Abstract Given that surgical stress response and surgical excision may increase the likelihood of post-surgery cancer dissemination and metastasis, the appropriate choice of surgical anesthetics may be important for oncologic outcomes. We evaluated the association of anesthetics used for general anesthesia with overall survival and recurrence-free survival in patients who underwent esophageal cancer surgery. Adult patients (922) underwent elective esophageal cancer surgery were included. The patients were divided into two groups according to the anesthetics administered during surgery: volatile anesthesia (VA) or intravenous anesthesia with propofol (TIVA). Propensity score and Cox regression analyses were performed. There were 191 patients in the VA group and 731 in the TIVA group. In the entire cohort, VA was independently associated with worse overall survival (HR 1.58; 95% CI 1.24–2.01; P < 0.001) and recurrence-free survival (HR 1.42; 95% CI 1.12–1.79; P = 0.003) after multivariable analysis adjustment. Similarly, in the propensity score matched cohorts, VA was associated with worse overall survival (HR 1.45; 95% CI 1.11–1.89; P = 0.006) and recurrence-free survival (HR 1.44; 95% CI 1.11–1.87; P = 0.006). TIVA during esophageal cancer surgery was associated with better postoperative survival rates compared with volatile anesthesia.
Transesophageal echocardiography (TEE) has become a standard intraoperative monitor during cardiac surgery.Although generally considered safe, some cases of major TEE-related complications have been reported.We present a case of a 71-year-old man with aortic aneurysm and aortic regurgitation scheduled for total arch replacement and aortic valve replacement.During the cardiopulmonary bypass period, massive gastric bleeding occurred.Emergency esophagogastroduodenoscopy (EGD) was performed during surgery and a 2-cm deep laceration was observed at the gastroesophageal junction, suggesting Mallory-Weiss syndrome caused by TEE.Since it was impossible to control massive bleeding using EGD, Sengstaken-Blakemore tube was inserted through the stomach to compress the bleeding site.Massive gastric bleeding was controlled after reversal of the effect of heparin.Since TEE might cause complications, anesthesiologists should manipulate the TEE probe gently with caution.If massive gastric bleeding is suspected during surgery, immediate EGD should be considered for diagnosis and further management.
Conventional, intravenous, patient-controlled analgesia, which is only administered by demand bolus without basal continuous infusion, is closely associated with inappropriate analgesia. Pharmacokinetic model-based dosing schemes can quantitatively describe the time course of drug effects and achieve optimal drug therapy. We compared the efficacy and safety of a conventional dosing regimen for intravenous patient-controlled analgesia that was administered by demand bolus without basal continuous infusion (group A) versus a pharmacokinetic model-based dosing scheme performed by decreasing the dosage of basal continuous infusion according to the model-based simulation used to achieve a targeted concentration (group B) following robot-assisted laparoscopic prostatectomy. In total, 70 patients were analyzed: 34 patients in group A and 36 patients in group B. The postoperative opioid requirements, pain scores assessed by the visual analog scale, and adverse events (eg, nausea, vomiting, pruritis, respiratory depression, desaturation, sedation, confusion, and urinary retention) were compared on admission to the postanesthesia care unit and at 0.5, 1, 4, 24, and 48 h after surgery between the 2 groups. All patients were kept for close observation in the postanesthesia care unit for 1 h, and then transferred to the general ward. The fentanyl requirements in the postanesthesia care unit for groups A and B were 110.0 ± 46.4 μg and 77.5 ± 35.3 μg, respectively. The pain scores assessed by visual analog scale at 0.5, 1, 4, and 24 h after surgery in group B were significantly lower than in group A (all P < 0.05). There were no differences in the adverse events between the 2 groups. We found that the pharmacokinetic model-based dosing scheme resulted in lower opioid requirements, lower pain scores, and no significant adverse events in the postanesthesia care unit following robot-assisted laparoscopic prostatectomy in comparison with conventional dosing regimen.
This study aimed to compare the controlling nutritional status (CONUT) score, prognostic nutritional index (PNI), and geriatric nutritional risk index (GNRI) for predicting postoperative outcomes in patients with esophageal squamous cell carcinoma undergoing esophagectomy.We retrospectively reviewed the data of 1265 consecutive patients who underwent elective esophageal surgery. The patients were classified into no risk, low-risk, moderate-risk, and high-risk groups based on nutritional scores.The moderate-risk (hazard ratio [HR]: 1.55, 95% confidence interval [CI]: 1.24-1.92, p < 0.001 in CONUT; HR: 1.61, 95% CI: 1.22-2.12, p = 0.001 in GNRI; HR: 1.65, 95% CI: 1.20-2.26, p = 0.002 in PNI) and high-risk groups (HR: 1.91, 95% CI: 1.47-2.48, p < 0.001 in CONUT; HR: 2.54, 95% CI: 1.64-3.93, p < 0.001 in GNRI; HR: 2.32, 95% CI: 1.77-3.06, p < 0.001 in PNI) exhibited significantly worse 5-year overall survival (OS) compared with the no-risk group. As the nutritional status worsened, the trend in the OS rates decreased (p for trend in all indexes < 0.05).Malnutrition, evaluated by any of three nutritional indexes, was an independent prognostic factor for postoperative survival.
Abstract Funding Acknowledgements Type of funding sources: None. OnBehalf Portuguese Registry of Acute Coronary Syndromes Background Acute coronary syndromes (ACS) are common and several scores were proposed to identify high-risk patients that presented worse prognosis in short and long-term follow up. CHA2DS2-VASc score is the score used to decide the initiation of anticoagulation therapy in atrial fibrillation (AF) patients. It is an easy and convenient score, used by physicians in clinical practice, which is helpful to apply in ACS predicting the high-risk patients. Objective CHA2DS2-VASc score as a prognosis method in ACS. Methods Multicenter retrospective study, based on the Portuguese Registry of ACS between 1/10/2010-4/09/2019. CHA2DS2-VASc test as a predictor of AF with a receiver operating characteristic curve. Logistic regression to access if the score was a predictor of AF. According with a punctuation of CHA2DS2-VASc as 0, 1 and ≥2, was performed a Kaplan-Meier test to establish the survival rates and cardiovascular admission at one year of follow-up. Results 25271 patients had ACS, 1023 patients (4.2%) presented de novo AF. CHA2DS2-VASc score was a median predictor of de novo AF (Area Under Curve: 0.642, confidence interval (CI) 0.625-0.659), with a 66.7% sensibility and 55.1% specificity. Logistic regression revealed that the CHA2DS2-VASc score was a predictor of de novo AF in ACS (odds ratio (OR) 2.07, p < 0.001, CI 1.74-2.47). Mortality rates at one year of follow-up, even showing higher mortality rates associated with higher CHA2DS2-VASc punctuation, do not revealed to be significant, p = 0.099. On the other hand, the score exhibited a significant value, p = 0.050, for re-admission for all causes, according to the classification as 0, 1 or ≥2. Regarding re-admission for cardiovascular causes at one year of follow-up was associated with the score classification, with a Kaplan-Meier test of p = 0.011. Conclusions CHA2DS2-VASc score was a predictor of de novo AF in ACS and can be used as a prognostic method for all causes of re-admission and, in special, for cardiovascular cause of re-admission.
Aims This retrospective, observational, longitudinal study aimed to document the distribution, changes in renal function [measured by estimated glomerular filtration (eGFR)] and antithrombotic treatment pattern in atrial fibrillation (AF) patients in real-world settings managed by general practitioners in Germany. Methods and results Data were extracted from the German Longitudinal Patient Database. A total of 15,900 patients with AF were identified. Among 1660 having eGFR available at baseline, 3.4% had severely impaired eGFR, 9.7% and 25.6% had moderate severe decrease and moderate decrease in eGFR, respectively, and 61.3% had mildly decreased/normal eGFR. Patients with moderately and severely decreased eGFR tended to be older. The proportion of patients with a CHADS2 score ≥ 2 was 92.9% in those with severely decreased eGFR, and 87.0% and 79.1% in those with moderately severe and moderately decreased eGFR. During follow up, 52.1% of patients with severely decreased eGFR, and 26.3% to 23.7% of patients with moderately decreased eGFR were not treated by antithrombotic. When comparing baseline with follow-up eGFR, 55.0% of patients showed decreased eGFR. Age, diabetes, dyslipidaemia and history of myocardial infarction were identified as significant predictors for renal function deterioration based on results from multivariate Cox regression model. Conclusions Moderate-to-severe renal dysfunction is prevalent (~38%) in German AF patients with documented eGFR managed in actual clinical practices. The risk of stroke, as measured by the CHADS2 score, was associated with decreased renal function. Treatment with anticoagulation therapies decreased with decreasing renal function, despite increasing risk of stroke. Anticoagulation treatments remain suboptimal during the 12-month follow up in patients with moderate or severe renal impairment.
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