Postoperative enzime changes in the radical operations in case of gastric cancer

USMF ”N. Testemițanu”, catedra Hematologie și Oncologie, IMSP Institutul Oncologic laboratorul gastropulmonologie, Al XI-lea Congres al Asociației Chirurgilor „Nicolae Anestiadi” din Republica Moldova și cea de-a XXXIII-a Reuniune a Chirurgilor din Moldova „Iacomi-Răzeșu” 27-30 septembrie 2011Pe parcursul anilor – 2009-2011 sub supravegherea noastră au fost 13 bolnavi de cancer gastric – 8 bărbați şi 5 femei cu vârsta 40-65 ani – care au suportat operații radicale pe motive de cancer. Am monitorizat bolnavii în aspectul modificării indicilor enzimatici: α-amilaza, proteina C-reactivă, amilaza pancreatică şi lipaza în ziua operației, primele 3 zile, dacă indicii reveneau la normă, se repeta determinarea lor şi în ziua externării bolnavului. În cazul, că enzimele rămâneau la nivele sporite, determinarea lor se prelungea pe toată perioada până la externare. În rezultatul studiului am stabilit că amilaza plasmatică suporta devieri de la cifrele normale cu sporirea indicilor săi chiar în ziua operației şi, îndeosebi, în primele 3 zile postoperatorii. Cele mai profunde şi durabile modificări au fost înregistrate din partea lipazei, care s-a manifestat mai târziu și „normalizat” după o perioadă de tratament foarte îndelungat. În cazul, când indicii enzimatici persistau o perioadă mai îndelungată şi, în pofida tratamentului cu inhibitori sau cu administrare de citostatice, nu aveau tendința spre normalizare ne-am convins, în cele din urmă, că pancreatita a evoluat în pancreonecroză (2 cazuri) şi tratamentul a durat în timp cu vindecare peste 20-30 şi mai multe zile. Concluzii:1. Pancreatitele postoperatorii în cancerul gastric corelează cu 2 factori principali: 1) extinderea tumorii gastrice cu implicarea pancreasului; 2) traumatizarea glandei pancreatice în timpul mobilizării stomacului sau în cazul rezecției parțiale a pancreasului şi în splenectomie. 2. Cel mai precoce se modifică indicii amilazei, dar modificarea lipazei care persistă îndelungat este rezultatul evoluției în pancreonecroză şi normalizarea lor este criteriul vindecării pancreatitei.In our study we were monitorised and analised changes of ensimatic indixes of 13 patients radical operated with gastric cancer. We were find, that, in a fact, the exopancreatic sistem is very sensible than smolest traumatic actions during operations. More earlier was change amilase, but if increases lipase and persistes more time, probability of pancreatitis this is very higher, what was confirmate in our study

Clinical practice guidelines of the European Association for Endoscopic Surgery (EAES) on bariatric surgery: update 2020 endorsed by IFSO-EC, EASO and ESPCOP

Background: Surgery for obesity and metabolic diseases has been evolved in the light of new scientific evidence, long-term outcomes and accumulated experience. EAES has sponsored an update of previous guidelines on bariatric surgery. Methods: A multidisciplinary group of bariatric surgeons, obesity physicians, nutritional experts, psychologists, anesthetists and a patient representative comprised the guideline development panel. Development and reporting conformed to GRADE guidelines and AGREE II standards. Results: Systematic review of databases, record selection, data extraction and synthesis, evidence appraisal and evidence-to-decision frameworks were developed for 42 key questions in the domains Indication; Preoperative work-up; Perioperative management; Non-bypass, bypass and one-anastomosis procedures; Revisional surgery; Postoperative care; and Investigational procedures. A total of 36 recommendations and position statements were formed through a modified Delphi procedure. Conclusion: This document summarizes the latest evidence on bariatric surgery through state-of-the art guideline development, aiming to facilitate evidence-based clinical decisions

Protective intraoperative ventilation with higher versus lower levels of positive end-expiratory pressure in obese patients (PROBESE): study protocol for a randomized controlled trial

Background: Postoperative pulmonary complications (PPCs) increase the morbidity and mortality of surgery in obese patients. High levels of positive end-expiratory pressure (PEEP) with lung recruitment maneuvers may improve intraoperative respiratory function, but they can also compromise hemodynamics, and the effects on PPCs are uncertain. We hypothesized that intraoperative mechanical ventilation using high PEEP with periodic recruitment maneuvers, as compared with low PEEP without recruitment maneuvers, prevents PPCs in obese patients. Methods/design The PRotective Ventilation with Higher versus Lower PEEP during General Anesthesia for Surgery in OBESE Patients (PROBESE) study is a multicenter, two-arm, international randomized controlled trial. In total, 2013 obese patients with body mass index ≥35 kg/m2 scheduled for at least 2 h of surgery under general anesthesia and at intermediate to high risk for PPCs will be included. Patients are ventilated intraoperatively with a low tidal volume of 7 ml/kg (predicted body weight) and randomly assigned to PEEP of 12 cmH2O with lung recruitment maneuvers (high PEEP) or PEEP of 4 cmH2O without recruitment maneuvers (low PEEP). The occurrence of PPCs will be recorded as collapsed composite of single adverse pulmonary events and represents the primary endpoint. Discussion To our knowledge, the PROBESE trial is the first multicenter, international randomized controlled trial to compare the effects of two different levels of intraoperative PEEP during protective low tidal volume ventilation on PPCs in obese patients. The results of the PROBESE trial will support anesthesiologists in their decision to choose a certain PEEP level during general anesthesia for surgery in obese patients in an attempt to prevent PPCs. Trial registration ClinicalTrials.gov identifier: NCT02148692. Registered on 23 May 2014; last updated 7 June 2016. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-1929-0) contains supplementary material, which is available to authorized users

Extended lymphadenectomy in palliative gastrectomy in gastric cancer

IMSP Institutul Oncologic, laboratorul gastropulmonologie, Al XI-lea Congres al Asociației Chirurgilor „Nicolae Anestiadi” din Republica Moldova și cea de-a XXXIII-a Reuniune a Chirurgilor din Moldova „Iacomi-Răzeșu” 27-30 septembrie 2011Tratamentul chirurgical paliativ în cancerul gastric avansat este o realitate indiscutabilă, aceptată de comunitatea medicală. Gastrectomia paliativă previne asemenea complicații ca stenoza, hemoragia, perforația, reduce intoxicarea tumorală, creând condiții mai favorabile pentru chimioterapie şi radioterapie. Volumul operațiilor paliative în multe cazuri se limitează la înlăturarea stomacului, omentului mare şi mic. În ultimul timp aplicăm tot mai frecvent limfadenectomia lărgită curativă în regiunea ateriei hepatice şi ramificărilor ei – H, trunchiului celiac –C, aortei –A, arteriei lienale şi hilul splinei – L. Uneori se efectuează şi limfadenectomie retroperitonială la baza mezoului intestinal. În studiu au fost incluşi 52 de bolnavi de cancer gastric avansat ,care au suportat gastrectomie paliativă cu omentectomie şi 49 bolnavi, la care operația a fost lărgită prin linfadenectomie retroperitoneală Hepatoceliacoaortică şi Hepatolienalociliacoaortică. În perioada postoperatorie la pacienții primului grup s-au înregistrat 4 complicații purulente, 3 pancreatite acute, o dehiscență a anastomozei esofagojejunale. În grupul doi s-au constatat 2 complicații purulente, 7 pancreatite acute. La 5 pacienți s-a înregistrat limforee. După tratamentul conservativ administrat, toate complicațiile au fost lichidate. Bolnavii incluşi in studiu au beneficiat de tratament chimioterapicîin perioada postoperatorie. Analizînd rezultatele la distanță, am constatat manifestări de avansare a procesului după 16 luni de la operație în primul grup şi după 24 luni - la pacienții care au suportat limfadenectomie lărgită în volum de Hepatoceliacoaortica şi Hepatolienalociliacoaortică.Curative lymphodissection HCA and HLCA in cases of palliative total gastric rezections does not signifficantly influence on the postoperative complications, eventhow it does contribute to the late cancer progression and increasing the average period of survival

Combined operations in the surgery of retroperitoneal primitiv tumors

IMSP IO laboratorul gastropulmonologie, Al XI-lea Congres al Asociației Chirurgilor „Nicolae Anestiadi” din Republica Moldova și cea de-a XXXIII-a Reuniune a Chirurgilor din Moldova „Iacomi-Răzeșu” 27-30 septembrie 2011Tumorile retroperitoneale primitive se întâlnesc destul de rar, constituind 0,03-1% în structura oncologică. Stadiile incipiente sunt depistate incidental prin investigațiile de rutină. O bună parte sunt diagnosticate, când procesul se extinde la organele adiacente, şi necesită operații combinate. Principalele întrebări, care cer răspuns sunt: este tumora întradevăr retroperitoneală primitivă; implică ea organele adiacente şi dacă poate fi înlăturată radical. Studiul nostru este constituit din 120 de bolnavi, 100 au suportat operații radicale dintre care 46 au avut caracter combinat: 15 cazuri cu nefrectomie; 7 cazuri cu splenectomie; 5 rezecții hepatice; 6 adrenalectomii; 4 rezecții pancreatice corporeo-caudale în bloc cu splina; 6 rezecții de intestin subțire şi colon şi 3 rezecții gastrice. Am înregistrat o corelare a operațiilor combinate în conformitate cu dimensiunile tumorii. Astfel în tumorile de până la 10 cm operațiile combinate au fost efectuate în 15%, în cele de 10-20 cm procentul creşte la 45-50%, în recidivele tumorii operațiile combinate ating 60%. Rezultatele imediate şi la distanță au fost următoarele: cu toate că tumora a fost înlăturată radical cu capsula integră şi cu sacrificarea organelor adiacente, în 5 cazuri au fost înregistrate recidive pe locul formațiunii primitive. Mai frecvent s-au dezvoltat recidivele în lipo- şi angiosarcoame. În 2 cazuri au avut loc complicații grave. La unul dintre pacienți s-a declanşat o hemoragie din loja tumorii. S-a efectuat relaparotomia cu hemostază, dar a survenit sindromul CID, în urma căruia bolnavul a decedat. În cel de al doilea caz s-a constatat o fistulă intestinală – în cadrul relaparotomiei a fost efectuată rezecția intestinului subțire. Bolnavul a supraviețuit. The data on 46 combined operations from 120 operated patients with the retroperitoneal tumors have been prezented.Nephrectomy, splenectomy, the liver rezection, adrenalectomy, the bouce and smale intestine rezection, or the stomach rezection have been fulfiled „en block” with retroperitoneal tumors. The surgical treatment nearest results were satisfactory with lethal outcome in one case. The 5 patients prezented the tumor’s recurrence.The data on 46 combined operations from 120 operated patients with the retroperitoneal tumors have been prezented.Nephrectomy, splenectomy, the liver rezection, adrenalectomy, the bouce and smale intestine rezection, or the stomach rezection have been fulfiled „en block” with retroperitoneal tumors. The surgical treatment nearest results were satisfactory with lethal outcome in one case. The 5 patients prezented the tumor’s recurrence

EAES rapid guideline: systematic review, network meta-analysis, CINeMA and GRADE assessment, and European consensus on bariatric surgery–extension 2022

none38Background: The European Association for Endoscopic Surgery Bariatric Guidelines Group identified a gap in bariatric surgery recommendations with a structured, contextualized consideration of multiple bariatric interventions. Objective: To provide evidence-informed, transparent and trustworthy recommendations on the use of sleeve gastrectomy, Roux-en-Y gastric bypass, adjustable gastric banding, gastric plication, biliopancreatic diversion with duodenal switch, one anastomosis gastric bypass, and single anastomosis duodeno-ileal bypass with sleeve gastrectomy in patients with severe obesity and metabolic diseases. Only laparoscopic procedures in adults were considered. Methods: A European interdisciplinary panel including general surgeons, obesity physicians, anesthetists, a psychologist and a patient representative informed outcome importance and minimal important differences. We conducted a systematic review and frequentist fixed and random-effects network meta-analysis of randomized-controlled trials (RCTs) using the graph theory approach for each outcome. We calculated the odds ratio or the (standardized) mean differences with 95% confidence intervals for binary and continuous outcomes, respectively. We assessed the certainty of evidence using the CINeMA and GRADE methodologies. We considered the risk/benefit outcomes within a GRADE evidence to decision framework to arrive at recommendations, which were validated through an anonymous Delphi process of the panel. Results: We identified 43 records reporting on 24 RCTs. Most network information surrounded sleeve gastrectomy and Roux-en-Y gastric bypass. Under consideration of the certainty of the evidence and evidence to decision parameters, we suggest sleeve gastrectomy or laparoscopic Roux-en-Y gastric bypass over adjustable gastric banding, biliopancreatic diversion with duodenal switch and gastric plication for the management of severe obesity and associated metabolic diseases. One anastomosis gastric bypass and single anastomosis duodeno-ileal bypass with sleeve gastrectomy are suggested as alternatives, although evidence on benefits and harms, and specific selection criteria is limited compared to sleeve gastrectomy and Roux-en-Y gastric bypass. The guideline, with recommendations, evidence summaries and decision aids in user friendly formats can also be accessed in MAGICapp: https://app.magicapp.org/#/guideline/Lpv2kE Conclusions: This rapid guideline provides evidence-informed, pertinent recommendations on the use of bariatric and metabolic surgery for the management of severe obesity and metabolic diseases. The guideline replaces relevant recommendations published in the EAES Bariatric Guidelines 2020.noneCarrano F.M.; Iossa A.; Di Lorenzo N.; Silecchia G.; Kontouli K.-M.; Mavridis D.; Alarcon I.; Felsenreich D.M.; Sanchez-Cordero S.; Di Vincenzo A.; Balague-Ponz M.C.; Batterham R.L.; Bouvy N.; Copaescu C.; Dicker D.; Fried M.; Godoroja D.; Goitein D.; Halford J.C.G.; Kalogridaki M.; De Luca M.; Morales-Conde S.; Prager G.; Pucci A.; Vilallonga R.; Zani I.; Vandvik P.O.; Antoniou S.A.; Agresta F.; Azran C.; Busetto L.; Buza M.; Prats B.G.; Herlesova J.; Piatto G.; Pruijssers S.; Rayman S.; Romano E.Carrano, F. M.; Iossa, A.; Di Lorenzo, N.; Silecchia, G.; Kontouli, K. -M.; Mavridis, D.; Alarcon, I.; Felsenreich, D. M.; Sanchez-Cordero, S.; Di Vincenzo, A.; Balague-Ponz, M. C.; Batterham, R. L.; Bouvy, N.; Copaescu, C.; Dicker, D.; Fried, M.; Godoroja, D.; Goitein, D.; Halford, J. C. G.; Kalogridaki, M.; De Luca, M.; Morales-Conde, S.; Prager, G.; Pucci, A.; Vilallonga, R.; Zani, I.; Vandvik, P. O.; Antoniou, S. A.; Agresta, F.; Azran, C.; Busetto, L.; Buza, M.; Prats, B. G.; Herlesova, J.; Piatto, G.; Pruijssers, S.; Rayman, S.; Romano, E

Protective intraoperative ventilation with higher versus lower levels of positive end-expiratory pressure in obese patients (PROBESE): Study protocol for a randomized controlled trial

Background: Postoperative pulmonary complications (PPCs) increase the morbidity and mortality of surgery in obese patients. High levels of positive end-expiratory pressure (PEEP) with lung recruitment maneuvers may improve intraoperative respiratory function, but they can also compromise hemodynamics, and the effects on PPCs are uncertain. We hypothesized that intraoperative mechanical ventilation using high PEEP with periodic recruitment maneuvers, as compared with low PEEP without recruitment maneuvers, prevents PPCs in obese patients. Methods/design: The PRotective Ventilation with Higher versus Lower PEEP during General Anesthesia for Surgery in OBESE Patients (PROBESE) study is a multicenter, two-arm, international randomized controlled trial. In total, 2013 obese patients with body mass index ≥35 kg/m2 scheduled for at least 2 h of surgery under general anesthesia and at intermediate to high risk for PPCs will be included. Patients are ventilated intraoperatively with a low tidal volume of 7 ml/kg (predicted body weight) and randomly assigned to PEEP of 12 cmH2O with lung recruitment maneuvers (high PEEP) or PEEP of 4 cmH2O without recruitment maneuvers (low PEEP). The occurrence of PPCs will be recorded as collapsed composite of single adverse pulmonary events and represents the primary endpoint. Discussion: To our knowledge, the PROBESE trial is the first multicenter, international randomized controlled trial to compare the effects of two different levels of intraoperative PEEP during protective low tidal volume ventilation on PPCs in obese patients. The results of the PROBESE trial will support anesthesiologists in their decision to choose a certain PEEP level during general anesthesia for surgery in obese patients in an attempt to prevent PPCs. Trial registration: ClinicalTrials.gov identifier: NCT02148692. Registered on 23 May 2014; last updated 7 June 2016

Impact of retrograde transillumination while securing the airway in obese patients undergoing bariatric surgery

Video laryngoscopy (VL) is a well-established technique used in anaesthetising obese patients who present with higher risks of airway-related difficulties and desaturations due to shorter safe apnoea periods. However, VL has certain limitations and may fail. We present the Infrared Red Intubation System (IRRIS), a new technique facilitating glottis identification in severely obese patients undergoing anaesthesia for bariatric surgery. This single-centre, prospective trial assessed the efficacy of the IRRIS for VL tracheal intubation in 20 severely obese adult patients undergoing elective bariatric surgery under general anaesthesia. We assessed the ability of the IRRIS to differentiate the transilluminated glottis from the oesophagus and laryngeal folds and evaluated the ease of intubation. The average weight in the investigated patient cohort was 145 ± 29 kg, the suprasternal tissue thickness was 12 ± 4 mm. The median IQR [range] larynx recognition time was 10 [2–50] s, which was similar to that of lean patients. The degree of obesity correlated with the duration to achieve optimal laryngoscopic view and complete the intubation procedure. We achieved successful VL insertion on the first attempt in 13 of 20 cases (65%), and on the second attempt in 7 cases (35%), emphasising the increased probability of successful intubation on the first attempt. Tracheal intubation with the IRRIS lasted 50 [IQR 20–100] s. The lowest SpO2 during intubation was 98 [IQR 83–100] %. Addition of IRRIS to VL insertion facilitated the intubation of difficult airways in severely obese patients. IRRIS improves the visualization of the intubation pathway by selectively highlighting the airway entrance and shortens the time to successfully conclude the intubation procedure