Current Role and Potential of Oesophogeal and Gastric Fluoroscopy in the Choice of Surgical Treatment for Achalasia of Cardia

Background. Fluoroscopy of the esophagus and stomach provides a reliable assessment of the specific radiological criteria for achalasia (of cardia), which underlie the classification of the disease by stages. The stage of achalasia is one of the key factors to determine the management of treatment, including the choice of a specific type of surgical intervention. However, no methodological standards for performing and interpreting fluoroscopy of the esophagus and stomach in achalasia have been developed.Objectives. Creation of a unified protocol for performing and interpreting fluoroscopy of esophagus and stomach in achalasia and development of an algorithm for diagnosing achalasia based on fluoroscopy of the esophagus and stomach, which will help to determine the appropriate surgery.Methods. The developed algorithm was applied in a study of 104 patients. The examination was carried out using Duodiagnost X-ray machine by Philips, equipped with a remote control. The X-ray technician’s workplace was tooled with a personal computer, a digital identifier (ID) and a digitizer-scanning device. Drystardt 5000B film (by AGFA) was used for X-ray examinations. The description of X-ray examination was carried out by a radiologist in a separate office equipped with two workstations.Results. A protocol for fluoroscopy of the esophagus and stomach in patients with achalasia and a checklist for the description of fluoroscopy in achalasia have been developed. Conclusion. The developed algorithm for diagnosing achalasia of cardia based on fluoroscopy of the esophagus and stomach showed its high efficiency for clarifying the stage of the disease, and, consequently, choosing the right treatment and method of surgical intervention, as well as for providing objective control over the dynamics of the disease after surgery. In addition, the introduction of the developed algorithm into the widespread practice of radiologists will ensure continuity at all stages of treatment of patients with achalasia in different medical institutions: from diagnosis to dynamic monitoring of the patient’s condition after surgical treatment in specialized centers

Epidemiology, practice of ventilation and outcome for patients at increased risk of postoperative pulmonary complications

BACKGROUND Limited information exists about the epidemiology and outcome of surgical patients at increased risk of postoperative pulmonary complications (PPCs), and how intraoperative ventilation was managed in these patients. OBJECTIVES To determine the incidence of surgical patients at increased risk of PPCs, and to compare the intraoperative ventilation management and postoperative outcomes with patients at low risk of PPCs. DESIGN This was a prospective international 1-week observational study using the ‘Assess Respiratory Risk in Surgical Patients in Catalonia risk score’ (ARISCAT score) for PPC for risk stratification. PATIENTS AND SETTING Adult patients requiring intraoperative ventilation during general anaesthesia for surgery in 146 hospitals across 29 countries. MAIN OUTCOME MEASURES The primary outcome was the incidence of patients at increased risk of PPCs based on the ARISCAT score. Secondary outcomes included intraoperative ventilatory management and clinical outcomes. RESULTS A total of 9864 patients fulfilled the inclusion criteria. The incidence of patients at increased risk was 28.4%. The most frequently chosen tidal volume (VT) size was 500 ml, or 7 to 9 ml kg1 predicted body weight, slightly lower in patients at increased risk of PPCs. Levels of positive end-expiratory pressure (PEEP) were slightly higher in patients at increased risk of PPCs, with 14.3% receiving more than 5 cmH2O PEEP compared with 7.6% in patients at low risk of PPCs (P < 0.001). Patients with a predicted preoperative increased risk of PPCs developed PPCs more frequently: 19 versus 7%, relative risk (RR) 3.16 (95% confidence interval 2.76 to 3.61), P < 0.001) and had longer hospital stays. The only ventilatory factor associated with the occurrence of PPCs was the peak pressure. CONCLUSION The incidence of patients with a predicted increased risk of PPCs is high. A large proportion of patients receive high VT and low PEEP levels. PPCs occur frequently in patients at increased risk, with worse clinical outcome

Epidemiology, practice of ventilation and outcome for patients at increased risk of postoperative pulmonary complications: LAS VEGAS - An observational study in 29 countries

BACKGROUND Limited information exists about the epidemiology and outcome of surgical patients at increased risk of postoperative pulmonary complications (PPCs), and how intraoperative ventilation was managed in these patients. OBJECTIVES To determine the incidence of surgical patients at increased risk of PPCs, and to compare the intraoperative ventilation management and postoperative outcomes with patients at low risk of PPCs. DESIGN This was a prospective international 1-week observational study using the ‘Assess Respiratory Risk in Surgical Patients in Catalonia risk score’ (ARISCAT score) for PPC for risk stratification. PATIENTS AND SETTING Adult patients requiring intraoperative ventilation during general anaesthesia for surgery in 146 hospitals across 29 countries. MAIN OUTCOME MEASURES The primary outcome was the incidence of patients at increased risk of PPCs based on the ARISCAT score. Secondary outcomes included intraoperative ventilatory management and clinical outcomes. RESULTS A total of 9864 patients fulfilled the inclusion criteria. The incidence of patients at increased risk was 28.4%. The most frequently chosen tidal volume (V T) size was 500 ml, or 7 to 9 ml kg−1 predicted body weight, slightly lower in patients at increased risk of PPCs. Levels of positive end-expiratory pressure (PEEP) were slightly higher in patients at increased risk of PPCs, with 14.3% receiving more than 5 cmH2O PEEP compared with 7.6% in patients at low risk of PPCs (P ˂ 0.001). Patients with a predicted preoperative increased risk of PPCs developed PPCs more frequently: 19 versus 7%, relative risk (RR) 3.16 (95% confidence interval 2.76 to 3.61), P ˂ 0.001) and had longer hospital stays. The only ventilatory factor associated with the occurrence of PPCs was the peak pressure. CONCLUSION The incidence of patients with a predicted increased risk of PPCs is high. A large proportion of patients receive high V T and low PEEP levels. PPCs occur frequently in patients at increased risk, with worse clinical outcome.</p

Sex difference and intra-operative tidal volume: Insights from the LAS VEGAS study

BACKGROUND: One key element of lung-protective ventilation is the use of a low tidal volume (VT). A sex difference in use of low tidal volume ventilation (LTVV) has been described in critically ill ICU patients.OBJECTIVES: The aim of this study was to determine whether a sex difference in use of LTVV also exists in operating room patients, and if present what factors drive this difference.DESIGN, PATIENTS AND SETTING: This is a posthoc analysis of LAS VEGAS, a 1-week worldwide observational study in adults requiring intra-operative ventilation during general anaesthesia for surgery in 146 hospitals in 29 countries.MAIN OUTCOME MEASURES: Women and men were compared with respect to use of LTVV, defined as VT of 8 ml kg-1 or less predicted bodyweight (PBW). A VT was deemed 'default' if the set VT was a round number. A mediation analysis assessed which factors may explain the sex difference in use of LTVV during intra-operative ventilation.RESULTS: This analysis includes 9864 patients, of whom 5425 (55%) were women. A default VT was often set, both in women and men; mode VT was 500 ml. Median [IQR] VT was higher in women than in men (8.6 [7.7 to 9.6] vs. 7.6 [6.8 to 8.4] ml kg-1 PBW, P &lt; 0.001). Compared with men, women were twice as likely not to receive LTVV [68.8 vs. 36.0%; relative risk ratio 2.1 (95% CI 1.9 to 2.1), P &lt; 0.001]. In the mediation analysis, patients' height and actual body weight (ABW) explained 81 and 18% of the sex difference in use of LTVV, respectively; it was not explained by the use of a default VT.CONCLUSION: In this worldwide cohort of patients receiving intra-operative ventilation during general anaesthesia for surgery, women received a higher VT than men during intra-operative ventilation. The risk for a female not to receive LTVV during surgery was double that of males. Height and ABW were the two mediators of the sex difference in use of LTVV.TRIAL REGISTRATION: The study was registered at Clinicaltrials.gov, NCT01601223

Specifics of the perioperative management of the patients undergoing surgery for malignant neoplasms during the COVID-19 pandemic

Background: The worse prognosis in cancer patients with COVID-19 infection in the context of the pandemic, compared to that in the general population, poses new challenges to ensure the perioperative safety.Aim: To reduce the risk of infection for cancer patients in the perioperative period and to prevent severe COVID-19.Materials and methods: During two months of the COVID-19 (from March to April 2020), we performed 158 surgical interventions: 49 for breast cancer, 31 for lung cancer (videothoracoscopic segmental and lobar resections), 12 for stomach cancer (8 distal and 1 proximal laparoscopic subtotal gastric resections, 3 gastrectomies), 16 laparoscopic resections for colorectal cancer, 29 resections with a reconstructive plastic for malignant skin tumors, 21 palliative and diagnostic operations (diagnostic thoracoscopy and laparoscopy, laparoscopic colostomy).Results: Preventive administration during preparation for surgery (interferon-al-pha2b and low molecular weight heparins) and for suspected infection (antibiotics, low molecular weight heparins and dexamethasone 12 mg/day intravenously) allowed for lower rates of the new coronavirus infection (1.3%) and its severe cases (0%) during surgical treatment of malignant tumors.Conclusion: Surgical treatment of cancer patients in the context of a new coronavirus infection pandemic should be carried out with strict adherence to anti-epidemic measures

OPPORTUNITIES OF LAPAROSCOPY IN THE TREATMENT OF ESOPHAGEAL ACHALASIA

The article describes opportunities and results of laparoscopic oesophagocardiomiotomy and laparoscopic transhiatal oesophagus removal without hand assistance in esophageal achalasia (cardiospasm). In total, such operations were performed in 196 and 31 of cases (of 423 patients), respectively. There were minimal numbers of relapses (below 2.3%) after laparoscopic oesophagocardiomiotomy done by the proposed technique. All cases of reflux esophagitis were diagnosed after esophagocardiomiotomy with Dor fundoplication.After cardiodilatation, disease relapses were registered in 57% of patients. The advantages of a laparoscopic access for oesophagectomy are shown and technical particular of this intervention are analyzed based on a case history. The principles of Fast track surgery in this patient category are discussed that allow for reduction of the length of hospital stay by 40%

LAPAROSCOPIC FUNDOPLICATION IN THE TREATMENT OF BARRETT’S ESOPHAGUS

The  results  of  treatment  of  Barrett's  oesophagus diagnosed in 22 (9.2%) of 238 patients  with gastroesophageal reflux disease  and  hiatal  hernia are  presented. A high  degree  dysplasia  was found  in 54.5%  (12/22) of patients. All patients were administered combination therapy with proton   pump  inhibitors, prokinetics, third  generation  H2 histamine  receptor  blockers  for 3 to 4 weeks. If no regress of dysplasia was obtained,   Barrett's epithelium  was removed  by a holmium laser  (14 patients). The advantages of a laparoscopic fundoplication  technique proposed by the authors  in the treatment of Barrett's oesophagus were shown. This surgical intervention reliably prevents  the gastroesophageal reflux that has led to the development of this disease

Efficacy and safety of glycyrrhizic acid and essential phospholipids (Phosphogliv) combination for alcoholic liver disease: results of the double-blind randomized placebo-controlled multicenter post-registration (phase IV) clinical trial «Jaguar» (PHG-M2/P03-12)

Material and methods. The original study included overall 120 patients with ALD, who were randomized in two identical groups. The patients of the main group (group A) received 2 courses of therapy: the first - Phosphogliv 5 mg/day as intravenous bolus injection for 2 wks, followed by the oral intake of 2 capsules t.i.d. for 10 wks (the total treatment duration was 24 wks). Patients of the control group (group B) received placebo in the same regimen. The dynamics of serum alanine transaminase (ALT), aspartate transaminase (AST), liver scores by noninvasive FibroMax test was applied to assess the treatment efficacy and safety, along with change in quality of life of patients. Results. In 24 wks in group A in comparison to the group B significantly lower mean ALT level was found: 35,2±29,4 U/l vs 48,4±36,1 U/l (р =0,044), AST level became normal in higher rate of patients: 69,4% vs 47,7% (р =0,034), that had more prominent decrease in gamma-glutamyltranspeptidase (GGT) level - 47,4±36,5% vs 25,1±63,9% (р =0,039), the rate of patients with Aktitest A2-A3 range decreased - 8,5% vs 21,4% (

The Association of Intraoperative driving pressure with postoperative pulmonary complications in open versus closed abdominal surgery patients - a posthoc propensity score-weighted cohort analysis of the LAS VEGAS study

BackgroundIt is uncertain whether the association of the intraoperative driving pressure (Delta P) with postoperative pulmonary complications (PPCs) depends on the surgical approach during abdominal surgery. Our primary objective was to determine and compare the association of time-weighted average Delta P (Delta P-TW) with PPCs. We also tested the association of Delta P-TW with intraoperative adverse events.MethodsPosthoc retrospective propensity score-weighted cohort analysis of patients undergoing open or closed abdominal surgery in the 'Local ASsessment of Ventilatory management during General Anaesthesia for Surgery' (LAS VEGAS) study, that included patients in 146 hospitals across 29 countries. The primary endpoint was a composite of PPCs. The secondary endpoint was a composite of intraoperative adverse events.ResultsThe analysis included 1128 and 906 patients undergoing open or closed abdominal surgery, respectively. The PPC rate was 5%. Delta P was lower in open abdominal surgery patients, but Delta P-TW was not different between groups. The association of Delta P-TW with PPCs was significant in both groups and had a higher risk ratio in closed compared to open abdominal surgery patients (1.11 [95%CI 1.10 to 1.20], P &lt; 0.001 versus 1.05 [95%CI 1.05 to 1.05], P &lt; 0.001; risk difference 0.05 [95%CI 0.04 to 0.06], P &lt; 0.001). The association of &lt;Delta&gt;P-TW with intraoperative adverse events was also significant in both groups but had higher odds ratio in closed compared to open abdominal surgery patients (1.13 [95%CI 1.12- to 1.14], P &lt; 0.001 versus 1.07 [95%CI 1.05 to 1.10], P &lt; 0.001; risk difference 0.05 [95%CI 0.030.07], P &lt; 0.001).Conclusions&lt;Delta&gt;P is associated with PPC and intraoperative adverse events in abdominal surgery, both in open and closed abdominal surgery.Trial registrationLAS VEGAS was registered at clinicaltrials.gov (trial identifier NCT01601223)

Intraoperative ventilator settings and their association with postoperative pulmonary complications in neurosurgical patients: Post-hoc analysis of LAS VEGAS study

Background: Limited information is available regarding intraoperative ventilator settings and the incidence of postoperative pulmonary complications (PPCs) in patients undergoing neurosurgical procedures. The aim of this post-hoc analysis of the 'Multicentre Local ASsessment of VEntilatory management during General Anaesthesia for Surgery' (LAS VEGAS) study was to examine the ventilator settings of patients undergoing neurosurgical procedures, and to explore the association between perioperative variables and the development of PPCs in neurosurgical patients. Methods: Post-hoc analysis of LAS VEGAS study, restricted to patients undergoing neurosurgery. Patients were stratified into groups based on the type of surgery (brain and spine), the occurrence of PPCs and the assess respiratory risk in surgical patients in Catalonia (ARISCAT) score risk for PPCs. Results: Seven hundred eighty-four patients were included in the analysis; 408 patients (52%) underwent spine surgery and 376 patients (48%) brain surgery. Median tidal volume (VT) was 8 ml [Interquartile Range, IQR = 7.3-9] per predicted body weight; median positive end-expiratory pressure (PEEP) was 5 [3 to 5] cmH20. Planned recruitment manoeuvres were used in the 6.9% of patients. No differences in ventilator settings were found among the sub-groups. PPCs occurred in 81 patients (10.3%). Duration of anaesthesia (odds ratio, 1.295 [95% confidence interval 1.067 to 1.572]; p = 0.009) and higher age for the brain group (odds ratio, 0.000 [0.000 to 0.189]; p = 0.031), but not intraoperative ventilator settings were independently associated with development of PPCs. Conclusions: Neurosurgical patients are ventilated with low VT and low PEEP, while recruitment manoeuvres are seldom applied. Intraoperative ventilator settings are not associated with PPCs