risk of Bias tool. A total of 6 studies were included in the quality analysis and systematic review. A meta-analysis was not conducted for several reasons, including high heterogeneity among studies, low quality of the reports, and lack of standardized outcomes definitions. Although the literature suggests that regional anesthesia has some modulatory effects on the inflammatory and immunological response in the studied patient population, our systematic review indicates that there is no evidence to support or refute the use of epidural anesthesia or analgesia with the goal of reducing cancer recurrence after gastroesophageal cancer surgery.

Comparison of the didactic lecture with the simulation/model approach for the teaching of a novel perioperative ultrasound curriculum to anesthesiology residents.

STUDY OBJECTIVE: To expose residents to two methods of education for point-of-care ultrasound, a traditional didactic lecture and a model/simulation-based lecture, which focus on concepts of cardiopulmonary function, volume status, and evaluation of severe thoracic/abdominal injuries; and to assess which method is more effective. DESIGN: Single-center, prospective, blinded trial. SETTING: University hospital. SUBJECTS: Anesthesiology residents who were assigned to an educational day during the two-month research study period. MEASUREMENTS: Residents were allocated to two groups to receive either a 90-minute, one-on-one didactic lecture or a 90-minute lecture in a simulation center, during which they practiced on a human model and simulation mannequin (normal pathology). Data points included a pre-lecture multiple-choice test, post-lecture multiple-choice test, and post-lecture, human model-based examination. Post-lecture tests were performed within three weeks of the lecture. An experienced sonographer who was blinded to the education modality graded the model-based skill assessment examinations. Participants completed a follow-up survey to assess the perceptions of the quality of their instruction between the two groups. MAIN RESULTS: 20 residents completed the study. No differences were noted between the two groups in pre-lecture test scores (P = 0.97), but significantly higher scores for the model/simulation group occurred on both the post-lecture multiple choice (P = 0.038) and post-lecture model (P = 0.041) examinations. Follow-up resident surveys showed significantly higher scores in the model/simulation group regarding overall interest in perioperative ultrasound (P = 0.047) as well understanding of the physiologic concepts (P = 0.021). CONCLUSIONS: A model/simulation-based based lecture series may be more effective in teaching the skills needed to perform a point-of-care ultrasound examination to anesthesiology residents.